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PEMERINTAH KABUPATEN MURUNG RAYA

DINAS KESEHATAN
UPT PUSKESMAS PURUK CAHU SEBERANG
Jl. Bhayangkara No.53B.Kel.Puruk Cahu. Kec. Murung Kode Pos 73912
Telp.081235382115, email : pkm.purukcahuseberang12@gmail.com

RESUME KLINIS PASIEN RUJUKAN UPT PUSKESMAS PURUK CAHU SEBERANG

No ...........................................................

Nama pasien : ............................................No register :...................................


Umur : ............................................No BPJS .......................................
Alamat : ...................................................................................................
Riwayat penyakit dahulu : ...................................................................................................
Riwayat penyakit keluarga : ...................................................................................................
Riwayat alergi : ...................................................................................................
Anamnesa : ...................................................................................................
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Pemeriksaan :
 Vital sign :TD =............mmHg. Nadi =.........x/menit, Suhu : ...........c
R =............x/menit, SpO2 =..........% dengan/tanpa O2 .........lpm
 Antropometri : BB............kg. TB: ............cm
 Pemeriksaan fisik : ....................................................................................................
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Pemeriksaan penunjang : ......................................................................................................


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Diagnosa : .......................................................................................................
Terapi : .......................................................................................................
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UPT Puskesmas
Puruk Cahu Seberang,..........................
Petugas

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