Professional Documents
Culture Documents
Nomor RM : ...................................................................
CATATAN MEDIS Nama Lengkap : ...................................................................
Tanggal Lahir : ...................................................................
GAWAT DARURAT Jenis Kelamin : ...................................................................
BB/TB : ...................................................................
1. Formulir ini khusus untuk dokter di Unit Gawat Darurat Rumah Almah
2. Beri tanda () pada kotak yang tersedia sesuai dengan hasil pemeriksaan
Tanggal/ Jam Datang
1. TRIAGE
Merah Kuning Hijau Hitam
Prioritas Triage :
Trauma Non trauma
Sendiri Diantar :............................. DOA
Cara pasien datang :
Ambulans
2. PEMERIKSAAN DOKTER
A. Data Subyektif : Auto Anamnesa Allo Anamnesa
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B. Data Obyektif
Keadaan Umum : Baik Sedang Buruk
Kesadaran : CM Apatis Koma
GDS : Soporocoma coma
Status psikologis : E .................... M .................. V ......................
Marah Cemas Gelisah Tidak ada masalah
Takut Depresi Kecenderungan bunuh diri Lain-lain
Nilai nyeri : (Tidak ada nyeri – nyeri sangat berat)
Lokasi :
Durasi :
*)Lingkari angka yang sesuai dengan keluhan pasien
3. Tanda Vital
Tekanan darah .................... mmHg Suhu : .........................oC
Pernafasan .................... x/mnt Saturasi O2 : ......................... %
Nadi .................... x/mnt Berat badan : ......................... Kg
RUMAH SAKIT ALMAH
Jln. Jendral Sudirman, Kec. Tanjung Pandan, Kab. Belitung
ProvinsiKepulauan Bangka Belitung, Indonesia
E-mail : almah.belitung@gmail.com
Telpon: (0719) 9225 666 Fax : (0719) 9225 333 Phone: 087 797 500005
4. PEMERIKSAAN AWAL
Pupil : Isokor/Anisokor Reflek Cahaya : ............/...........
Airway & C-Spine Breathing Circulation Disability Eksposure: Prehospital
Bersih Normal Pallor GCS: Perdarahan RJP
Slem sumbatan Whezzing Mottling Eye Fraktur Intubasi
Partial Ronchi Cyanosis Movement Parase O2
Sumbatan Total Retraction Capilary Reflek Plegi Ecollar
Lain-lain Nasal Flaring Refill Motorik Paraperesis Balut/Bi
Abnormal Verbal Obat
Position
5. PEMERIKSAAN FISIK Gambar tubuh
Bagian Tubuh Normal Jika Tidak Normal
Jelaskan
Kepala
Mata
THT
Leher
Dada
Jantung
Paru
Abdomen
Eksremitas Luka/lesi
Anus-genetalia Pendarahan
Diagnosis kerja (ICD X) : Diagnosis invasif :
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6. PENATALAKSANAAN
Oksigen
- Saturasi .............. %
- Oksigen : Kanul NRM RM Simple Mask
- Flow : ............ Liter/menit
Infus
Cairan infus Infus Infus Pump Syringe Pump
7. PENATALAKSANAAN LAIN
Kompres : Hangat Dingin
Lokasi :.............................................. Waktu : ..................................................................
NGT : Dilakukan Tidak
Ukuran :...................... Produksi cairan : Ya Tidak Warna : .........................
Waktu pemasangan :...................... Volume : ........................
Foley Catheter : Dilakukan Tidak
Warna : .......................... Volume cairan : ...........................
Waktu pemasangan : .......................... Urin Inisial : ........................... Warna : .........................
Chest tube : Drain :
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RUMAH SAKIT ALMAH
Jln. Jendral Sudirman, Kec. Tanjung Pandan, Kab. Belitung
ProvinsiKepulauan Bangka Belitung, Indonesia
E-mail : almah.belitung@gmail.com
Telpon: (0719) 9225 666 Fax : (0719) 9225 333 Phone: 087 797 500005
7. OBSERVASI
Observasi tanda vital tiap ...............menit/Jam
Observasi lain :
Jenis Dilakukan Frekuensi
Saturasi O2 Ya Tidak Tiap ...............menit/Jam
Gula darah Ya Tidak Tiap ...............menit/Jam
Cairan Ya Tidak Tiap ...............menit/Jam