......................................................................................... Sobek Disini ........................................................................................................
Penderita diterima oleh :
Dengan Diaknosa :.................................................................................................................................................................................
Dikirim oleh UOBF Puskesmas PrambonTergayang Soko-Tuban Ke RS......................................................................................
Nama Penderita :................................................................................Umur.....................................Laki-laki/Perempuan
Lembar untuk Dinas Kesehatan, Pengendalian Penduduk dan Keluarga Berencana
Dokter yang merawat :................................................... ....
Pengobatan lanjutan di :.....................................................
PRAMBONTERGAYANG TS.Dokter...................................... ............................................................TS.DOKTER..........................
Tgl............................20................................................................... Tgl...................................................20.................................................
Di.................................................................
Di UOBF PUSKESMAS PRAMBONTERGAYANG
Bersama ini kami kirim kembali penderita / berita dari
Bersama ini kami kirim penderita dengan : penderita dengan No. Reg : ..............................................................
No.Reg :............................................................................ Nama : ..................................................Umur...............................Th
Nama :............................................................................ Dengan:
Alamat (tempat tinggal tetap/domisisli):................................................. DIAGNOSA :..........................................................................
..................................................................................................................... PERSANGKAAN
Alamat sementara (menumpang):........................................................... Diagnosa akhir :..........................................................................
..................................................................................................................... ..............................................................................................................
Tanggal :.....................................................................................................................................
Nama :.....................................................................................................................................
Dengan : Terapi :..........................................................................
DIAGNOSA :.......................................................................................... ..............................................................................................................
PERSANGKAAN ..............................................................................................................
Keluhan/Gejala Utama : Dengan saran-saran :.........................................................................
..................................................................................................................... ..............................................................................................................
..................................................................................................................... ..............................................................................................................
Tanda Tangan :................................................................................................
..................................................................................................................... Pengawasan selanjutnya:..................................................................
Keterangan lain-lain : ..............................................................................................................
Hasilpemeriksaan : GCS=................. T=.....................mmHg Terapi yang dianjurkan :..................................................................
N=..........x/menit RR=...............x/menit ax=...........°C ..............................................................................................................
..................................................................................................................... ..............................................................................................................
..................................................................................................................... Prognose :..........................................................................
Berupa :................................................................................
Tanda Tangan :...................................................................
..................................................................................................................... Saran-saran lain :..........................................................................
Terapi yang telah diberikan :................................................................... ..............................................................................................................
..................................................................................................................... ..............................................................................................................
..................................................................................................................... Kontrol kembali tgl:..............................................20.........................
Kami mohon : a. Konsultasi Telah meninggal tgl:..............................................20........................
b. Pemeriksaan/ Pengobatan/ Pengawasan Spesialis Karena/setelah :..........................................................................
Dan apabila sudah selesai harap dikirim kembali bersama formulir Salam sejawat,
Pengiriman kembali (kanan) terlampir (yang telah di sobek). Dokter yang memeriksa :
Terimakasih dan salam sejawat Nama :.......................................................................................
Tanda Tangan:...................................................................................
Dokter yang mengirim
dr. SITI NUR AZIZAH
NIP.19781017 201201 2 001
Tanggal :..................................................................................
