RESUME MEDIS
Nama Pasien : …………………………………………... No. Jaminan : ………………………………………..
Tempat, tgl lahir: …………………………………………... Tgl. Masuk : ………………………………………..
Umur : …………………………………………... Tgl. Keluar : ………………………………………..
Jenis Kelamin : …………………………………………... Dokter Pengirim : ………………………………………..
Alamat : …………………………………………... DPJP : …………………………………….....
1. JENIS KASUS
Lainnya : .........................................................................................
2. Diagnosis Awal
a. Anamnesis singkat:
.............................................................................................................................................................
.............................................................................................................................................................
b. Pemeriksaan Fisik : Keadaan Umum
penderita:.............................................................................................
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
(.................................................)
021a/02/RI/Rev.01/MS/2020