DINAS KESEHATAN
Nomor Rekam
Medis:
Nama Pasien: Tanggal Lahir: Umur: Jenis Kelamin:
L/P
Tanggal Masuk: Tanggal Keluar/Meninggal: Ruang Rawat Terakhir:
RESUME MEDIS
Ringkasan Riwayat Penyakit : ________________________________________________________
________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Pemeriksaan Fisik : ________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Pemeriksaan Penunjung/ _________________________________________________________
Diagnostik Terpenting : _________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Terapi/Pengobatan selama ________________________________________________________
Di Puskesmas : _________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Hasil Konsultasi: _________________________________________________________
________________________________________________________
_________________________________________________________
_________________________________________________________
Nama Pasien:
Nomor Rekam Medis:
Pengobatan Dilanjutkan:
Poliklinik
Rumah Sakit
Puskesmas lain
Dokter Spesialis
Lain – lain ____________________________________________________________________
Terapi Pulang:
Nama Obat Jumlah Dosis Frekuensi Cara Pemberian
Muara Hemat,
Dokter Penanggung Jawab Pelayanan
______________________________
Tanda Tangan
Lembar 1: Pasien
Lembar 2: Rekam Medis