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FORM DATA PASIEN YANG DIRUJUK DALAM APLIKASI SISRUTE

NO. REKAM MEDIS : ..........................................................................................................................


NAMA PASIEN : ..........................................................................................................................
NO. KONTAK : ................................. (KELUARGA PENDAMPING ......................................)
................................. (PERAWAT PERUJUK ...............................................)
ALAMAT LENGKAP : ..........................................................................................................................
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TEMPAT LAHIR:
TANGGAL LAHIR : (0000-00-00 / TAHUN-BULAN-HARI)
JENIS KELAMIN : LAKI/PEREMPUAN
NO KARTU JKN : ..........................................................................................................................
NIK (KTP) : ..........................................................................................................................
TUJUAN RUJUK : RS ....................................................................................................................
TRANSPORTASI : AMBULANCE/PESAWAT/KENDARAAN AIR
PILIH AMBULANCE : NO PLAT ................................. DRIVER .........................................................
JENIS RUJUKAN : RAWAT JALAN/RAWAT DARURAT
ALASAN RUJUKAN : - PENANGANAN/PERAWATAN LANJUT PASIEN (MEDIK)
- SARANA PRASARANA (RUANG PERAWATAN BIASA)
- SARANA PRASARANA (RUANG INTENSIVE : ICU, NICU, PICU, HCU)
- SARANA PRASARANA (RUANG ISOLASI)
- DOKTER SPESIALIS/SUB SPESIALIS TIDAK TERSEDIA
- TINDAKAN KHUSUS
KETERANGAN :
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DIAGNOSA : ..........................................................................................................................
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KU PASIEN : SADAR/TIDAK SADAR
TTV : TD ................. MMHG NADI .......... X/MENIT RR .......... X/MENIT
SUHU ............ °C
NYERI : BERAT/RINGAN/TIDAK NYERI
KETERANGAN LAIN (KELUHAN/PEMERIKSAAN FISIK) :
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HASIL LAB : ..........................................................................................................................
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HASIL RADIOLOGI (RO, USG, EKG) :
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TERAPI/TINDAKAN YANG DIBERIKAN (INFUS, INJEKSI, ORAL, TERPASANG ALAT INVASIF) :
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