Scribd Logo
Upload

Welcome to Scribd!

  • Catatan Medis Gawat Darurat

    Uploaded by

    kukun
    114 views1 page
    This 3 sentence summary provides the high level information from the emergency medical record document: The document records the triage priority and how the patient presented, whether by themselves or with someone else. It includes both subjective data like allergies and past medical history, and objective data such as vital signs, weight, and physical exam findings. The nurse's signature, date, and time are at the bottom to document their assessment of the patient.

    Original Description:

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This 3 sentence summary provides the high level information from the emergency medical record document: The document records the triage priority and how the patient presented, whether by themselves or with someone else. It includes both subjective data like allergies and past medical history, and objective data such as vital signs, weight, and physical exam findings. The nurse's signature, date, and time are at the bottom to document their assessment of the patient.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    114 views1 page

    Catatan Medis Gawat Darurat

    Uploaded by

    kukun
    This 3 sentence summary provides the high level information from the emergency medical record document: The document records the triage priority and how the patient presented, whether by themselves or with someone else. It includes both subjective data like allergies and past medical history, and objective data such as vital signs, weight, and physical exam findings. The nurse's signature, date, and time are at the bottom to document their assessment of the patient.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    CATATAN MEDIS GAWAT DARURAT Accident Emergency Medical Record 1.

    TRIAGE Prioritas Triage/Triage Priority : Cara Pasien Datang

    The Patient Presented

    Trauma Sendiri

    By him/herself

    Non Trauma Diantar :..................................................

    Come with

    2. Pengkajian Perawat /Nurse Assesment Data Subyektif / Subjective Data : Auto Anamnesa

    Allo Anamnesa

    Riwayat Alergi / History of Allergy :

    Tidak Ya, terhadap ...................... No Yes, allergic with Riwayat Penyakit Dahulu/ Past Disease History

    Data Obyektif / Objective Data : Keadaan Umum Baik Sedang Buruk General Condition Good Fair Bad Nilai Nyeri/ Pain Score : ( Tidak ada nyeri/ No pain - Nyeri Sangat Berat / Painful)

    0
    Tekanan darah : Blood Pressure Pernafasan : Respiration

    10
    0

    mm Hg x/ menit

    Nadi : Pulse BB : Weight

    x/ menit Kg

    Suhu : Temperature Saturasi O2 : O2 Saturation

    Tanda Tangan dan Nama Lengkap Perawat Nurse Signature and Full name

    Tanggal / Date : Jam / Time

    You might also like