RM 11

Nama Pasien : ...................................... No. RM :

Jenis Kelamin : L / P Tgl Lahir : .........................../.........Thn/ Bln/ Hr

Ruang / Kelas : ......................../.............. Tgl Masuk : ................................. Jam :

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RESUME MEDIS
Diagnosa Masuk : ...........................................................................................................................................................
Indikasi Rawat : ...........................................................................................................................................................
Anamnesis : ...........................................................................................................................................................
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Pemeriksaaan Fisik : ...........................................................................................................................................................
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Pemeriksaaan : ...........................................................................................................................................................
Penunjang ...........................................................................................................................................................
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Obat Selama Rawat : ...........................................................................................................................................................
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Diagnosa Akhir : ........................................................................................................................... ICD-10: ............
Komplikasi : ........................................................................................................................... ICD-10: ............
Komorbid : ........................................................................................................................... ICD-10: ............
ICD-9CM:1. ...........
Tindakan/ Operasi : 1. .....................................................................................................................
2. ...........
2. ......................................................................................................................
Riwayat Alergi : ...........................................................................................................................................................
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Obat/ Terapi Pulang : ...........................................................................................................................................................
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Kondisi Saat Pulang : Sembuh Perbaikan Pulang Atas Permintaan Sendiri Meninggal
Dirujuk ke .......................................................... Alasan ..............................................................
Pengobatan Lanjutan : Poliklinik .......................................................... Tanggal Kontrol : .............................................
Segera Bawa ke RS Bila : ....................................................................................................................................................

Tulungagung, ..................................... Jam : .......

Dokter Penanggung Jawab Pelayanan

Severity : 1 2 3

Telah Diverifikasi Telah Dikode Legalisasi Severity

Tanggal Paraf Verifikator Tanggal Paraf Koder Komite Medis

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Tanda
Keterangan : Mohon tidak menggunakan singkatan dalam penulisan diagnosa dan tindakan serta tulis dengan rapi Tangan & Nama Terang
Rev2-Agust 2015
Lembar 1 : Rekam Medis
Lembar 2 : Penjamin
Lembar 3 : Pasien