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) ______________________________________________________________

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Hasil Laboratorium ______________________________________________________________
Belum selesai ______________________________________________________________
(Pending) ______________________________________________________________
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Diet: ______________________________________________________________
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Instruksi/Anjuran ______________________________________________________________
Dan Edukasi _____________________________________________________________
(Follow Up) : _____________________________________________________________
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Kondisi Waktu Keluar:

Sembuh
Rujuk RS
Meninggal
Lain lain ___________________________________________________________________

Pengobatan Dilanjutkan:
Poliklinik
Rumah Sakit
Puskesmas lain
Dokter Spesialis
Lain lain ____________________________________________________________________

Terapi Pulang:
Nama Obat Jumlah Dosis Frekuensi Cara Pemberian

Pilangkenceng,
Dokter Penanggung Jawab Pelayanan

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Tanda Tangan

Lembar 1: Pasien
Lembar 2: Rekam Medis