RJ.

04/RM/2020/REV1

PEMERINTAH KABUPATEN BELITUNG NAMA :

DINAS KESEHATAN
UPT. RUMAH SAKIT UMUM DAERAH TANGGAL LAHIR :
dr. H. MARSIDI JUDONO
JL. JEND.SUDIRMAN KM 5, TANJUNG PANDAN, BELITUNG
TELP / FAX : 0719-21071 / 22190 NOMOR RM :

RESUME MEDIS IGD / RAWAT JALAN E-KTP :

Tanggal Masuk /Jam:

Riwayat Alergi :
Keadaan Saat Pulang *:
1. perbaikan 2. Meninggal 3. Lain-lain:..............................................
Tindak Lanjut Lanjut Perawatan* :
1. Boleh Pulang 2. Menolak dirawat 3. Dirujuk Ke.................................
*Lingkari Yang Sesuai
Ringkasan riwayat penyakit:
..........................................................................................................................................................................
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Pemeriksaan fisik saat datang:
Keadaan umum: ................GCS:.........T:......... N:........R:.......S:........ skala nyeri :.........
..........................................................................................................................................................................
..........................................................................................................................................................................
Status lokalisata:..............................................................................................................................................
Hasil pemeriksaan penunjang:
Laboratorium::...................................................................................................................................................
Radiologi :.........................................................................................................................................................
Pemeriksaan Penunjang lain:...........................................................................................................................
..........................................................................................................................................................................
Diagnosa:
1........................................................................................................ICD 9/10:.......................
2........................................................................................................ICD 9/10:.......................
3........................................................................................................ICD 9/10:.......................
Terapi :
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
Tindakan:
..........................................................................................................................................................................
Kontrol: ............................................................................................................................................................
Rencana tindak lanjut:......................................................................................................................................
Tempat/tanggal/jam : UPT. RSUD H.M. Judono, Belitung/............................/..............

DPJP

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