RM 16

RUMAH SAKIT Nama : .................................................................

amanah umat
PURWOREJO
Tgl. Lahir
Alamat
:
:
.................................... Jenis Kel : L / P
.................................................................
Jl. Brigjend Katamso No. 144 A Purworejo 54115 Tanggal Masuk : .................................................................
Telp. (0275) 325260 Fax. (0275) 324776 Tanggal Keluar : .................................................................
IGD (0275) 324211
Ruang : .................................................................

RINGKASAN KELUAR (RESUME)

Diagnosa Utama :
....................................................................................................................... ICD 10 : .............................................
....................................................................................................................... ICD 10 : .............................................
Diagnosa Tambahan :
....................................................................................................................... ICD 10 : .............................................
....................................................................................................................... ICD 10 : .............................................
Tindakan Prosedur Operasi :
....................................................................................................................... ICD 9 CM : ........................................
....................................................................................................................... ICD 9 CM : ........................................

Riwayat Penyakit : .................................................................................................................................................................

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

Laboratorium : .......................................................................................................................................................................
...................................................................................................................................................................................................
Pemeriksaan penunjang lain : ..............................................................................................................................................

- EKG : ..................................................................................................................................................
....................................................................................................................................................
- Rontgen : ..................................................................................................................................................
....................................................................................................................................................
- CT Scan : ..................................................................................................................................................
....................................................................................................................................................
- Pemeriksaan lain : ..................................................................................................................................................
....................................................................................................................................................
Terapi / Pengobatan : .............................................................................................................................................................
...................................................................................................................................................................................................
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Instruksi Perawatan Lanjutan : ............................................................................................................................................

...................................................................................................................................................................................................
...................................................................................................................................................................................................
Cara Pulang : Ijin Dokter Pindah Rumah Sakit Permintaan Sendiri Melarikan Diri Rujuk
Kondisi Saat Pulang : Sembuh Membaik Belum Sembuh Meninggal
Pengobatan Lanjut Ke : Poliklinik Puskesmas/Dokter Keluarga RS..............................

Purworejo, ......................................
Dokter Penanggung Jawab Pasien

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