FORM

LAPORAN KONDISI KORBAN

Surname : ……………… ……….

………………. ……….
First Name : ……….
Company : ……….
Splinting  Frac Straps  KED
Sex :  Traction  Inflantable
Date of Birth :  Box Others (specify)
Date :
OBSERVATIONS Time :
Onset Time : Respiratory Rate :
Oxygen Saturation (Sa O2) :
PRIMARY SURVEY Time : Blood Pressure :
Airway  Clear  Obstructed Pulse Rate :

Breathing  Spontaneous  Difficulty EXPOSURE/INJURY

C. Spine  Normal  Possible Injury
Circulation/  External  Internal
Haemorrhage  None/Slight  Possible
 Moderate
 Severe
Disability  Alert  Pain
respond to  Visual Stimuli  Unresponsive

PRIMARY MANAGEMENT
Airway  Oropharyngeal  Nasal
 C/Thryrotomy  ET Tube
 Oxygen  Suction
Breathing  Ventilated  Chest Drain
C. Spine  Sand Bags  Stiff Neck
Circulation Cannula Size :
Rt……………. Lt. …………….
IV Fluid Vol. Time
 Ringers Sline ……… ….….
 Hemaccel ……… ..……

SECONDARY SURVEY
Eye Opening Spontaneous 4
To voice 3
To pain 2
None 1
Best Verbal Oriented 5
Response Confused 4
Inappropriate 3
Incomprehensible 2
None 1
Note:
Motor Response Obeys command 6
Localizes pain 5
Withdrawal (pain) 4
Flexion (pain) BAGIAN INI DI ISI HANYA PADA SAAT SERAH TERIMA
3 PASIEN EVAKUASI
Extension (pain) 2
None 1
Pupils React R L MENYERAHKAN, MENERIMA,
Constricted R L
Normal R L
None R L
Coma Score Nama :
Time : ……… Score : ……………. Jabatan :
Comments Perusahaan:

SECONDARY MANAGEMENT
treatment Dose Time