RUMAH SAKIT

ARUN LHOKSEUMAWE
Komplek Perumahan PT Arun NGL Jl. Plaju No 1 CATATAN PINDAH KE RS LAIN /
Telp. (0645) 653165– Fax.57890
Lhokseumawe - Aceh
RUJUKAN PASIEN

Asal Pasien Dirawat :  IRJ  GP Poli : .........................................  IBS  IGD

 IRIN : ...........  ICU

Kepada Yth : Ts ................................................................................................................................................................

Di RS : .....................................................................................................................................................................
Alamat : .....................................................................................................................................................................
.................................................................................................... Telp : .....................................................
Nama dan Jabatan Kontak Person yang sudah dihubungi dan siap menerima pasien di RS Tujuan :

Dengan Hormat,
Bersama ini kami kirim / rujuk pasien :

Nama : ............................................................................................................................ Jenis Kelamin : L / P )*

No. RM : .......................................
Tanggal Lahir : ..................................................................................................................................................................
Alamat : ........................................................................................................................... RT : ......... RW : ...........
Kelurahan : ................................................................ Kecamatan : .......................................................
Wilayah : ................................................................... Kode Pos : ..........................................................

Alasan dirawat di RS Arun Lhokseumawe : ....................................................................................................................................

Diagnosis Utama :

Diagnosis Sekunder :

Alasan dirujuk :  Ruang Rawat Penuh  Perlu Fasilitas lebih baik  Permintaan Sendiri  Kasus Polisi

Keterangan : .....................................................................................................................................................................
Hasil pemeriksaan selama di rawat (Pemeriksaan Fisik dan Penunjang yang mendukung Diagnosis)

Prosedur / Tindakan yang sudah dilakukan :

1. Infus : .................................................................................................................................................................. ..
 2. Obat : ................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
3. Tindakan : ..................................................................................................................................................................
Kondisi Pasien Saat Pindah :

Kesadaran :  CM  Apatis  Delirium  Sopor GCS : E : .......... M : .......... V : ..........

Skala Nyeri :

Tekanan Darah : .................Mm Hg, Nadi : .................x/mnt, Pernafasan : .................x/mnt, Suhu : .................°C

Penggunaan Oksigen : .................:/mnt, Cairan Parenterai : .................cc/24 Jam, Transfusi : .................Cc

Penggunaan Cateter : Ada / Tidak, Pemakaian ke : ................. Tanggal : .......................................... Jam : .................

Diet : ..................................................................................................................................................................
Mobilisasi :  Bed Rest  Aktif

Edukasi :

Cara Transportasi

 Ambulance RS Arun Lhokseumawe

 Kendaraan Umum  Kendaraan Pribadi, Alasan : .......................................................

Atas kerjasama yang baik kami ucapkan terima kasih,

Batuphat, .............................. Pukul : .............WIB

Salam Sejawat

Tanda Tangan & Nama Jelas DPJP

)* Coret yang tidak perlu