RM.

20

NO. RM

Nama :
Tanggal Lahir/Umur :
Jenis Kelamin :
RESUME MEDIS PASIEN PULANG No. BPJS Kesehatan :
Tanggal Masuk : (Dicharge Summary) Tanggal keluar :
(Admission Date) (Discaharge Date)
Ruang Rawat Terakhir (last Word) :

 RINGKASAN RIWAYAT PENYAKIT :

(History of disease summary)
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 PEMERIKSAAN FISIK :
(Physical Findings)
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 PEMERIKSAAN PENUNJANG :
(Supporting examination)
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 TERAPI/PENGOBATAN SELAMA DIRUMAH SAKIT :
(Therapy/treatment in hospital)
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 REAKSI OBAT : YA TIDAK
Bila Ya :

N NAMA OBAT MANIFESTASI KLINIS KETERANGAN

O

 DIET :
(Diet)
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 HASIL KONSULTASI :
(The result of consultatons)
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 DIAGNOSA UTAMA :
(Primary diagnosis)
................................................................................................................ ICD 10 .....................................
 DIAGNOSA TAMBAHAN :
(Additional diagnosis)
................................................................................................................ ICD 10 .....................................