KLINIK PRATAMA RAWAT INAP

MITRA KELUARGA SEJAHTERA

Jl. Untung Suropati No. 41 Sukowono – Jember ,
Email: klinikmks01@gmail.com, Telp: 082233179899 / 0331-5680906

SURAT RUJUKAN

Dari : Klinik Mitra Keluarga Sejahtera Kepada Yth: .............................

Tanggal : .................................... Sdr. Dokter: ..............................
Di..............................................
Bersama ini kami kirim penderita:
No. RM : .........................
Nama : ....................................................
Status : ( ) Umum ( ) BPJS
Alamat : .............................................................................................................
Anamnesa : .............................................................................................................
Diagnosa : .............................................................................................................
Hasil Pemeriksaan : .............................................................................................................
K/U : .............................................................................................................
GCS : .............................................................................................................
TD : ................ mmHg N : ............................ BB: ………..
Suhu : ............... °C SPO2 : .............................
RR : ................ x/mnt
Terapi yang diberikan : ..........................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Alasan dirujuk : ..........................................................................................................................
Terimakasih dan salam sejawat

Dokter Pengirim

( .........................................)

SURAT JAWABAN RUJUKAN

Dari : ............................................. Kepada Yth: .............................

Tanggal: .................................... Sdr. Dokter: ..............................
Di..............................................
Bersama ini kami kirim penderita:
No. RM : .........................
Nama : ....................................................
Status : ( ) Umum ( ) BPJS
Alamat : .............................................................................................................
Anamnesa : .............................................................................................................
Diagnosa Akhir : .............................................................................................................
Terapi yang diberikan : ..........................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Anjuran : .............................................................................................................
Kontrol Kembali : .............................................................................................................
Telah meninggal tgl : .............................................................................................................
Karena / setelah : .............................................................................................................
Terimakasih dan salam sejawat
Dokter Pengirim

( .........................................)