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PEMERINTAH KOTA SURABAYA

DINAS KESEHATAN
UPTD PUSKESMAS KEDURUS
JL. Raya Mastrip No.46 Surabaya 60223 telp : (031) 7663237

RESUME MEDIS RUJUKAN


Nama : Jenis kelamin :L/P
Umur / Tanggal lahir : Unit :
Alamat :
No RM :
Anamnesis : ........................................................................................
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Pemeriksaan Fisik : ........................................................................................


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Laboratorium : ........................................................................................
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Diagnosis : .........................................................................…………

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Terapi prosedur atau tindakan yang telah dilakukan :


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Kebutuhan pasien akan tindak lanjut :

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Petugas RS Rujukan Surabaya,.........................

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

 PUTIH ARSIP PUSKESMAS


 WARNA UNTUK RUMAH SAKIT
 PUTIH ARSIP PUSKESMAS
 WARNA UNTUK RUMAH SAKIT

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