KLINIK PRATAMA RAWAT INAP

AISYIYAH SRAGEN
Jl. Pemuda No 4 Kauman, Sragen Wetan, Sragen
Telp. 0271-892889, Kode Pos 57214

RINGKASAN PULANG
LABEL PASIEN
Nama Pasien : ........................................................... Ruang : .............................
Tgl. Lahir/Jenis Kel : ........................................................... Pasien masuk : tgl .............jam......
No. RM : ........................................................... Pasien keluar : tgl ..............jam......
Alamat : ............................................................
(Harap diisi atau menempelkan stiker bila ada)

DI ISI OLEH DOKTER

1. KELUHAN UTAMA :
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2. RIWAYAT PENYAKIT DAN PEMERIKSAAN FISIK :
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3. DIAGNOSA MASUK :
a. ...................................................................................................................................................
b. ...................................................................................................................................................
4. DIAGNOSA AKHIR / UTAMA :
.............................................................................................................................................................
5. DIAGNOSA SEKUNDER :
a. ........................................................................................................ ( ICD X .............................. )
b. ........................................................................................................ ( .......................................... )
c. ........................................................................................................ ( .......................................... )
d. ........................................................................................................ ( .......................................... )
e. ........................................................................................................ ( .......................................... )
f. ........................................................................................................ ( .......................................... )
g. ........................................................................................................ ( .......................................... )
h. ........................................................................................................ ( .......................................... )
6. TEMUAN PENTING :
a. Laboratorium : .............................................................................................................................
b. Radiologi : ............................................................................................................................
c. Lain-lain : ............................................................................................................................
7. TINDAKAN MEDIS OPERATIF :
a. ......................................................................................................... ( ICD XI ............................ )
b. ......................................................................................................... ( ......................................... )
c. ..........................................................................................................( ......................................... )
8. TINDAKAN MEDIS NON OPERATIF :
a. ......................................................................................................... ( ICD XI ............................ )
b. ......................................................................................................... ( ......................................... )
c. ..........................................................................................................( ......................................... )

Keterangan : Lembar 1 : untuk pasien, Lembar 2 : Untuk arsip Dokumen Rekam Medis, Lembar 3 :untuk administrasi
 RINGKASAN PULANG (2)
LABEL PASIEN
Nama Pasien : ........................................................... Ruang : .............................
Tgl. Lahir/Jenis Kel : ........................................................... Pasien masuk : tgl .............jam......
No. RM : ........................................................... Pasien keluar : tgl ..............jam......
Alamat : ............................................................
(Harap diisi atau menempelkan stiker bila ada)
DI ISI OLEH DOKTER
9. RIWAYAT PEMBERIAN OBAT DI RUMAH SAKIT / KLINIK
a. Obat yang diberikan :
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b. Reaksi obat / efek samping obat : (coret yang tidak perlu)
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DILANJUTKAN DI RUMAH
Nama Obat Jumlah Cara Pemberian Petunjuk Khusus

10. PROGNOSIS : .................................................................................................................................

11. PERINTAH WAKTU PULANG DAN TIDAK LANJUT
a. Pemeriksaan Penunjang : .........................................................................................................
b. Di rujuk ke : RS .......................................... Lain-lain .........................
c. Kondisi waktu keluar RS : Dalam Perbaikan Cacat Meninggal <48 jam
Meninggal >48 jam Lain-lain
d. Kontrol kembali tanggal : ..........................................................................................................
e. Kemoterapi kembali tanggal : .....................................................................................................
12. KONDISI PASIEN SAA AKAN PULANG :
Kesadaran : ............ TD : .......... mm/Hg, S : ......... OC, RR : ........... x/mnt, HR : ........... x/mnt
Alkes yang masih terpasang : ............. Kondisi Alkes ........... Luka : .......... Kondisi luka : ............
Lain – lain : ........................................................................................................................................

Diterima, Sragen , ..............................................

Dokter,

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Pasien/ penanggung jawab Tanda tangan & nama terang