PEMERINTAH KABUPATEN LAHAT PEMERINTAH KABUPATEN LAHAT

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RUMAH SAKIT UMUM DAERAH LAHAT
Jl Letjen Harun Sohar I No 28 Lahat, Kode Pos 31414, Provinsi Sumatera Selatan
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RUMAH SAKIT UMUM DAERAH LAHAT
Jl Letjen Harun Sohar I No 28 Lahat, Kode Pos 31414, Provinsi Sumatera Selatan
Telp/ Fax.(0731) 321785/323080, Email : rsudlahat@yahoo.co.id Telp/ Fax.(0731) 321785/323080, Email : rsudlahat@yahoo.co.id

RM. 53 RM. 53

SURAT RUJUK BALIK SURAT RUJUK BALIK

Teman Sejawat Yth, Teman Sejawat Yth,
Mohon kontrol selanjutnya penderita : Mohon kontrol selanjutnya penderita :
Nama : ................................................................................................ Nama : ................................................................................................

Diagnosa : ................................................................................................ Diagnosa : ................................................................................................

Tindak Lanjut yang dianjurkan Tindak Lanjut yang dianjurkan

Pengobatan dengan obat-obatan :
1) ....................................................................................................
2) ....................................................................................................
3) ....................................................................................................
4) ....................................................................................................
Pengobatan dengan obat-obatan :
1) ....................................................................................................
2) ....................................................................................................
3) ....................................................................................................
4) ....................................................................................................

Perlu Rawat Inap Perlu Rawat Inap

Konsultasi selesai Konsultasi selesai
Kontrol kembali ke RS tanggal : ............................................................... Kontrol kembali ke RS tanggal : ...............................................................
Lain-lain : .......................................................................................... Lain-lain : ..........................................................................................
.......................................................................................... ..........................................................................................

.......................,...20..... .......................,...20.....

Dokter RSUD, Dokter RSUD,

( .............................) ( .............................)