No.RM:

RUMAH SAKIT ISLAM MALANG UNISMA JL. MT. Haryono No.139 Malang

Telp. (0341)551356, IGD. (0341)570400, Fax. (0341)551257

REKAM MEDIS PASIEN GAWAT DARURAT

Nama : ............................................................................................................................ Jenis Kelamin: LK/PRTanggal Lahir : .............................................................. Umur...................... Th/bl/Hr. Agama:..................................Alamat : ........................................................................................................................ RT/RW: ........../..........

Kec................................................................................... Tlp:..............................................................Pendidikan : ................................................................................. Status:................................................................Nama Suami/Ayah : .................................................................................. Pekerjaan:.........................................................

Jam Pendaftaran : .................................... WIBPernyebab Cedera/Keracunan : .........................................................................................................................................Tanggal kejadian : ....................... Pukul:................... Tempat Kejadian:......................................................Tiba di IGD : ....................... Pukul :...................Status medik : Emergency Trauma Emergency Non Trauma

Non Emergency Trauma Non Emergency Non TraumaTransportasi Waktu Datang : Ambulans 118 Ambulans Lain Kendaraan LainnyaKeadaan Pra Hospita : GCS Tensi:..........mmHg Nadi:..........x/mnt

Pernapasan...........x/mnt Suhu:..........x/mntTindakan Pra Hospital : CPR O2 Infus NGT

ETT Suction Trakeostomi BVM Kateter Urin Bebat Tekan Bidai Penjahitan Lain-lain Obat-obatan

ALERGI TERHADAP:...............................................................................................................................................................a. Anamnesis:......................................Diperiksa oleh Dokter:............................................................ Jam:.....................b. Pemeriksaan Fisik..............................................................................................................................................................c. Keadaan Umum : Baik Sedang BurukJalan Napas Pernapasan Sirkulasi Neorologi Paten Gerakan Dada : Nadi Carotis : ....................... X/Mnt R. Mata : ......................... Obstruktif Partial Simetri Asimetri Nadi Radialis : ....................... X/Mnt R. Verbal : ......................... Obstruktif Total Pernapasan : (B) Kulit/ Mukosa R. Motorik : .........................

Stidor Normal Retractive Jaundice Kusmaul Cyanosis Cheynestoke Pucat Tachypnoe Berkeringat Total

BELAKANG DEPAN

DIAGNOSA UTAMA : .......................................................................................................... ICD-X : .................................DIAGNOSA BANDING : .......................................................................................................... ICD-X : .................................TERAPI/TINDAKAN : .......................................................................................................................................................

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.......................................................................................................................................................Tanggal:..............................................Tanda Tangan Dokter:....................................................

GRADING

RUMAH SAKIT ISLAM MALANG UNISMAJL. MT. Haryono No.139 MalangTelp. (0341)551356, IGD. (0341)570400, Fax. (0341)551257

LEMBAR OBSERVASI PASIEN

TGL&JAM OBSERVASI & PEMERIKSAAN DIAGNOSA&TERAPINAMA TERANG& PARAF DOKTER