NO RM :

PROGRAM STUDI DIV KEPERAWATAN

GAWAT DARURAT SURABAYA NAMA :
TGL LAHIR : RK
POLTEKKES KEMENKES SURABAYA
1a

SURAT KETERANGAN DIRAWAT

Yang bertanda tangan di bawah ini Dokter : .............................................. menyatakan bahwa:

Nama : ...............................................................................................................
Umur : ...............................................................................................................
Jenis Kelamin : ...............................................................................................................
Alamat : ...............................................................................................................
Pekerjaan : ...............................................................................................................
Dalam keadaan SAKIT dan sedang dirawat di Unit Rawat Inap Rumah Sakit Dr. Soetomo,
mulai tanggal ......................................... s.d saat ini.

Surabaya, ................................

(.........................................................)
 NO RM :
PROGRAM STUDI DIV KEPERAWATAN
GAWAT DARURAT SURABAYA NAMA :
RK
POLTEKKES KEMENKES SURABAYA TGL LAHIR : 1b

SURAT PENDAFTARAN OPERASI

Nama Pasien : ....................................................................................................

No. RM : ....................................................................................................
Jenis kelamin : ........................................ Umur : .........Th
Ruangan : ....................................................................................................
Tanggal Operasi : ....................................................................................................
Dokter Operasi : ....................................................................................................
Sifat Operasi :  Efektif  Darurat  Day Care
Jenis Operasi :  Bersih  Bersih-Kontaminasi  Kotor
Perkiraan Lama Operasi : ....................................................................................................
Diagnosa Pre Operasi : ....................................................................................................
Rencana Operasi : ....................................................................................................
Permintaan khusus
1. Alat : ....................................................................................................
2. Posisi pasien : ....................................................................................................
3. Lain-lain : ....................................................................................................
Tanggal Permintaan pendaftaran : .......... / ......... / .................. Jam : ..................

Pemesan, Penerima,

(................................) (......................................) (..................................)

Operator Perawat Ruangan Staf kamar operasi
 NO RM :
PROGRAM STUDI DIV KEPERAWATAN
GAWAT DARURAT SURABAYA NAMA :
TGL LAHIR : RK
POLTEKKES KEMENKES SURABAYA
1c

SURAT KETERANGAN ISTIRAHAT

Yang bertanda tangan di bawah ini Dokter : ...............................................menyatakan bahwa:

Nama : ................................................................................................................
Umur/Jenis Kelamin : ........... tahun / L/P
Alamat : ................................................................................................................
Pekerjaan : ................................................................................................................
Dalam keadaan SAKIT dan membutuhkan istirahat selama : ............ (.............................) hari
dari tanggal : ..........................................s.d ................................................................................

Surabaya, .............................................

( .................................................)
 NO RM :
PROGRAM STUDI DIV KEPERAWATAN
GAWAT DARURAT SURABAYA NAMA :
TGL LAHIR : RK
POLTEKKES KEMENKES SURABAYA 1d

SURAT KETERANGAN KONTROL KE POLIKLINIK

Kepada Yth:
Dokter poliklinik .............................
RS.............................
Di tempat

Menghadapkan pasien atas nama : .......................................... umur : ................................. L/P

Alamat : .......................................................................................................................................
Datang ke URD/URI hari : ......................Tanggal : ....................................................................
Dengan keluhan ......................................................diagnosa di UGD/URI : ..............................
Telah diberikan terapi : ................................................................................................................
...............................................................................................................
Mohon tindak lanjut penanganan terhadap pasien tersebut. Sekian terima kasih.

Surabaya, .....................................
Dokter

(...................................................)

Catatan :
Semua hasil pemeriksaan LABORAT/FOTO RONTGEN harap dibawa saat kontrol.