Rekam Medis Ugd - Puskesmas

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KEGIATAN GAWAT DARURAT PUSKESMAS
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  KARTU UNIT RAWAT DARURATPUSKESMAS ………………PEMERIKSAAN FISIK :   No : 3.L e h e r : JPV. 5 ± : .......................................................................................................Lain-lain : .......................................................................................................Tanggal : Hari : Jam :Datang : Ambulance/ en!iri / Diantar oleh elaurga / Tetangga / Teman / Poli#i   ANAMNESE : eluhan $tama : ...........................................................................%i&a'at Pen'a(it #ebelumn'a : .................................................................Lainn'a : ..................................................................................................... $ : e#a!aran : )* / A+a,# / e+oro# / omatu# / oma T : ...................*m Hg N : .................. / mm  : .......................... : ...................  ) P : .................. / mm T : ..........................   e+ala : *ata : )e(ung 0/-1 )on2u(,a Anemi# : 0/-1 (elera 4(teru# 0/- Pu+il : 4#o(or (i !an (a 0/- *i!ria#i# / *io#i# $(uran ..........cm%ee(# caha'a (i 0/-1 (a 0/- Lain-lain : ......................................................................................................Thora : - Jantung : un'i 4 !an 44 Jela#/Ti!a(1 un'i Tambahan 0/-1 *urmur 0/- - Paru : %on(hi ba#ah halu# / (a#ar / n'aring / ta( n'aring %on(hi ering 0/- Lain-lain : ........................................................................................................6(#tremita# : iano#i# 0/-1 )lubing 0/-1 Jari (eri+ut 0/- Dingin 0/-6!ema 0/-1 en!i beng(a( 0/- !i ................................................................Para+are#e 0/- u+erior / 4nterior1 Hemi+are#e 0/- (iri / (anan IDENTITAS PASIEN : N a m a : ............................................$ m u r : ..................... La(i / 7anitaA g a m a : ............................................A l a m a t : ............................................................ Tele+on : ........................ IDENTITAS PENGANTAR PASIEN : N a m a : ............................................$ m u r : ..................... La(i / 7anitaA g a m a : ............................................A l a m a t : ............................................................ Tele+on : ........................  9.Luka – luka   Ab!omen : Datar / )e(ung / embung / Lema# / Tegang N'eri te(an 0/- De8an# *u#coler 0/-1 Turgor Normal / Turun elotemen 0/-1 i#ing $#u# : 9 / - / normal / n /  /  He+ar ,!a( teraba / membe#ar ................................. 2+ ..............................2+a en'al / Luna( / era# / %ata / Ti!a( %ata N'eri Te(an 0/- Lim+a : ............................................;in2al : ............................................ an!ung encing : ................................Lain-lain : ............................................ emam+uan: ;) : 6 .............................. * : ............................... V : .................................Pemeri(#aan Tambahan : - Laboratorium :- Foto Ronggent :- USG Abdomen :- E K G :- Lain – lain :  <=.Tin!a(an : .............................................................................................................................<<. Diagno#a ementara : <. .......................................................................................................>. .......................................................................................................<>. Pengobatan :<. (#igen .......................... lt / mnt1 2am : ......................................>. 4n8u# .................................. Tete# / menit1 2am : ..........................3. bat ral : a. .........................................................................b. .........................................................................c. .........................................................................?. bat un,( : a. .........................................................................b. .........................................................................c. .........................................................................<3. eterangan : <. Di+ulang(an / #embuh / belum #embuh >. Alih %a&atan (e agian .......................................................................3. Alih %a&atan (e %umah a(it .............................................................. arena tem+at +enuh / +ermintaan  / el. Jam .............Tgl.............?. Alih %a&at Jalan (e Poli(lini( agian ..................................................5. *eninggal #e#u!ah !ira&at ..................... Jam : ...........Hari : ...............ebab ema,an : @@@@@@@@@@@........................................... eluar !ari 4%D Tgl @@@@.@. Hari ..................... Jam..................... Pera&at Bang ertuga#1 Do(ter Tang ertuga#1 C......................................... C........................................
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