Contoh Form Rujukan Eksternal [PDF]

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Nama RS……



RUJUKAN EKSTERNAL EXTERNAL REFERRAL



Kepada Yth : …………………………………………………………………….. To …………………………………………………………………….. Dengan ini kami kirimkan pasien untuk perawatan selanjutnya. Here I refer a patient for further treatment, Nama Pasien Name : ……………………………………………………………… Jenis kelamin : …………………………………. Name of patient Sexuality Tanggal lahir / umur : …………………………………………………………….. Rekam Medik : …………………………………. Birth date/ Age Medical Record Nama pengantar / keluarga : ……………..……………………………………………… No Telp / HP : ………………………………………………… Name of relatives Phone Number Keluhan utama Chief Complaint



: …………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………….. .…………………………………………………………………………………………………………………………………………….



Pemeriksaan fisik Physical Examination



: …………………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………….



Pemeriksaan Penunjang : ……………………………………………………………………………………………………………………………………………… Additional Examination …………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………….. Diagnosa Diagnosis



: ……………………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………..



Terapi dan tindakan yang diberikan :…………………………………………………………………………………………………………………………….. Performed medication & procedure ……………………………………………………………………………………………………………………………… .…………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………….. Alasan dirujuk / Reasons referenced Tempat penuh/ Unavailable Room Atas permintaan pasien atau keluarga/ Patient’s or families preferable Fasilitas tidak tersedia/No Facility Terima kasih atas kerjasamanya. Thank you for your cooperation Jakarta,……………………………………. Dokter yang merawat/Attending Physician



Tanda tangan & Nama lengkap/Signature & Full Name Petugas yang mengirim : ………………………………………………………… Sent by Petugas yang menerima : …………………………………………………………. Accepted by