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RUMAH SAKIT TK IV 14.07.01 M. YASIN RUMAH SAKIT TK IV 14.07.01 M. YASIN
SURAT RUJUKAN BALIK SURAT RUJUKAN BALIK
Teman sejawat Yth. Teman sejawat Yth.
Mohon kontrol selanjutnya penderita: Mohon kontrol selanjutnya penderita:
Nama :................................................................................................................... Nama :...................................................................................................................
Diagnosa:............................................................................................................... Diagnosa:...............................................................................................................
No. Kartu:............................................................................................................... No. Kartu:...............................................................................................................
Tindak lanjut yang dianjurkan Tindak lanjut yang dianjurkan
Pengobatan dengan obat-obatan : Pengobatan dengan obat-obatan :
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Kontrol kembali ke RS tanggal : ..................................... Perlu Rawat Inap Kontrol kembali ke RS tanggal : ..................................... Perlu Rawat Inap
Lain-lain : ........................................................................ Konsultasi selesai Lain-lain : ........................................................................ Konsultasi selesai
Watampone, - - 20 Watampone, - - 20
Dokter RS, Dokter RS,
( ) ( )