PEMERINTAH KABUPATEN BADUNG

DINAS KESEHATAN
UPT PUSKESMAS KUTA I
JL. RAYA KUTA NO. 117, KUTA, BADUNG
TELP : (0361) 751311
E-mail : info@puskesmaskutasatu.com
Website : www.puskesmaskutasatu.com

RESUME MEDIS

Nama Pasien :
Tanggal Lahir/Umur :
Jenis Kelamin :
Alamat :
No. RM :

1. Anamnesa : ...............................................................................................................................
.................................................................................................................................
2. Pemeriksaan Fisik :TD : mmHg, HR : x/menit, RR : x/menit, Suhu : 0
C
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
3. Diagnosa : ...............................................................................................................................
4. Tindakan/Terapi : ...............................................................................................................................
.................................................................................................................................
.................................................................................................................................
5. Perjalanan Penyakit :................................................................................................................................
.................................................................................................................................
.................................................................................................................................
6. Cara Keluar : Diijinkan Pulang / Pulang Paksa / Lari / Pindah / Dirujuk ke .................................

Faskes Tempat Rujukan Kuta, ..........................20

Faskes TK 1 (yang merujuk)

(.....................................) (.........................................)

Pasien / Anggota Keluarga

(.........................................)
 PEMERINTAH KABUPATEN BADUNG
DINAS KESEHATAN
UPT PUSKESMAS KUTA I
JL. RAYA KUTA NO. 117, KUTA, BADUNG
TELP : (0361) 751311
E-mail : info@puskesmaskutasatu.com
Website : www.puskesmaskutasatu.com

BUKTI PELAYANAN AMBULAN

IDENTITAS

Nama Pasien : ..........................................................................................

Nomor Kartu BPJS : ..........................................................................................

Tangga lLahir : ..........................................................................................

Jenis Kelamin : P / L

Diagnosa : ..........................................................................................

Waktu Pelayanan Hari : ..............................

Tanggal : ...............................

Jam Berangkat: ................. Jam Tiba : .......................

Nama Faskes TK I : ..........................................................................................

Dirujuk ke : ..........................................................................................

Jarak Tempuh ..................... Km

Faskes TK I Faskes yang dirujuk

(yang merujuk)

(......................................) (.........................................)

Pasien / Anggota Keluarga

(...............................................)
 PEMERINTAH KABUPATEN BADUNG
DINAS KESEHATAN
UPT PUSKESMAS KUTA I
JL. RAYA KUTA NO. 117, KUTA, BADUNG
TELP : (0361) 751311
E-mail : info@puskesmaskutasatu.com
Website : www.puskesmaskutasatu.com

BUKTI PELAYANAN

Yang bertandatangan di bawah ini :

Nama :
Alamat :
Hubungan Keluarga :

Menerangkan bahwa :
Nama Penderita :
Umur :
Nomor Kartu :
NomorTlp/Hp :
Alamat :
Diagnosis :
Tanggal Masuk :
Telah mendapatkan pelayanan dari tanggal ......./......../....... sampai tanggal ......../......../........

...........,................... 20
Dokter / Tenaga Kesehatan Yang Membuat Pernyataan

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