Surat

Rumah jawaban
Sakit : dari Rumah Sakit Rujukan
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Kabupaten :…..................................................
Nomor : 445/ /PKM-DB /2022 Nomor :
Hal : Rujukan Umum / Jamkesmas / BPJS ASKES Lampiran :
Nomor identitras : Hal :
Kepada Yth :
Kepada Yth:
Melalui surat ini kami sampaikan atas : Puskesmas :
Di-
Nama :….................................................................. …................................
Umur :….................................................................. Menjawab Rujukan atas Penderita yang di Rujuk
jenis Kelamin :….................................................................. Oleh :…..............................................
Alamat :….................................................................. Nama :…..............................................
:….................................................................. UMUR :…..............................................
Jenis Kelamin :…..............................................
Dengan Anamnesis sebagai berikut :........................................... Alamat :…..............................................
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........................................................................................................ Kami Temukan :
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........................................................................................................ Anamnesis:…......................................................
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Pemeriksaan Fisik = ……....................................................
K/U =…...............................................
Kesadaran =…............................................... Pemeriksaan (Fisik /Laboratorium / RO / DII) :
TD =…............................................... ….........................................................................
POLS =…............................................... ….........................................................................
RESPIRASI =…............................................... ….........................................................................
SUHU =…...............................................
PF lain dan penunjang =…............................................... Pengobatan dan Tindakan yang telah diberikan
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Dengan Diagnosis Sementara : Anjuran / Lain-lain :…........................................
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Tindakan Serta Theraphy yang diberikan: Atas perhatian Sejawat kami ucapkan Terima Kasih
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•….......................................................................................... Dokter Yang Memeriksa / Merawat
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NIP/NRPTT…...........................
Demikianlah atas bantuan dan perhatian serta kerja samanya.
Tidak lupa kami ucapkan Terima Kasih.

Dusun Besar,….......................................2022
Yang Mengirim /merujuk

dr. MUHAMMAD SUBHAN

NIP.19930328 202203 1 004