No. RM : ....................................

PEMERINTAH KABUPATEN MUSI BANYUASIN

NAMA : ....................................
DINAS KESEHATAN
TGL. LAHIR : ....................................
PUSKESMAS BANDAR AGUNG
Alamat : Desa Bandar Agung P.5 Kecamatan Lalan AGAMA : ....................................
JENIS KELAMIN : ....................................
ALAMAT : ....................................
RESUME MEDIS
Tanggal Masuk : Tanggal Keluar :

Dokter yang Memeriksa : Dokter yg Merawat :

Keluarga Pananggung Jawab : Jenis Asuransi :

Keluhan Utama : .....................................................................................................................................

Anamnesa : .....................................................................................................................................

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

Vital Sign

Kesadaran :
Pemeriksaan Fisik : HR ………… TD………. RR………. ND………. IKTERIK : +/- ANEMI : + / -

Resume : .....................................................................................................................................

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

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

Pemeriksaan Penunjang / Lab : .....................................................................................................................................

Diagnosis Utama : ................................................................................................. ICD 10 : .............

Diagnosis Banding : 1. ............................................................................................. ICD 10 : 1 ............

2. ............................................................................................. 2 ............

3. ............................................................................................. 3 ............

Tindakan / Prosedur : 1. ............................................................................................. ICD 10 : 1 ............

2. ............................................................................................. 2 ............

3. ............................................................................................. 3 ............

4. ............................................................................................. 4 ............

5. ............................................................................................. 5 ............
 No. RM : ....................................
PEMERINTAH KABUPATEN MUSI BANYUASIN
NAMA : ....................................
DINAS KESEHATAN
TGL. LAHIR : ....................................
PUSKESMAS BANDAR AGUNG
Alamat : Desa Bandar Agung P.5 Kecamatan Lalan AGAMA : ....................................
JENIS KELAMIN : ....................................
ALAMAT : ....................................
SAMBUNGAN RESUME MEDIS

Alergi (Reaksi Obat) : .........................................................................................................................................

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

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

Diet : .........................................................................................................................................

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

Instruksi / anjuran dan edukasi : .........................................................................................................................................

(Follow Up) .........................................................................................................................................

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

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

Prognosis : .........................................................................................................................................

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

Kondisi waktu keluar :  Sembuh  Rujuk  Pulang Paksa  Meninggal

Terapi Rawatan Terapi Rawat Jalan

Nama Cara Cara
Jumlah Dosis Frekuensi Nama Obat Jumlah Dosis Frekuensi
Obat Pemberian Pemberian

Lalan, …………………………………….. Pukul ……………….

Dokter Penanggung Jawab Pelayanan

…………………………………………….
Tanggal Keluhan Terapi Ket Paraf
 LEMBAR OBSERVASI PERAWAT
CATATAN PERKEMBANGAN

NAMA : ………………………………. L/P Nomor RM : …………………………………

UMUR : ……………. Tahun Bangsal / Kelas : …………………………………
TINDAKAN PARAF
Tgl – Jam CATATAN OBSERVASI INSTRUKSI DOKTER
KHUSUS PERAWAT