Surat Rujukan APK [PDF]

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RS WAVA HUSADA



SURAT RUJUKAN



Jl. Panglima Sudirman No.99A. Kepanjen Malang Telp. 0341-393000 Fax. 0341-398398



Kepada Yth.



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Pengirim Dokter pengirim



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Instalasi/Unit



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Tanggal



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Mohon penatalaksanaan lebih lanjut pada pasien : Identitas No. Rekam medis



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Nama pasien



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Tanggal lahir



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Alamat



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Tindakan yang telah diberikan : ............................................................................................................. ............................................................................................................. .............................................................................................................



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Resume Medis Diagnosa



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Pemeriksaan



: GCS ...........................................



Temuan lain



............................................................................................................. Terapi yang telah diberikan : .............................................................................................................



TD :.................... RR :..............



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N



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:.................... S



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Alasan dirujuk



: ............................................................................................. Dokter,



Dokumen yang disertakan :  Lab  Rontgen  ECG  USG  CT Scan  MRI  ................ Keterangan tambahan



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dr.............................................. (Tanda Tangan & Nama Terang)



* Staf yang menyetujui pengiriman ......................................



KOLOM OBSERVASI PASIEN SAAT RUJUKAN Jam



Tensi



Nadi



RR



Suhu



SPO2



GCS



Terapi & Tindakan



Keterangan :



Serah Terima Pasien Kepanjen, ......................................... Penerima Rujukan



Petugas Perujuk



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(Tanda Tangan & Nama Terang)



(Tanda Tangan & Nama Terang)