REV.01.07-2019 RM.

18

Rumah Sakit No. RM : ...................................

PERMATA HUSADA Nama :........................................... L / P
Jln Ir. Pangeran M. Noor No. 50A RT. 004 RW. 001 Kelurahan Sungai Ulin,
Kecamatan Banjarbaru Utara, Kota Banjarbaru Kalimantan Selatan
Tlp : (0511) 5912712
Tgl. Lahir :......................................(........th)
RESUME MEDIS
RAHASIA
Tanggal Masuk Tanggal Keluar:
Ringkasan Riwayat :.....................................................................................................................................................................
Penyakit .......................................................................................................................................................................
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Pemeriksaan Fisik :..............................................................
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Pemeriksaan :.....................................................................................................................................................................
Penunjang/ Diagnostik .......................................................................................................................................................................
Terpenting .......................................................................................................................................................................
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Terapi/ Pengobatan :.....................................................................................................................................................................
Selama di Rumah Sakit .......................................................................................................................................................................
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Hasil Konsultasi :.....................................................................................................................................................................
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Diagnosis Utama :................................................................ ICD 10:...................................................
Diagnosis Sekunder :1.............................................................. ICD 10:...................................................
:2.............................................................. ICD 10:...................................................
:3.............................................................. ICD 10:....................................................
:4.............................................................. ICD 10:....................................................
ICD 10:....................................................
Tindakan/ Prosedur :1.............................................................. ICD 9 :....................................................
:2............................................................. ICD 9 :...................................................
Alergi (reaksi Obat) :..................................................................................................................................................................
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Diet :..................................................................................................................................................................
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Intruksi/ Anjuran dan :.....................................................................................................................................................................
Edukasi (Follow Up) .......................................................................................................................................................................
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Kondisi Waktu Keluar :  Sembuh  Membaik  APS  Meninggal  Lain-lain.............................
Pengobatan dilanjutkan :  Poliklinik  RS lain  Puskesmas  Dokter luar
Tanggal Kontrol :...........................................................
Poliklinik :...........................................................
Terapi Pulang :...........................................................
Nama Obat
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Banjarbaru................................................... Dokter Penanggung Jawab Pelayanan

Lembar 1 : Rekam Medis

Lembar 2 : Pasien
Lembar 3 : Jaminan
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