RM-01

REKAM MEDIS
Nama Pasien :
Nomor RM :
Tanggal lahir :
Alamat :

No Telp :

Melayani Dengan Sepenuh Hati

 RM-02

PERSETUJUAN PASIEN RAWAT INAP No. Rekam Medis : ...............

Yang bertandatangan di bawah ini :

PENANGGUNG JAWAB / PASIEN *)

Nama : ....................................................................................................................

No. KTP / SIM : ....................................................................................................................

Alamat : ....................................................................................................................

Pekerjaan : ....................................................................................................................

Dengan ini menyatakan dengan sesungguhnya bahwa saya setuju untuk dilakukan rawat inap di
kamar .............. Dan sanggup membayar biaya yang timbul selama perawatan terhadap diri
saya/suami/istri/anak/orang tua/saudara*) saya :dengan nama

.............................................................. (L/P) umur : .................................................

Tirtoyudo, .........................................

Petugas Rumah Sakit : Yang Menyatakan :

Tandatangan dan nama terang Tandatangan dan nama terang

CATATAN : .........................................................................................................................

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

*) Coret yang tidak perlu

STATUS PASIEN RM-03

UGD TRIAGE
No. Rekam Medis

NAMA : ........................................................................
JENIS KELAMIN: L / P UMUR : ............................HR/BLN/TH
ALAMAT : ........................................................................
........................................................................ TGL./JAM : ............................/ .................WIB
........................................................................ (kedatangan)

TB GOLONGAN DARAH : ........................

/BB : ....................CM/ ...................K
G

Riwayat Penyakit Dahulu ALERGI : .........................

(RPD) : .......................................................

TGL. JAM : ........................../....................WIB

( penanganan)

SUBYEKTIF :

Ax/ Hx :

OBYEKTIF :

KEADAAN UMUM :
T : ............../................mmHg N : .................X/menit RR : ......................X/menit t : ............. °C
PEMERIKSAAN FISIK :
KEPALA / LEHER :
THORAX :
ABDOMEN :
EXTREMITAS :
TAMPAK DEPAN TAMPAK BELAKANG

RM-04
PEMERIKSAAN PENUNJANG MEDIS (LAB, RO’, EKG, DLL)

ASSESMENT :

DX KERJA : DX BANDING :

PLANNING :

PENATALAKSANAAN :

TINDAK LANJUT :
 PX PULANG PX MRS PX MENOLAK MRS PX MENINGGAL

PX DIRUJUK DLL

DOKTER JAGA UGD

Tirtoyudo, ...........................................

( .......................................................)

RM-05.A
No. RekamMedis

/ /

INSTRUKSI DOKTER

Nama Lengkap : ............................................................ Umur : .......................................................................

Ruangan : ............................................................ Kelas : ......................................................................

Perhatian :untuk semua jenis instruksi yang diberikan oleh dokter, misalnya
mengenai perjalanan penyakit, pemberian obat, diit, perawatan
Tanggal khusus, infus, X-Ray, laboratorium. Jangan lupa tanggal, pukul, Paraf
tanda tangan dan nama terang juga dicantumkan

PERJALANAN PENYAKIT PENGOBATAN / INSTRUKSI

 Perhatian :untuk semua jenis instruksi yang diberikan oleh dokter, misalnya
mengenai perjalanan penyakit, pemberian obat, diit, perawatan
Tanggal khusus, infus, X-Ray, laboratorium. Jangan lupa tanggal, pukul, Paraf
tanda tangan dan nama terang juga dicantumkan

PERJALANAN PENYAKIT PENGOBATAN / INSTRUKSI

No. RekamMedis

/ /
RM-06
INJEKSI
NAMA : ............................................ DX : ....................................
ALAMAT : ............................................. DOKTER :

............................................. RUANG :

UMUR : ............................................JENIS KELAMIN: L / P

TGL : ............................................................. TGL : .............................................................

INJEKSI PAGI SORE MALAM PAGI SORE MALAM
JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET

TGL : ............................................................. TGL : .............................................................

INJEKSI PAGI SORE MALAM PAGI SORE MALAM
JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET
No. RekamMedis

/ /
RM-07

ORAL

NAMA : ............................................ DX

ALAMAT : ............................................. DOKTER :

............................................. RUANG :

UMUR : ............................................JENIS KELAMIN: L / P

TGL : ............................................................. TGL : .............................................................

ORAL PAGI SORE MALAM PAGI SORE MALAM
JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET

TGL : ............................................................. TGL : .............................................................

ORAL PAGI SORE MALAM PAGI SORE MALAM
JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET JAM PRF KET
 ASUHAN KEPERAWATAN / KEBIDANAN RM-08.A

Tgl Diagnosa Perencanaan

Shift Tindakan keperawatan / kebidanan Evaluasi TT
Jam Keperawatan / Kebid Tujuan& KH Intervensi
 ASUHAN KEPERAWATAN / KEBIDANAN RM-08.B

Tgl Diagnosa Perencanaan

Shift Tindakan keperawatan / kebidanan Evaluasi TT
Jam Keperawatan / Kebid Tujuan& KH Intervensi
 RM- 9
No. RekamMedis

CATATAN OBAT / ALKES / /

Nama Lengkap : Umur : .

Ruangan : Kelas :

TANGGAL KEMBALI KET

N NAMA ERA
TTD TTD
O. OBAT/ALKES TG NGA
JML KELUAR PETUGA
L GA S
N

KepalaRuangan
 RM-10
No. RekamMedis
PENEMPELAN SALINAN
/ /
HASIL PEMERIKSAAN LABORATORIUM
Nama Lengkap : ............................................................... Umur : ...................................................................

Ruangan : ................................................................ Kelas : ...................................................................

Tempelkan disini
 RM-11
SURAT KONTROL
KLINIK TIRTA MEDIKA
NO. REKAM MEDIS : .......................................................................................................................................................

NAMA : ...................................................... .................................L/P. UMUR : ................TH/BLN/HR

ALAMAT : ............................................................................................................................................

DX : ...........................................................................................MRS : .................................................

KRS : .................................................

DOKTER : ..............................................................................................................................................

TERAPI : MRS :.............................................................................................................................................

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

KRS : ...........................................................................................................................................

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

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

KONTROL : HARI/TANGGAL : ..................................../...............................................................................

PUKUL /.TEMPAT : ..................................../ ..............................................................................

SARAN-SARAN : .............................................................................................................................................

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

TANGGAL :

MENGETAHUI

DOKTER YANG MERAWAT

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