ctt pemindahan ps dari icu ke ruangan
DESCRIPTION
icuTRANSCRIPT
CATATAN PEMINDAHAN PASIEN DARI R. INTENSIF KE RUANGANLABEL PASIEN
Nama Pasien : _______________________________Tgl. Lahir / Jenis Kel. :_______________________________No. RM :_______________________________Alamat :_______________________________
Ruang :_____________________________Tanggal :_____________________________Jam :_____________________________
DIISI OLEH PERAWATDari Ruang :______________________________________Ke :____________________________________________
1. SituationDokter yang merawat :1. _______________________________________Diagnosa :___________________________________________2. _______________________________________Diagnosa :___________________________________________Masalah Keperawatan utama saat ini:____________________________________________________________________________________________
2. BackgroundRiwayat alergi / reaksi Obat: Ya Tidak Nama Obat:___________________________________________Intervensi medik & Keperawatan selama di ruang intensif____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. AssesmentObservasi terakhir jam :.............................Kesadaran :...................GCS : E:..................M:...................V:...................Tekanan Darah (TD) :.........................mmHg MAP :........................................................Nadi :.........................X/mnt Pupil & Reaksi cahaya :Kanan.................Kiri:......................Suhu :.............................. ᵒC Respirasi Rate (RR) :....................Teratur / Tidak TeraturPaO2 :................................... Skala nyeri :........................................................Saturasi :................................... PaCO2 :........................................................Deit / Nutrisi Oral NGT Batasan cairan:..................
Diet Khusus:.............. Puasa Jenis:..................................BAB Normal IleustomyBAK Spontan Kateter tgl pasang: Volume:.............................Transfer / Mobilisasi Mandiri Dibantu sebagian Dibantu penuhLuka / dicubitus Tidak Ya
Kondisi:........................ Lokasi:......................... Ukuran:..............................Infus Tidak Ya Tgl:.....................................CVC Tidak Ya Tgl:.....................................Tindakan / Kebutuhan Restrain Risiko Pasien JatuhKhusus Perawatan luka Hygiene
Diagnosa Selama Keperawatan di Ruang Intensif Sudah teratasi Belum teratasi1. 2. 3. 4. 5.
4. RecommendationProgram Theraphy:1. ........................................................................ 6. .......................................................................................2. ........................................................................ 7. .......................................................................................3. ........................................................................ 8. .......................................................................................4. ........................................................................ 9. .......................................................................................5. ........................................................................ 10. .....................................................................................
Rencana pemeriksaan laborat : ...........................................................................................................Rencana pemeriksaan radiologi : ...........................................................................................................Fisioterapi / Mobilitas : ...........................................................................................................Rencana tindakan lebih lanjut : ...........................................................................................................Obat, Barang, Dokumen yang disertakan : ...........................................................................................................
NO ITEM RUANG INTENSIF
RUANGAN NO ITEM RUANG INTENSIF
RUANGAN
1 Persetujuan Umum
9 ECG
2 Rekam Medis 10 ECHO3 Rekam Medis lama 11 USG4 MC 12 MRI5 Obat-obatan 13 Rujukan dari dokter / RS6 Hasil laboratorium 14 Inform Consent7 Hasil foto rontgen 15 Gelang nama8 CT Scan 16 Perhiasan
5. Lain-lain
Persetujuan Dokter Ruang IntensifSurakarta, ............................Jam................
(............................................)Tanda tangan & nama terang dokter
Surakarta, ............................Jam................Yang Menerima
(............................................)Tanda tangan & nama terang dokter
Surakarta, ............................Jam................Yang Menyerahkan
(............................................)Tanda tangan & nama terang dokter