RS.

HARAPAN BUNDA
JL. T.UMAR No.181-211 BANDA FORMFORM TRANSFER
TRANSFER
ACEH
PASIEN INTRA RSHB
NAMA PASIEN : .............................................. No. RM : .................................................
TGL. LAHIR : .........................................L/P DPJP : .................................................
TANGGAL MASUK : ............................................... ASAL RUANGAN : .................................................
JAMINAN : ............................................... RUANGAN DITUJU : .................................................
DIAGNOSIS MASUK : ............................................... JAM PINDAH : .................................................
1. PEMERIKSAAN FISIK
A. Keadaan Umum : .................................................................................................................................
B. Kesadaran :E: M: V: =
C. Tanda tanda Vital : TD : .............. mmHg, N : ............... x/i, RR : ................ x/i, T : ..................C
D. Keluhan Masuk : .................................................................................................................................
E. Riwayat Penyakit : .................................................................................................................................
F. Riwayat Alergi : ............................................................................ Terpasang Gelang : Ya / Tidak
2. PEMERIKSAAN DIAGNOSIS YANG SUDAH DILAKUKAN
A. Laboratorium : .................................................................................................................................
B. ECG : Sudah/Belum
C. Radiologi : .................................................................................................................................
D. CT Scan : .................................................................................................................................
E. Lain lain : .................................................................................................................................
3. PEMBERIAN TERAPI
A. INFUS : .............................................................................................................................................
B. OBAT INJEKSI
a. ................................................................... e. .........................................................................
b. ................................................................... f. ..........................................................................
c. ................................................................... g. .........................................................................
C. OBAT ORAL
a. ................................................................... e. .........................................................................
b. ................................................................... f. ..........................................................................
c. ................................................................... g. .........................................................................
4. KONDISI PASIEN
A. Kondisi Pasien Saat Dipindahkan : Sadar/Tidak Sadar, Stabil/Tidak Stabil
B. Resiko Jatuh : Ya / Tidak Terpasang Gelang : Ya / Tidak
C. Cara Pemindahan Pasien : Jalan Brankar Kursi Roda Lain-lain
D. Waktu Serah Terima Pasien : Banda Aceh, Tanggal ..........................., Jam : ..................WIB
E. Catatan Penting : .........................................................................................................
Yang Menerima Pasien Yang Menyerahkan Pasien
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(Sdr/i ......................................) (Sdr/i ......................................)

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