FORM HAND OVER

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PAGI Pemberi Operan Penerima Operan

Situation............................................................................................... (.........................) (.........................)

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Situation................................................................................................
Background
Dx/Medis....................................................................... DPJP :........ ................................................................................................................

Background
Asesmen.............................................................................................. Dx/Medis....................................................................... DPJP :..........
Kesadaran GCS............
:.................................................................. Asesmen................................................................................................
Tanda Vital : *D mmHg : HR ......................X/mnt Kesadaran GCS..............
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Suhu :....................⁰C ; H R ........... X/mnt ; Nyeri* ......................... Tanda Vital : *D mmHg : HR ......................X/mnt
Oksigen :.....................X/mnt ; Infus :......................................tts/mnt; ...........................
Transfusi :............................tts/mnt ; Kateter : Y / T ; NGT : Y / T Suhu :....................⁰C ; H R ........... X/mnt ; Nyeri* ............................
Makan/Minum : Oksigen :.....................X/mnt ; Infus :......................................tts/mnt;
Toileting : Transfusi :............................tts/mnt ; Kateter : Y / T ; NGT : Y / T
Aktifitas/Gerak : Makan/Minum :
Skor Jatuh : Toileting :
Aktifitas/Gerak :
Recomendation.......................................................................................... Skor Jatuh :
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Pemberi Operan
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Recomendation.......................................................................................
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