Rm 50. Formulir Rujukan Pasien

FORMULIR RUJUKAN PASIEN PASIEN

Dari R# $$$$$$$$$$$$$$$. $$$$$$$$$$$$$$$$$$$$ *ang ga gal $$$$$$$$$$ $$ $$$$...

Kepada Yth Teman sejawat :

di Bers Bersam amai aini ni kami kami kiri kirimk mkan an pend pender erit ita a deng dengan an : No. No. RM : ____ ______ ____ ____ ____ ____ ____ ____ ____ __ Nama Nama : ______ _________ ______ ______ ______ ______ ______ ______ ______ ______ ______ _____ __ U mu mu r : _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ ( Lk Lk / P rr)) Alamat Alamat : ______ _________ ______ ______ ______ ______ ______ ______ ______ ______ ______ _____ __ DA!N"#A : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.. %elu&an/ge'alautama %elu&an/ge'alautama $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$. ..................................................................................................................................................................... %eterangan %eterangan lainlain: asilpemeriksaan :$$$$$$$$$$$$$$$$$$.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ *erapi *erapi +ang tela& di,erikan : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Dengan Dengan permo&onan permo&onan : a)

FORMULIR JAWABAN RUJUKAN PASIEN

RM 50

%onsultas %onsultasii

,) Pemeriksaan / pengo,atan pengo,atan / pera-atan pera-atan spesialis Dan apa,ila suda& selesai mo&on dikirim ,ersama ormulir pengiriman kem,ali (di sisikanan ) +ang tela& terlampir. *erimakasi& dan salam se'a-at. Dokter +ang mengirim

%epada 0t& *eman se'a-at : ________________________ di ______________________

Bersamaini kami kirim kem,ali penderita / ,erita dari penderita dengan : No. Reg / RM : _________________/ _________________/ Nama Nama : ______ _________ ______ _____ _____ ______ ______ ______ ______ ______ ______ _____ _____ ______ ____ _ Umur Umur :_____ :________ ______ ______ ______ ______ ___ (Laki (Lakilak laki/P i/Pere erempu mpuan) an) Dengan : DA!N"#A P1R#AN!%AAN Diagnosaak Diagnosaak&ir &ir :$$$$$$$$$$ :$$$$$$$$$$$$$$$$ $$$$$$$$$$$$ $$$$$$$$$$$$ $$$$$$$$$$$$ $$$$$$$$$$$$ $$$$$$$$$$$ $$$$$$$$ $$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ *erap *erapii : $$$$$$ $$$$$$$$$ $$$$$$ $$$$$$ $$$$$$ $$$$$$ $$$$$$ $$$$$$ $$$$$$ $$$$$$$ $$$$$$$$ $$$$$$$ $$$$$$ $$$$$$ $$$.. ..   $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$..   $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.. Dan dengan saran 2 saran Penga-asan selan'utn+a : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.. *erapi +ang dian'urkan : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Prognosa : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.. #aran 2 saran lain : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.. *ela& meninggaltgl : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$. %arena/setela& %arena/setela& : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$..

($$$$$$$$$$$$$$$$.) *ela& diterima ole& petugas di $$$$$$$$$$$$$$$$$$. $$$$$$$$$$$$$$$$$$. pada tanggal tanggal $$$$$$$$$. Pk$$$. Petugas Pengantar Pasien Petugas Penerima Pasien

($$$$$$$$$$$$$)

3. R# *u'uan Ru'ukan 4. Rekam Rekam medis

($$$$$$$$$$$$$$$$)

#alam se'a-at *anggal : _______________ _______________ Dokter +ang memeriksa

($$$$$$$$$$$$$$$$$.)