Nomor Rekam

RESUME MEDIS Medis:

Nama Pasien: Tanggal Lahir: Umur: Jenis Kelamin:
L/P
Tanggal Masuk: Tanggal Ruang Rawat Terakhir:
Keluar/Meninggal:
Penanggung Pembayaran: Diagnosis/Masalah Sewaktu Masuk:

Ringkasan Riwayat Penyakit : __________________________________________

________________________________________
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Pemeriksaan Fisik : _________________________________________
________________________________________
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Pemeriksaan Penunjung/ ___________________________________________
Diagnostik Terpenting : __________________________________________
________________________________________
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________________________________________
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Terapi/Pengobatan selama __________________________________________
Di Puskesmas : _________________________________________
________________________________________
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Hasil Konsultasi: _________________________________________
________________________________________
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Diagnosis Utama: ____________________________ ICD 10: _________________

Diagnosis 1. _______________________________ ICD 10: 1. _____________

Sekunder: 2. _______________________________ 2. _____________
3. ______________________________ 3. _____________
4. ______________________________ 4. _____________
Sambungan RESUME MEDIS

Nama Pasien: Nomor Rekam

Medis:

Alergi (Reaksi Obat) : ________________________________________________

________________________________________________
Hasil Laboratorium :_________________________________________________
Belum selesai ________________________________________________
(Pending) _________________________________________________
________________________________________________
Diet: : _______________________________________________
________________________________________________
Instruksi/Anjuran __________________________________________________
Dan Edukasi ________________________________________________
(Follow Up) : ________________________________________________
________________________________________________
________________________________________________

Kondisi Waktu Keluar:

 Sembuh
 Rujuk RS
 Meninggal
 Lain – lain
______________________________________________________________
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Pengobatan Dilanjutkan:
 Ruang pemeriksaan Umum
 Rumah Sakit
 Puskesmas lain
 Dokter Spesialis
 Lain – lain
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Terapi Pulang:
Nama Obat Jumlah Dosis Frekuensi Cara Pemberian

Tompasobaru,
Dokter Penanggung jawab Pelayanan

Lembar 1: Pasien (……………………………)

Lembar 2: Rekam Medis