TANGGAL PENYERAHAN :....................................................................................

PETUGAS PENERIMA :....................................................................................

KODE SEGEL :....................................................................................
DIVISI :....................................................................................

EMERGENCY TROLLEY UMUM

EXPIRED
NO NAMA BRAND UKURAN SATUAN JUMLAH DATE
A AIRWAY
1/60 mm PCS 1
2/70 mm PCS 1
Oropharengeal Air
1 3/80 mm PCS 1
way / Guedel
4/90 mm PCS 1
5/100 mm PCS 1
5,5 cuff PCS 1
3 cuff PCS 1
3,5cuff PCS 1
4 cuff PCS 1

Endotracheal Tub 4,5 cuff PCS 1

2
e (ETT) 5 cuff PCS 1
6 cuff PCS 1
7 cuff PCS 1
7,5 cuff PCS 1

B BREATHING
Bag valve mask de
PCS 1
1 wasa (AMBU bag) ADULT
Oxygen Nasal Can
PCS 1
2 ul Dewasa ADULT
Rebreathing Mask
PCS 1
3 Dewasa ADULT
Non Rebreathing
PCS 1
4 Mask Dewasa ADULT
C CIRCULATION
Transfusion Set De
PCS 1
1 wasa -
Infusion Set Dewa 20 TETES/M
PCS 1
2 sa L
3 Folley Catether No 8 PCS 1

16 PCS 1
18 PCS 1
4 Abbocath
20 PCS 1
22 PCS 1
24 PCS 1

Ringer Laktat 500ML Flabot 1

5
 Threeway PCS 1
6

Dextrose 5 % 5% (500ML) Flabot 1

7
10% (500M
Dextrose 10 % Flabot 1
8 L)

Dextrose 40% 25
40% (25ML) Flabot 1
9 ML
0,9% (500M
NaCl 0,9% Flabot 1
10 L)
11 MGSO4 20% 20% (25 ml) Flabot 1
3 ML PCS 1
12 Spuit 5 ML PCS 1
10 ML PCS 1

D DRUG

1 Aminofilin 24MG/ML ampul 2

2 Dexamethason 5MG/ML ampul 2

Diazepam inj 10 m
10MG/2ML ampul 1
3 g/2 ml
4 Epinefrin 50MG/ML ampul 2

5 Atropin Sulfat 0,25MG/ML ampul 2

6 FUROSEMID 10MG/ML ampul 2

7 WFI 25ML ampul 2

8 Lidocain 20MG/ML ampul 2

9 ISDN 5 mg tablet 5

10 Ketorolac 30 mg/ml Injeksi 2

11 Clopidrogel 75mg Tablet 5

12 Diphenhidramine 10mg/ml Ampul 2

:...................................... ......................
PETUGAS YANG MEMBUKA SEGEL . PARAF: .
:......................................
TANGGAL BUKA SEGEL .
:......................................
JAM BUKA SEGEL .
:......................................
JAM KONFIRMASI KE FARMASI .