Anda di halaman 1dari 2

RUMAH SAKIT UMUM Dr.

SAIFUL ANWAR MALANG (RSSA)


Jalan Jaksa Agung Suprapto 2 Malang - Jatim 65100. Telp. (0341)
362101 -362102. Fax. (0341) 362103. E-mail: info@rssamalang.com
DISCHARGE PLANNING
(PERENCANAAN PULANG)
Nama

: ______________________________________________________

Usia

: ______________________________________________________

Alamat

: ______________________________________________________

No. MR

: ______________________________________________________

Tanggal pulang

: ______________________________________________________

Dx Medis

: ______________________________________________________

Dx Keperawatan

: ______________________________________________________
_______________________________________________________
_______________________________________________________

Saran setelah pulang : ______________________________________________________


______________________________________________________
______________________________________________________
Jadwal control
Tanggal

: ______________________________________________________

Tujuan

: ______________________________________________________

Keterangan

: ______________________________________________________
______________________________________________________

Obat yang harus diminum:


_________________________________

_____________________________________

______________________________________________________________________
______________________________________________________________________
Makanan khusus:
_________________________________________________________________________
_________________________________________________________________________
Lain-lain:
_________________________________________________________________________
Malang,
Penerima
_________________

Perawat Penyuluh
____________________
1

Anda mungkin juga menyukai