RSUD dr.

PALEMMAI TANDI
JL.SAMIUN No.2 TELP.0471-21018 KOTA PALOPO

RM.2/RI/2019

RINGKASAN PULANG
Nama Pasien : No. RM : Tgl. Lahir : Jenis Kelamin : L / P

Tgl. Masuk : Tgl. Keluar/Meninggal : Ruang Rawat Terakhir :

Penanggung Pembayaran : Keluhan Saat Masuk RS :

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

....................................................................................................................................

Pemeriksaan Fisis : ....................................................................................................................................

... .................................................................................................................................

Pemeriksaan Penunjang/ ....................................................................................................................................

Diagnostik Terpenting ....................................................................................................................................
....................................................................................................................................

Terapi / Pengobatan ....................................................................................................................................

Selama di Rumah Sakit : ....................................................................................................................................
........................................................................................................................ ............... ........
....................................................................................................................................
Terapi /Pengobatan....................................................................................................................
setelah pulang ...................... ............ ................................................................
........................................................................ ..........
.................................................................................................. ......................................
.......................................................................................................................................................................................

Hasil Konsultasi : ....................................................................................................................................

....................................................................................................................................
Diagnosis Utama .................................................................................. ICD 10 : .................................

Diagnosis 1. ......................................................................... .................................

Sekunder : 2. ......................................................................... ICD 10 : .................................
3. ......................................................................... .................................
4. ......................................................................... .................................
Tindakan / 1. ......................................................................... .................................
Prosedur : 2. ......................................................................... ICD 9 CM : .................................
3. ......................................................................... .................................
4. ......................................................................... .................................
Alergi (Reaksi Obat) ..........................................................................................................................................
..........................................................................................................................................

Instruksi tindak lanjut ...........................................................................................................................................

..... .....................................................................................................................................
* MOHON UNTUK TIDAK MENGGUNAKAN SINGKATAN DALAM PENULISAN DIAGNOSA DAN TINDAKAN SERTA DITULIS DENGAN RAPIH
1/2
Palopo, .................................Jam.......

Dokter Penanggung Jawab Pelayanan Pasien /Keluarga

...................................................... ...................................................
Tanda Tangan dan Nama Lengkap Tanda Tangan dan Nama Lengkap
 RSUD dr. PALEMMAI TANDI
JL. SAMIUN No.2 TLP.(0471)21018 -KOTA PALOPO
Nama Pasien :
Instruksi Pulang :
Edukasi (Follow Up)
Kondisi Waktu Keluar RS :
SEMBUH
BELUM SEMBUH
MEMBAIK
MENINGGAL > 48 JAM
MENINGGAL < 48 JAM
Pengobatan yang dilanjutkan :
Terapi Pulang :
Nama Obat Jumlah
Dokter Penanggung Jawab Pelayanan
......................................................
Tanda Tangan dan Nama Lengkap
RM.2/RI/2019
SURAT KONTROL
No. RM : Tgl.Lahir : Jenis Kelamin : L / P
Kontrol Tanggal :
Poliklinik Tempat :
Rencana Diet ...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
................................................................................. Segera kembali ke Gawat Darurat
................................................................................. Rumah Sakit jika terjadi :
................................................................................ ..............................................................
.................................................................................. ..............................................................
.................................................................................. ..............................................................
.................................................................................. ..............................................................
.................................................................................. ..............................................................
..................................................................................
Cara Keluar :
DIIJINKAN PULANG
PULANG ATAS PERMINTAAN SENDIRI
PINDAH RS
DIRUJUK KE .....................................................
LAIN-LAIN .......................................................
POLIKLINIK UPTDRSUDdr.PALEMMAITD RS. LAIN PUSKESMAS DOKTER LUAR ........
Cara Cara
Dosis Frekuensi Nama Obat Jumlah Dosis Frekuensi
Pemberian Pemberian
Palopo, ......................................... Jam ............
Dokter
Pasien /Penanggung
Keluarga Jawab Pelayanan
...................................................
Tanda Tangan dan Nama Lengkap
Lembar Putih : Rekam Medis
Lembar Pink : Pasien
Lembar Biru : Penjamin 2/2