02
Rumah Sakit No. RM :.........................................
PERMATA HUSADA
Jln Ir. Pangeran M. Noor No. 50A RT. 004 RW. 001 Kelurahan Sungai Ulin, Nama :........................................... L / P
Kecamatan Banjarbaru Utara, Kota Banjarbaru Kalimantan Selatan
Tlp : (0511) 5912712
Tgl. Lahir :......................................(........th)
RINGKASAN MASUK DAN KELUAR
Pertama Rawat terakhir ALERGI
Perawatan
Kedua tgl.:
yang ke :
Ketiga TIDAK YA :
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Alamat : Penanggung jawab dalam kondisi darurat :
nama :
telpon :
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DIAGNOSIS AKHIR
Diagnosis Utama : ICD-X :
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Et Causa :
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Komplikasi :
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Diagnosis Sekunder :
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TINDAKAN ICD-9CM
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KONDISI PASIEN
Cara keluar: Saat masuk : Saat keluar : Pasien meninggal :
Dipulangkan Baik Penampilan : Penyakit : Sebab :
Atas Permintaan (APS) Cukup Baik Sehat Terminal state Kecelakaan / KTD
Lemah Cukup Cacat Progresi penyakit
Lari Bunuh diri
Jelek Lemah Mulai sembuh Penyulit terapi
Meninggal Jelek Belum sembuh Usia / senesens
Jelek sekali Penyulit operasi
Dirujuk ke ................ Jelek sekali Meninggal ......... jam ............................
DPJP Akhir : Perawat Penanggung Jawab :