PEMERINTAH KOTA BEKASI NRM. : ….............................

DINAS KESEHATAN Nama Pasien : …...........................

RSUD KELAS D TELUK PUCUNG Tanggal Lahir : …............................
Jl. Lingkar Utara Rt 002 RW 006 Umur : ………………Tahun/Bulan
kel. Teluk Pucung kec. Bekasi Utara. Kota Bekasi. Jawa barat Jenis Kelamin : L/P

Alamat Lengkap : .........................................

...........................................
( Tempelkan stiker disini/jika ada )
LEMBAR KONSULTASI

Dokter Yang Merawat : ….......................................................................….......................................................................….......................................................................….................................................................

Yth. Sejawat dr. : .............................................................…......................................................................,….......................................................................…......................................................................…......

Pada pemeriksaan pasien tersebut, didapatkan :
....................................................................................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................................................................................

Diagnosa
: .............................................................................................................................................................................................................................................................................................
Diagnosa Banding.
: .............................................................................................................................................................................................................................................................................................
Terapi yang sudah diberikan :

....................................................................................................................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................................................................................................................

Mohon bantuan sejawat untuk:

Konsul Ambil alih untuk pemeriksaan dan pengobatan selanjutnya

Rawat Bersama Pemeriksaan prebedah dan anjuran oleh dokter anestesi

Lainnya : …..............................................................................................................................................................................................................................................................................................................

Tanggal:
Tanda tangan

(dr. )

JAWABAN KONSULTASI

Yth. Sejawat dr : ...........................................................................................................................................................................................................................................................................................................

Bersama ini kami :

Kembalikan kepada sejawat

Rawat bersama

Bila sejawat setuju akan kami ambil alih untuk pemeriksaan dan pengobatan lebih lanjut

Lainnya : …..........................................................................................................................................................................................................................................................................................................

Pada pemeriksaan pada pasien tersebut, kami dapatkan:

...................................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................................

...................................................................................................................................................................................................................................................................................................................................

Diagnosa
: .............................................................................................................................................................................................................................................................................................
Diagnosa Banding.
: .............................................................................................................................................................................................................................................................................................
Terapi dan anjuran:

...................................................................................................................................................................................................................................................................................................................................

...................................................................................................................................................................................................................................................................................................................................

Terima kasih atas kepercayaan sejawat kepada kami,

Tanggal :

Tanda tangan. :

(dr. )

rsud btg/triase/I/2020/004/00
...................................................….......................................................................….................................................................

.....................................,….......................................................................…......................................................................…......

rsud btg/triase/I/2020/004/00