No.

RM :
Nama :
UPT PUSKESMAS Tgl Lahir : L/P
PERUMNAS 1 LEMBAR RUJUKAN PASIEN
KE RUMAH SAKIT

Kepada Yth. : dr. : .........................................................

Bagian : .............................. RS : ...............................................................................................................................

Dengan ini mohon pemeriksaan lebih lanjut pada penderita :

Nama : ..................................................................................................................
Tanggal Lahir : ..................................................................................................................
Jenis Kelamin : ..................................................................................................................
Alamat : ..................................................................................................................
Jenis Pembayaran : ..................................................................................................................

Alasan Masuk : ..................................................................................................................

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Temuan yang signifikan : ..................................................................................................................
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Dengan hasil pemeriksaan sebagai berikut :
Anamnesa : ..................................................................................................................
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Pemeriksaan Fisik : ..................................................................................................................
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Pemeriksaan Laboratorium : ..................................................................................................................
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Pemeriksaan Foto : ..................................................................................................................
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Lain – lain : ..................................................................................................................
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Diagnosa : ..................................................................................................................
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Obat yang telah diberikan : ..................................................................................................................
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Alasan dirujuk : ..................................................................................................................
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Observasi kondisi pasien : ..................................................................................................................
selama di perjalanan : ..................................................................................................................
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Atas bantuan dan perhatian serta kesediaan sejawat memberikan kabar kepada kami diucapkan terima kasih.

Pontianak, ...............................

Dokter yang merujuk, Perawat yang merujuk Perawat yang menerima pasien

Nama, tanda tangan Nama, tanda tangan Nama, tanda tangan

Dibuat Rangkap 2 ; satu lembar untuk Puskesmas, satu lembar untuk Rumah Sakit rujukan