Formulir Rujukan Hiv [PDF]

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RUMAH SAKIT MITRA MEDIKA NAROM Jl. Jatiwangi-Cikedokan/ Sebelah Selatan Kawasan MM 2100 Kp. Kamurang RT 01 RW 1 Desa Cikedokan Cikarang Barat – Kab. Bekasi Telp. 021- 89983741 Fax: 021-89983575



FORMULIR RUJUKAN HIV / AIDS Nama Instansi Pengirim ................................................................................................................................................................. Nama Instansi Penerima................................................................................................................................................................. Nama Pasien.......................................................................................Umur..................Tahun, Jenis kelamin: L/P Alamat Lengkap .............................................................................................................................................................................. ............................................................................................................................................................................. No. Rekam Medis :   



No. MR :  - 



Tanggal konfirmasi tes HIV + : .....................................................Tempat : ................................................................................. Keadaan pada saat rujukan :    



Stadium klinis WHO Berat Badan Status fungsional Rejimen yang diberikan



  



IO yang terjadi terapi Profilaksis IO Status TB



: : : :



1/ 2/ 3/ 4 .............kg K/ Amb/ Bar ......................................................................................................................................... ......................................................................................................................................... : ......................................................................................................................................... : ......................................................................................................................................... : 1. Bukan TB; 2. Suspek TB; 3. TB dalam pengobatan



Bersama ini kami lampirkan pula salinan ikhtisar perawatan HIV dan ART



Bekasi, tgl



(Dr



)



RUMAH SAKIT MITRA MEDIKA NAROM Jl. Jatiwangi-Cikedokan/ Sebelah Selatan Kawasan MM 2100 Kp. Kamurang RT 01 RW 1 Desa Cikedokan Cikarang Barat – Kab. Bekasi Telp. 021- 89983741 Fax: 021-89983575