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DINAS KESEHATAN KABUPATEN LAMONGAN

UPT PUSKESMAS KECAMATAN MADURAN

REKAM MEDIS RAWAT JALAN


No. RekamMedis : No. Sikda :
Nama :……………………………………… (Tn/Ny/Nn/Sdr/An/By) (L/P)
Tempat/tanggal lahir :........................................................... Umur : …………(Th/Bln)
Alamat : ………………………………… No. BPJS : …………………………
DIAGNOSA PARAF
TGL POLI PEMERIKSAAN PENATALAKSANAAN KIE
(Kode ICD X) PETUGAS
Jam panggil :...... selesai : ...... Tx :
Anamnesa: ................................
Keluhan Utama : ................................
.................................................. ................................
................................................. ................................
RPS : ................................
................................................. ................................
................................................. ...............................
RPD: Rujuk :
................................................ ................................
Pemeriksaan fisik : ...............................
TD : t :
n : BB : kg
RR : TB : cm
..................................................
..................................................
Pemeriksaan penunjang
..................................................

Jam panggil :...... selesai : ...... Tx :


Anamnesa: ................................
Keluhan Utama : ................................
.................................................. ................................
................................................. ................................
RPS : ................................
................................................. ................................
................................................. ...............................
RPD: Rujuk :
................................................ ................................
Pemeriksaan fisik : ...............................
TD : t :
N : BB : kg
RR : TB : cm
..................................................
Pemeriksaan penunjang
..................................................
.................................................
Jam panggil :...... selesai : ...... Tx :
Anamnesa: ................................
Keluhan Utama : ................................
.................................................. ................................
................................................. ................................
RPS : ................................
................................................. ................................
................................................. ...............................
RPD: Rujuk :
................................................ ................................
Pemeriksaan fisik : ...............................
TD : t :
n : BB : kg
RR : TB : cm
..................................................
Pemeriksaan penunjang
..................................................
.................................................
Jam panggil :...... selesai : ...... Tx :
Anamnesa: ................................
Keluhan Utama : ................................
.................................................. ................................
................................................. ................................
RPS : ................................
................................................. ................................
................................................. ...............................
RPD: Rujuk :
................................................ ................................
Pemeriksaan fisik : ...............................
TD : t :
N : BB : kg
RR : TB : cm
..................................................
Pemeriksaan penunjang
..................................................
.................................................
Jam panggil :...... selesai : ...... Tx :
Anamnesa: ................................
Keluhan Utama : ................................
.................................................. ................................
................................................. ................................
RPS : ................................
................................................. ................................
................................................. ...............................
RPD: Rujuk :
................................................ ................................
Pemeriksaan fisik : ...............................
TD : t :
N : BB : kg
RR : TB :
..................................................
Pemeriksaan penunjang
..................................................
.................................................
Jam panggil :...... selesai : ...... Tx :
Anamnesa: ................................
Keluhan Utama : ................................
.................................................. ................................
................................................. ................................
RPS : ................................
................................................. ................................
................................................. ...............................
RPD: Rujuk :
................................................ ................................
Pemeriksaan fisik : ...............................
TD : t :
N : BB : kg
RR : TB : cm
..................................................
Pemeriksaan penunjang
..................................................
.................................................
Jam panggil :...... selesai : ...... Tx :
Anamnesa: ................................
Keluhan Utama : ................................
.................................................. ................................
................................................. ................................
RPS : ................................
................................................. ................................
................................................. ...............................
RPD: Rujuk :
................................................ ................................
Pemeriksaan fisik : ...............................
TD : t :
n : BB : kg
RR : TB : cm
..................................................
Pemeriksaan penunjang
..................................................

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