ER HOSPITAL PUPUK KALTIM SIAGA RAMANIA

Date: ........................ time: ......................

I. GENERAL DATAo Name : .................................................................o Address / Telephone Number : ................................................o Ages : .................................. M/F : .....................o Jobs : .................................................................o Religion : ................................................................o To Hospital : - Alone : - - Police :

- Family : - Other :

o Responsible Person: ...............................................................o Jobs : ................................................................

Registration Number : ....................................

Crisis1. Serious & Emergency2. Serious, Non Emergency3. Emergency, Not Serious4. Not Serious, Non EmergencyResponse time1. Time Of The Incident : .................................2. Time Come Patient : .................................3. Time Action : .................................4. Consultation Time : ................................5. Time Enter The Room : ...............................6. Time Of Death :................................

II. STATUS OF PATIENTSANAMTESIS : ........................................................................... VITAL SIGN ........................................................................... Blood Pressure : ........................... mmHg...................................................................................................... Pulse : ........................... x / minuteHistory Of Internist : ................................................................ Respiration : ............................ x / minuteHistory Of Allergy : ................................................................. Temparature : ............................ 0CHistory Of Drugs : ................................................................ weight : ............................ Kg

Food History : .................................................................

PHYSICAL EXAMITIONConscious : CM : Delirium : Coma : GCS : ...............................................Condition come : Nice : Medium : Bad : Bleeding : DOA :

Head / Neck : ................................................................... Abdomen : ..................................................................... .................................................................... ......................................................................

Thoraks : .................................................................... Extremity : ..................................................................... .................................................................... ....................................................................Other : .................................................................... ....................................................................

WORK DIAGNOSIS : .................................................................................................................................................................................................................................................................................................

PLANNING ACTION : ............................................................................................................................................... .............................................................................................................................................. .............................................................................................................................................. ..............................................................................................................................................

INVESTIGATION : ..................................................................................................................................................... ....................................................................................................................................................

ER HOSPITAL PUPUK KALTIM SIAGA RAMANIA

III. FUTHER ACTION PLAN :

1. Consult dr. Specialist : .................................................................................................................................. ................................................................................................................................... ................................................................................................................................... ...................................................................................................................................

2. Care : - Hospitalization Room : .................................... - Referenced- ICU / ICCU - Died- Out Patient

3. Cyto Operation / Follow-Up : ..........................................................................................................................................................................................................................................................................................................................................................................................

4. Obsevation : ............................................................................................................................. ..............................................................................................................................

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

IV. IMAGE ANALYSIS OF EVENTS ( WHEN NEEDED )AUTOPSY / WOUND BURN

PICTURE EXPLANATION :

Doctor Hospital Pupuk Kaltim Siaga Ramania Responsible,

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