Form RM Ri-Resume Medis Asuransi [PDF]

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MITRA SETIA Jl. Garuda No. 22 Ungaran 50514 Jawa Tengah, Indonesia. Telp (+62) 24 6923179 Email : [email protected]



RM 21



RESUME MEDIS Nama Pasien : …………………………………………... Tgl lahir : …………………………………………... Umur : …………………………………………... Jenis Kelamin : ………… ………………………………... Alamat : …………………………………………...



Alasan datang ke RS: Rujukan :



Penyakit



KLL



No. Jaminan Tgl. Masuk Tgl. Keluar Dokter Pengirim DPJP



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



Kecelakaan kerja



Kecelakaan lain



VR



Ya, dari Poliklinik UII/Dokter



: ................................................................................



Ya, dari RS/Puskesmas/Dokter



: ................................................................................



Tidak, datang sendiri/diantar



: ................................................................................



1. JENIS KASUS Obsgi



Bedah



Lainnya



Trauma



Non Trauma



Non Bedah



Interna



Anak



: .........................................................................................



2. Diagnosis Awal a. Anamnesis singkat: ............................................................................................................................................................. ............................................................................................................................................................. b. Pemeriksaan Fisik : Keadaan Umum penderita:............................................................................................. Tensi



: ...............mmHg



Nadi



: ................X / menit



BB : ...............Kg



Suhu



: ...............ᵒC



Nafas : ................X / menit



TB : ...............cm



c. Laboratorium *)



: ..................................................................................................................... ..................................................................................................................... d. Pemeriks. Radiologi*) : ..................................................................................................................... ..................................................................................................................... e. Pemeriks. lainnya*) : …................................................................................................................. ..................................................................................................................... 3. TERAPI/TINDAKAN Terapi/Tindakan yang diberikan



: ......................................................................................................... : ......................................................................................................... : .........................................................................................................



4. DIAGNOSIS AKHIR ................................................................................................................................................................. Kategori Kasus : Akut Sub akut Kronis 5. TINDAKAN LANJUT Sembuh



Dipulangkan, untuk kontrol/berobat jalan periodik tiap: ..........................................



Dirujuk: ............................................... Atas dasar:



Tempat penuh



Pengobatan lebih lanjut Ungaran, .........................,........ Dokter yang merawat



(.................................................)



021b/02/RI/Rev.01/MS/2020