PEMERINTAH KABUPATEN KATINGAN

DINAS KESEHATAN
UPTD KECAMATAN MENDAWAI PUSKESMAS MENDAWAI
Jl. Bandar Jalil No. 79
Email:uptdkesehatan.mendawai@gmail.com
Mendawai 74464

SURAT RUJUKAN
Mendawai,…………………….

Nomor : ………………………………… Kepada Yth………………................

Perihal : ................................................... ...........................................................

Dengan Hormat,
Mohon tindakan serta penanganan lebih lanjut atas pasien :
Nama :..................................................................................................................................
Umur :..................................................................................................................................
Alamat :..................................................................................................................................
Keluhan Utama :...............................................................................................................................
...........................................................................................................................................................
Riw. Kehamilan : G......P.......A...... HPHT :........................... TP:............................

Hasil Pemeriksaan :

KU :.................... Kesadaran:.......................
TD : ................mmHg, N : ........... x/mnt, Rr : ............x/mnt, S: .............
Palp. Abdomen : ...........................................................................................................................
Auskultasi : DJJ : ...................x/mnt. Puctum Maksimum : .............................................
(Pkl..............WIB) VT : Ø..........cm, Portio:................, Ketb..........,UUK.............,Hodge...........
STLD :..................................................................................................................................

Diagnosa Kebidanan : ......................................................................................................................

Tindakan/Therapi :......................................................................................................................
Atas kesediaannya , kami sampaikan Terimakasih.
Hormat Kami,
Bidan Perujuk

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