Ruang : Barcode

Kelas : Nama :
No. Register : Tgl Lahir :
Tgl. Masuk : No.Med.Rec :
Tgl. Keluar :
(diisi oleh dokter )
1. Anamnesis ( Reason ,for admission )
- Keluhan utama ( Main complaint ) : ..............................................................................................................
- Riwayat perjalanan penyakit ( History of Ilnes ) .............................................................................................
..........................................................................................................................................................................
2. Pemeriksaan Fisik ( Physical Examination ) : ...................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
3. Temuan Klinik ( Clinical Finding ) :
- Pemeriksaan Radiologi : Tidak Ya, sebutkan ........................................................................
- Pemeriksaan PA : Tidak Ya, sebutkan (termasuk nomor PA) ...................................
- Lain –lain (jika ada) .......................................................................................................................................
4. Diagnosa ( Diagnosis )
- Diagnosis masuk (ICD 10) : ....................................................................................... ICD X
........................................................................................ ICD X
- Diagnosis akhir (ICD 10) :
 Primer : ........................................................................................ ICD X
 Sekunder : ........................................................................................ ICD X
: ........................................................................................ ICD X
: ........................................................................................ ICD X
- Diagnosis komplikasi / penyulit (ICD 10) : ................................................................. ICD X
: ................................................................. ICD X
5. Pengobatan selama dirumah sakit ( Therapy ) : ................................................................................................
.................................................................................................................................................................................
........................................................................................................................................
6. Tindakan selama dirumah sakit ( Procedure ) : .................................................................. ICD 9CM
................................................................................................................................................. ICD 9CM
7. Alasan pulang ( Discharge reason ) : Sembuh Dapat berobat jalan Pulang paksa Cacat
Pindah ke RS lain .....................................(sebutkan RS yang dituju) Meninggal (no 8,9 dan 10 tidak diisi)
8. Kondisi saat pulang (Discharge condition) : Mandiri
Tidak Mandiri , karena memakai alat bantu :
Infus / OGT / NGT / WSD / Spalk / lain-lain ......................
...................................................................... (sebutkan)
9. Pengobatan Lanjutan : Poliklinik RSAgung Puskesmas RS Lain……………………………
10.Anjuran / Rencana Lanjutan / Kontrol (follow up)
- Diet : ...........................................................................................................................................
- Education : ...........................................................................................................................................
- Terapi pulang :
Jum- Fre- Cara Jam pemberian Petunjuk Khusus
No Nama obat Dosis
lah kwensi pemberian
1
2
3
4
5

DPJP yang merawat (Attending Physician)

Tanggal / Date :
Pukul / Time :
(…………………………………….)
NIP.
* Putih : Arsip RS (RM) * Merah : Tagihan * Kuning : Pasien
RESUME MEDIS (Summary Letter) RM (Revisi ke ... )