LEMBAR TRANSFER INTERNAL

I. IDENTITAS PASIEN
Nama Pasien : ....................................... DPJP : .......................................
Jenis Kelamin : L/P Tanggal masuk : .......................................
Tanggal Lahir : ....................................... Ruang/ Kamar : .......................................
Diagnosis Masuk : ....................................... Status Pasien : BPJS/ Asuransi*/ Pribadi

II. RINGKASAN MEDIS

Anamnesis
Keluhan ..............................................................................................................
Riwayat alergi ..............................................................................................................
Riwayat penyakit risiko tinggi ..............................................................................................................
Pemeriksaan fisik
Tanda vital td ...../..... mmHg; nadi ...... bpm; napas ..... x/i; suhu ..... oC
Keadaan umum ..............................................................................................................
Pemeriksaan penunjang
Laboratorium ..............................................................................................................
Radiologi ..............................................................................................................

III. PEMBERIAN TERAPI

Infus ..............................................................................................................
..............................................................................................................
Obat injeksi ..............................................................................................................
..............................................................................................................
..............................................................................................................
Obat oral ..............................................................................................................
..............................................................................................................
..............................................................................................................

IV. TINDAKAN MEDIS DAN OBSERVASI

.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................

V. KONDISI PASIEN
Sebelum Transfer Setelah Transfer
Keadaan umum : ...................................................... Keadaan umum : .....................................................
Kesadaran : ..................................................... Kesadaran : ....................................................
Pemeriksaan tanda vital Pemeriksaan tanda vital
td ...../..... mmHg; nadi ...... bpm; napas ..... x/i; td ...../..... mmHg; nadi ...... bpm; napas .....
suhu ..... oC x/i; suhu ..... oC
Catatan penting : ..................................................... Catatan penting : ....................................................
...................................................... .......................... ................................................................................
Petugas yang menyerahkan Petugas yang menerima
Petugas Medis Petugas Medis

( ) ( )