FORMULIR RUJUKAN

PUSKESMAS

IDENTITAS PASIEN
NAMA PASIEN :
TEMPAT/TGL LAHIR :
ALAMAT :
JENIS KELAMIN :
KONTAK :
NoNIK :
NoJKN :

RUJUKAN PASIEN
JENIS RUJUKAN:DARURAT/R.INAP
TGL MASUK TGL RUJUK: NAMA RUMAH SAKIT YANG DITUJU:
DIPUSKESMAS:

TRANSPORTASI: PENDAMPING :
AMBULANSPKM DOKTER
KENDARAANPRIBADI PETUGASPKM
KENDARAAN UMUM KELUARGA
DLL

DIAGNOSA:

CODE ICD X:

ALASAN
RUJUK :..........................................................................................................................
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FASKES TUJUAN RUJUKAN :

KONDISIU MUM PASEN&TANDA VITAL

ANAMNESIS/PEMERIKASAAN FISIK:
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 KESADARAN: SADAR GCS: TEKANANDA NAPAS: NADI: SUHU:
TIDAKS RAH:
ADAR
NYERI: TIDAKN NYERIRIN NYERIBE
YERI GAN RAT
RIWAYAT ALERGI:
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PERIKSAANPENUNJANG(DILAMPIRKAN)
HASIL LABORATORIUM
HASIL EKG
DLL
TERAPIPINDAH
CARAPEMBERI
NAMAOBAT JUMLAH DOSIS FREKUENSI
AN

TINDAKAN DI PUSKESMAS
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FOLLOWUP SELAMA PROSES TRANSFER
KONDISIPAS TEKANANDA
JAM PERNAPASAN NADI LAIN-LAIN
EN RAH

……………………,…………………..…
DPJPRS.
Yang Menerima, DPJP Puskesmas.
Yang Mengirim,

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PetugasTransfer

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 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 :
Sudah Dilakukan
(Recommendation)
Instruksi Dokter :

Paraf Dokter Paraf Perawat

( ) ( )

TBaK ( Tulis Baca Konfirmasi)

Pemberi Instruksi : Penerima Instruksi :

Tanggal : Tanggal :

Jam : Jam :

Nama : Nama :

Paraf : Paraf :