PEMERINTAH KABUPATEN INDRAGIRI HILIR

RSUD TENGKU SULUNG

Jalan Penunjang No HP 085220132875 Pulau Kijang
Email : rsudtengkusulung@gmail.com Kecamatan Reteh – Riau

(Diisi oleh Dokter) Hal. 1/2

RESUME MEDIS PASIEN PULANG Label Identitas Pasien
(Discharge Summary)

Tanggal Masuk : Tanggal Keluar :

(Admission Date)(Discharge Date)
Ruang Rawat Terakhir (Last Ward)
 RINGKASAN RIWAYAT PENYAKIT :
(History of disease summary)
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………

 PEMERIKSAAN FISIK :
(Physical Findings)
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………

 PEMERIKSAAN PENUNJANG :
(Supporting Examination)
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………

 TERAPI/PENGOBATAN SELAMA DIRUMAH SAKIT :

(Therapy/Treatment in Hospital)
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………

 REAKSI OBAT :
(Bilaya) :
NO NAMA OBAT MANIFESTASI KLINIS KETERANGAN

 DIET :
(Diet)
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………

 HASIL KONSULTASI :
(The Results of consultations)
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
 DIAGNOSA UTAMA :
(Primary diagnosa)
……………………………………………………………………………………………………………………………………………………………ICD10………………………………………………

RM.RI 02/13 Rev 01

 DIAGNOSA TAMBAHAN :
(Additional diagnosis)
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………

 TINDAKAN/PROSEDUR/OPERASI :
(Action/Procedur/Surgery)
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………

 INSTUKSI PERAWATN LANJUTAN/EDUKASI :

(Continued Care Instruction/education)
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………

 Cara Pulang Izin Dokter : Pindah Rumah Sakit : Permintaan Sendiri : Melarikan diri*)
 Kondisi Saat Pulang Sembuh: Perbaikan: Tidak Sembuh : Meninggal ≤ 48 Jam : Meninggal ≥ 48 Jam
 Pengobatan dilanjutkan ke : Poli Klinik Rs ……………. Dokter
PUSKESMAS………………………………………………
 TERAPI PULANG
(Take Home therapy)

NO NAMA OBAT JUMLAH DOSIS FREKUENSI CARA PEMEBERIAN

 PROCNOSIS : Ad Vitam : Ad Bonam Ad Dalam Dubia Bonam Dubia Ad am

(Prognosis )*) Ad Functionam Ad ) Ad Bonam Ad Malam Dubia Bonam Dubia Malam
……………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………

8)

Dokter Penanggung Jawab

(……………………………………………..