(Diisi oleh dokter)

No. Rekam Medis :

Nama Pasien :
RESUME PASIEN PULANG
Tanggal Lahir :
(Discharge Summary) Berat Badan :
RSUD Jenis Kelamin : L /P
MAJALENGKA BB Lahir :

TANGGAL MASUK : TANGGAL KELUAR :

RUANG RAWAT TERAKHIR :

 RINGKASAN RIWAYAT PENYAKIT/ANAMNESA :

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 PEMERIKSAAN FISIK :
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 PEMERIKSAAN PENUNJANG :
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 TERAPI PENGOBATAN SELAMA DI RUMAH SAKIT :

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 REAKSI OBAT :  YA  TIDAK

BILA YA :
No. Nama Obat Manifestasi Klinis Keterangan

 DIET : :
..................................................................................................................................................................
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 HASIL KONSULTASI :
..................................................................................................................................................................
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 DIAGNOSA UTAMA :
............................................................................... ICD 10 : ...................................................
 DIAGNOSA TAMBAHAN :
............................................................................... ICD 10 : ...................................................
............................................................................... ICD 10 : ...................................................
............................................................................... ICD 10 : ...................................................
............................................................................... ICD 10 : ...................................................
 TINDAKAN :
............................................................................... ICD 9 CM : ...................................................
............................................................................... ICD 9 CM : ...................................................
............................................................................... ICD 9 CM : ....................................................
............................................................................... ICD 9 CM : ...................................................
............................................................................... ICD 9 CM : ...................................................
............................................................................... ICD 9 CM : ....................................................
............................................................................... ICD 9 CM : ...................................................

RM.RANAP.01/2017

(Diisi oleh dokter)

 INSTRUKSI PERAWATAN LANJUTAN EDUKASI :

....................................................................................................................................................................
....................................................................................................................................................................
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 CARA PULANG :  Izin Dokter  Pindah Rumah Sakit  Permintaan Sendiri  Melarikan Diri

 KONDISI SAAT PULANG :  Sembuh  Perbaikan  Tidak Sembuh  Meninggal < 48 Jam

 Meninggal > 48 Jam

 PENGOBATAN DILANJUTKAN KE :  Poliklinik  RS ...................................................

 Puskesmas  Dokter ............................................
 Lain-lain ........................................................................
 TERAFI PULANG :

No. Nama Obat Jumlah Frekuensi Cara Pemberian

 PROGNOSIS : Ad Vitam :  Ad Bonam  Ad Malam  Dubia Ad Bonam  Dubia Ad Malam

Prognosis *) Ad Functional :  Ad Bonam  Ad Malam  Dubia Ad Bonam  Dubia Ad Malam

 Berilah tanda silang (x) sesuai pilihan
Buat rangkap 3 ( Lembar ke 1 untuk Rekam Medis, Lembar ke 2 untuk Penjamin, Lembar ke 3 untuk
Pasien )
Majalengka, ..............................................
Dokter Penanggung Jawab Pelayanan

( .......................................................... )
NIP.
Tanda Tangan dan Nama Jelas