RINGKASAN RIWAYAT MASUK

DAN KELUAR No. RM :

Nama Bayi :....................................... Tgl. Lahir / Jam Lahir / Umur :.........................

Jenis Kelamin : Lk/Pr Agama :.................... Suku / Bangsa :....................
Nama Bapak :........................... Pekerjaan :.................... Pendidikan Terakhir :...............
Nama Ibu :........................... Pekerjaan :.................... Pendidikan Terakhir :...............
Alamat :...................................................................................................................................
Telepon :................................................
Nama Famili Dekat :.................................... Nama Penjamin :.........................................
Alamat Famili Dekat :.................................... Alamat Penjamin :.........................................
......................................................................... ......................................................................
Telepon :................................................ Telepon :.........................................
Tanda tangan :
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Tgl Masuk :.................................... Tgl Keluar :............................... Jumlah hari :.........
Jam :.................................... Jam :...............................
Ruang Rawat :................................ Kelas :.................... Kiriman dari :.................
Diagnosis waktu masuk :...................................................................................................................
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Diagnosis Akhir :...................................................... Utama :..............................................
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Sekunder :............................................
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Penyebab kematian (bila keluar mati) :.............................................................................................
...................................................................... Tgl :...................... Jam :...................
Operasi / Tindakan Khusus :............................................ Tgl :..............................................
Jenis Anestesi................................................................... Tgl :..............................................
Infeksi Nosokomial :..........................................................................................................................
Imunisasi yang pernah didapat selama dirawat :
1. BCG 3. Hepatitis B 5. Campak
2. DPT 4. Polio 6................................................
Transfusi Darah :....................cc Ya Tidak
Keadaan waktu pulang : Catatan pulang :
Sembuh Diijinkan pulang
Membaik Atas permintaan sendiri
Tidak sembuh Melarikan diri
Meninggal 48 jam Dirujuk ke........................
Meninggal 48 jam ..........................
Dokter Jaga :.................................................
Dokter yang merawat : ........................................

Tandan tangan : ________________________________

RM.14