RUMAH SAKIT CITRA HUSADA

Jl. Dharma Bakti No. 45 C Nanga Pinoh

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MELAWI – KALBAR
Nomor Surat :………………………………… Tgl. Masuk RS : ....................................................
No. RM : ............................. L P
Tgl. Pindah RS : ....................................................
Nama / Umur : ................................../................
Alamat : .................................................... RS Tujuan : ....................................................

Penjamin Pembayaran Umum BPJS ............................ Lainnya : ............................

Alasan Pindah Tempat Penuh Permintaan Pasien / Keluarga

RS
Perlu Pemeriksaan / Perawatan khusus : ....................................................
Transportasi Non Ambulans Ambulans, Pendamping : ……………………

Keadaan Umum : ....................... Kesadaran : ......................... GCS : E ........ V ........ M ........

Tanda-Tanda Vital : Tekanan Darah Nadi Respirasi Suhu SpO2 BB TB

......./......Mmhg .....x/m .......x/m .....oC .....% .....kg .....cm

Keluhan Utama : ....................................................................................................................................

Riwayat Penyakit : ....................................................................................................................................

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Pemeriksaan Fisik : ....................................................................................................................................

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Pemeriksaan Penunjang : ....................................................................................................................................

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Diagnosis : ....................................................................................................................................
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Terapi / Tindakan : ....................................................................................................................................

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Mohon pemeriksaan dan pengobatan lebih lanjut. Atas perhatian dan kerjasamanya, diucapkan terima kasih.
Nanga Pinoh,……………………….

Rumah Sakit Yang Menerima Dokter Penanggungjawab Pelayanan

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Lembar 1 : Rumah sakit tujuan Lembar 2 : Arsip rekam medik Lembar 3 : Penjamin pembayaran