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TitleFormulir Transfer Pasien
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RUMAH SAKIT
SARI ASIH

FORMULIR TRANSFER PASIEN

Nama Pasien

Tanggal Lahir

DPJP

Dokter Konsulen 1

Dokter Konsulen 2

Diagnosis Masuk

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Jenis Kelamin

Tanggal Masuk

Ruang / Kamar

Tanggal / Jam Pindah

Pindah ke Ruang / Kamar

Diagnnosis Sekarang

: L / P

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I. RINGKASAN RIWAYAT PASIEN

Anamnesis
Keluhan utama : ...............................................................................................................................................................................................................

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Riwayat penyakit : ...............................................................................................................................................................................................................
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Pemeriksaan Fisik : ...............................................................................................................................................................................................................

Pemeriksaan tanda-tanda vital : Tensi : mmHg Suhu : C Nadi : x/mnt
Keadaan umum : ...............................................................................................................................................................................................................

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Alasan transfer

II. PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN

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III. TINDAKAN MEDIS YANG SUDAH DILAKUKAN

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IV. PEMBERIAN TERAPI

Infus : ..............................................................................................................................................................................................................................................
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Obat Injeksi :
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Obat Oral :

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Derajat kebutuhan perawatan pasien
Derajat 0
Derajat 1

Derajat 2
Derajat 3

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