RESUME MEDIS

Nama Pasien : ............................................ No. Jaminan : .......................................

Umur/ Kelamin : ............................................ Tgl. Masuk : .......................................
Agama : ............................................ Tgl Keluar : .......................................
Pekerjaan : ............................................ Paramedis Pengirim : ......................................
Alamat : ............................................ Dokter yang Merawat : ....................................

Alasan datang ke Puskesmas : □ Penyakit □ KLL □ Kecelakaan Kerja □ Kecelakaan Lain □ VR

Rujukan : □ Ya, dari Puskesmas Pembantu ...............................................................
□ Tidak, datang sendiri/ diantar* ......................................................................

1. JENIS KASUS
□ Bedah : □ Trauma □ Non Trauma
□ Non Bedah : □ Interna □ Anak □ Obsgin □ Lainnya

2. DIAGNOSIS AWAL
a. Anamnesis singkat : ..............................................................................................................................
........................................................................................................................................
b. Pemeriksaan Fisik : Keadaan Umum Penderita : .......................................................................
□ Tensi ................... mmHg □ Nadi ........... x/ menit □ BB ............ Kg
□ Suhu .................... °C □ Nafas ......... x/ menit □ TB ........... cm
c. Laboratorium : ..............................................................................................................................
........................................................................................................................................
d. Pemeriksaan lain : ..............................................................................................................................
........................................................................................................................................

3. TERAPI/ TINDAKAN
Terapi/ Tindakan yang : ..................................................................................................................
diberikan .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

4. DIAGNOSIS AKHIR : ..................................................................................................................

....................................................................................................................
Kategori Kasus : □ Akut □ Subakut □ Kronis

5. TINDAKAN LANJUT
□ Sembuh □ Pulang Paksa
□ Dirujuk ke : ................................. Atas dasar : .............................................................
□ Dipulangkan, untuk kontrol/ berobat jalan periodik tiap* ................................................

Tumbang Kunyi, ............................................

* Coret yang tidak perlu Dokter yang Merawat

( .......................................................... )
NIP/ NRPTT ..................................................