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  FORMULIR TRANSFER PASIEN I.   RINGKASAN RIWAYAT PASIEN  AnamnesisKeluhan utama : ...................................................................................................... Riwayat penyakit : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………  Pemeriksaan tanda-tanda vital : Tensi : ……. mmHg Suhu : ….  C Nadi : x/mnt RR:... x/menit Keadaan umum :………..  Pemeriksaan Fisik : .................................................................................................................................................................................................................................................................................................................................: ............................................................................................................................................................................................................... ............................................................................................................................................................................................................... ....................................................................................................................................................................................Alasan transfer : ……………………………………………………………………………………………………………………………………………………………………………………………………   II.   PEMERIKSAAN PENUNJANG YANG SUDAH DILAKUKAN  1.   Laboratorium :  o   Daraj lengkap : ……………………………………………………………………   o   Kimia darah :…………………………………………………………………….   o   Elektrolit :…………………………………………………………………….  2.   Radiologi o   Rontgen : …………………………………………………………………….   o   USG abdomen :……………………………………………………………………..   o   BNO-IVP :……………………………………………………………………..   III.   TINDAKAN MEDIS YANG SUDAH DILAKUKAN   ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………  Nama Pasien :................................ Tanggal Lahir :............................... DPJP : ……………………..  Dokter Konsulen 1 : ............................... Dokter Konsulen 2 : ............................... Diagnosis masuk :……………………   Jenis Kelamin : L / P Tanggal Masuk : ……………..  Ruang / Kamar :……………..  Tanggal / Jam Pindah :……………  Pindah ke /rujuk :……………  Diagnosis Sekarang : …………….    ………………………………………………………………………………………………………………………………………………………………………………………………………………   IV.   PEMBERIAN TERAPI   A.   Infus : …………………………………………………………………………….   B.   Obat Injeksi :...................................................................................................................... C.   Obat Oral :………………… ..........................................................................................  V.   Derajat kebutuhan perawatan pasien  o   Derajat 0 o   Derajat 1  o   Derajat 2  o   Derajat 3  Tanjung selor, ……………………………. 2017  Salam sejawat, ( ) NIP/NRPTT:
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