RM 01/A3

Rev.0/ 2017
RS GRAMEDIKA 10
Jl. Raya Besi-Jangkang No.20, Sardonoharejo, Ngaglik, NO. RM ........................................................................
Sleman, DI Yogyakarta 55581
Telepon (0274) 898501, Email : rsgramedika@gmail.com NAMA ........................................................................
TANGGAL LAHIR ...................................UMUR .........................
JENIS KELAMIN ........................................................................
RUANG RAWAT ........................................................................
PENILAIAN TINGKAT NYERI INSTALASI GAWAT DARURAT

VISUAL ANALOG SCALEWONG BAKER FACES PAIN SCALE

0 0 2 4 6 8 10
NO HURT HURT HURT S HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST

Tidak Nyeri (0) Sedang (4-6) Tidak Nyeri (0) Sedang (4-6)

Ringan (1-3) Berat (7-0) Ringan (1-3) Berat (7-10)

Skala Nyeri : ................................................. Skala Nyeri :......................................................

TRIASE
TANGGAL : PUKUL :
KELUHAN UTAMA

LEVEL TRIASE (PATIENTS ACUITY CATEGORIZATION SCALE/PACS)

PACS 1 PACS 2 PACS 3 PACS 4
WORTHING PHYSIOLOGICAL SCORING SYSTEM (WPSS)
TANDA VITAL SKOR 0 SKOR 1 SKOR 2 SKOR 3
KESADARAN Sadar Penuh Selain Sadar Penuh
TEKANAN DARAH 100 99
NADI 101 102
RESPIRASI 19 20-21 22
TEMPERATUR 35.3 < 35.3
SATURASI O 96-100 24-25 92-93 < 92
TOTAL 5 2-4 0-1
CATATAN KHUSUS PETUGAS TRIASE
Pukul : .................
KEPUTUSAN :
Ruang Resusitasi
Ruang Non Resusitasi
( ......................................)
Klinik Umum 24 Jam
DOA (Death OnArrrival )