8/9/2019 Formulir Monitoring Pasien Di Ambulan

1/3

FORMULIR MONITORING PASIEN DI AMBULAN

Nama Pasien : .................... Nama Perawat : .......................

Umur : .................... Dokter Pemam!in" : .......................

#amar : .................... Nama Pen"enara : .......................

Dia"nosa : .................... $am Beran"kat Dari RSB %EE& : .......................

Nama DP$P : .................... $am ti'a Di RS Tu(uan : .......................

RS )an" Setu(u : .................... $am ti'a i RSB %EE* : .......................

Tu(uan O!erasi : Pemeriksaan !enun(an" : ..........................................

Tinakan Meis : ..........................................

#onsu+tasi : ..........................................

Lain,+ain : ..........................................

#eaaan umum !asien : ......................................................................................

#esaaran -M A!atis Somno+en So!orous -oma

Pernaasan : S!ontan

: Den"an 'antuan O/ : .......Liter 0 Menit

: ETT

: Tra12eostomi

: Am'u'a"

Pasien men""unakan : NGT

: Drain: #ateter

: Lain,+ain ........................................................

MONITORING TANDA,TANDA 3ITAL

$amTD 4R RR

#eteran"anMm 4" #a+i 0 mnt #a+i 0 mnt

8/9/2019 Formulir Monitoring Pasien Di Ambulan

2/3

$amTD 4R RR

#eteran"anMm 4" #a+i 0 mnt #a+i 0 mnt

8/9/2019 Formulir Monitoring Pasien Di Ambulan

3/3