PEMERINTAH KABUPATEN TAPANULI TENGAH

DINAS KESEHATAN
PUSKESMAS TUKKA
KECAMATAN TUKKA
Jl.Humala Tambunan No. Kelurahan Tukka Kode Pos: 22618
Email: puskesmas.tukka@yahoo.com Telepon ( 0631 ) 3730569

RESUME KLINIS PASIEN RUJUKAN PUSKESMAS

I Identitas pasien :
a. Nama pasien :
b. Umur :
c. Jenis kelamin:
d. Alamat :
e. No. BPJS/Jamkesda:
II Keluhan utama pasien :

III Pemeriksaan fisik :

a. Keadaan umum :
b. GCS :
c. Tanda-tanda Vital:
 Tekanan darah :
 Nadi :
 Pernafasan :
 Suhu :
d. Kelainan yang bermasalah :

IV Diagnosa:

V Tindakan yang telah dilakukan :

a. ....................................................................................................................................
b. ..................................................................................................................................
c. ..................................................................................................................................
d. ..................................................................................................................................
VI Terapi yang diberikan :
a. ..................................................................................................................................
b. ..................................................................................................................................
c. ...................................................................................................................................
d. ...................................................................................................................................
VI Alasan merujuk :
I