PEMERINTAH KABUPATEN BEKASI

RUMAH SAKIT UMUM DAERAH CABANGBUNGIN

Kp. Bojong RT 07 RW 04 Desa Jayalaksana Kec. Cabangbungin
Tlp. (021) 12345678, Email :

No. RM :
Nama :
FORMULIR RESUME MEDIS Tanggal Lahir :
Ruangan :

Alasan Masuk Dirawat : ......................................................................................................................................................

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Ringkasan Riwayat : ......................................................................................................................................................

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Pemeriksaan Fisik : ......................................................................................................................................................

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Hasil Laboratorium : ......................................................................................................................................................

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Terapi Pengobatan : ......................................................................................................................................................

Selama di RS ......................................................................................................................................................
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Diagnosa Utama : ......................................................................................................................................................

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Intruksi/ Anjuran dan : ......................................................................................................................................................

Edukasi (Follow Up) ......................................................................................................................................................
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Kondisi Waktu Keluar :  Sembuh  Pindah RS  Pulang Atas  Meninggal  Lain-Lain,
Permintaan .......................
Sendiri .......................

Pengobatan :  Poli Klinik  RS Lain  Puskesmas  Dokter Luar  ......................

dilanjutkan ......................
Tanggal Kontrol Poli : ......................................................................................................................................................
Klinik ......................................................................................................................................................

Terapi Pulang :
Nama Obat Jumlah Dosis Frekuaensi Cara Pemberian Nama Obat Jumlah Dosis Frekuaensi Cara Pemberian

Cabangbungin, ...............................................
Dokter Penanggung Jawab Pelayanan

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Tanda Tangan & Nama Jelas