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$rmasi 'e)a(a )asien/'e#uar%a..................................................................su(a!/ "e#um
3. is......................................................................................................................................................................................................................................................................................................
R
ASESMEN KONDISI RUANANKONDISI RUANAN SKALA -Lanai Kamar Li?in
Ti(a' Li?inLanai Kamar Man(i Li?in
Ti(a' Li?inK$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'
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