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  • 7.5.3.1. Form-Monitoring-Selama-Rujukan (DR Adis)

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    7.5.3.1. Form-Monitoring-Selama-Rujukan (dr adis)

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    4 views1 page

    7.5.3.1. Form-Monitoring-Selama-Rujukan (DR Adis)

    Uploaded by

    Novari Setiawan

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    © All Rights Reserved
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    of 1

    PEMERINTAH KABUPATEN PASER

    DINAS KESEHATAN
    UPTD PUSKESMAS SULILIRAN BARU
    Jl. Nusa Indah Telp. 0543-2705381 Suliliran Baru
    Paser Belengkong 76271
    Email : puskesmassuliliranbaru@yahoo.com

    FORM MONITORING STATUS PASIEN SELAMA


    RUJUKAN

    Nama : No RM :
    Jenis Kelamin :[ ] Laki-laki [ ] Perempuan
    Umur :
    Alamat :

    PERKEMBANGAN PASIEN
    KONDISI AWAL KONDISI DALAM KONDISI DI
    PERJALANAN TEMPAT RUJUKAN
    - Airway
    - Breathing
    RR
    - Circulation
     TD
     Nadi
     SaO2
    - GCS E: V: M: E: V: M: E: V: M:

    KONDISI SPESIFIK
    KONDISI KLINIS TINDAKAN / TERAPI

    Mengetahui, Suliliran Baru,

    …………………………… …………………………
    (Perawat Penerima) (Perawat Perujuk)

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