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DIAGNOSA UTAMA

DIAGNOSA KOMPLIKASI

TINDAKAN / PENUNJANG

TINDAK LANJUT

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2. .................................................................................................
3. .................................................................................................

ICD X : ......................
ICD X : ......................
ICD X : ......................
ICD X : ......................
ICD IX : .....................
ICD IX : .....................

ICD IX : .....................
DIRUJUK KE POLI : .............

KONSULTASI SELESAI

DIRUJUK BALIK

DIRUJUK KE RS LAIN

PEMERIKSAAN PENUNJANG : ...............

PERLU RAWAT INAP

KONTROL ULANG HARI/TANGGAL: .

R/

Slawi, ...........................................
DokterPenanggungJawabPasien
Catatan:
Lembar Putih
Lembar Kuning
Lembar Merah

: Apotik
: Pasien
: Asuransi/RM

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TandaTangandanNamaTerang