REFERRAL LETTER (SURAT RUJUKAN)

No No
Dokumen: Revisi
OSA/F-029 0.0

To: Dokter Spesialis Penyakit Dalam

After examination and treatment performed in Clinic, employee below:

(Setelah dilakukan pemeriksaan Kesehatan di Klinik, karyawan atas nama):

Name (Nama) : FAHRUL

Employed by (Karyawan dari) : PT – PETRONESIA

Site/Project (lokasi site) : SITE KONAWE

Position (Posisi) : OPT EXCA

Examination Result / Hasil Pemeriksaan Kesehatan:

Berdasarkan hasil MCU di dapatkan : TG : 885, CT : 269, SGPT : 95, AU : 10,3

DIAGNOSIS : HIPERKOLESTROL + HIPERTRIGLISERID + HIPERURISEMIA + ELEVATED LIVER ENZIM

PLAN : KONSULTASI, PEMERIKSAAN LANJUTAN DAN TATALAKSANA TERAPI LEBIH LANJUT

Thus, we send this reference letter, we ask that an examination and other procedures be carried out in
accordance with the recommendations. We thank you for your attention.

Demikian surat rujukan ini kami kirim, kami mohon dapat dilakukan lebih lanjut serta tatalaksana lainnya
sesuai dengan anjuran. Atas perhatian Bapak/Ibu kami mengucapkan terima kasih.

Lalomerui, 24/02/2024

dr. Rio Karsontani

Occupational Health Physician

SIP:517/069.26/SIPD/DPM-PTSP/2021
 No. Dokumen:
STANDARD PARAMETER No. Revisi : 0.0
REFERRAL LETTER (SURAT RUJUKAN)
Halaman : 02 / 02

ID Badge (Nomor Karyawan) :

Employed by (Karyawan dari) :
Site/Project (lokasi site) :
Position (Posisi) :

History of presenting illness:

Physical examination:

Laboratory or other test result:

Diagnose:

Treatment (Further investigation, Medication, Suggestion):

Conclusion (FIT/FIT with note/Temporary UNFIT/UNFIT):

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Examining Doctor Name and Signature