RUMAH SAKIT UMUM AT MEDIKA KOTA PALOPO

JL Andi Djemma No. 06 Palopo 91921 Telepon : (0471) 21596 Faksimal : (0471) 23008-32607

PINDAH RUMAH SAKIT

Nama Pasien: No.RM: Tgl.Lahir: Jenis Kelamin:L/Pr

Tgl. Masuk: Tgl. Pindah: Nama Rumah Sakit dan Alamat yang dituju:

Penanggung Pembayaran: DPJPRS.Pengirim: DPJPRS.Penerima:

Tanda Vital pada saat Alasan Pindah Rumah Sakit:

pindah:Suhu....................oC Nadi.......................x/menit Fasilitas KurangPermintaan Keluarga
Tensi........................mmHg Respirasi...............x/menit Tempat PenuhLain-lain……………

Transportasi:Kendaraan Umum/Pribadi Pendamping:DokterPerawat

AmbulanceRS Ambulance118/119 AmbulancePolisi KeluargaTidakada
Lainnya:…………………………………………………
PemeriksaanFisis: …………………………………………………………………………………………………
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PemeriksaanPenunjang/ …………………………………………………………………………………………………
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Terapi/Pengobatan selama di …………………………………………………………………………………………………
RumahSakit: …………………………………………………………………………………………………
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DiagnosisUtama: ……………………………………………………………………… ICD10:……………………

Diagnosis 1. ……………………………………………………………………… 1.………...........…….
Sekunder:
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ICD10: 3.……...........….……
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Tindakan/ 1. ……………………………………………………………………… 1. ………...........…….
Prosedur:
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ICD9CM:
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 Nama Pasien: No.RM: Tgl.Lahir: Jenis Kelamin:L/P

Alergi (ReaksiObat) Tidak

Ya,Sebutkan:1...................................................................................................................................................
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Diet …………………………………………………………………………………………………
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Rencana Perawatan …………………………………………………………………………………………………
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NamaObat Jumlah Dosis Frekuensi CaraPemberian
TerapiPindah:

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Jam KondisiPasien TekananDarah Pernapasan Nadi Lain-lain

Palopo,……………………
DPJPRS.Yang Menerima, DPJPRS.Yang Mengirim,

Tanda Tangan dan Nama Lengkap Tanda Tangan dan Nama Lengkap

PetugasTransfer

Tanda Tangan dan Nama Lengkap

Lembar1:RS.Pengirim
Lembar2:RS.Penerima

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