PEMERINTAH KABUPATEN XXXX

DINAS KESEHATAN
UPTD PUSKESMAS

RESUME MEDIS Nomor Rekam Medis:

Nama Pasien: Tanggal Lahir: Umur: Jenis Kelamin: L/P

Tanggal Masuk: Tanggal Keluar/Meninggal: Ruang Rawat Terakhir:

Penanggung Pembayaran: Diagnosis/Masalah Sewaktu Masuk:

Ringkasan Riwayat Penyakit : ________________________________________________________

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Pemeriksaan Fisik : ________________________________________________________
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Pemeriksaan Penunjung/ _________________________________________________________
Diagnostik Terpenting : _________________________________________________________
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Terapi/Pengobatan selama ________________________________________________________
Di Puskesmas : _________________________________________________________
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Hasil Konsultasi: _________________________________________________________
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Diagnosis Utama: _____________________________________ ICD 10: ______________________

Diagnosis 1. _________________________________________ ICD 10: 1. ___________________

Sekunder: 2. _________________________________________ 2. ___________________
3. _________________________________________ 3. ___________________
4. _________________________________________ 4. ___________________

Sambungan RESUME MEDIS

 PEMERINTAH KABUPATEN XXXX
DINAS KESEHATAN
UPTD PUSKESMAS

Nama Pasien:
Nomor Rekam Medis:

Alergi (Reaksi Obat) _______________________________________________________________

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Hasil Laboratorium ________________________________________________________________
Belum selesai _______________________________________________________________
(Pending) ________________________________________________________________
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Diet: _______________________________________________________________
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Instruksi/Anjuran ________________________________________________________________
Dan Edukasi _______________________________________________________________
(Follow Up) : _______________________________________________________________
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________________________________________________________________

Kondisi Waktu Keluar:

 Sembuh
 Rujuk RS
 Meninggal
 Lain – lain ___________________________________________________________________

Pengobatan Dilanjutkan:
 Poliklinik
 Rumah Sakit
 Puskesmas lain
 Dokter Spesialis
 Lain – lain ____________________________________________________________________

Terapi Pulang:
Nama Obat Jumlah Dosis Frekuensi Cara Pemberian

UPTD Puskesmas,
Dokter Penanggung Jawab Pelayanan

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Tanda Tangan

Lembar 1: Pasien
Lembar 2: Rekam Medis