RUMAH SAKIT UMUM ALIYAH

JL. BUNGGASI POROS ANDUONOHU-POASIA KENDARI

Nama :
No. RM :
LEMBAR KONSULTASI
Tgl. Lahir :
(ANTAR DPJP)
JK : P/L

Konsultasi kepada : dr. Dari :

Departemen / Unit : dr. :
PERMINTAAN KONSULTASI
Teman Sejawat Yth,
Sudilah kiranya memeriksa dan mengobati pasien ( nama tersebut diatas ) dengan
kemungkinan / sangkaan ........................................................................................................................
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1. Di Departemen kami pasien ini diobati untuk ....................................................................................
............................................................................................................................................................
Telah ditemukan kelainan-kelainan dan keadaan pasien saat ini :
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
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2. Pengobatan yang telah dilakukan
............................................................................................................................................................
............................................................................................................................................................
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3. Mohon perhatian khusus terhadap
............................................................................................................................................................
............................................................................................................................................................
Sudilah sejawat untuk :
a. Alih Rawat
b. Rawat Bersama
c. Konsultasi 1 X
Atas bantuannya, diucapkan terima kasih
Dokter yang mengirim

Tanggal : Jam :
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RM 016/RSUA