PEMERINTAH KABUPATEN ACEH UTARA

DINAS KESEHATAN
UPTD PUSKESMAS BABAH BULOH
Jl. Gampong Teungoh – PT. KKA Desa Babah Buloh
Kec. Sawang – Kab. Aceh Utara
Email : puskesmasbabahbuloh@gmail.com

SURAT PENGANTAR RAWAT INAP/UGD PUSKESMAS

Nomor : 445/ /PKM/2023

Babah Buloh, Tanggal :........................

Kepada Yth, :........................
Bagian :........................
Di - :........................

Dengan hormat,
Mohon konsul/Advus dan tindakan selanjutnya terhadap Pasien :
Nama : .....................................................................
Umur : .....................................................................
Pekerjaan : .....................................................................

No. Kartu : .....................................................................

Alamat : .....................................................................
Keluhan : .....................................................................

Diagnosa : .....................................................................
Obat yang telah diberikan : .....................................................................
: .....................................................................
: .....................................................................
: .....................................................................

DOKTER PUSKESMAS BABAH BULOH

(________________________)
Nip.

Demikian atas kerja sama yang baiak kami ucapkan terima kasih.
..............................................................................................................
..............................................................................................................

RUJUKAN BALIK
Tindak lanjut yang dianjurkan
...................................................................................
...................................................................................
DOKTER …………………….
Terapy
...................................................................................
...................................................................................
...................................................................................
Lain-Lain
................................................................................... (________________________)
................................................................................... Nip
...................................................................................
 PEMERINTAH KABUPATEN ACEH UTARA
DINAS KESEHATAN
UPTD PUSKESMAS BABAH BULOH
Jl. Gampong Teungoh – PT. KKA Desa Babah Buloh
Kec. Sawang – Kab. Aceh Utara
Email : puskesmasbabahbuloh@gmail.com

RESUME MEDIS
Nomor Rekam Medik :

Nama Pasien :............................................. No. Identitas Peserta JKN :......................

Umur :............................................. Jenis Kelamin :......................
Alamat :.................................................................................................................
Ruang Rawat :.................................................................................................................
Tanggal Masuk :................................., Pukul : WIB
Tanggal Keluar/Meninggal :................................., Pukul : WIB

Keluhan ketika Masuk : ......................................................................................................

......................................................................................................
......................................................................................................
Anamnesa ketika masuk : ......................................................................................................
......................................................................................................
......................................................................................................
Tanda vital : Tensi :............ mmHg Nadi :..................x /menit
Respirasi :............x/menit Suhu :..................oC
Pemeriksaan Fisik : Kepala :........................... Mata :...............................
Leher :........................... Thorax :...............................
Abdomen :........................... Ekstremitas :...............................
Lain-lain :......................................................................................
Pemeriksaan Penunjang : ......................................................................................................
......................................................................................................
Diagnosa Akhir : ......................................................................................................
Terapi yang di berikan : ......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
Keadaan saat keluar : sembuh/Dirujuk ke RS/Pulang APS/Meninggal/Lain-Lain*
Anjuran : ......................................................................................................
......................................................................................................
......................................................................................................

Babah Buloh, 2023

Dokter yang merawat

(_____________________)
Nip.