PEMERINTAH PROVINSI JAWA TIMUR DRM 50 / REV.

01
DINAS KESEHATAN
RUMAH SAKIT UMUM MOHAMMAD NOER
JL. Bonorogo No. 17 Telp. (0324) 322594 – 323085 NO. RM :..............................................
PAMEKASAN
NAMA :..............................................
Tgl. LAHIR:..............................................

RINGKASAN PULANG

Tgl. Masuk RS : ...................................... Ruang Perawatan : ......................................

Jam : ...................................... Kamar : ......................................
Tgl. Keluar RS : ...................................... DPJP : ......................................
Jam : ...................................... Diagnosa Masuk : ......................................
Tgl. Meninggal : ...................................... Indikasi Rawat Inap : ......................................
Jam : ......................................

1. ANAMNESIS
- Keluhan Utama : .........................................................................................................
- Riwayat Penyakit : .........................................................................................................
.........................................................................................................
.........................................................................................................

2. PEMERIKSAAN FISIK
- Keadaan Umum : .........................................................................................................
- Tanda Vital : Tekanan Darah : .................. Suhu : ..................
Frequensi Nafas : .................. Nadi : ..................
- Pemeriksaan Fisik : .........................................................................................................
.........................................................................................................
.........................................................................................................
.........................................................................................................

3. PEMERIKSAAN PENUNJANG
- Laboratorium : ...............................................................................................
..........
.........................................................................................................
- Radiologi : .........................................................................................................
.........................................................................................................
- Lain- Lain : .........................................................................................................
.........................................................................................................
4. TERAPI/ TINDAKAN MEDIS SELAMA DI RUMAH SAKIT
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

5. DIAGNOSA
- Diagnosa Utama : ......................................................... ICD-10 ....................
- Diagnosa Sekunder : 1. ..................................................... ICD-10 1. .................
2. ..................................................... 2. .................
3. ..................................................... 3. .................
4. ..................................................... 4. .................
- Tindakan/ Prosedur : 1. ..................................................... ICD-9CM 1. .................
2. ..................................................... 2. .................
3. ..................................................... 3. .................
 PEMERINTAH PROVINSI JAWA TIMUR LAMP. DRM 50 / REV. 01
DINAS KESEHATAN
RUMAH SAKIT UMUM MOHAMMAD NOER
JL. Bonorogo No. 17 Telp. (0324) 322594 – 323085 NO. RM :..............................................
PAMEKASAN
NAMA :..............................................
Tgl. LAHIR:..............................................

6. DIET
..............................................................................................................................................
..............................................................................................................................................

7. INSTRUKSI DAN EDUKASI ( TINDAK LANJUT)

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..............................................................................................................................................
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11. KONDISI SAAT PULANG ( Status Present)

- Keadaan Umum : .........................................................................................................
- Kesadaran : ............................................. GCS : ............................................
- Tanda Vital : Tekanan Darah : .................. Suhu : ..................
Frequensi Nafas : .................. Nadi : ..................
Nyeri : ..................
- Catatan Penting ( Kondisi Pasien Saat Ini )
: ........................................................................
............................................................................................................................................
8. CARA KELUAR RS
Pulang Atas Persetujuan Dokter Dirujuk Melarikan Diri
Pulang Atas Permintaan Sendiri Meninggal

9. TINDAK LANJUT
Kontrol Ke Poli : .................................... Hari/ Tanggal : ....................................
Dirujuk Ke : .................................... Hari/ Tanggal : ....................................
Catatan : .........................................................................................................
.........................................................................................................

10. TERAPI PULANG

NO NAMA OBAT JUMLAH DOSIS CARA PEMBERIAN
1
2
3
4
5
6
7
8
9
10

Pamekasan, .......................................
Pasien/ Penanggung Jawab DPJP

............................................... ...............................................
Nama Terang dan Tanda Tangan Nama Terang dan Tanda Tangan

NB:Ringkasan Pulang ini harap dibawa dan ditunjukkan pada dokter yang memeriksa saat kontrol