LOGO RS

RINGKASAN PERAWATAN PASIEN PULANG

MEDICAL DISCHARGE SUMMARY
Nama Pasien : No. Rekam Medis :
Patient Name Medical Record Number
Nama Orang Tua/Suami :
Tanggal Masuk : ..........................................................
Family Name
Admitted
Tanggal Lahir / Umur : .........................../.............
Tanggal Keluar : ..........................................................
Age Kamar/Kelas .........../..........
Discharge
Room/Class
RINGKASAN RIWAYAT & PEMERIKSAAN FISIK (Yang Penting/Berhubungan) :
Brief history & Essential Physical Examination

HASIL LABORATORIUM RONTGENT,USG,DLL (Yang Penting/Berhubungan) :

Significant Laboratory Result, X-Ray, USG, etc

ALASAN MASUK DIRAWAT :

Reasons of Inpatient

DIAGNOSIS AWAL :
Early Diagnose

DIAGNOSIS PRIMER :
Primary Diagnose

DIAGNOSIS SEKUNDER :
Secondary Diagnose

TINDAKAN / PROSEDUR BEDAH :

Surgical Procedures

TERAPI SELAMA DIRAWAT:

Therapy During Treatment

TERAPI PULANG :
Take Away Therapy

KONDISI PULANG : Sembuh Pindah RS / Rujuk Pulang APS Meninggal Lain-lain .................
Conditions Home Recover Referance home by own request Died etc

ANJURAN :
Suggestion

DOKTER YANG IKUT MERAWAT : Samarinda,..............................................

Doctors who took care
1. ..............................................
2. ..............................................
3. ..............................................
..............................................
_______________________________
Tanda Tangan Pasien / Keluarga Dokter Penanggung Jawab Pelayanan
Patient’s Signature Doctor in charge of service

Revisi 01|25 Oktober 2017 RM|SMC – 02 - RI

Lembar : 1. Rekam Medis 2. Asuransi 3. Pasien