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MITRA SETIA

Jl. Garuda No. 22 Ungaran 50514 Jawa Tengah, Indonesia. RM 21


Telp (+62) 24 6923179 Email : mitrasetia.ungaran@gmail.com

RESUME MEDIS
Nama Pasien : …………………………………………... No. Jaminan : ………………………………………..
Tgl lahir : …………………………………………... Tgl. Masuk : ………………………………………..
Umur : …………………………………………... Tgl. Keluar : ………………………………………..
Jenis Kelamin : ………… Dokter Pengirim : ………………………………………..
………………………………... DPJP : …………………………………….....
Alamat : …………………………………………...
Alasan datang ke RS: Penyakit KLL Kecelakaan kerja Kecelakaan lain VR

Rujukan : Ya, dari Poliklinik UII/Dokter : ................................................................................

Ya, dari RS/Puskesmas/Dokter : ................................................................................

Tidak, datang sendiri/diantar : ................................................................................

1. JENIS KASUS

Bedah Trauma Non Trauma Non Bedah Interna Anak


Obsgi

Lainnya : .........................................................................................

2. Diagnosis Awal
a. Anamnesis singkat:
.............................................................................................................................................................
.............................................................................................................................................................
b. Pemeriksaan Fisik : Keadaan Umum
penderita:.............................................................................................

Tensi : ...............mmHg Nadi : ................X / menit BB : ...............Kg

Suhu : ...............ᵒC Nafas : ................X / menit TB : ...............cm

c. Laboratorium *) : .....................................................................................................................
.....................................................................................................................
d. Pemeriks. Radiologi*) : .....................................................................................................................
.....................................................................................................................
e. Pemeriks. lainnya*) : ….................................................................................................................
.....................................................................................................................
3. TERAPI/TINDAKAN
Terapi/Tindakan yang diberikan : .........................................................................................................
: .........................................................................................................
: .........................................................................................................
4. DIAGNOSIS AKHIR

.................................................................................................................................................................
Kategori Kasus : Akut Sub akut Kronis

5. TINDAKAN LANJUT
Sembuh Dipulangkan, untuk kontrol/berobat jalan periodik tiap: ..........................................
Dirujuk: ...............................................
Atas dasar: Tempat penuh Pengobatan lebih lanjut
Ungaran, .........................,........
Dokter yang merawat

(.................................................)

021b/02/RI/Rev.01/MS/2020

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