 24 Hours Medical Emergency

 On Call/Home Visit Service

 Vaccination & IV Hangover Cure
 Pharmacy & Laboratory
 Medical Evacuation
 Insurance Service
 Guarantee Medical Bill

BOAT ASSESMENT FORM

PATIENT DETAILS

NAME DATE OF ASSESMENT

NATIONALITY AGE / DOB
DIAGNOSE PASSPORT NO

ESCORT DETAILS

NAME OF ESCORT DOCTOR

NAME OF ESCORT NURSE
PATIENT COMPANION 1
2
3
FROM / HOSPITAL TO / HOSPITAL

BRIEF DESCRIPTION OF MEDICAL PROBLEM

VITAL SIGN BP: / PULSE: TEMP: RESP:

PRESENT COMPLAINT

PAST MEDICAL HISTORY

ALLERGIES
CURRENT MEDICATION DOSE CURRENT MEDICATION DOSE

PHYSICAL EXAMINATION
NEUROLOGICAL DEFICIT

HEART SOUND

CHEST

ABDOMEN

Head Office : Jl. Raden Mas Panji Anom Perumahan Graha Pagutan, Block B, No. 08, Pagutan, Mataram, NTB. 83117
Clinic Branch : Gili Trawangan, Gili Air, East Lombok
E-mail : bsmedicalgroup@gmail.com
Helpline : +6282340816911
  24 Hours Medical Emergency
 On Call/Home Visit Service
 Vaccination & IV Hangover Cure
 Pharmacy & Laboratory
 Medical Evacuation
 Insurance Service
 Guarantee Medical Bill

LIMBS

PATIENT MONITORING RECORD

VITAL SIGN
TIME
02 Sat
PULSE =* 220
BP= vΔ 200
RR= x 160
T=o 140
120
100
80
60
40
20

MEDICATION RECORD
TIME MEDICATION DOSE

IV INFUSION
DRUGS TIME /RATE TIME / RATE TIME / RATE TOTAL

ORAL / NGT INTAKE ORAL / NGT OUTPUT

TIME LIQUIDS TOTAL TIME BLOOD URINE VOMIT TOTAL

Head Office : Jl. Raden Mas Panji Anom Perumahan Graha Pagutan, Block B, No. 08, Pagutan, Mataram, NTB. 83117
Clinic Branch : Gili Trawangan, Gili Air, East Lombok
E-mail : bsmedicalgroup@gmail.com
Helpline : +6282340816911
  24 Hours Medical Emergency
 On Call/Home Visit Service
 Vaccination & IV Hangover Cure
 Pharmacy & Laboratory
 Medical Evacuation
 Insurance Service
 Guarantee Medical Bill

CLINIC NOTES

DATE CLINIC NOTES

PLACE OF HANDOVER :  HARBOUR  HOSPITAL

CURRENT CONDITION WHEN HANDOVER : __________________________________________________

___________________________________________________

DATE (DD/MM/YY) : ______/______/______ TIME : _______________________________________

ESCORT DOCTOR RECEIVING DOCTOR

NAME : ________________________________ NAME : __________________________

SIGNATURE : _____________________________ SIGNATURE : _____________________

Head Office : Jl. Raden Mas Panji Anom Perumahan Graha Pagutan, Block B, No. 08, Pagutan, Mataram, NTB. 83117
Clinic Branch : Gili Trawangan, Gili Air, East Lombok
E-mail : bsmedicalgroup@gmail.com
Helpline : +6282340816911
  24 Hours Medical Emergency
 On Call/Home Visit Service
 Vaccination & IV Hangover Cure
 Pharmacy & Laboratory
 Medical Evacuation
 Insurance Service
 Guarantee Medical Bill

MEDICAL EVACUATION REPORT

NAME OF PATIENT : ______________________________________ ___SEX : MALE / FEMALE

EVACUATION FROM : _________________________________TO ____________________________

MEDICAL ESCORT TEAM

DOCTOR : ________________________________ NURSE : ________________________

INFLIGHT MONITORING EQUIPMENT

(please tick)
DEFIBRILATOR OXYGEN BOTTLE
PULSE OXYMETER VENTILATOR
SPLINTS INTUBATION SET
URINARY CATHETER SYRINGE PUMP
IV LINES PATIENT MONITOR
NG TUBE DIAGNOSE SET

PROBLEM WITH MEDEVAC PREPARATIONS : _________________________________________________

_____________________________________________________________________________________

PROBLEM WITH MEDICAL EQUIPMENT :  YES  NO ( if yes please specify ) ____________

_____________________________________________________________________________________

EQUIPMENT / MEDICATION YOU DID NOT HAVE, BUT WOULD HAVE HELPED ? _____________________

_____________________________________________________________________________________

COMMENTS, SUGENSTION ? _____________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Head Office : Jl. Raden Mas Panji Anom Perumahan Graha Pagutan, Block B, No. 08, Pagutan, Mataram, NTB. 83117
Clinic Branch : Gili Trawangan, Gili Air, East Lombok
E-mail : bsmedicalgroup@gmail.com
Helpline : +6282340816911