FORMULIR RUJUKAN PASIEN

FORMULIR JAWABAN RUJUAKAN PASIEN

Kepada Yth. Teman Sejawat,
Dari RS ................................................ Kepada Yth. Teman Sejawat,
di ..............................................................
Tanggal ................................................ di
Bersama ini kami kirimkan penderita dengan :
No. RM :
Nama : ____________________________________________________________ Bersama ini kami kirim kembali penderita / berita dari penderita dengan :
Umur : ________________________________________ (Laki-laki / Perempuan) No. RM :
Alamat : ____________________________________________________________ Nama : ___________________________________________________________
Dengan : Umur : ___________________________________________________________
DIAGNOSA : ............................................................................................ Alamat : ___________________________________________________________
PERSANGKAAN Dengan :
Keluhan / Gejala Utama : ............................................................................................ DIAGNOSA ; .................................................................................................
.............................................................................................................................................. PERSANGKAAN
.............................................................................................................................................. Diagnosa akhir : .................................................................................................
Keterangan lain-lain : Terapi : .................................................................................................
Hasil-hasil Pemeriksaan : ............................................................................................ ..............................................................................................................................................
.............................................................................................................................................. ..............................................................................................................................................
.............................................................................................................................................. Dan dengan saran-saran :
Terapi yang telah diberikan : ............................................................................................ Pengawasan selanjutnya : .................................................................................................
.............................................................................................................................................. ..............................................................................................................................................
.............................................................................................................................................. Terapi yang dianjurkan : .................................................................................................
.............................................................................................................................................. ..............................................................................................................................................
Dengan permohonan ..............................................................................................................................................
a. Konsultasi Prognosa : .................................................................................................
b. Pemeriksaan / Pengobatan / Perawatan Spesialis Saran-saran lain : .................................................................................................
Dan apabila sudah selesai, mohon dikirim bersama formuli pengiriman kembali (disisi kanan) ..............................................................................................................................................
yang telah terlampir. ..............................................................................................................................................
Terima kasih dan salam sejawat. Telah meninggal tanggal : .................................................................................................
Karena / setelah : .................................................................................................
Lumajang, Salam sejawat,
Dokter yang mengirim, Tanggal
Dokter yang memeriksa

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