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PEMERINTAH KABUPATEN JAYAPURA

DINAS KESEHATAN
UPT RSUD YOWARI SEN TANI
Jln. Raya Sentani - Depapre No.Telp./Fax (0967- 5195084) Doyo Baru 99352

SURAT KONSUL

Kepada Yth : dr. ..................................................... Konsul : □ Alih Rawat


Di Tempat □ Terapi
□ Rawat Bersama
Dengan hormat,
Kami kirimkan penderita
Nama : ......................................................... Kelamin : .....................................................
Umur : ......................................................... Ruangan : .....................................................

Keluhan : ..................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
Pemeriksaan Fisik : KU : .......................................................... Kesadaran : ........................................................
Tanda Vital : TD : ............................. N: .......................... RR: ............................. Sb : ...............................
Kepala : ..................................................................................................................................................
Thoraks : ..................................................................................................................................................
Abdomen : ..................................................................................................................................................
Ekstremitas : ..................................................................................................................................................
Lain-lain : ..................................................................................................................................................
Laboratorium : ..................................................................................................................................................
Radiologi : ..................................................................................................................................................
Diagnosis : ..................................................................................................................................................
Terapi : ..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

Tanggal/Jam ............................./.............
Hormat Kami,

Dr..........................................................

Telah kami laksanakan pemeriksaan atas konsul teman sejawat.


Hasil pemeriksaan adalah sebagai berikut:
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
Kesimpulan/Diagnosis : .........................................................................................................................................
Anjuran terapi : .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Anjuran pemeriksaan : .........................................................................................................................................
Atas perhatiannya kami sampaikan terimakasih.

Setuju : □ Konsul Terapi Tanggal/Jam ............................./.............


Hormat Kami,
□ Konsul Alih Rawat
□ Konsul Rawat Bersama
Dr..........................................................

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