No.

RM :
RSUD KOLONODALE Nama :
Tgl.Lahir :
Jenis Kelamin : Laki-laki Perempuan
FORMULIR SERAH TERIMA (HANDOVER) ANTAR SHIFT JAGA
RUANGAN :
HARI / TANGGAL :
PAGI SORE MALAM
Situation : …………………………………………………… Situation : …………………………………………………… Situation : ……………………………………………………
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Background : ……………………………………………….. Background : ……………………………………………….. Background : ………………………………………………..

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Dx. Medis: ………………………………………………….. Dx. Medis: ………………………………………………….. Dx. Medis: …………………………………………………..

DPJP : dr…………………………………………………….. DPJP : dr…………………………………………………….. DPJP : dr……………………………………………………..
dr…………………………………………………….. dr…………………………………………………….. dr……………………………………………………..
Assesment : …………………………………………………. Assesment : …………………………………………………. Assesment : ………………………………………………….

Kesadaran : …………………………GCS…..E….V….M…. Kesadaran : ……………………… GCS…….E….V….M…. Kesadaran : ……………………… GCS…….E….V….M….

TTV : TD : ………...mmHg Nadi : ….x/menit RR :…x/menit TTV : TD : ………...mmHg Nadi : ….x/menit RR :…x/menit TTV : TD : ………...mmHg Nadi : ….x/menit RR :…x/menit
Suhu : …..0C SPO2 : …...% Nyeri:……………. Suhu : …..0C SPO2 : …...% Nyeri:……………. Suhu : …..0C SPO2 : …...% Nyeri:…………….
Oksigen :………L/menit Infus :……………….tts/menit Oksigen :………L/menit Infus :……………….tts/menit Oksigen :………L/menit Infus :……………….tts/menit
Transfusi : ……...................tts/menit Kateter Y/T NGT Y/T Transfusi : ……………......tts/menit Kateter Y/T NGT Y/T Transfusi : …………….…..tts/menit Kateter Y/T NGT Y/T
WSD Y/T WSD Y/T WSD Y/T
Makan / Minum : …………….Toileting:…………………… Makan / Minum : …………….Toileting:…………………… Makan / Minum : …………….Toileting:……………………
Aktivitas / Gerak………………..….. Score Jatuh ………… Aktivitas / Gerak…………………….. Score Jatuh ………... Aktivitas / Gerak……………………... Score Jatuh ………..
Recomendation : ……………………………………………. Recomendation : ……………………………………………. Recomendation : …………………………………………….
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Pemberi Operan Penerima Operan Pemberi Operan Penerima Operan Pemberi Operan Penerima Operan

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