8/17/2019 Form Asesmen Resiko Pasien Jatuh

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RSIA PRIMA HUSADA

FORM  : ASESMEN RESIKO PASIEN JATUH & TINDAK LANUTNYAA. IDENTITAS :

 Nama Pasien : L/P, Umur: !/"#n, N$. RM :A#ama :Tan%%a# : Jam :

Peu%as an% me#a'u'an asesmen : Nama : ............................... Dr/"i(an/)era*a/)eu%as #ain +............................................

ASESMEN RESIKO PASIEN JATUH menuru MORSEK$n(isi Pasien SKALA Ni#ai -

Ri*aa Jau!Ya

Ti(a' 0

Dia%n$sa se'un(er Ya 1

Ti(a' 0

A#a 2anu Ja#anPera#aan K!usus 30T$n%'a/ 4a#'er 1

Kursi R$(a / Tan)a A#a 2anu 0

Pasien Di In5us Ya 0Ti(a' 0

6ara 2er7a#anTer%an%%u 0

Lema! 10 N$rma# 0

K$n(isi Mena#Keer"aasan Daa In%a/)en%aru!

O"a 2ius1

 N$rma# 0TOTAL S6ORE ......

Score total, tingkat resiko dan Warna Gelang

Resi'$ Tin%%i 89 e#an% mera! Se(an% ;99 Kunin% Ren(a! 0;9 Hi7au2.T

INDAK LANJUT PASIEN RESIKO JATUH S6ORE TINI1. Pasan% %e#an% .................................................................................................su(a!/ "e#um

. In5$rmasi 'e)a(a )asien/'e#uar%a..................................................................su(a!/ "e#um

3. is......................................................................................................................................................................................................................................................................................................

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ASESMEN KONDISI RUANANKONDISI RUANAN SKALA -Lanai Kamar Li?in

Ti(a' Li?inLanai Kamar Man(i Li?in

Ti(a' Li?inK$n(isi 2e( 2ai' 

Ti(a' 2ai' Pen?a!aaan 2ai'

6u'u)Kuran%2e# ruan%an 2er5un%si

Rusa'Pen(in%in Ruan%an 2er5un%si

Rusa'Pinu Kamar Man(i 2er5un%si

Rusa'