RSD MANGUSADA KABUPATEN BADUNG RM.2.

20
Nama :
FORMULIR RAWAT JALAN
Tgl Lahir : L/P
LAYANAN KEDOKTERAN FISIK
DAN REHABILITASI No RM :
M
Tgl :……../……../……. Jam :……….Wita ...... Klinik : E
A. Diisi Oleh Pasien
Nama
Tanggal Lahir
:..........................................................................................................................................................
: .........................................................................................................................................................
D
Alamat
Telp/No. HP
: .........................................................................................................................................................
: ......................................................................................................................................................... I
Penanggung Jawab : .........................................................................................................................................................
Hubungan dengan pasien
B. Diisi Oleh Dokter Sp. KFR
: suami/istri/anak (lingkari jawaban)
S
a. Anamnesa :.......................................................................................................................

b. Pemeriksaan Fisik dan uji Fungsi : .......................................................................................................................

c. Diagnosis Medis (ICD-10) : .......................................................................................................................

d. Diagnosis Fungsi (ICD-10) : .......................................................................................................................

e. Pemeriksaan Penunjang : .......................................................................................................................

f. Tata Laksana KFR (ICD-9 CM) : .......................................................................................................................

g. Anjuran : .......................................................................................................................

h. Evaluasi : .......................................................................................................................

i. Suspek Penyakit Akibat Kerja : .......................................................................................................................

Ya....................................................................................................................
Tidak...............................................................................................................

C. Diagnosis:

D. Pemeriksaan Terapi:
TTD
No. Program Tanggal
Pasien Dokter Terapis

Pasien/Keluarga/Penanggung Jawab Dokter

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