Nomor Rekam

RESUME MEDIS 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: ___________________________________________________

________________________________________________
_______________________________________________
_______________________________________________
________________________________________________
Pemeriksaan Fisik: __________________________________________________
________________________________________________
_______________________________________________
________________________________________________
_________________________________________________
Pemeriksaan Penunjung/ ____________________________________________________
Diagnostik Terpenting: ____________________________________________________
_________________________________________________
_________________________________________________
________________________________________________
_________________________________________________
Terapi/Pengobatan selama ____________________________________________________
Di Rumah Sakit: _________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Hasil Konsultasi: __________________________________________________
________________________________________________
________________________________________________
________________________________________________

Diagnosis Utama: __________________________________ ICD 10: ____________________

Diagnosis 1.______________________________________ ICD 10: 1.________________

Sekunder: 2._______________________________________ 2._______________
3._____________________________________ 3._______________
4. ____________________________________ 4._______________
Tindakan/ 1. ______________________________________ ICD9CM: 1._________________
Prosedur: 2. ________________________________________ 2.________________
3._____________________________________ 3. _______________
4. ____________________________________ 4. _______________

Sambungan RESUME MEDIS

Nama Pasien: Nomor Rekam
Medis:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Alergi (Reaksi Obat) ___________________________________________________________
_________________________________________________________
________________________________________________________
Hasil Laboratorium ___________________________________________________________
Belum selesai __________________________________________________________
(Pending) ___________________________________________________________
_________________________________________________________
_________________________________________________________
Diet: _________________________________________________________
_________________________________________________________
Instruksi/Anjuran ____________________________________________________________
Dan Edukasi __________________________________________________________
(Follow Up): __________________________________________________________
_________________________________________________________
________________________________________________________
_________________________________________________________

Kondisi Waktu Keluar: 1.Sembuh 2.Pindah RS 3.PAPS

4.Meninggal 5.Lain Lain

Pengobatan Dilanjutkan: 1.Poliklinik 2.RS Lain 3.PUSKESMAS

4.Dokter Luar 5...................

Terapi Pulang:
Nama Obat Jumlah Dosis Frekuen Cara
si Pemberian

Jakarta,
Dokter Penanggung Jawab
Pelayanan

______________________________
Tanda Tangan

Lembar 1: Pasien
Lembar 2: Rekam Medis