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PEMERINTAH KABUPATEN NGAWI Lbr.

DINAS KESEHATAN
UPTD PUSKESMAS TEGUHAN
Alamat : Jl. Raya Ngawi-Jogorogo No.100 Paron Ngawi (63253)
Telp.081333114446
email: puskteguhan@gmail.com

RESUME MEDIS
Nama Pasien : No BPJS :
Umur / Kelamin : Tgl. Masuk :
Pekerjaan : Tgl. Keluar :
Alamat : Dokter yang merawat :

Alasan datang ke Puskesmas : Penyakit KLL VR

Rujukan : ya, dari ...................................................

tidak, datang sendiri / diantar ......................

1. DIAGNOSA AWAL
a. Anamnesa Singkat : ................................................................................................
.................................................................................................
.................................................................................................
b. Pemeriksaan fisik : Keadaan umum pasien : ..................................................

Tensi mmHg Nadi X/Menit

Suhu ⁰C Nafas X/Menit

c. Laboratorium : ..............................................................................................
...............................................................................................
...............................................................................................

2. Terapi / Tindakan
Terapi / tindakan yang diberikan : ..........................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

3. DIAGNOSA AKHIR
.................................................................................................................................................
................................................................................................................................

4. TINDAKAN LANJUT
Sembuh

Dipulangkan, untuk kontrol / berobat jalan periodik tiap :

Dirujuk ke .................................. atas dasar tempat penuh

Meninggal pengobatan lebih lanjut

Pulang atas permintaan sendiri

Teguhan, .......................................
Dokter yang merawat

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

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