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<!DOCTYPE html>
<html>
<head>
<title>Triage</title>
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font-size:10pt;
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border: 1px solid #fffff;
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<body>
<table border="0">
<tr>
<td width="25%"><img src="https://daftar.rsaulia.com/assets/img/logo-new.png" width="150"></td>
<td width="50%"> </td>
<td width="25%">
<table border="1">
<tr>
<td>NO FORM : FR.GD.01-03</td>
</tr>
<tr>
<td>NO REV : 01</td>
</tr>
</table>
</td>
</tr>
</table>
<center><h2><B>FORMULIR TRIAGE ANAK</B></h2></center>
<table border="1">
<tr valign="top">
<td colspan="3">Nama : ..................</td>
<td colspan="2">Tanggal Lahir : ..................</td>
<td colspan="3">Jenis Kelamin : <input type="checkbox"> Laki-laki <input type="checkbox"> Perempuan</td>
</tr>
<tr valign="top">
<td>Cara Datang</td>
<td>
<input type="checkbox"> Sendiri
</td>
<td>
<input type="checkbox"> Ambulans
</td>
<td>
<input type="checkbox"> Diantar Polisi
</td>
<td colspan="2" rowspan="2">Jam Datang : ....... </td>
<td rowspan="2">
<input type="checkbox"> DOA<br>
Jam DOA : .......
</td>
</tr>
<tr valign="top">
<td>Jenis Kasus</td>
<td>
<input type="checkbox"> Non Trauma<br>
<input type="checkbox"> Trauma
</td>
<td>
<input type="checkbox"> Kecelakaan Lalu Lintas<br>
<input type="checkbox"> (KKL)
</td>
<td>
<input type="checkbox"> Lain-lain
</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="5"><b>TRIAGE PRIMER</b></td>
<td><b>TRIAGE SEKUNDER</b></td>
</tr>
<tr valign="top">
<td><b>PEMERIKSAAAN</b></td>
<td><b>Katagori I</b></td>
<td><b>Katagori II</b></td>
<td><b>Katagori III</b></td>
<td><b>Katagori IV</b></td>
<td><b>Katagori V</b></td>
<td><b>Tanda Vital</b></td>
</tr>
<tr valign="top">
<td>Jalan Nafas<br>Air Way</td>
<td>
<input type="checkbox"> Sumbatan Total<br>
<input type="checkbox"> Sumbatan sebagian disertai distress pernapasan berat
</td>
<td>
<input type="checkbox"> Sumbatan Total<br>
<input type="checkbox"> Sumbatan sebagian disertai distress pernapasan berat
</td>
<td>
<input type="checkbox"> Sumbatan Total<br>
<input type="checkbox"> Sumbatan sebagian disertai distress pernapasan berat
</td>
<td><input type="checkbox"> Bebas</td>
<td><input type="checkbox"> Bebas</td>
<td><input type="checkbox"> Keadaan Umum</td>
</tr>
<tr valign="top">
<td>Pernafasan<br>Breathing</td>
<td>
<input type="checkbox"> Nafas Spontan (-)<br>
<input type="checkbox"> Hipoventilasi<br>
<input type="checkbox"> Distress pernapasan berat<br>
(otot diafragma berat, retraksi berat, sianosis akut)
</td>
<td>
<input type="checkbox"> Nafas Spontan (+)<br>
<input type="checkbox"> Distress pernapasan sedang<br>
(otot diafragma sedang, retraksi sedang, kulit pucat)
</td>
<td>
<input type="checkbox"> Nafas Spontan (+)<br>
<input type="checkbox"> Distress pernapasan ringan<br>
(otot diafragma ringan, retraksi sedikit, kulit kemerahan)
</td>
<td>
<input type="checkbox"> Nafas Spontan (+)<br>
<input type="checkbox"> Tidak ada Distress pernapasan<br>
(otot diafragma normal, retraksi tidak ada)
</td>
<td>
<input type="checkbox"> Nafas Spontan (+)<br>
<input type="checkbox"> Tidak ada Distress pernapasan<br>
(otot diafragma normal, retraksi tidak ada)
</td>
<td>
Suhu : ....... C<br>
Sa02 : ....... %
</td>
</tr>
<tr valign="top">
<td>Sirkulasi<br>Circulation</td>
<td>
<input type="checkbox"> Abser Sirkulasi<br>
<input type="checkbox"> Siniftikan bradikardia<br> ch:<60 pada bayi<br>
<input type="checkbox"> Gangguan hemodinamik berat<br>
<input type="checkbox"> Nadi perifer (-)<br>
<input type="checkbox"> Kulit pucat, akral <br>dingin, bintik-bintik merah pada ekstremitas<br>
<input type="checkbox"> Takikardia berat<br>
<input type="checkbox"> Pengisian kapiler >4 detik<br>
<input type="checkbox"> Peredaran darah tidak terkontrol
</td>
<td>
