Formulir Hand Over

Nama

: ................................ ............................................... .................... .....

No.RM : ................................ .................................... ....

Tgl Lahir : ................................ ................................................ .................... .... FORMULIR SERAH TERIMA ANTAR SHIF PAGI

SORE

MALAM

Situation

Situation

Situation

.................................. ................................................... .......................... .........

.................................. .................................................. .......................... ..........

.................................. .................................................. .......................... ..........

.................................. .................................................... .......................... ........

.................................. .................................................. .......................... ..........

.................................. .................................................. .......................... ..........

Background

: ................................ ......................................... .........

Background

: ................................ ......................................... .........

Background

: ................................ ......................................... .........

DX Medis

: ................................ ......................................... .........

DX Medis

: ............................... ......................................... ..........

DX Medis

: ............................... ......................................... ..........

DPJP

: ................................ .................................................. ..................

DPJP

: ................................ .................................................. ..................

DPJP

: ................................ ................................................. ...................

Asesmen

: ................................ ........................................ ........

Asesmen

: ................................ ........................................ ........

Asesmen

: ................................ ........................................ ........

Kesadaran

: ............................ ............................ GCS :.....

Kesadaran

: ............................ ............................ GCS :.....

Kesadaran

: ............................ ............................ GCS :.....

Tandavital : TD =...........mmHg HR=........x/mnt

Tandavital : TD =...........mmHg HR=........x/mnt

Tandavital : TD =...........mmHg HR=........x/mnt

Suhu : ........C. RR=............x/mnt. Nyeri=....... Nyeri=.......

Suhu : ........C. RR=............x/mnt. Nyeri=....... Nyeri=.......

Suhu : ........C. RR=............x/mnt. Nyeri=....... Nyeri=.......

Infus : ............tts/mnt. Oksigen : .........Lt/mnt

Infus : ............tts/mnt. Oksigen : .........Lt/mnt

Infus : ............tts/mnt. Oksigen : .........Lt/mnt

Transfusi :........tts/mnt, Kateter : Y/T. NGT:Y/T

Transfusi :........tts/mnt, Kateter : Y/T. NGT:Y/T

Transfusi :........tts/mnt, Kateter : Y/T. NGT:Y/T

Makan/Minum :................................. :.......................................... .........

Makan/Minum :.................................. :.......................................... ........

Makan/Minum :................................. :.......................................... .........

Toileting : ................................... ................................................ .............

Toileting : ................................. ................................................ ...............

Toileting : ................................. ................................................ ...............

Aktifitas : ................................. ............................................... ................

Aktifitas : ................................ ............................................... .................

Aktifitas : .................................. ................................................ ..............

Skor Jatuh : .............................. ............................................. ...............

Skor Jatuh : .............................. ............................................. ...............

Skor Jatuh : .............................. ............................................. ...............

Recomendation

Recomendation

Recomendation

................................. ................................................. ............................ ............

................................. ................................................. ............................ ............

................................. ................................................. ............................ ............

................................. ................................................. ............................ ............

................................. ................................................. ............................ ............

................................. ................................................. ............................ ............

Pemberi Operan

Penerima Operan

Pemberi Operan

Penerima Operan

Pemberi Operan

Penerima Operan

(..................)

(.......................)

(..................)

(.......................)

(..................)

(.......................)