PEMERINTAH KABUPATEN SUMBA BARAT DAYA PEMERINTAH KABUPATEN SUMBA BARAT DAYA

RUMAH SAKIT UMUM DAERAH PRATAMA REDA BOLO RUMAH SAKIT UMUM DAERAH PRATAMA REDA BOLO
Jl. Weelonda, Ds. Watukawula Kec Tambolaka – Sumba Barat Daya Jl. Weelonda, Tambolaka – Sumba Barat Daya

SURAT RUJUKAN SURAT RUJUKAN

Nomor : / / /RSUD/ /20... Nomor : / /RSUD/ /20...

Kepada Yth : Kepada Yth :

TS : ............................................ TS : ............................................
di : ............................................ di : ............................................

Dengan hormat. Dengan hormat.

Bersama ini saya rujuk penderita :
Nama : .................................................................................................................................
No. Identitas : .................................................................................................................................
Umur : .............tahun / bulan / hari*, Jenis Kelamin : Laki-laki / Perempuan*
Alamat : .................................................................................................................................
.................................................................................................................................
Anamnesis : .................................................................................................................................
Pemeriksaan Fisik : .................................................................................................................................
.................................................................................................................................
Diagnosis/Diagnosis Sementara : ............................................................................................................
............................................................................................................................. Kode ICD : ...............
Pengobatan/tindakan selama dalam perawatan di RSUD Pratama Reda Bolo : ....................................
..................................................................................................................................................................
Mohon Pemeriksaan/tindakan selanjutnya berupa : ................................................................................
..................................................................................................................................................................
Atas kerjasamanya diucapkan terimakasih.
Bersama ini saya rujuk penderita :
Nama : .................................................................................................................................
No. Identitas : .................................................................................................................................
Umur : .............tahun / bulan / hari*, Jenis Kelamin : Laki-laki / Perempuan*
Alamat : .................................................................................................................................
.................................................................................................................................
Anamnesis : .................................................................................................................................
Pemeriksaan Fisik : .................................................................................................................................
.................................................................................................................................
Diagnosis/Diagnosis Sementara : ............................................................................................................
............................................................................................................................. Kode ICD : ...............
Pengobatan/tindakan selama dalam perawatan di RSUD Pratama Reda Bolo : ....................................
..................................................................................................................................................................
Mohon Pemeriksaan/tindakan selanjutnya berupa : ................................................................................
..................................................................................................................................................................
Atas kerjasamanya diucapkan terimakasih.

Tambolaka, ........../........./............ Tambolaka, ........../........./............

Catatan (Pasien yang membutuhkan rawat inap) Dokter yang memeriksa Catatan (Pasien yang membutuhkan rawat inap) Dokter yang memeriksa
telah menghubungi RS : .................Jam............. telah menghubungi RS : .................Jam.............
Penerima telepon : ........................................... Penerima telepon : ...........................................
Alasan pindah Rs : ........................................... Alasan pindah Rs : ...........................................
........................................................... ...........................................................
*Coret yang tidak perlu TTD dan Nama Lengkap *Coret yang tidak perlu TTD dan Nama Lengkap