RUMAH SAKIT CHECK LIST RUJUKAN DARI RS LAIN C

PERTAMINA PLAJU
PERTAMEDIKA NRM : H
Jalan Pengantingan No. 1 Komplek
Pertamina Plaju Sumatera Selatan Nama : .................................................... L / P
30268 - Indonesia E
Telepon : (0711) 597401 Fax : Tanggal/Lahir : ............................................................
(0711) 542388 C
Eselon : ............................................................
K
Surat Rujukan Ada Tidak Alasan rujuk : .......................................................
Diagnosis : ..............................................................................
: .............................................................................. L
Pemeriksaan Penunjang
I
Laboratorium Tanggal : ...... / ........ / ..................
Radiologi Tanggal : ...... / ........ / .................. Jenis 1 .................................... S
2 ....................................
EKG Tanggal : ...... / ........ / .................. T

Therapi yang sudah diberikan

Infus : Jenis 1 ................................... 2 .................................... R
Terpasang di : Tangan kanan Tangan kiri CVP Tanggal :
Tempat lain ................................................ ......../........./........ U

Jumlah cairan : ........................ CC Sisa Cairan yang terpasang ............. CC J

Obat : Jenis Diberikan terakhir

1 ..............................................
2 ..............................................
3 ..............................................
4 ..............................................
5 ..............................................
Tindakan yang sudah diberikan
U
.................................................
K
.................................................
................................................. A
.................................................
................................................. N

Dower Kateter Tanggal : ...... / ...... / ...... Ket : .....................................

NGT Tanggal : ...... / ...... / ...... Ket : ..................................... D
Intubasi Tanggal : ...... / ...... / ...... Ket : .....................................
Lain-lain ............ Tanggal : ...... / ...... / ...... Ket : ..................................... A
Keterangan lain R
.....................................................................................................................................................................
..................................................................................................................................................................... I
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
..................................................................................................................................................................... R
.....................................................................................................................................................................
..................................................................................................................................................................... S

Tanggal : ........................ Jam : ...................... Tanggal : ........................ Jam : ......................

Perawat Pengirim Perawat Penerima L
A
I
( ................................................ ) ( ................................................ )
N
FRM RM 138/2017/Rev.00