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RESUME MEDIS Nomor Rekam

Medis:
Nama Pasien: Tanggal Lahir: Umur: Jenis Kelamin:
L/P
Tanggal Masuk: Tanggal Ruang Rawat Terakhir:
Keluar/Meninggal:
Penanggung Pembayaran: Diagnosis/Masalah Sewaktu Masuk:

Ringkasan Riwayat Penyakit : __________________________________________________


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Pemeriksaan Fisik : _________________________________________________
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Pemeriksaan Penunjung/ ___________________________________________________
Diagnostik Terpenting : __________________________________________________
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Terapi/Pengobatan selama ___________________________________________________
Di Puskesmas : _________________________________________________
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Hasil Konsultasi: _________________________________________________
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Diagnosis Utama: __________________________________ ICD 10: ____________________

Diagnosis 1. _____________________________________ ICD 10: 1. ________________


Sekunder: 2. ______________________________________ 2. _______________
3. ____________________________________ 3. _______________
4. ____________________________________ 4. _______________

Sambungan RESUME MEDIS

Nama Pasien: Nomor Rekam


Medis:

Alergi (Reaksi Obat) ___________________________________________________________


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Hasil Laboratorium ___________________________________________________________
Belum selesai __________________________________________________________
(Pending) ___________________________________________________________
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Diet: _________________________________________________________
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Instruksi/Anjuran ____________________________________________________________
Dan Edukasi __________________________________________________________
(Follow Up) : __________________________________________________________
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Kondisi Waktu Keluar:


Sembuh
Rujuk RS
Meninggal
Lain lain ___________________________________________________________________

Pengobatan Dilanjutkan:
Poliklinik
Rumah Sakit
Puskesmas lain
Dokter Spesialis
Lain lain
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Terapi Pulang:
Frekuen Cara
Nama Obat Jumlah Dosis
si Pemberian

Pilangkenceng,
Dokter Penanggung Jawab
Pelayanan

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Tanda Tangan

Lembar 1: Pasien
Lembar 2: Rekam Medis