<input type="checkbox"> Sirkulasi (+)<br>
<input type="checkbox"> Gangguan hemodinamik sedang<br>
<input type="checkbox"> Nadi brach lemah kulit pucat, akral dingin, takikardia sedang<br>
<input type="checkbox"> Pengisian kapiler 2-4 detik >6 dehidrasi<br>
</td>
<td>
<input type="checkbox"> Sirkulasi (+)<br>
<input type="checkbox"> Gangguan hemodinamik ringan<br>
<input type="checkbox"> Nadi perifer teraba<br>
<input type="checkbox"> Kulit pucat, akral hangat<br>
<input type="checkbox"> Takikardia ringan<br>
<input type="checkbox"> 3-6 tanda dehidrasi
</td>
<td>
<input type="checkbox"> Sirkulasi (+)<br>
<input type="checkbox"> Gangguan hemodinamik (-)<br>
<input type="checkbox"> Nadi perifer teraba<br>
<input type="checkbox"> Kulit kemerahan, akral hangat<br>
<input type="checkbox"> Takikardia ringan<br>
<input type="checkbox"> <3 tanda dehidrasi
</td>
<td>
<input type="checkbox"> Sirkulasi (+)<br>
<input type="checkbox"> Gangguan hemodinamik (-)<br>
<input type="checkbox"> Nadi perifer teraba<br>
<input type="checkbox"> Kulit kemerahan, akral hangat<br>
<input type="checkbox"> Takikardia ringan<br>
<input type="checkbox"> tanda dehidrasi (-)
</td>
<td>
Frekuensi<br>
Nadi.................x/mnt<br>
<br><br>
Napas.................x/mnt<br>
TD.................MMHg
</td>
</tr>
<tr valign="top">
<td><b>KESADARAN</b></td>
<td><b>GCS <8</b></td>
<td><b>GCS 9-12</b></td>
<td><b>GCS >13</b></td>
<td><b>GCS 15</b></td>
<td><b>GCS 15</b></td>
<td><b>RIWAYAT ALERGI</b></td>
</tr>
<tr valign="top">
<td>Pernafasan<br>Breathing</td>
<td>
<input type="checkbox"> Kejang sedang<br> berlangsung<br>
<input type="checkbox"> Respon nyeri(+)<br>
<input type="checkbox"> Trauma kepala<br> hebat
</td>
<td>
<input type="checkbox"> Gelisah<br>
<input type="checkbox"> Irritable<br>
<input type="checkbox"> Demam dengan<br> tanda-tanda kejang<br>
<input type="checkbox"> Sakit Kepala<br>
<input type="checkbox"> Kaku leher<br>
<input type="checkbox"> Bayi usia <28 hari
</td>
<td>
<input type="checkbox"> Apatis<br>
<input type="checkbox"> Sommolen<br>
<input type="checkbox"> Nyeri perut hebat<br>
<input type="checkbox"> Fraktur ekstremitas<br>
<input type="checkbox"> Laserasi kulit<br>
<input type="checkbox"> Luka kotor
</td>
<td>
<input type="checkbox"> Cedera tanpa penurunan kesadaran<br>
<input type="checkbox"> Nyeri abdomen tidak hebat<br>
<input type="checkbox"> Nyeri sedang<br>
<input type="checkbox"> Dislokasi sendi<br>
<input type="checkbox"> Informasi/benda asing pada mata<br>
<input type="checkbox"> Indeks paru<br>
<input type="checkbox"> Demam<br>
<input type="checkbox"> Subfebris<br>
</td>
<td>
<input type="checkbox"> Gejala klinis<br>
<input type="checkbox"> Rencana imunisasi<br>
<input type="checkbox"> Nyeri telinga<br>
<input type="checkbox"> Tidak demam<br>
<input type="checkbox"> Sakit dengan gejala ringan<br>
<input type="checkbox"> Lebam post trauma ringan
</td>
<td>
<input type="checkbox"> Makanan<br>
<input type="checkbox"> Obat<br>
<input type="checkbox"> Lain-lain<br>
<input type="checkbox"> GDS
</td>
</tr>
<tr valign="top">
<td align="center">RESPON TIME</td>
<td align="center">Immediate</td>
<td align="center">< 10 Menit</td>
<td align="center">30 Menit</td>
<td align="center">60 Menit</td>
<td align="center">120 Menit</td>
<td align="center" rowspan="4">Tanggal .. / .. / 20..</td>
</tr>
<tr valign="top">
<td align="center">Observasi</td>
<td align="center">Ruang Resusitasi</td>
<td align="center">Ruang Resusitasi</td>
<td align="center">Ruang Observasi Biasa/<br>Bedah Non Resusitasi</td>
<td align="center">Ruang Observasi Biasa/<br>Bedah Non Resusitasi</td>
<td align="center">Ruang Observasi Biasa/<br>Bedah Non Resusitasi</td>
</tr>
<tr valign="top">
<td colspan="6">
<input type="checkbox"> <b>TRUE EMERGENCY</b>
</td>
</tr>
<tr valign="top">
<td colspan="6">
<input type="checkbox"> <b>FALSE EMERGENCY</b>
</td>
</tr>
</table>
</body>
</html>