RESUME Nomor Rekam

Medis:
MEDIS
Nama Pasien: Tanggal Lahir: Umur: Jenis Kelamin:
L/P
Tanggal Masuk: Tanggal Keluar/Meninggal: Ruang Rawat Terakhir:

Penanggung Pembayaran: Diagnosis/Masalah Sewaktu Masuk:

Ringkasan Riwayat Penyakit : ________________________________________________

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Pemeriksaan Fisik : _______________________________________________
______________________________________________
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Pemeriksaan Penunjung/ _________________________________________________
Diagnostik Terpenting : ________________________________________________
______________________________________________
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Terapi/Pengobatan selama ________________________________________________
Di Puskesmas : _______________________________________________
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Hasil Konsultasi: ________________________________________________
______________________________________________
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Diagnosis Utama: ________________________________ ICD 10: ___________________

Diagnosis 1. ___________________________________ ICD 10: 1. _______________

Sekunder: 2. ___________________________________ 2. _______________
3. __________________________________ 3. _______________
4. __________________________________ 4. _______________
Sambungan RESUME MEDIS

Nama Pasien: Nomor Rekam

Medis:

Alergi (Reaksi Obat) _______________________________________________________

______________________________________________________
Hasil Laboratorium ________________________________________________________
Belum selesai _______________________________________________________
(Pending) _______________________________________________________
______________________________________________________
Diet: ______________________________________________________
______________________________________________________
Instruksi/Anjuran ________________________________________________________
Dan Edukasi ______________________________________________________
(Follow Up) : _______________________________________________________
______________________________________________________
______________________________________________________

Kondisi Waktu Keluar:

 Sembuh
 Rujuk RS
 Meninggal
 Lain – lain
___________________________________________________________________

Pengobatan Dilanjutkan:
 Poliklinik
 Rumah Sakit
 Puskesmas lain
 Dokter Spesialis
 Lain – lain
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Terapi Pulang:
Nama Obat Jumlah Dosis Frekuensi Cara Pemberian

Batu Anam,
Dokter Penanggung Jawab
Pelayanan

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Tanda Tangan

Lembar 1: Pasien
Lembar 2: Rekam Medis