RINGKASAN PASIEN MASUK DAN KELUAR RM 01

Diisi oleh Petugas Admisi

1. NAMA LENGKAP PASIEN : .............................................. 2. NO. RM :
3. JENIS KELAMIN : L / P *)
4. TEMPAT / TGL LAHIR : .................................................................... Umur : ........ BB : ........
5. ALAMAT LENGKAP : ...............................................................................................................
RT : ........ RW : ........ Kel : ............................ Kec : ...........................
6. NOMOR TELP. : ...............................................................................................................
7. NOMOR IDENTITAS : ...............................................................................................................
8. STATUS PERKAWINAN : Kawin / Belum / Janda / Duda *)
9. SUKU / BANGSA : ...............................................................................................................
10. AGAMA : Islam / Kristen / Katolik / Hindu / Budha *)
11. PENDIDIKAN TERAKHIR : SD / SMP / SMA / D3 / S1 / ..................... *)
12. PEKERJAAN : PNS / BUMN / TNI / POLRI / Swasta / ..................... *)

13. NAMA AYAH / IBU / SUAMI /

ISTRI *) : ..............................................................................................................
 Pekerjaan : .............................................................................................................
 Alamat : .............................................................................................................
 Nomor Telp. : .............................................................................................................

14. PENANGGUNG BIAYA

a. UMUM
 Nama : .............................................................................................................
b. JAMINAN (JKN, ASURANSI LAIN) *)
 Nama : ..............................................................................................................
Diisi oleh Perawat
15. MASUK RS. : Tanggal : Jam :
Ruang : Kelas :
Dokter / Rumah Sakit Perujuk *) :
Diagnosis Rujukan :
Prosedur Masuk : RJ / IGD *)
Cara Masuk RS : Rujukan / Datang Sendiri *)
DPJP : 1. ......................................... 2. .............................................
Dokter Konsultan : 1. ......................................... 3. .............................................
2. ......................................... 4. .............................................

16. PINDAH RUANG :

Tanggal Jam Ruang / Kelas

*) lingkari yang benar

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Diisi oleh Dokter
DIAGNOSIS KERJA ICD
17. PRIMER ....................................................................................................................... ..................
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18. SEKUNDER ....................................................................................................................... ..................

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19. KOMPLIKASI ....................................................................................................................... ..................

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20. PATOLOGI ....................................................................................................................... ..................

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21. OPERASI / TINDAKAN : ................................................................................................................

ICD 9-CM : ....................................
22. PERTOLONGAN PERSALINAN
ICD 9-CM : ....................................
Tgl Persalinan :
Cara Persalinan : SPONTAN / SC / ..................... *)

23. KEADAAN BAYI :

APGAR SCORE Bugar Tidak Bugar
Diisi oleh Perawat

24. KELUAR RS. : Tanggal : Jam :

25. CARA KELUAR : Sembuh / Pulang Paksa / Rujuk / Meninggal *)
26. LAMA PERAWATAN : ............. Hari / Bulan

Nama dan Tanda Tangan Nama dan Tanda Tangan

Kepala ruangan Dokter yang merawat

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