FORMULIR RUJUKAN

PUSKESMAS
IDENTITAS PASIEN
NAMA PASIEN TEMPAT/TGL LAHIR : ALAMAT : JENIS KONTAK
: KELAMIN :
L/P :
No NIK : No JKN :
RUJUKAN PASIEN
JENIS RUJUKAN : DARURAT/R.INAP
TGL TGL RUJUK : NAMA RUMAH SAKIT YANG DITUJU :
MASUK
DIPUSKE
SMAS:
TRANSPORTASI : PENDAMPIN
AMBULANS PKM : DOKTER
KENDARAAN PRIBADI PETUGAS
KENDARAAN UMUM PKM
KELUARGA
DIAGNOSA :

CODE ICD X :
ALASAN
RUJUK: .................................................................................................................................
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FASKES TUJUAN
RUJUKAN :
KONDISI UMUM PASEN & TANDA VITAL
ANAMNESIS/PEMERIKASAAN FISIK :
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KESADARA SADAR GCS : TEKANAN NAPAS: NADI SUHU
N: TIDAK DARAH : : :
SADAR
NYERI : TIDAK NYERI NYERI
NYERI RINGAN BERAT
RIWAYAT ALERGI :
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PERIKSAAN PENUNJANG (DILAMPIRKAN)
HASIL LABORATORIUM
HASIL EKG
DLL

TERAPI PINDAH
NAMA OBAT JUMLAH DOSIS FREKUENSI CARA
PEMBERIAN
 TINDAKAN DI PUSKESMAS
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FOLLOW UP SELAMA PROSES TRANSFER
JAM KONDISI TEKANAN PERNAPASAN NADI LAIN-
PASEN DARAH LAIN

XXXX, ...................
DPJP RS.Yang DPJP
Menerima, Puskesmas.Yang
Mengirim,

Tanda Tangan Dan

Nama Lengkap
Petugas
Transfer

Tanda Tangan Dan Nama Lengkap

 Nama :

No RM :

Tanggal Masuk :
S (Situation)
Umur :

Diagnosa Masuk :

Keluhan Saat Ini :

Riwayat Penyakit :

B (Background) Alergi :

Terapi Dokter :

Kesadaran :

Tekanan Darah :

A (Assessment) Nadi :

RR :

Suhu :

Tindakan yang
:
R (Recommendation) Sudah Dilakukan

Instruksi Dokter :

Paraf Dokter Paraf Perawat

( ) ( )
 STEMPEL TBAK

TBaK ( Tulis Baca Konfirmasi)

Pemberi Instruksi :

Tanggal :

Jam :

Nama :

Paraf :