Surat Permintaan Konsultasi [PDF]

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PANGKALAN UTAMA TNI AL XIII RUMKITAL ILYAS TARAKAN NO. RM : ............................



SURAT PERMINTAAN KONSULTASI Nama



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Tgl / Pukul



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No. RM



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Biasa / Cito*



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Ruangan



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Kepada Yth.Ts



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Mohon bantuan sejawat atas pasien ini untuk : Konsultasi saat ini / Alih rawat / Rawat bersama* Diagnosis kerja : ................................................................. Keterangan klinik terpenting adalah : ...................................................................................................... .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. BTK SS, Wassalam, dr : ........................................ Spesialis



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*Coret yang tidak perlu



JAWABAN KONSULTASI Sesuai permohonan konsultasi pada kasus ini dijumpai : ....................................................................... .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. Saran tindak medik / Pengobatan : .......................................................................................................... .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. Tarakan, .................................................... Hormat kami,



Dr : ............................................................. Bila perlu, gunakan halaman berikutnya