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RESUME MEDIK

NAMA : ……………………………… NOMOR RM : …………………


ALAMAT : ……………………………… UMUR : …………………
NOMOR KARTU : ................................................ LAKI-LAKI/PEREMPUAN

Dokter Pengirim : ………………………….. Tanggal Masuk : …………………….


Dokter yang Merawat : ………………………….. Tanggal Keluar : .................................
Diagnosa Masuk : .......................................... Diagnosa Keluar: .................................

Anamnesa : .........................................................................................................
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Pemeriksaan Waktu MRS
Pemeriksaan Fisik : ..........................................................................................................
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Laboratorium : ..........................................................................................................
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Lain-lain : ..........................................................................................................
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Pengobatan dan Tindakan : ..........................................................................................................
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Prognosis : ..........................................................................................................
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Pengobatan Lanjutan : .........................................................................................................
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Anjuran : ..........................................................................................................
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Infeksi Nosokomial : Ya Tidak

Keadaan Waktu Keluar : Sembuh Meninggal< 48 jam


Rujuk Meninggal > 48 jam

Sidoarjo, …………………………….
Dokter Yang Merawat

(…………………………………)

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