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PEMERINTAH KABUPATEN INDRAGIRI HILIR
RSUD TENGKU SULUNG Jalan Penunjang No HP 085220132875 Pulau Kijang Email : [email protected] Kecamatan Reteh – Riau (Diisi oleh Dokter) RESUME MEDIS PASIEN PULANG (Discharge Summary)
Tanggal Masuk : (Admission Date)(Discharge Date) Ruang Rawat Terakhir (Last Ward) RINGKASAN RIWAYAT PENYAKIT :
Hal. 1/2 Label Identitas Pasien
Tanggal Keluar :
(History of disease summary) …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………
PEMERIKSAAN FISIK :
PEMERIKSAAN PENUNJANG :
TERAPI/PENGOBATAN SELAMA DIRUMAH SAKIT :
REAKSI OBAT :
(Physical Findings) …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………
(Supporting Examination) …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………
(Therapy/Treatment in Hospital) …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………
(Bilaya) : NO
DIET :
HASIL KONSULTASI :
DIAGNOSA UTAMA :
NAMA OBAT
MANIFESTASI KLINIS
KETERANGAN
(Diet) …………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………
(The Results of consultations) …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… (Primary diagnosa) ……………………………………………………………………………………………………………………………………………………………ICD10………………………………………………
RM.RI 02/13 Rev 01
DIAGNOSA TAMBAHAN :
TINDAKAN/PROSEDUR/OPERASI :
INSTUKSI PERAWATN LANJUTAN/EDUKASI :
Cara Pulang Izin Dokter : Pindah Rumah Sakit : Permintaan Sendiri : Melarikan diri*) Kondisi Saat Pulang Sembuh: Perbaikan: Tidak Sembuh : Meninggal ≤ 48 Jam : Meninggal ≥ 48 Jam Pengobatan dilanjutkan ke : Poli Klinik Rs ……………. Dokter PUSKESMAS……………………………………………… TERAPI PULANG (Take Home therapy)
(Additional diagnosis) …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………
(Action/Procedur/Surgery) …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………
(Continued Care Instruction/education) …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………
NO
NAMA OBAT
PROCNOSIS : Ad Vitam :
JUMLAH
Ad Bonam
Ad Dalam
DOSIS
Dubia
FREKUENSI
Bonam Dubia Ad
CARA PEMEBERIAN
am
(Prognosis )*) Ad Functionam Ad ) Ad Bonam Ad Malam Dubia Bonam Dubia Malam …………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………
8)
Dokter Penanggung Jawab
(……………………………………………..