PROGRAM PENDIDIKAN PROFESI NERS

FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

DI RUANG ROSELLA I
RUMAH SAKIT DR. SOETOMO SURABAYA

No RM :
Nama
:
Tgl Lahir :

SURAT KETERANGAN DIRAWAT

Yang bertanda tangan di bawah ini Dokter : .............................................. menyatakan bahwa:
Nama
: ...............................................................................................................
Umur
: ...............................................................................................................
Jenis Kelamin
: ...............................................................................................................
Alamat
: ...............................................................................................................
Pekerjaan
: ...............................................................................................................
Dalam keadaan SAKIT dan sedang dirawat di Unit Rawat Inap Rumah Sakit Universitas
Airlangga, mulai tanggal ......................................... s.d saat ini.
Surabaya, ................................

(.........................................................)

RK
1a

PROGRAM PENDIDIKAN PROFESI NERS

FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
DI RUANG ROSELLA I
RUMAH SAKIT DR. SOETOMO SURABAYA

No RM :
Nama
:
Tgl Lahir :

SURAT PENDAFTARAN OPERASI

Nama Pasien
: ....................................................................................................
No. RM
: ....................................................................................................
Jenis kelamin
: ........................................ Umur : .........Th
Ruangan
: ....................................................................................................
Tanggal Operasi
: ....................................................................................................
Dokter Operasi
: ....................................................................................................
Sifat Operasi
: Efektif Darurat
Day Care
Jenis Operasi
: Bersih
Bersih-Kontaminasi
Kotor
Perkiraan Lama Operasi
: ....................................................................................................
Diagnosa Pre Operasi
: ....................................................................................................
Rencana Operasi
: ....................................................................................................
Permintaan khusus
1. Alat
: ....................................................................................................
2. Posisi pasien
: ....................................................................................................
3. Lain-lain
: ....................................................................................................
Tanggal Permintaan pendaftaran : .......... / ......... / .................. Jam : ..................
Pemesan,

(................................) (......................................)
Operator
Perawat Ruangan

Penerima,

(..................................)
Staf kamar operasi

RK
1b

PROGRAM PENDIDIKAN PROFESI NERS

FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
DI RUANG ROSELLA I
RUMAH SAKIT DR. SOETOMO SURABAYA

No RM :
Nama
:
Tgl Lahir :

SURAT KETERANGAN ISTIRAHAT

Yang bertanda tangan di bawah ini Dokter : ...............................................menyatakan bahwa:
Nama
: ................................................................................................................
Umur/Jenis Kelamin : ........... tahun /
L/P
Alamat
: ................................................................................................................
Pekerjaan
: ................................................................................................................
Dalam keadaan SAKIT dan membutuhkan istirahat selama : ............ (.............................) hari
dari tanggal : ..........................................s.d ................................................................................
Surabaya, .............................................

( .................................................)

RK
1c

PROGRAM PENDIDIKAN PROFESI NERS

FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
DI RUANG ROSELLA I
RUMAH SAKIT DR. SOETOMO SURABAYA

No RM :
Nama
:
Tgl Lahir :

SURAT KETERANGAN KONTROL KE POLIKLINIK

Kepada Yth:
Dokter poliklinik .............................
RS Universitas Airlangga
Di tempat
Menghadapkan pasien atas nama : .......................................... umur : ................................. L/P
Alamat : .......................................................................................................................................
Datang ke URD/URI hari : ......................Tanggal : ....................................................................
Dengan keluhan ......................................................diagnosa di UGD/URI : ..............................
Telah diberikan terapi : ................................................................................................................
...............................................................................................................
Mohon tindak lanjut penanganan terhadap pasien tersebut. Sekian terima kasih.
Surabaya, .....................................
Dokter

(...................................................)
Catatan :
Semua hasil pemeriksaan LABORAT/FOTO RONTGEN harap dibawa saat kontrol.

RK
1d