TRIAGE

GOVERNMENT OF THE CITY OF BOGOR  RED

No. RM : ___________________
Name : ___________________
BOGOR CITY PUBLIC HOSPITAL  YELLOW Sex : ___________________
Dr. Sumeru. 120 Ph. (0251) 8312292  GREEN Date of birth : ___________________
Fax. 8371001 BOGOR – 16111  BLACK ( Please fill in or attach a sticker if you have one )

Patient Address (As per ID)

ID Number :
Address :

Religion Rate Nation Police case

Marital status Type of payment Education Profession

How to Come Transportation to the ER Communication

Instructions put a mark (V) in the column that you think is appropriate to the patient's condition
Date : ................................ Time : ................................

I.TRIAGE FILLED BY THE DOCTOR

Main complaint

GCS : E :.......... V :........ M :....... TD : ......./....... mmHg

Pupil :..........mm/.......... mm Temperature .......... C
Vital sign Light reflex : ………./………. SpO2 ……... %
Pulse ......x/ min regular/iregular
Exhalation ..........x/min

Allergy Status No Yes, Mention :

Not distrubed There is a distraction

Behavioral Disorders
Not dangerous Endanger themselves / others

TRIAGE SCALE INFORMATION TIME RESPONSE

SCALE 1 Emergency Immediately ( 0 minute )

SCALE 2 Potential Emergency Non
10 minute
SCALE 3 Emergency
30 minute- 60 minute

Doctor's name and signature

II. NURSING ASSESSMENT (COMPLETED BY THE NURSE)

1. Information obtained from  Auto-Anamnesa  Nama :
 Hetero-Anamnesa  Hubungan :
2. How to enter  Walk without assistance  Wheel chair
 Walk with help  Push bed
3. Originally entered  Non Reference  Reference
4. Current Disease History
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Weight Height ____________________________________________________________________

Kg Cm ____________________________________________________________________
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4. Past medical history ________________________________________________________________________

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5. Previous medical history ________________________________________________________________________

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Pain Scale
PAIN INTENSITY “WONG BAKER FACES PAIN RANTING SCALE” AND
“NUMERIC RATING SCALE” (NRS)
FOR CHILDREN> 6 YEARS OLD AND ADULT

No Pain Mild Pain Moderate Pain Severe Pain

FLACC scale for children 6 years

Assessment 0 1 2 Score
Face  Smile / no special expression  Sometimes grimacing / pulling away  Often shakes chin and
clenched jaw
Feet  Normal movement /  Not calm / tense  Foot kicking / pulling
Activities relaxation  Movement of
 Sleep, normal position, easy to wriggling, rolling, stiff  Back / leg arches / stomps
Cry move
 Don't cry (wake up / sleep)  Moaning, whining  Continuous crying, sobbing,
Voiced  Normal voice, calm screaming
 Calm down when tapped to be  It's hard to be blissful
carried / spoken to
TOTAL SCORE
0 = Comfortable 4-6 = Moderate pain
SCALE :
1-3 = Less comfortable 7-10 = Severe pain
Assessment of functions: daily activities Independent With the help of
Assessment of the risk of falling patients:
* Has it fallen in the last 3 months? □ Yes □ No
* Do you use tools? (walker, cane etc.) □ Yes □ No
* Are you having trouble walking □ Yes □ No
If one of the answers is "yes" then perform the patient risk interval interval below:
1. Install safety railings and lock the bed wheels
2. Patient prevention education for the risk of falling
3. Put the fall risk clip sign on the patient identification bracelet (for inpatients)

Decubitus risk assessment

* Is the patient in a wheelchair or in need of assistance? □ Yes □ No
* Is there urinary or alvi incontinence? □ Yes □ No
* Is there a history of decubitus or pressure sores? □ Yes □ No
* Is the patient over 65 years □ Yes □ No
Children only
* Are the extremities and body not developmentally appropriate? □ Yes □ No
If one of the answers is "yes" then conduct education on prevention of decubitus

IGD PONEK: (filled by the midwife)

GPA : ................. AUSCULTATION : .................
HPHT : ................. BJF / DJJ : .................
INSPECTION : ................. VT : .................
PALPATION : .................

________________________
Midwife's name and signature

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III. MEDICAL ASSESSMENT

Doctor's Examination, At:

Subjective :

Objective :
Front Rght side Left side Back
Image code:
A : Abrasi U : Ulkus
C : Combutsio H : Hematoma
VA : Vulnus appertum L : Others (give information)
D : Deformitas N : Pain
SUPPORTING INVESTIGATION
 EKG : ________________________________________________________________
 RADIOLOGY : ________________________________________________________________
 LABORATORY : ________________________________________________________________

ASSESMENT
 WORK DIAGNOSIS : _______________________________________________________________
 APPEAL DIAGNOSIS : _______________________________________________________________

PLANNING: MANAGEMENT / TREATMENT / ACTION PLAN / CONSULTATION

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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IV. NURSING / MIDWIFERY PROBLEMS EVALUATION (S O A P)

 Loss of consciousness
 Seizures
 Ineffective airway clearance
 Crowded
 Pain
 Fluid volume disturbance: More / less
 Impaired skin integrity
 Discontinuity of bone tissue
 Increase in body temperature



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V.GIVING MEDICINES / INFUSES
Patient /
Date / Nurse's
Drug / Liquid Name Dosage / drops per minute The checking nurse family
Time signature
signature

V. ACTION
Date / Nurse's
ACTION
Time signature

VII. PATIENT CONDITIONS WHEN MOVING / GETTING HOME FROM ER

Check Hours: GCS : E :..........V :..........M :.......... TD :........../..........mmHg Pulse..........x/minute
Temperature .......... C Breathing : ..........x/minute regular/iregular
SpO2 : ..........%
 Enter the Hospital, in the room : The receiving officer :
 Follow up on :  Koperating  Cath-Lab  Birthing room  OPD Specialist  Hemodialisa
room
 Referred to the : -----------------------------------------------
hospital
 Returned at : -----------------------  Died at : -------------------------------------
Return transportation  Kprivate vehicle  Ambulance  The hearse
Home patient education:  Eat / take medication regularly  Keep the wound clean
 Diet  Etc
 Primary Diagnosis  ICD :
Doctor's name / signature Nurse's Name / Signature

VIII. FOLLOW UP
Nurse's Name / Signature
 No  Yes, date

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