RS RUMA SEAT TERPA%U %0MPET %UA4A L E M B AR T R I AG E Nama Pasien :
No. RM
Tanggal Lahir :
Jenis Kelamin :
Triage Tanggal Tanggal
:
Anamnese Keluhan Utama Utama
:
Anamnese Terpimpi Terpimpin n PEMERIKSA AN (Examination ) JALAN NAFAS ( Airway ) PERNAFASA N (Breathing)
Jam :
WIB
L / P
Oleh Dokter Triage/Perawat Triage/Perawa t :
:
RESUSITASI / EMERGENC !P"#
URGENT !P$#
Sumbatan (obstruction)
Bebas (Patent)
%enti na'as (breating Arrest)
Fre$ Na'as (RR) 12301 -.mnt
Fre$ na'as (RR) *+,-.mnt
4ee5ing
Fre$ na'as (RR) / 01-.mnt
Lain3lain"$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
Neonatus
Neonatus
A&neau.mega&3mega&
Fre$ Na'as/6,-.mnt
Fre$ Na'as Na'as *6,-.mnt atau * 2, -.mnt
TAN%A &ITAL (Vital Sign) !" (BP)##$$mm%g (BP)##$$mm%g
Fre na'as (RR) #$$$$-.mnt
Sinosis sentral7mengilang sentral7mengilang 8engan 91
%enti ;antung (
Na8i teraba lema +1,3+=, -.mnt
LESS URGENT !P'#
Bebas (&atent)
Normal
Normal
Sinosis sentral7meneta& 8engan 91 SIRK:LASI (Circulation)
:
Fre na8i (%R) ##$$-.mnt
Fre na8i (%R) /+1,-.mnt * 6, -.mnt ! Sist / +=, mm%g ! Sist * >, mm%g ! !iast !iast / +,, mm%g mm%g Normal
Neonatus
Neonatus
Fre$ Na8i Na8i *6,-.mnt
Fre na8i (%R) *+,,-.mnt
Pucat (&ale)
Pucat (Pale) Aral !ingin (
Aral 8ingin (
KESA!ARAN (Disability )
Neonatus
Neonatus
@
@
S:%:"##$$ (em&t)
@
Neonatus
Neonatus
Neonatus
* 067= c
/ 0C7= c
06 c
Skala Nyeri :................... (Metode VAS/BPS/NIPS/FLACC) VAS/BPS/NIPS/FLACC) Pera)a* !N+rse# TRIAGE : AN% 0&ER 0&ER TIM JAGA : RESUSITASI/BE%A/INTERNA/KAR%I0/0BGN/ ANAK/TT/NEUR0/MATA/JI1A/KUL2KEL/P0LI IG% !ingkari Kesimpulan
Area Neri : %o,*er !Ps -siian# TRIAGE : Tan3a Tangan %o,*er : !Signa*+re#
MENINGGA L !P(#
