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  • Surat Permintaan Konsultasi

    Diunggah oleh

    Sri Wahyuni Samsir
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    Surat Permintaan Konsultasi.docx

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    Surat Permintaan Konsultasi

    Diunggah oleh

    Sri Wahyuni Samsir

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 1

    PANGKALAN UTAMA TNI AL XIII

    RUMKITAL ILYAS TARAKAN

    NO. RM : ............................

    SURAT PERMINTAAN KONSULTASI


    Nama : ................................................................. Tgl / Pukul : ..............................

    No. RM : ................................................................. Biasa / Cito* : ..............................

    Ruangan : .................................................................

    Kepada Yth.Ts : .................................................................

    Mohon bantuan sejawat atas pasien ini untuk : Konsultasi saat ini / Alih rawat / Rawat bersama*

    Diagnosis kerja : .................................................................

    Keterangan klinik terpenting adalah : ......................................................................................................

    ..................................................................................................................................................................

    ..................................................................................................................................................................

    ..................................................................................................................................................................

    ..................................................................................................................................................................

    ..................................................................................................................................................................

    BTK SS, Wassalam, dr : ........................................

    Spesialis : ........................................

    *Coret yang tidak perlu

    JAWABAN KONSULTASI
    Sesuai permohonan konsultasi pada kasus ini dijumpai : .......................................................................

    ..................................................................................................................................................................

    ..................................................................................................................................................................

    ..................................................................................................................................................................

    ..................................................................................................................................................................

    Saran tindak medik / Pengobatan : ..........................................................................................................

    ..................................................................................................................................................................

    ..................................................................................................................................................................

    ..................................................................................................................................................................

    ..................................................................................................................................................................

    Tarakan, ....................................................
    Hormat kami,

    Dr : .............................................................

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