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DISCHARGE PLANNING

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


Ruang Rawat Inap : ..................................................................................................
No. Rekam Medik : ..................................................................................................
Tanggal Masuk : ..................................................................................................
Tanggal Keluar : ..................................................................................................
Penanggung Jawab : ..................................................................................................

Diisi Oleh Dokter Penanggung Jawab Pasien (DPJP)


A. Anamnesis
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B. Riwayat Perjalanan Penyakit
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C. Pemeriksaan Fisik
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D. Penemuan Klinik
1. Laboratorium
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2. Rontgen
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E. Diagnosa Utama
1. ............................................................................................................... ICD-10
2. ............................................................................................................... ICD-10
F. Diagnosa Sekunder
1. ............................................................................................................... ICD-10
2. ............................................................................................................... ICD-10
G. Obat Selama Di RS
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H. Tindakan Selama Di Rumah Sakit
1. .......................................................................................................... ICD-9CM
2. .......................................................................................................... ICD-9CM
I. Kondisi Pada Saat Pulang
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J. Anjuran/Rencana Kontrol Selanjutnya:
K. Alasan Pulang
Dapat Berobat Jalan Pindah Ke RS lain Sembuh
Meninggal Pulang Atas Permintaan Sendiri
L. Terapi Pulang
Jam Pemberian
No Nama Obat Beserta Dosis

Dokter Penanggung Jawab Pasien

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