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STIKES RS.

Baptis Kediri
Jl. Mayjend Panjaitan No. 3B Kediri 64102
Telp/Fax : (0354) 683470

SURAT TUGAS PEMAKAIAN AMBULANCE


Setelah mendapat perintah dari Dokter ..................................................................................., maka dengan ini
RS Baptis menugaskan kepada Sopir Ambulance untuk mengantarkan :
Nama Pasien : ..................................................................... Umur : .............................................
Nomor Register/ Opname : .................................................................... Ruang : .............................................
Tempat Tujuan : ................................................................................................................................
Sopir Kediri, ..........................................
Perawat yang bertugas,

Menyetujui,
Dokter Yang Menugaskan

Agar menjaga kebersihan dan kesehatan untuk penumpang berikutnya, Maka sopir berkewajiban membersihkan
kendaraan luar dan dalam ambulance setiap kali kembali dari mengantar pasien

STIKES RS. Baptis Kediri


Jl. Mayjend Panjaitan No. 3B Kediri 64102
Telp/Fax : (0354) 683470

SURAT TUGAS PEMAKAIAN AMBULANCE


Setelah mendapat perintah dari Dokter ..................................................................................., maka dengan ini
RS Baptis menugaskan kepada Sopir Ambulance untuk mengantarkan :
Nama Pasien : ..................................................................... Umur : .............................................
Nomor Register/ Opname : .................................................................... Ruang : .............................................
Tempat Tujuan : ................................................................................................................................

Sopir Kediri, ..........................................


Perawat yang bertugas,

Menyetujui,
Dokter Yang Menugaskan

Agar menjaga kebersihan dan kesehatan untuk penumpang berikutnya, Maka sopir berkewajiban membersihkan
kendaraan luar dan dalam ambulance setiap kali kembali dari mengantar pasien
STIKES RS. BAPTIS KEDIRI
PRODI KEPERAWATAN STRATA 1
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FORMAT RESUME ON CALL AMBULANCE

A. IDENTITAS
a. Nama Pasien : ……………………
b. No RM/ Reg : ……………………
c. Umur : ……………………
d. Status : ……………………
e. Agama : ……………………
f. Pendidikan : ……………………
g. Pekerjaan : ……………………
h. Alamat : ……………………
i. MRS : ……………………

B. DIAGNOSIS MEDIS :
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C. RIWAYAT PENYAKIT PASIEN


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D. RUJUKAN
Dari RS : ...............................................................................................................................................
Ke RS : ...............................................................................................................................................
Lain-lain : ...............................................................................................................................................

E. PERSIAPAN SEBELUM BERANGKAT


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F. TANDA – TANDA VITAL


Suhu : ...............................................................................................................................................
Tekanan Darah : ...............................................................................................................................................
Frekuensi Nafas : ...............................................................................................................................................
Frekuensi Nadi : ...............................................................................................................................................
G. PETUGAS YANG MERUJUK
PERAWAT : ............................................................................................................................................
MAHASISWA : ............................................................................................................................................
SOPIR : ............................................................................................................................................

H. KRONOLOGIS ONCALL AMBULANCE


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I. HAL YANG DILAKUKAN DI TEMPAT RUJUKAN


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Mengetahui, Kediri,.................................................
Perawat Mahasiswa

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LAPORAN ON CALL AMBULANCE

MERUJUK PASIEN Tn. S DENGAN EFUSI PLEURA KE RSU SAIFUL ANWAR MALANG

STIKES RS. BAPTIS KEDIRI

PRODI KEPERAWATAN STRATA 1

TAHU AJARAN 2017/2018