RS.

Kasih Kita
Jalan Kupu Kupu No 01
FORMULIR TRANSFER PASIEN
Nama pasien : ………………………………………………………………………Jenis kelamin : L/P NO. Rekam Medis : .....................................

Tanggal lahir : ……………….…………………………………. Tanggal masuk : ……………….…………………………………………………..................

DPJP : ……………….…………………………………. Ruang/kamar : ……………….…………………………………………………..................

Dokter konsulen 1 : ……………….…………………………………. Tanggal/jam pindah : ……………….…………………………………………………..................

Dokter konsulen 2 : ……………….…………………………………. Pindah ke ruang/kamar : ……………….…………………………………………………..................

Diagnosis masuk : ……………….…………………………………. Indikasi dirawat : ……………….…………………………………………………..................

I. RINGKASAN RIWAYAT PASIEN

Anamnesis
Keluhan utama : ..............................................................................................................................................................................................

..............................................................................................................................................................................................

Riwayat penyakit : ..............................................................................................................................................................................................

..............................................................................................................................................................................................

Riwayat Alergi : ..............................................................................................................................................................................................

Pemeriksaan fisik : ..............................................................................................................................................................................................

Pemeriksaan tanda-tanda vital : Tensi : ................mmHg Suhu : ......................... ⁰c Nadi :...........................x/mnt

Keadaan umum : ..............................................................................................................................................................................................

..............................................................................................................................................................................................
..............................................................................................................................................................................................
Alasan transfer : ..............................................................................................................................................................................................

II. PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN

……………………………………………………………………………………………………………………………………………………………………………………………........................................
……………………………………………………………………………………………………………………………………………………………………………………………........................................
……………………………………………………………………………………………………………………………………………………………………………………………........................................
……………………………………………………………………………………………………………………………………………………………………………………………........................................
……………………………………………………………………………………………………………………………………………………………………………………………........................................
……………………………………………………………………………………………………………………………………………………………………………………………........................................
……………………………………………………………………………………………………………………………………………………………………………………………........................................

III. TINDAKAN MEDIS YANG SUDAH DILAKUKAN

……………………………………………………………………………………………………………………………………………………………………………………………........................................

……………………………………………………………………………………………………………………………………………………………………………………………........................................

IV. PEMBERIAN THERAPI

Infus : ……………………………………………………………………………………………………………………………………………………………………….............................................
……………………………………………………………………………………………………………………………………………………………………………………………........................................
……………………………………………………………………………………………………………………………………………………………………………………………........................................
Obat injeksi :
1. ……………………………….. Jam : ..................... 4. …………………………………………………
Jam : .....................
2. …………………………………… Jam : ..................... 5. …………………………………………………
Jam : .....................
3. …………………………...… Jam : ..................... 7. …………………………………………………
Jam : .....................

Obat oral :
1. ……………………………….. Jam : ..................... 5. …………………………………………………
Jam : .....................
2. …………………………………… Jam : ..................... 6. …………………………………………………
Jam : .....................
3. …………………………...… Jam : ..................... 7. …………………………………………………
Jam : .....................
4. …………………………...… Jam : ..................... 8. …………………………………………………
Jam : .....................
V. LAIN-LAIN
……………………………………………………………………………………………………………………………………………………………………………………………........................................
……………………………………………………………………………………………………………………………………………………………………………………………........................................

Dokter UGD / DPJP Pemberi Keputusan

 .......................................................................................
KATEGORI PASIEN TRANSFER
NO Derajat Pasien Nama petugas pendamping :
1 Derajat 0

2 Derajat 1

3 Derajat 2

4 Derajat 3

V. KONDISI PASIEN

Sebelum Transfer Jam : Setelah Transfer Jam :

Keadaan umum : ………………………………………… Keadaan umum : …………………………………………...............
Kesadaran : ……………….………………… Kesadaran : …………………………………………...............
Pemeriksaan tanda-tanda vital : Pemeriksaan tanda-tanda vital :
Tensi : MmHg Tensi : MmHg
Suhu : ⁰C Suhu : ⁰C
Nadi : x/mnt Nadi : x/mnt
Catatan penting : ................................................... Catatan penting : ...................................................
................................................... ...................................................
................................................... ...................................................
.................................................. ..................................................
Petugas Medis yang menyerahkan Petugas Medis Penerima Pasien

( .............................................................................................. ) ( ................................................................................. )