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  • Uptd Puskesmas Bandar Agung: Rujukan Eksternal

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    irsyad robani
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    This document is an external referral form from a community health center in Bandar Agung, Lampung Tengah, Indonesia. It contains information about a referred patient, including their name, age, medical history, chief complaint, physical exam findings, additional tests, diagnosis, treatment provided, and reason for referral. The form is addressed to another healthcare provider and requests further treatment of the patient. It collects key medical details to inform the receiving doctor about the patient's case. The attending physician's signature is required to authorize the referral to another facility for continued care.

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    Form rujukan

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    This document is an external referral form from a community health center in Bandar Agung, Lampung Tengah, Indonesia. It contains information about a referred patient, including their name, age, medical history, chief complaint, physical exam findings, additional tests, diagnosis, treatment provided, and reason for referral. The form is addressed to another healthcare provider and requests further treatment of the patient. It collects key medical details to inform the receiving doctor about the patient's case. The attending physician's signature is required to authorize the referral to another facility for continued care.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    52 views1 page

    Uptd Puskesmas Bandar Agung: Rujukan Eksternal

    Uploaded by

    irsyad robani
    This document is an external referral form from a community health center in Bandar Agung, Lampung Tengah, Indonesia. It contains information about a referred patient, including their name, age, medical history, chief complaint, physical exam findings, additional tests, diagnosis, treatment provided, and reason for referral. The form is addressed to another healthcare provider and requests further treatment of the patient. It collects key medical details to inform the receiving doctor about the patient's case. The attending physician's signature is required to authorize the referral to another facility for continued care.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    PEMERINTAH KABUPATEN LAMPUNG TENGAH

    DINAS KESEHATAN
    UPTD PUSKESMAS BANDAR AGUNG
    Jalan Lintas Timur Sumatera Km 84 Bandar Agung Lampung Tengah
    email : pkmbandaragung@yahoo.com

    RUJUKAN EKSTERNAL
    EXTERNAL REFERRAL

    Kepada Yth : ……………………………………………………………………..


    To ……………………………………………………………………..

    Dengan ini kami kirimkan pasien untuk perawatan selanjutnya.


    Here I refer a patient for further treatment,

    Nama Pasien Name : ……………………………………………………………… Jenis kelamin : ………………………………….


    Name of patient Sexuality
    Tanggal lahir / umur : …………………………………………………………….. Rekam Medik : ………………………………….
    Birth date/ Age Medical Record
    Nama pengantar / keluarga : ……………..……………………………………………… No Telp / HP : ……………………………………
    Name of relatives Phone Number

    Keluhan utama : ……………………………………………………………………………………………………………………………………………..


    Chief Complaint ……………………………………………………………………………………………………………………………………………..
    .…………………………………………………………………………………………………………………………………………….

    Pemeriksaan fisik : ……………………………………………………………………………………………………………………………………………..


    Physical Examination …………………………………………………………………………………………………………………………………………….
    …………………………………………………………………………………………………………………………………………….

    Pemeriksaan Penunjang : ………………………………………………………………………………………………………………………………………………


    Additional Examination ……………………………………………………………………………………………………………………………………………..
    ……………………………………………………………………………………………………………………………………………..

    Diagnosa : ………………………………………………………………………………………………………………………………………………..
    Diagnosis ………………………………………………………………………………………………………………………………………………..
    ………………………………………………………………………………………………………………………………………………..

    Terapi dan tindakan yang diberikan :……………………………………………………………………………………………………………………………..


    Performed medication & procedure ………………………………………………………………………………………………………………………………
    .……………………………………………………………………………………………………………………………..
    ……………………………………………………………………………………………………………………………..
    ……………………………………………………………………………………………………………………………..
    ……………………………………………………………………………………………………………………………..
    Alasan dirujuk / Reasons referenced
    Tempat penuh/ Unavailable Room
    Atas permintaan pasien atau keluarga/ Patient’s or families preferable
    Fasilitas tidak tersedia/No Facility

    Terima kasih atas kerjasamanya.


    Thank you for your cooperation

    Bandar Agung,…………………………………….
    Dokter yang merawat/Attending Physician

    Tanda tangan & Nama lengkap/Signature & Full Name


    Petugas yang mengirim : …………………………………………………………
    Sent by

    Petugas yang menerima : ………………………………………………………….


    Accepted by

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