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  • Form Handover 26 April 2018

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    Hendra limbong
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    Form Handover 26 April 2018 (2).docx

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    4 views2 pages

    Form Handover 26 April 2018

    Uploaded by

    Hendra limbong

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Nama :………………………………………………….

    Ruangan :………………………………….. Tgllahir :……………………………………………………


    Hari/ Tanggal :…………………………………. RM……
    No RM :…………………………………………………..

    PAGI SORE MALAM


    Situation……………………………………………………………… Situation……………………………………………………………… Situation………………………………………………………………

    ……………………………………………………………………………… ……………………………………………………………………………… ………………………………………………………………………………

    Background Background Background


    Dx/ Medis………………………DPJP:…………………… Dx/ Medis………………………DPJP:…………………… Dx/ Medis………………………DPJP:……………………

    Asesmen……………………………………………………… Asesmen……………………………………………………… Asesmen………………………………………………………


    Kesadaran :………………………..GCS…………………… Kesadaran :………………………..GCS…………………… Kesadaran :………………………..GCS……………………
    TandaVital : TD =………mmHg; HR =…….. X/mnt TandaVital : TD =………mmHg; HR =…….. X/mnt TandaVital : TD =………mmHg; HR =…….. X/mnt
    Suhu:……..°C; RR =…………X/mnt; Nyeri=…………. Suhu:……..°C; RR =…………X/mnt; Nyeri=…………. Suhu:……..°C; RR =…………X/mnt; Nyeri=………….
    Oksigen:………L/mnt; Infus : ……………tts/ mnt; Oksigen:………L/mnt; Infus : ……………tts/ mnt; Oksigen:………L/mnt; Infus : ……………tts/ mnt;
    Tranfusi:…… tts/mnt; Kateter: Y / T; NGT: Y / T Tranfusi:…… tts/mnt; Kateter: Y / T; NGT: Y / T Tranfusi:…… tts/mnt; Kateter: Y / T; NGT: Y / T
    Makan/minum: Makan/minum: Makan/minum:
    Toileting: Toileting: Toileting:
    Aktifitas/ Gerak: Aktifitas/ Gerak: Aktifitas/ Gerak:
    SkoreJatuh: SkoreJatuh: SkoreJatuh:
    Recomendation………………………………………….…… Recomendation………………………………………….…… Recomendation………………………………………….……
    ……………………………………………………………………….. ……………………………………………………………………….. ………………………………………………………………………..
    ……………………………………………………………………….. ……………………………………………………………………….. ………………………………………………………………………..
    ……………………………………………………………………….. ……………………………………………………………………….. ………………………………………………………………………..
    PemberiOperanPenerimaOperan PemberiOperanPenerimaOperan PemberiOperanPenerimaOperan

    (………………………) (…………………………) (………………………) (…………………………) (………………………) (…………………………)


    Nama :………………………………………………….
    Ruangan :………………………………….. Tgllahir :……………………………………………………
    Hari/ Tanggal :…………………………………. RM……
    No RM :…………………………………………………..

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