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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
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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
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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