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Nama RS……

RUJUKAN EKSTERNAL
EXTERNAL REFERRAL

Kepada Yth : ……………………………………………………………………..


To ……………………………………………………………………..

Dengan ini kami kirimkan pasien untuk perawatan selanjutnya.


Here I refer a patient for further treatment,

Nama Pasien Name : ……………………………………………………………… Jenis kelamin : ………………………………….


Name of patient Sexuality
Tanggal lahir / umur : …………………………………………………………….. Rekam Medik : ………………………………….
Birth date/ Age Medical Record
Nama pengantar / keluarga : ……………..……………………………………………… No Telp / HP : …………………………………………………
Name of relatives Phone Number

Keluhan utama : ……………………………………………………………………………………………………………………………………………..


Chief Complaint ……………………………………………………………………………………………………………………………………………..
.…………………………………………………………………………………………………………………………………………….

Pemeriksaan fisik : ……………………………………………………………………………………………………………………………………………..


Physical Examination …………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………….

Pemeriksaan Penunjang : ………………………………………………………………………………………………………………………………………………


Additional Examination ……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..

Diagnosa : ………………………………………………………………………………………………………………………………………………..
Diagnosis ………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………..

Terapi dan tindakan yang diberikan :……………………………………………………………………………………………………………………………..


Performed medication & procedure ………………………………………………………………………………………………………………………………
.……………………………………………………………………………………………………………………………..
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Alasan dirujuk / Reasons referenced
Tempat penuh/ Unavailable Room
Atas permintaan pasien atau keluarga/ Patient’s or families preferable
Fasilitas tidak tersedia/No Facility

Terima kasih atas kerjasamanya.


Thank you for your cooperation

Jakarta,…………………………………….
Dokter yang merawat/Attending Physician

Tanda tangan & Nama lengkap/Signature & Full Name


Petugas yang mengirim : …………………………………………………………
Sent by

Petugas yang menerima : ………………………………………………………….


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