Formulir Resume Pasien Pulang

RESUME Nomor Rekam Medis:

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 : _______________________________________________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________ Pemeriksaan Fisik : _______________________________________________________ ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________ Pemeriksaan Penunjung/ _______________________________________________________ ________________________________ _______________________ Diagnostik Terpenting : _______________________________________________________ ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________ Terapi/Pengobatan selama ______________________________________________________ _______________________________ _______________________ Di Puskesmas : _______________________________________________________ ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________ Hasil Konsultasi: _______________________________________________________ ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________  _______________________________________________________  ________________________________ _______________________ Diagnosis Utama: ____________________________________ ICD 10: ____________________ Diagnosis 1. _______________________________ _______________________________________ ________ ICD 10: Sekunder: 2. _______________________________________ _______________________________________ 3. _______________________________ _______________________________________ ________ 4. _______________________________ _______________________________________ ________

1. 2. 3. 4.

_________________ _________________ _________________ _________________ _________________

Sambungan RESUME MEDIS

Nama Pasien:

Nomor Rekam Medis:

Alergi (Reaksi Obat) ______________________________________________________________  ______________________________________________________________ Hasil Laboratorium ______________________________________________________________ Belum selesai ______________________________________________________________ (Pending) ______________________________________________________________  ______________________________________________________________ Diet: ______________________________________________________________  ______________________________________________________________ Instruksi/Anjuran ______________________________________________________________ Dan Edukasi _____________________________________________________________ (Follow Up) : _____________________________________________________________  ______________________________________________________________  ______________________________________________________________ Kondisi Waktu Keluar:  Sembuh  Rujuk RS  Meninggal  Lain – lain ___________________________________________________________________ Pengobatan Dilanjutkan:  Poliklinik  Rumah Sakit  Puskesmas lain  Dokter Spesialis  Lain – lain ____________________________________________________________________ Terapi Pulang:

Nama Obat

Jumlah

Dosis

Frekuensi

Cara Pemberian

Pilangkenceng, Dokter Penanggung Jawab Pelayanan

 ____________________________ Tanda Tangan Lembar 1: Pasien

Lembar 2: Rekam Medis