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PEMERINTAH KABUPATEN BANYUASIN

DINAS KESEHATAN
UPT PUSKESMAS GASING
Jl. Tanjung Api-api Desa Gasing Kecamatan Talang Kelapa
Email : gasing.pkm@gmail.com

RESUME KLINIS PASIEN

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. Tandatanda Vital :

- Tekanan Darah : / mmhg


- Nadi : X/Menit
- Pernafasan : X/ Menit
- Suhu : °C

d. Kelainan yang

bermasalah : ......................................................................................

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

...
IV Diagnosa :

V Tindakan yang dilakukan :

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

VI. Terapi yang diberikan :


a. .................................................................................................................................
.....
b. .................................................................................................................................
.....
c. .................................................................................................................................
......
d. .................................................................................................................................
......
PEMERINTAH KABUPATEN BANYUASIN
DINAS KESEHATAN
UPT PUSKESMAS GASING
Jl. Tanjung Api-api Desa Gasing Kecamatan Talang Kelapa
Email : gasing.pkm@gmail.com

VII Alasan Merujuk :

Gasing,
Dokter yang merujuk

(....................................................)
PEMERINTAH KABUPATEN BANYUASIN
DINAS KESEHATAN
UPT PUSKESMAS GASING
Jl. Tanjung Api-api Desa Gasing Kecamatan Talang Kelapa
Email : gasing.pkm@gmail.com

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