KLINIK KARYA HUSADA

FORMULIR RUJUKAN PASIEN

Nomor:_____/KLINIK-KH/____/20

Hari/Tanggal : …………………………………………………
Kepada Yth. Dokter jaga………………………………………….
di- Selong

Mohon bantuan perawatan dan pengobatan selanjutnya kepada Pasien:

IDENTITAS PASIEN
Nama :……………………………………………………………. Pria Wanita
Umur :……………………………………………………………. (hr/ bln/ thn)
Alamat :…………………………………………………………….
Agama :…………………………………………………………….
Status Pasien Umum BPJS PBI BPJS Non PBI ………………………
ANAMNESA :............................................................................................................................................
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PEMERIKSAAN FISIK :............................................................................................................................................
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Keadaan Umum Baik Sedang Lemah Buruk
o
GCS:…………….. TD:…./……mmHg N : ……….m/mnt S : ..... C RR : …..x/mnt DJJ:………..x/mnt
PEM. PENUNJANG :............................................................................................................................................
DIAGNOSA K :............................................................................................................................................
TERAPI/TINDAKAN
Obat-obatan :............................................................................................................................................
RJP Balut Tekan IVFD Bidai Oksigen OFT NGT Suction
Hecting Luka Dower Cateter Bagging ETT Tindakan Lain :………………………………
TRANSPORTASI
Mobil Ambulance Kendaraan Umum Kendaraan Pribadi
KOMUNIKASI SEBELUMNYA Ya Tidak
RSUD Dr. Soedjono (118) RS Risa Sentra Medika RS Namira RS Permata Cinta
KRITERIA GAWAT DARURAT MEDIK
Emergency Perawatan Lanjutan
AMBULANCE
Berangkat Jam :……………………Wita Tiba di IGD RS :……………………Wita

Petugas Penerima Keluarga Pasien Petugas Pengirim

(………………………………….) (…..………………………………) (…..………………………………)