PEMERINTAH KABUPATEN GIANYAR

DINAS KESEHATAN

UPT. KESEHATAN MASYARAKAT TAMPAKSIRING II

Jln. Raya Ir. Sukarno, Pejeng Tampaksiring

Telp. 0361 981847

RESUME REKAM MEDIS

Nama

:
:
Umur / JK
:
Alamat :
Ruang :

........................................................................
No. RM
.........................................................
: ............................................................... L / P No. Kartu
.........................................................
........................................................................
Tgl Masuk
........................................................................
Tgl Keluar

:
:

Anamnesa :

Diagnosa
Tgl

Pemeriksaan
Fisik

:
Catatan Dokter

Waktu
(Jam)

Kode ICD :
Catatan Perawat

Tgl

Pemeriksaan
Fisik

Catatan Dokter

Waktu
(Jam)

Catatan Perawat

Bukti Pelayanan Ambulance

1. Identitas Pasien
Nama
: ...........................................................................................................
..
Umur / Jenis Kelamin
: .............................................................................................
L / P
No. Kartu
: ...........................................................................................................
..
Alamat
: ...........................................................................................................
..
2. Waktu Pelayanan
Hari / Tanggal
: ...........................................................................................................
..
Jarak (km)
: ...........................................................................................................
..
Jam Berangkat
: ...........................................................................................................
..
Jam Tiba
: ...........................................................................................................
..
Faskes penerima
: ...........................................................................................................
..
Faskes Perujuk
Rujukan
UPT. Kesmas Tampaksiring II
________________________

Faskes Penerima

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Surat Keterangan Medis

Yang bertanda tangan di bawah ini menerangkan dengan sebenarnya bahwa :
Nama
: ......................................................................................................................
.....
Umur / Jenis Kelamin
: .............................................................................................................
L
/ P

Alamat
: ......................................................................................................................
....
No. Kartu
: ......................................................................................................................
....
Diagnosa
....
Tujuan Rujukan

: ......................................................................................................................
: ......................................................................................................................

....
Kondisi medis pada saat akan dirujuk :
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...................................
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Demikian Surat Keterangan ini dibuat, sehingga bisa digunakan sebagaimana mestinya.
Tampaksiring, ....................................
Dokter yang merawat,

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