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 Penunjang/ ___________________________________________________
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. _______________

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
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Terapi Pulang:
Nama Obat Jumlah Dosis Frekuensi Cara Pemberian

Bengkayang,
Dokter Penanggung Jawab Pelayanan

dr. Krista Steffyani Temi Separang

NIP. 198907112022032007

Lembar 1: Pasien
Lembar 2: Rekam Medis