Radiologi dan Diagnostik Imejing Rumah Sakit

Putri Tk II Putri Hijau

NO. RM : ................................................. NO. R.I : .......................................................

NAMA : ................................................. NAMA DOKTER : .......................................................
TGL.LAHIR/UMUR : ................................................. TANGGAL : .......................................................
JENIS KELAMIN : .................................................
ALAMAT : .................................................
O Hasil dikirim ke Dokter O Hasil diserahkan ke Pasien
Pemeriksaan yang diminta harap diberi tanda 
(#) Untuk persiapan pemeriksaan hubungi petugas Radiologi dan Diagnostik Imejing

X-RAY SPECIAL EXAMINATION

O Thorax (PA/Erect) O Ankle Joint Sinistra (AP/Lateral) O BNO-IVP #
O Thorax (PA/Lateral) O Ankle Joint Sinistra (AP/Lateral) O Appendix #
O Thorax Portable O Calcaneus Sinistra O Fistulography #
O BNO O Calcaneus Dextra O dll.....
O Plain Abdomen 3 posisi O Pedis Sinistra (AP/Oblique)
O Plain Abdomen 2 posisi O Pedis Dextra (AP/Oblique)
O Babygram Foto O Cervical Spine (Lateral/Oblique)
O Schedel (skull) (AP/Lateral) O Thoracic Spine (AP/Lateral)
O Sinus Paranasal (PA/Lateral) O Lumbosacral Spine (AP/Lateral)
O Mandibula CT-SCAN
O Temporo Mandibular Joint (TMJ) O Brain Routine
O Mastoid Dextra O Sella Tursica
O Mastoid Sinistra O Paranasal Sinus CT-SCAN CONTRAST
O Clavicula Dextra O Nasopharynx O Brain With Contrast #
O Clavicula Sinistra O Orbita O Thorax With Contrast #
O Shoulder Joint Dextra O Temporal Bone O Lower Abdomen With Contrast #
(AP/Oblique) O Mandibula O Upper Abdomen With Contrast #
O Shoulder Joint Sinistra O Facial Bone O Upper-Lower Abdomen
(AP/Oblique) O Cervical Spine With Contrast #
O Humerus Dextra (AP/Lateral) O Thoracal Spine O Appendix With Contrast #
O Humerus Sinistra (AP/Lateral) O Lumbar Spine
O Elbow Dextra (AP/Lateral) O Thorax
O Elbow Sinistra (AP/Lateral) O Upper Abdomen
O Antebrachii Dextra (AP/Lateral) O Lower Abdomen
O Antebrachii Sinistra (AP/Lateral) O Upper-Lower Abdomen
O Wrist Joint Dextra (AP/Lateral) O Pelvic
O Wrist Joint Sinistra (AP/Lateral) O Neck ULTRASONOGRAPHY/USG
O Manus Dextra (AP/Oblique) O Shoulder Joint O Upper-Lower Abdomen #
O Manus Sinistra (AP/Oblique) O Elbow Joint O Thyroid
O Pelvis (AP) O Wrist Joint O Testis
O Femur Dextra (AP/Lateral) O Manus O Appendix
O Femur Sinistra (AP/Lateral) O Genu/Knee Joint O Mammae
O Genu Dextra (AP/Lateral) O Ankle Joint
O Genu Sinistra (AP/Lateral) O Extremitas Long Bone
O Cruris Dextra (AP/Lateral) O Tractus Urinaria
O Cruris Sinistra (AP/Lateral) O Appendix

Diagnosa/Keterangan Klinis : ........................................................................ DOKTER PENGIRIM :

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RM /III/2018/REV