PEMERINTAH KABUPATEN HULU SUNGAI TENGAH

DINAS KESEHATAN
PUSKESMAS KAMBAT UTARA
KECAMATAN PANDAWAN
Alamat : Ds. Kambat Utara 01/I Kec. Pandawan Kode Pos 71352
Alamat Email : pkmkambatutara@gmail.com

SURAT RUJUKAN
NO. 455/.........../PKM-K.UT/20....

Bersama ini kami kirimkan penderita :

A. IDENTITAS PASIEN
1. Nama : ............................................................................................
2. Jenis Kelamin : ............................................................................................
3. Alamat : ............................................................................................
4. Umur : ............................................................................................
5. Nama Kepala Keluarga : ............................................................................................
6. No Kartu JKN : ............................................................................................
B. HASIL PEMERIKSAAN
1. ANAMNESA : ............................................................................................
: ............................................................................................
2. PEMERIKSAAN FISIK : - Kesadaran : ................................................
- GCS : ................................................
- Tanda Vital
1. Tekanan darah : ......................... mmHg
2. Pernafasan : ......................... X/Menit
3. Nadi : ......................... X/Menit
4. Suhu : ......................... C

3. DIAGNOSA : ............................................................................................
4. TINDAKAN YANG TELAH DILAKUKAN : ...........................................................................
: ...........................................................................
: ...........................................................................
: ...........................................................................
5. TERAPI YANG DIBERIKAN : ...........................................................................
: ...........................................................................
: ...........................................................................
: ...........................................................................
6. ALASAN DIRUJUK : ...........................................................................
: ...........................................................................

Kambat Utara,...................................20.....
Diterima Surat Rujukan Tgl.......................... Dokter Puskesmas Kambat Utara
Kecamatan Pandawan

Mengetahui:
Dokter/Perawat Jaga :.................................. (............................................................)