Nama :

No. RM :
Jl. Lettu rohani No.6B Kalianda Lampung Selatan
Telp. 0727-322159, 322160 fax 0727-322801 Tgl lahir :

RESUME MEDIS RAWAT JALAN

DIAGNOSA UTAMA .......................................................................................... ICD X : ......................

DIAGNOSA 1. ................................................................................... ICD X : ......................

KOMPLIKASI
2. ................................................................................... ICD X : ......................

TINDAKAN/ 1. ....................................................................................
PENUNJANG
2. ....................................................................................

THERAPI ..........................................................................................

..........................................................................................

..........................................................................................

TINDAK LANJUT Konsultasi Selesai Dirujuk Ke Poli : ………...

Dirujuk Ke Rs Lain Pemeriksaan Penunjang : …................
Perlu Rawat Inap Kontrol Ulang Hari/Tanggal: …………

Bandar Lampung, ............................

Dokter Penanggung Jawab Pasien

( ......................................................)
Tanda Tangan dan Nama Terang

Catatan:
Lembar Putih : Apotik
Lembar Merah : Rekam Medis
Lembar Kuning : Penjamin/BPJS