RSUD KABUPATEN JOMBANG

Nama :
Jl. KH. Wahid Hasyim No. 52 Jombang Kode Pos : 61411
Tgl. Lahir : Umur :
TELP. (0321) 865716 - 863502 FAX. (0321) 879316
Jenis Kelamin :  Laki-laki  Perempuan
Alamat :
ASSESMENT PRA HOSPITAL
Tanggal : Jam Telepon : Jam Tiba di TKP : Jam Evakuasi :

Jenis Kasus :  Trauma  Non Trauma  Obstetri  Psikiatri  Kasus Polisi

Tanggal & Jam Kejadian : Tempat Kejadian :

KELUHAN UTAMA :

Airway Breathing Circulation Disability Exposure

PRIMARY SURVEY

 Clear  Spontan CRT : detik  Alert  Active Bleeding

 Gargling  Apneu Acral :  Kering  Verbal respon  Deformitas

 Snooring  Dyspneu  Hangat  Pain respon Skin :  Pucat

 Stridor  Tachypneu  Dingin  Unrespon  Dingin

 Retraksi  Basah Pupil : /  Cyanosis

RR : Nadi : RC : /  Mottled

Nadi : RR : SpO2 : Tensi : Suhu : GDA :

SECONDARY SURVEY

Sign & Symptoms :

Allergies :

Medications :

Past Illness :

Last Meal : Jam : Jenis :

Event :

STATUS LOKALIS :
(DCAP-BLS)
 WORKING DIAGNOSE

INITIAL TREATMENT (Directed by Medical Director)

MONITORING
Skala
Jam Nadi RR SpO2 Tensi Suhu GCS Output Keterangan
Nyeri

Crew Ambulance Medical Director Triage Officer

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