RM 12.

0
NO.RM :

NAMA PASIEN :
TGL. LAHIR :
RESUME MEDIS
RSUD dr. R. Soeprapto

RM 12.0
Jl.Ronggolawe No 50 Cepu ALAMAT :
Tgl Masuk : ........................................................................................ Dokter yang Merawat : ..................................................................

Tgl Keluar : ........................................................................................ .......................................................................................................

Diagnosa Masuk : .......................................................................................................................................................................................

Indikasi Rawat : ......................................................................................................................................................................................
Diagnosa Keluar : ......................................................................................................................................................................................
: ............................................................................................................... Kode ICD-10 : .............................................
Komplikasi : .......................................................................................................................................................................................
Tindakan / Operasi : ........................................................................................................................................................................................
............................................... Tgl Dilakukan : ................................................. Kode ICD-9 CM : ..............................

Anamnesa
 Keluhan Utama : .......................................................................................................................................................................
 Gejala Penyerta : ......................................................................................................................................................................
 Riwayat Penyakit Dahulu : ........................................................................................................................................................................

Temuan Penting
 Pemeriksaan Fisik : .......................................................................................................................................................................
 Pemeriksaan Penunjang :
 Laboratorium : .......................................................................................................................................................................
 Pencitraan Diagnostik : .........................................................................................................................................................................
 Lainnya : ........................................................................................................................................................................

Konsultasi : .......................................................................................................................................................................
Obat Selama Perawatan : .......................................................................................................................................................................
Kondisi Saat Pulang : Sembuh Membaik Belum Sembuh Cara Pulang : Diijinkan pulang Lari
Meninggal<48 jam Meninggal>48 jam Atas permintaan sendiri Meninggal
Dirujuk ke ................................................

Obat Pulang : .......................................................................................................................................................................

........................................................................................................................................................................
Instruksi Lanjut
 Tanggal Kontrol : ...................................................................................................................................................................
 Poliklinik : ...................................................................................................................................................................
 Edukasi : ...................................................................................................................................................................
 Media Edukasi
Berkelanjutan : ...................................................................................................................................................................
 Lain- lain : ...................................................................................................................................................................

Cepu, .............................................. Jam : ...............

Pasien / Keluarga Perawat/Bidan Dokter yang Merawat
................................................... ................................................... ...................................................
(Tanda tangan dan nama terang) (Tanda tangan dan nama terang) (Tanda tangan dan nama terang)

Rev.1.22

Rangkap 1 : Arsip RS
2 : Untuk Pasien
3 : Untuk Praktisi Kesehatan Lanjutan
4 : Persyaratan Klaim