/2016
Kepada
Yth,
Dengan hormat,
TS
.................................
RS : ..................................
: .................................................................................................
: .................................hr/bulan/tahun...........L/P
: Kp ..................................................................... Desa: .......................................................
.............................................................................................................................................
Kecamatan : .......................................................................................................................
Anamnese
: .............................................................................................................................
Diagnosa Sementa
: .............................................................................................................................
Obat Yang Sudah diberikan
: ...........................................................................................................................
Terima kasih
: ............................................................................................................................
Salam sejawat
dr.Sutardi
NRPTT:873.32.14.11.1.
0413
Jawaban Rujukan
Konsul Selesai/Perlu Kontrol Kembali
Konsul Sesuai/Perlu kontrol Kembali
Perlu Konsul ke Ahli Lain (Sebutkan)
: ............................................................................................................................
Peerlu Tindakan Medis Lain (Sebutkan)
: ............................................................................................................................
Perlu dirawat dengan Indikasi (Sebutkan) :
l..................................................................................................................................
Diagnose
........
Terapi Yang Diberikan
Anjuran
Tanggal Dan Catatan
: ....................................................................................................................
: ............................................................................................................................
: ............................................................................................................................
.............................................................................................................................
Salam sejawat
( ..................................
......)
RUJUKAN
No:
/PKM/
/ 2016
Kepada
Yth,
Dengan hormat,
Ts ...........................
RS : ................................
Mohon Konsul/pemeriksa/Pengobatan lebih lanjut terhadap Penderita :
Nama Penderita
Umur
Alamat
: .................................................................................................
: .................................hr/bulan/tahun............L/P
: Kp ..................................................................... Desa: .......................................................
.............................................................................................................................................
Kecamatan : .......................................................................................................................
Anamnese
: .............................................................................................................................
Diagnosa Sementa
: .............................................................................................................................
Obat Yang Sudah diberikan
: ...........................................................................................................................
Terima kasih
: ............................................................................................................................
Salam sejawat
dr.Eneng Sukmayanti
NIP:
197703082014122001
Jawaban Rujukan
Konsul Selesai/Perlu Kontrol Kembali
Konsul Sesuai/Perlu kontrol Kembali
Perlu Konsul ke Ahli Lain (Sebutkan)
: .............................................................................................................................
Peerlu Tindakan Medis Lain
(Sebutkan)
: .............................................................................................................................
Perlu dirawat dengan Indikasi
(Sebutkan) : .............................................................................................................................
Diagnose
........
Terapi Yang Diberikan
: ....................................................................................................................
: .............................................................................................................................
Anjuran
Tanggal Dan Catatan
............................................................................................................................
.............................................................................................................................
Salam sejawat
( ..................................
......)