SURAT RUJUKAN

NO:............./.........../..........

Kepada YTH :

T.S Dokter

....................................................................................

RS ..............................................................................

Di ..............................................................................

Mohon perawatan pasien selanjutnya :

Nama pasien : .................................................

No MR :..................................................

Umur : .........................Tahun

Dengan hasil anamese sebagai berikut :

Anamese : ......................................................................................................................................................

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Pemeriksaan fisik : ......................................................................................................................................................

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Pemeriksaan penunjang : .............................................................................................................................................

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Diagnosa sementara : ............................................................................................................................................

Obat dan tindakan yang telah diberika atau dilakuka : .............................................................................................................

....................................................................................................................................................................................................

Vital sign terakhir : ....................................................................................................................................................................

Peralatan yang terpasang dan tanggal pemasangan : 1. ...........................................................................................

2. ...........................................................................................

3. ...........................................................................................

4. ...........................................................................................

Alasan rujuk

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Penerima telpon Mojokerto, ....................................

Dokter yang merujuk

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