PEMERINTAH KABUPATEN LAHAT

RUMAH SAKIT UMUM DAERAH LAHAT

Jl Letjen Harun Sohar I No 28 Lahat, Kode Pos 31414, Provinsi Sumatera Selatan
Telp/ Fax.(0731) 321785/323080, Email : rsud_lahat@yahoo.co.id

RM. 76. A
FORM OBSERVASI PASIEN SELAMA PERJALANAN RUJUKAN PASIEN

Nama Pasien : ...........................................................................

Tanggal lahir : ...........................................................................
Jenis Kelamin : ...........................................................................
No RM : ...........................................................................
Asal Ruangan : ...........................................................................
Diagnosa : ...........................................................................
Dokter yang merujuk : ...........................................................................
Rumah Sakit Rujukan yang dituju : ...........................................................................
Sarana tranportasi yang merujuk : ...........................................................................
Instruksi Penanganan pasien :
Selama rujukan

1. Pemasangan IVFD.................................................................................................................
2. ................................................................................................................................................
3. ................................................................................................................................................
4. ................................................................................................................................................
5. ................................................................................................................................................
6. ................................................................................................................................................
7. ................................................................................................................................................
8. ................................................................................................................................................
9. ................................................................................................................................................
10. ................................................................................................................................................

Bila terjadi kegawatan hubungi Dokter DPJP dengan No Hp : ..........................................................

Perawat Pendamping : ...........................................................................
Sopir ambulance : ............................................................................
Jam Berangkat : ............................................................................
Jam Tiba di RS Rujukan : ............................................................................

Ket :
 Lembar observasi di halaman belakang
 Setelah pasien selesai dirujuk maka form ini dilampirkan pada buku status pasien

Jam: .......... Lahat ,..............20....

Dokter yang merujuk

( )
 PEMERINTAH KABUPATEN LAHAT
RUMAH SAKIT UMUM DAERAH LAHAT
Jl Letjen Harun Sohar I No 28 Lahat, Kode Pos 31414, Provinsi Sumatera Selatan
Telp/ Fax.(0731) 321785/323080, Email : rsud_lahat@yahoo.co.id

LIST CONTROL
RM. 76. B

Nama Pasien : Asal Ruangan :

Umur : Dokter yang merujuk :
No RM : Diagnosa :

Tgl/jam Sens Tensi Temp Pols Resp Intake Output IVFD/ Obat- Keterangan
obatan