Nomor Rekam Medis:

RESUME MEDIS
Nama Pasien: Tanggal Lahir: Umur: Jenis Kelamin: L/P

Tanggal Masuk: Tanggal Keluar/Meninggal: Ruang Rawat Terakhir:

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 Rumah Sakit: _________________________________________________________
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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.___________________
Tindakan/ 1. _________________________________________ ICD9CM: 1.___________________
Prosedur: 2. ___________________________________________ 2.___________________
3._________________________________________ 3. ___________________
4. _________________________________________ 4. ___________________
Sambungan RESUME MEDIS

Nama Pasien: Nomor Rekam Medis:

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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: 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 Frekuensi Cara Pemberian

Jakarta,
Dokter Penanggung Jawab Pelayanan

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Tanda Tangan

Lembar 1: Pasien
Lembar 2: Rekam Medis