RUMAH SAKIT UMUM DAERAH PAKUHAJI KABUPATEN TANGERANG

Jl. KH. Saadullah No. 88 Kec. Pakuhaji Kab. Tangerang

Email: rsud_pakuhaji@gmail.com

MONITORING PASIEN DI AMBULANCE

NOMOR : TANGGAL : ________________________________
STATUS KEDARURATAN JAM-JAM :
 Merah Petugas ambulans : Kejadian : ________________________________
 Kuning Sopir/Satpam: _______________________________________ Panggilan : ________________________________
 Hijau Tim Medis : 1. ______________________________________ Berangkat : ________________________________
__
 Hitam 2. ______________________________________ Tiba di TKP : ________________________________
__
Tiba di RS : ________________________________
JENIS KASUS :
 Trauma Jemput di : ___________________________________________
 Non Trauma Rujuk ke : ___________________________________________

DATA PASIEN (NO RM: __________________________________________________ ) Tgl lahir/Umur : ____________________ thn/bln

Nama Pasien : _____________________________________________________ (L/P)
Alamat : ____________________________________________________________________________________________________________________________
Anamnesa : ____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Status Lokalis (Bila Ada) : ___________________________________________________________________________________________________________________________
Riwayat Penyakit Dahulu : ____________________________________________________________________________________________________________________________
Alergi obat : ____________________________________________________________________________________________________________________________

Observasi Tanda-tanda Vital

Jam
Kesadara Tensi SpO2 Temp
observas Nadi (x/m) RR (x/m) Skala Nyeri TINDAKAN / TERAPI
n (mmHg) (%) (0C)
i

PETUGAS/ TIM MEDIS

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