RESUME KLINIS PASIEN RUJUKAN

I IDENTITAS PASIEN
a. Nama Pasien :
b. Umur :
c. Jenis Kelamin :
d. Alamat :
e. No. BPJS/Jamkesda :
II Keluhan Utama Pasien :

III Pemeriksaan Fisik

a. Keadaan Umum :
b. GCS :
c. Tanda-Tanda Vital:
 Tekanan Darah: ..............mmHg
 Nadi : ...............x/Menit
 Pernafasan : ................x/Menit
 Suhu : ................ᵒC
d. Kelainan yang bermasalah:
IV Diagnosa:

V Tindakan yang telah dilakukan:

a. ........................................................................................................
b. ........................................................................................................
c. ........................................................................................................
d. ........................................................................................................

VI Terapi yang telah diberikan:

a. ........................................................................................................
b. ........................................................................................................
c. ........................................................................................................
d. ........................................................................................................

VII Alasan Merujuk :

Sei Piring,
Dokter Yang Merujuk