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No. RM :
RESUME MEDIS PASIEN PULANG Nama :
(Discharge Summary) Tgl. Lahir / umur :
Alamat :
Tanggal Masuk : Tanggal Keluar :
(Admision Date) (Discharge Date)
Ruang Rawat Terakhir :
(Last Ward)
 INDIKASI RAWAT INAP :
(Indication Hospitalization)
............................................................................................................................................................
............................................................................................................................................................
 RINGKASAN RIWAYAT PENYAKIT :
(History of Disease Summary)
............................................................................................................................................................
............................................................................................................................................................
 PEMERIKSAAN FISIK :
(Physical Findings)
................................................................................................................................
................................................................................................................................
 PEMERIKSAAN PENUNJANG :
(Supporting Examination)
................................................................................................................................................
................................................................................................................................................
 TERAPI/PENGOBATAN SELAMA DI RUMAH SAKI :
(Therapy / Treatment in Hospital)
................................................................................................................................................
................................................................................................................................................
 REAKSI OBAT: Ya Tidak
Bila ya:
No Nama Obat Manifestasi Keterangan

 DIET :
(Diet)
..............................................................................................................................................................
..............................................................................................................................................................
 HASIL KONSULTASI :
(The Results of Consulations)
..............................................................................................................................................................
..............................................................................................................................................................
 DIAGNOSA UTAMA :
(Primary Diagnosis)
........................................................................................................................ICD 10 : ...................
 DIAGNOSA TAMBAHAN :
(Additional Diagnosis)
........................................................................................................................ICD 10 : ...................
........................................................................................................................ICD 10 : ...................
........................................................................................................................ICD 10 : ...................
........................................................................................................................ICD 10 : ...................
 TINDAKAN/ PROSEDUR/ OPERASI :
(Action/ Procedur/ Surgery)
.......................................................................................................................ICD 9 CM : ...............
.......................................................................................................................ICD 9 CM : ...............
.......................................................................................................................ICD 9 CM : ...............
 RM.UM.06 14 Rev 01

 INSTRUKSI PERAWAT LANJUT/EDUKASI :

(Continued Care Instruction / Education)
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
 Cara Pulang*) :Izin DokterPindah Rumah Sakit Permintaan SendiriMelarikan Diri
 Kondisi Saat Pulang : Sembuh Perbaikan Tidak Sembuh Meninggal <48 jam
Meninggal >48 jam
 TERAPI PULANG
(Take Home Therapy)

No Nama Obat Jumlah Dosis Frekuensi Cara Pemberian

 Kontrol ke :
o Alamat : .................................................................................
o Tanggal : ..................................................................................
 Apabila dalam keadaan emergency dapat menghubungi :
o Nama :..................................................................................
o No. Telp : ...........................................................................................

 PROGNOSIS*) : Ad Vitam : Ad Bonam Ad Malam Dubia ad bonam Dubai ad malam
(Prognosis) Ad Functionam:Ad Bonam Ad Malam Dubai ad bonam Duabi ad malam

*) Beri tanda silang (x) sesuai pilihan

Dibuat rangkap 3 (1 untuk Rekam Medis, 1 untuk Pasien, 1 untuk Penjamin)

Mataram, .........................................
Dokter Penanggung Jawab Pelayanan

(..............................................................)
Tanda Tangan dan Nama Jelas
RM.RI.02/13 Rev 02