PEMERINTAH KABUPATEN OGAN KOMERING ULU TIMUR

UPTD PUSKESMAS JAYAPURA

KECAMATAN JAYAPURA PROVINSI SUMATERA SELATAN
Jln. Raya Desa Bunga Mayang Kec. Jayapura Kab. OKU Timur Kode Pos
32181
email : pkmjayapuraokut@gmail.comTelp. 082278783737

RESUME Nomor Rekam

MEDIS
Medis:

Nama Pasien: Tanggal Lahir: Umur: Jenis Kelamin: L/P

Tanggal Masuk: Tanggal Keluar/Meninggal: Ruang Rawat Terakhir:

Penanggung Pembayaran: Diagnosis/Masalah Sewaktu Masuk:

Ringkasan Riwayat Penyakit : ________________________________________________________

________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Pemeriksaan Fisik : ________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Pemeriksaan Penunjung/ _________________________________________________________
Diagnostik Terpenting : _________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Terapi/Pengobatan selama ________________________________________________________
Di Puskesmas : _________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Hasil Konsultasi: _________________________________________________________
________________________________________________________
_________________________________________________________
_________________________________________________________

Diagnosis Utama: _____________________________________ ICD 10: ______________________

Diagnosis 1. _________________________________________ ICD 10: 1. ___________________

Sekunder: 2. _________________________________________ 2. ___________________
3. _________________________________________ 3. ___________________
4. _________________________________________ 4. ___________________

Alergi (Reaksi Obat) _______________________________________________________________

________________________________________________________________
Hasil Laboratorium ________________________________________________________________
Belum selesai _______________________________________________________________
(Pending) ________________________________________________________________
 ________________________________________________________________
Diet: _______________________________________________________________
________________________________________________________________
Instruksi/Anjuran ________________________________________________________________
Dan Edukasi _______________________________________________________________
(Follow Up) : _______________________________________________________________
________________________________________________________________
________________________________________________________________
Kondisi Waktu Keluar:
 Sembuh
 Rujuk RS
 Meninggal
 Lain – lain ___________________________________________________________________

Pengobatan Dilanjutkan:
 Poliklinik
 Rumah Sakit
 Puskesmas lain
 Dokter Spesialis
 Lain – lain ____________________________________________________________________

Terapi Pulang:
Nama Obat Jumlah Dosis Frekuensi Cara Pemberian

Jayapura, .............................20
Dokter Penanggung Jawab Pelayanan

______________________________
Tanda Tangan

Lembar 1: Pasien
Lembar 2: Rekam Medis