PEMERINTAH KABUPATEN KOTABARU

DINAS KESEHATAN
PUSKESMAS MEKARPURA
Jl.TanjungSerdang-Sungai Pasir Km 1,5.Desa Salino
Kec. PulauLaut Tengah Kab. KotabaruKodePos 72151

SURAT RUJUKAN
NOMOR : 445 / / Rujukan

Kepada
Yth. Direktur RSUD Kotabaru
Bagian .....................................
di-
Kotabaru
Bersama ini kami hadapkan pasien :

Nama : .....................................................
Umur : .....................................................
Jenis Kelamin : .....................................................
Nomor : .....................................................

Dengan hasil anamnese dan pemeriksaan :

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

Diagnosis sementara :

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

Penatalaksanaan :

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

Atas bantuannya kami ucapkan terimakasih.

Mekarpura,................................2018

_____________________________
NIP / NRPTT :

SURAT RUJUKAN BALIK

Teman Sejawat Yth,

Mohon kontrol selanjutnya penderita
Nama : ....................................................
Diagnosa : ....................................................
Tindak lanjut yang diberikan
Pengobatan dengan obat ............................................ 2018
Dokter RS
N0 Nama Obat Jumlah Paraf Dokter

(...............................................)
 PEMERINTAH KABUPATEN KOTABARU
DINAS KESEHATAN
PUSKESMAS MEKARPURA
Jl.TanjungSerdang-Sungai Pasir Km 1,5.Desa Salino
Kec. PulauLaut Tengah Kab. KotabaruKodePos 72151

SURAT RUJUKAN
NOMOR : 445 / / Rujukan

Kepada
Yth. Direktur RSUD dr. H.Andi Abdurahman Noor
Bagian .....................................
di-
Tanah Bumbu
Bersama ini kami hadapkan pasien :

Nama : .....................................................
Umur : .....................................................
Jenis Kelamin : .....................................................
Nomor : .....................................................

Dengan hasil anamnese dan pemeriksaan :

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

Diagnosis sementara :

..........................................................................................................................................................................
Penatalaksanaan :

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

Atas bantuannya kami ucapkan terimakasih.

Mekarpura,................................2018

_____________________________
NIP / NRPTT :

SURAT RUJUKAN BALIK

Teman Sejawat Yth,

Mohon kontrol selanjutnya penderita
Nama : ....................................................
Diagnosa : ....................................................
Tindak lanjut yang diberikan
Pengobatan dengan obat ............................................ 2018
Dokter RS
N0 Nama Obat Jumlah Paraf Dokter

(...............................................)
 PEMERINTAH KABUPATEN KOTABARU
DINAS KESEHATAN
PUSKESMAS MEKARPURA
Jl.TanjungSerdang-Sungai Pasir Km 1,5.Desa Salino
Kec. PulauLaut Tengah Kab. KotabaruKodePos 72151

Form Monitoring Pasien Pemberian Anestesi Lokal

Nama :
TTL/Umur :
Alamat :

No Check List Ya Tidak Pengukuran Keterangan

Monitoring Tanda Vital
1 Apakah pasien sesak
nafas
2 Apakah pasien
jantungnya berdebar
3 Apakah kepala pasien
pusing
4 Apakah pandangan
berkunang-kunang
5 Apaka kulit sekitar
yang diberikan
anestesi local terasa
gatal
6 Petugas memantau
keadaan kulit sekitar
daerah anestesi

Petugas

( ………………… )