Document Text Contents
Page 1
RUMAH SAKIT
SARI ASIH
FORMULIR TRANSFER PASIEN
Nama Pasien
Tanggal Lahir
DPJP
Dokter Konsulen 1
Dokter Konsulen 2
Diagnosis Masuk
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
Jenis Kelamin
Tanggal Masuk
Ruang / Kamar
Tanggal / Jam Pindah
Pindah ke Ruang / Kamar
Diagnnosis Sekarang
: L / P
: .......................................................
: .......................................................
: .......................................................
: .......................................................
: .......................................................
I. RINGKASAN RIWAYAT PASIEN
Anamnesis
Keluhan utama : ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
Riwayat penyakit : ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
Pemeriksaan Fisik : ...............................................................................................................................................................................................................
Pemeriksaan tanda-tanda vital : Tensi : mmHg Suhu : C Nadi : x/mnt
Keadaan umum : ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
Alasan transfer
II. PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
III. TINDAKAN MEDIS YANG SUDAH DILAKUKAN
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
IV. PEMBERIAN TERAPI
Infus : ..............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Obat Injeksi :
1. ...................................................................................................................
2. ...................................................................................................................
3. ...................................................................................................................
4. ...................................................................................................................
5. ...................................................................................................................
6. ...................................................................................................................
Obat Oral :
1. ...................................................................................................................
2. ...................................................................................................................
3. ...................................................................................................................
4. ...................................................................................................................
5. ...................................................................................................................
6. ...................................................................................................................
7. ...................................................................................................................
8. ...................................................................................................................
Derajat kebutuhan perawatan pasien
Derajat 0
Derajat 1
Derajat 2
Derajat 3
: ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
0
RUMAH SAKIT
SARI ASIH
FORMULIR TRANSFER PASIEN
Nama Pasien
Tanggal Lahir
DPJP
Dokter Konsulen 1
Dokter Konsulen 2
Diagnosis Masuk
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
Jenis Kelamin
Tanggal Masuk
Ruang / Kamar
Tanggal / Jam Pindah
Pindah ke Ruang / Kamar
Diagnnosis Sekarang
: L / P
: .......................................................
: .......................................................
: .......................................................
: .......................................................
: .......................................................
I. RINGKASAN RIWAYAT PASIEN
Anamnesis
Keluhan utama : ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
Riwayat penyakit : ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
Pemeriksaan Fisik : ...............................................................................................................................................................................................................
Pemeriksaan tanda-tanda vital : Tensi : mmHg Suhu : C Nadi : x/mnt
Keadaan umum : ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
Alasan transfer
II. PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
III. TINDAKAN MEDIS YANG SUDAH DILAKUKAN
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
IV. PEMBERIAN TERAPI
Infus : ..............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Obat Injeksi :
1. ...................................................................................................................
2. ...................................................................................................................
3. ...................................................................................................................
4. ...................................................................................................................
5. ...................................................................................................................
6. ...................................................................................................................
Obat Oral :
1. ...................................................................................................................
2. ...................................................................................................................
3. ...................................................................................................................
4. ...................................................................................................................
5. ...................................................................................................................
6. ...................................................................................................................
7. ...................................................................................................................
8. ...................................................................................................................
Derajat kebutuhan perawatan pasien
Derajat 0
Derajat 1
Derajat 2
Derajat 3
: ...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
0
