Form Resume Medis [PDF]

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PEMERINTAH KABUPATEN BEKASI



RUMAH SAKIT UMUM DAERAH CABANGBUNGIN Kp. Bojong RT 07 RW 04 Desa Jayalaksana Kec. Cabangbungin Tlp. (021) 12345678, Email :



FORMULIR RESUME MEDIS



No. RM Nama Tanggal Lahir Ruangan



: : : :



Alasan Masuk Dirawat



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Ringkasan Riwayat Penyakit



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Pemeriksaan Fisik



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Pemeriksaan Penunjang



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Hasil Laboratorium



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Terapi Pengobatan Selama di RS



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Diagnosa Utama



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Intruksi/ Anjuran dan Edukasi (Follow Up)



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Kondisi Waktu Keluar



:  Sembuh



 Pindah RS



 Pulang Atas Permintaan Sendiri



 Meninggal



 Lain-Lain, ....................... .......................



Pengobatan dilanjutkan



:  Poli Klinik



 RS Lain



 Puskesmas



 Dokter Luar



 ...................... ......................



Tanggal Kontrol Poli Klinik



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Terapi Pulang : Nama Obat Jumlah



Dosis



Frekuaensi



Cara Pemberian



Nama Obat



Jumlah



Dosis



Frekuaensi



Cara Pemberian



Cabangbungin, ............................................... Dokter Penanggung Jawab Pelayanan



( ....................................................... ) Tanda Tangan & Nama Jelas