LEMBAR KONSULTASI(ANTAR DPJP)

Konsultasi kepada : dr. Dari :dr.

PERMINTAAN KONSULTASI
Teman Sejawat Yth,
Sudilah kiranya memeriksa dan mengobati pasien ( nama tersebut diatas ) dengan
kemungkinan / sangkaan ........................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
1. Pasien ini diobati untuk ....................................................................................
............................................................................................................................................................
Telah ditemukan kelainan-kelainan dan keadaan pasien saat ini :
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
2. Pengobatan yang telah dilakukan
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
3. Mohon perhatian khusus terhadap
............................................................................................................................................................
............................................................................................................................................................
Sudilah sejawat untuk :
a. Alih Rawat
b. Rawat Bersama
c. Konsultasi 1 X
Atas bantuannya, diucapkan terima kasih

Kendari, 20

Dokter yang mengirim

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