Formulir Rujukan Puskesmas Ke RS [PDF]

Citation preview

FORMULIR RUJUKAN RUMAH SAKIT IDENTITAS PASIEN NAMA PASIEN :



TEMPAT/TGL LAHIR :



No NIK :



ALAMAT :



JENIS KELAMIN L/P :



KONTAK :



No JKN :



RUJUKAN PASIEN JENIS RUJUKAN : DARURAT/R.INAP TGL MASUK DIPUSKESMAS:



TGL RUJUK :



TRANSPORTASI : AMBULANS PKM KENDARAAN UMUM KENDARAAN PRIBAD DIAGNOSA :



NAMA RUMAH SAKIT YANG DITUJU :



PENDAMPING : DOKTER PETUGAS PKM KELUARGA



DLL



CODE ICD X : ALASAN RUJUK: ................................................................................................................................................................................ ............................................................................................................................................................................................ ............................................................................................................................................................................................ ............ FASKES TUJUAN RUJUKAN :



KONDISI UMUM PASEN & TANDA VITAL ANAMNESIS/PEMERIKASAAN FISIK : ............................................................................................................................................................................................ ............................................................................................................................................................................................ ............................................................................................................................................................................................ ............................................................................................................................................................................................ ........................................................................................................................................................................................... KESADARAN :



SADAR TIDAK SADAR TIDAK NYERI



GCS :



TEKANANDARAH :



NAPAS:



NADI :



SUHU :



NYERI : NYERI RINGAN NYERI BERAT RIWAYAT ALERGI : ............................................................................................................................................................................................ ............................................................................................................................................................................................ PERIKSAAN PENUNJANG (DILAMPIRKAN) HASIL LABORATOIUM HASIL EKG DLL



TERAPI PINDAH NAMA OBAT



JUMLAH



DOSIS



FREKUENSI



CARA PEMBERIAN



TINDAKAN DI PUSKESMAS ............................................................................................................................................................................................ ............................................................................................................................................................................................ ........................................................................................................................................................................................... ............................................................................................................................................................................................ ............................................................................................................................................................................................ ........................................................................................................................................................................................... FOLLOW UP SELAMA PROSES TRANSFER JAM KONDISI PASEN TEKANAN PERNAPASAN NADI LAIN-LAIN DARAH



Majene ..................................... DPJP Puskesmas.Yang Mengirim,



DPJP RS.Yang Menerima,



Tanda Tangan Dan Nama Lengkap Tanda Tangan Dan Nama Lengkap



Petugas Transfer



Tanda Tangan Dan Nama Lengkap