PEMERINTAH KABUPATEN BARITO KUALA

DINAS KESEHATAN
UPT PUSKESMAS JELAPAT
Jl. Anjir Subarjo RT. 01 No. 44 Ds. Jelapat II Kec. Mekarsari Kode Pos (70568)

RESUME KLINIS PASIEN RUJUKAN

PUSKESMAS JELAPAT

I. IDENTITAS PASIEN
a. Nama : ...............................................................................................
b. Umur : ...............................................................................................
c. Jenis Kelamin : ...............................................................................................
d. Alamat : ...............................................................................................
e. No. BPJS/Jamkesda : ...............................................................................................

II. KELUHAN PASIEN

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
............................................................................................................................................................
III. PEMERIKSAAN FISIK
a. Keadaan Umum :
b. Kesadaran :
c. Tanda-tanda vital
 TD :
 Nadi :
 Respirasi :
 Suhu :
d. Pemeriksaan Khusus
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................

IV. DIAGNOSIS :

V. TINDAKAN YANG TELAH DILAKUKAN

a. ...................................................................................................................................................
b. ...................................................................................................................................................
c. ...................................................................................................................................................
d. ...................................................................................................................................................

VI. ALASAN MERUJUK

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

Jelapat,
Yang Merujuk
 PEMERINTAH KABUPATEN BARITO KUALA
DINAS KESEHATAN
UPT PUSKESMAS JELAPAT
Jl. Anjir Subarjo RT. 01 No. 44 Ds. Jelapat II Kec. Mekarsari Kode Pos (70568)

RESUME KLINIS PASIEN RUJUKAN

PUSKESMAS JELAPAT

VII. IDENTITAS PASIEN

a. Nama : ...............................................................................................
f. Umur : ...............................................................................................
g. Jenis Kelamin : ...............................................................................................
h. Alamat : ...............................................................................................
i. No. BPJS/Jamkesda : ...............................................................................................

b. KELUHAN PASIEN
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
............................................................................................................................................................
c. PEMERIKSAAN FISIK
e. Keadaan Umum :
f. Kesadaran :
g. Tanda-tanda vital
 TD :
 Nadi :
 Respirasi :
 Suhu :
h. Pemeriksaan Khusus
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................

d. DIAGNOSIS :

e. TINDAKAN YANG TELAH DILAKUKAN

e. ...................................................................................................................................................
f. ...................................................................................................................................................
g. ...................................................................................................................................................
h. ...................................................................................................................................................

f. ALASAN MERUJUK
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

Jelapat,
Yang Merujuk