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SURAT PENGANTAR OPNAME

IDENTITAS
NAMA

: ---------------------------------------------------------------USIA

ALAMAT

: ------------------------------------------------------------

: -------------------------------------

JAM DATANG : -------------------------------------

---------------------------------------------------------------STATUS

RUJUKAN

 UMUM
 KARTU (BPJS/ASKES/ASURANSI)

PUSKEMAS
: ------------------------------------DOKTER
: --------------------------------------RUMAH SAKIT : --------------------------DATANG SENDIRI :

ASESMEN UGD (Diisi oleh Dokter)
SUBYEKTIF
KU

:

RPS

: ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

RPD

: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

OBYEKTIF
KESADARAN : --------------------------------

GCS

: E __ V __ M __

TANDA VITAL:
Tekanan Darah :
Nadi

:

Pernapasan

:

Suhu

:

Status Alergi
PEMERIKSAAN FISIK

Nyeri (Wong Baker Face Pain Scale)

:

:
:

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Radiologi : ---‘ -----------------------------------------------------------------------------------------------4. Laboratorium : -------------------------------------------------------------------------------------------------2. EKG : -------------------------------------------------------------------------------------------------3. Lain – Lain : ------------------------------------------------------------------------------------------------ASSESMENT DIAGNOSIS UTAMA : DIAGNOSIS BANDING : PLANNING TATALAKSANA ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ RENCANA TINDAKAN -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------KONSULTASI ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Dokter Pemeriksa.--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------PEMERIKSAAN PENUNJANG: 1. ( ________________________________________) .