PEMERINTAH KABUPATEN LAHAT

DINAS KESEHATAN
UPTPUSKESMAS PAGAR GUNUNG
Jalan. Lintas Pagar Gunung – Mulak Desa Tanjung Agung
Telp : 081231565660, e-mail : pkmpagargunung123@gmail.com

RESUME MEDIS (SUMMARY LETTER)

Ruang : Nama :
Kelas : Tanggal Lahir :
No.Register : No. Med.Rec :
Taggal Masuk : Alamat :
Tanggal Keluar :
1. Anamnesis (Reason for admissnon)
Keluhan Utama (main complain):............................................................................................................................................
Riwayat perjalanan penyakit (history of illnes ):.......................................................................................................................
.................................................................................................................................................................................................
2. hPemeriksaan Fisik (Physical examination):.............................................................................................................................
.................................................................................................................................................................................................
3. Temuan Klinik (clinical finding):

Pemeriksaan Radiologi : Tidak Ya, Sebutkan .......................................................................................................

Pemeriksaan PA : Tidak Ya, Sebutkan........................................................................................................
Pemeriksaan Labor : Tidak Ya, Sebutkan........................................................................................................
Lain-Lainnya (jika ada) : Tidak Ya, Sebutkan........................................................................................................
4. Diagnosa (Diagnosis):

Diagnosa masuk (ICD 10) : ....................................................................................ICD X

: ....................................................................................ICD X

Diagnosa akhir (ICD 10) :

X Utama : ....................................................................................ICD X
X Sekunder : ....................................................................................ICD X
................................................ ....................................................................................ICD X
Diagnosa kompikasi : ....................................................................................ICD X
..............................................................................................................................................ICD X
..............................................................................................................................................ICD X
5. Pengobatan selama dirumah sakit (therapy):..........................................................................................................................
.................................................................................................................................................................................................
6. Tindakan selama dirmah sakit (proseduer):...................................................................................................Kode ICD-9 CM
.......................................................................................................................................................................Kode ICD-9 CM
7. Alasan Pulang (discharge reason) : Sembuh □ Dapat berobat Jalan □ Pulang paksa □ Cacat □ Meninggal □
Pindah Ke RS lain:...................................
8. Kondisi saat pulang (discharge condition): .............................................................................................................................
.................................................................................................................................................................................................
9. Pengobatan lanjutan : Poliklinik Puskesmas RS lain...........................................................................
10. Anjuran / rencana lanjutan / kontrol (follow up)
Diet :..............................................................................................................................................
Obat Pulang :...............................................................................................................................................

Nama Obat Jumlah Dosis Frekuensi Cara Pemberian Petunjuk Khusus

Perawat (attending physician) Tanggal/ Date :

Pukul/ Tiime :
Dokter/ Asisten

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