PUSKESMAS HARUYAN

TRIASE
NO. RM :.............................................................
NAMA :.............................................................
TGL. LAHIR :.............................................................
NO. KTP/SIM :............................................................................. JENIS KELAMIN :.............................................................
ALAMAT :.............................. RT/RW:.................................. AGAMA :.............................................................
KEL/DESA :............................................................................. SUKU :.............................................................
KEC. :............................................................................. BANGSA :.............................................................
KOTA/KAB :............................................................................. PENDIDIKAN :.............................................................
STATUS PERKAWINAN JENIS PEMBIAYAAN PEKERJAAN

Kontak awal pasien Tanggal: .............................................. Pukul :................

Cara masuk : Jalan Brandcar Kursi roda
Sudah Terpasang :.........................................................................................................................................................................
...........,..............................................................................................................................................................
Cara Kedatangan : Datang sendiri Polisi Rujukan dari:....................................
Kendaraan : Ambulance .............................
Identitas Pengantar : Nama :.. ............................................. No. Telpon..............................................................................
Kasus : Trauma Non trauma Kejadian Tanggal :...................................................................
MEKANISME TRAUMA
KLL Tunggal................................. Tempat Kejadian:............................................ Tanggal:.................. Pukul:.....................
KLL.......................vs..................... Tempat Kejadian:............................................ Tanggal:.................. Pukul:.....................
Jatuh dari ketinggian : Jelaskan........................................................................................................................................
.....................................................................................................................................................
Luka bakar : Jelaskan........................................................................................................................................
.....................................................................................................................................................
Trauma Listrik : Jelaskan........................................................................................................................................
.....................................................................................................................................................
Trauma zat kimia : Jelaskan........................................................................................................................................
.....................................................................................................................................................
Trauma lainnya : Jelaskan........................................................................................................................................
.....................................................................................................................................................
KELUHAN UTAMA

LEVEL TRIASE (PATIENT'S ACUITY CATEGORIZATION SCALE/PACS

1. PACS 1 2. PACS 2 3. PACS 3 4. PACS 4
TANDA VITAL
GCS: E.....V.....M..... Pupil :.........mm/.......mm/ Reflex cahaya:........../..........
Kesadaran Sadar penuh Respon suara Respon Nyeri Tidak aa respon
Tekanan darah : .......... mmHg Pernafasan :..........x/menit Saturasi O2:.............................. %
Nadi : ......... x/menit Suhu :..........C Nyeri :...............................
Status alergi : Tidak Ada sebutkan...........................................................................................................................
Gangguan : Tidak terganggu Ada gangguan Tidak membahayakan
Perilaku
Gangguan
Perilaku Membahayakan diri sendiri/orang lain
(Bila ada, lakukan pengkajian restrain
ANTROPOMETRI
Berat badan :............. Tinggi badan :......................... Lingkar kepala :.............. Lingkar lengan Atas :...............................
WORTHING PHYSIOLOGICAL SCORING SYSTEM (WPSS)
TANA VITAL SCOR 0 SCOR 1 SCOR 2 SCOR 3
KESADARAN Sadar penuh Selain sadar penuh
TEKANAN ARAH SISTOLIK ≥ 100 ≤99
NADI ≤ 101 ≥102
PERNAFASAN ≤ 19 20-21 ≥22
SUHU ≥35,5 < 35,3
SATURASI O2 96-100 94-95 92-93 < 92
TOTAL ≥5 2-4 0-1
Keputusan:................................ PETUGAS TRIASE
RESPON TIME
Pukul :................................
Ruang resusitasi Segera (0 menit)
Ruang non resisutasi 10 menit
Klinik Umum 24 Jam 30-60 menit (.................................................)
DOA (Death On Arrival)