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  • Format Handover

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    Ridwan Iwan
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    This document is a handover form for an ICU patient containing information to be transferred between shifts. It includes the patient's name, age, diagnosis, history, current condition including vital signs, treatments administered, procedures, assessments, diet, consultations and any additional notes. The form is designed to be filled out by the responsible staff for each shift to ensure continuity of care.

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    form ICU

    Original Title

    FORMAT HANDOVER

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    This document is a handover form for an ICU patient containing information to be transferred between shifts. It includes the patient's name, age, diagnosis, history, current condition including vital signs, treatments administered, procedures, assessments, diet, consultations and any additional notes. The form is designed to be filled out by the responsible staff for each shift to ensure continuity of care.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    10 views2 pages

    Format Handover

    Uploaded by

    Ridwan Iwan
    This document is a handover form for an ICU patient containing information to be transferred between shifts. It includes the patient's name, age, diagnosis, history, current condition including vital signs, treatments administered, procedures, assessments, diet, consultations and any additional notes. The form is designed to be filled out by the responsible staff for each shift to ensure continuity of care.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    of 2

    HAND OVER/ TIMBANG TERIMA RUANGAN ICU

    BED : / HARI RAWAT :


    SHIFT PAGI SHIFT SORE SHIFT MALAM
    HARI/ TANGGAL : TGL MASUK :

    NAMA PASIEN : KELAS/ JAMINAN :

    TGL LAHIR/ UMUR : DPJP :

    NOMOR RM : DOKTER KERJASAMA : DR.SATRIAWAN Sp.PD-KIC

    RIWAYAT : RIWAYAT :
    RIWAYAT :
    KEL.MASUK : KEL.MASUK : KEL.MASUK :

    KEL.SEKARANG: KEL.SEKARANG:
    KEL.SEKARANG:

    SITUASI :TINGKAT KESADARAN : E: V: M: GCS : SITUASI :TINGKAT KESADARAN : E: V: M: GCS : SITUASI :TINGKAT KESADARAN : E: V: M: GCS :
    O2 : PAKAI TGL: STOP TGL: O2 : PAKAI TGL: STOP TGL: O2 : PAKAI TGL: STOP TGL:

    IVFD : BOTOL KE : GANTI JAM : IVFD : BOTOL KE : GANTI JAM :


    IVFD : BOTOL KE : GANTI JAM :
    IVFD : BOTOL KE : GANTI JAM : IVFD : BOTOL KE : GANTI JAM :
    IVFD : BOTOL KE : GANTI JAM :

    IV.CATHETER : HARI : TGL.PASANG :


    IV.CATHETER : HARI - TGL.PASANG : IV.CATHETER : HARI - TGL.PASANG :
    IV.CATHETER : HARI : TGL.PASANG :
    IV.CATHETER : HARI : TGL.PASANG : IV.CATHETER : HARI - TGL.PASANG :
    NGT : HARI : FIKSASI : TGL.PASANG : NGT : HARI : FIKSASI : TGL.PASANG :
    NGT : HARI : FIKSASI : TGL.PASANG :
    KATETER : HARI : TGL.PASANG : KATETER : HARI - TGL.PASANG : KATETER : HARI - TGL.PASANG :

    BAB : URINE: IWL: RESIDU : DRAIN:


    BAB : URINE: IWL: RESIDU : DRAIN: BAB : URINE: IWL: RESIDU : DRAIN:

    BUNYI NAPAS : DECUBITUS : IN: OT: BC: BUNYI NAPAS : DECUBITUS : IN: OT: BC: BUNYI NAPAS : DECUBITUS : IN: OT: BC:
    ASSESMEN : ASSESMEN :
    ASSESMEN :

    DIET : DIET : DIET :

    RO : RO :
    RO :

    LAB : LAB : LAB :

    KONSUL : KONSUL :
    KONSUL :

    CATATAN TAMBAHAN : CATATAN TAMBAHAN : CATATAN TAMBAHAN :

    TANDA TANDA VITAL: BP: HR RR T SPO2


    TANDA TANDA VITAL: BP: HR RR T SPO2 TANDA TANDA VITAL: BP: HR RR T SPO2

    PP PAGI PP SORE PP SORE PP MALAM PP MALAM PP PAGI

    TANDA TANGAN PENANGGUNG JAWAB

    KETUA TIM KETUA TIM KETUA TIM

    MENGETAHUI KEPALA RUANGAN ICU


    KAMRIANI KAHAR,S.KEP.NS

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