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    Pengantar Rujukan Bpjs Uptd Puskesmas Lompoe Pengantar Rujukan Bpjs Uptd Puskesmas Lompoe

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    my chan
    This document is a referral form from a primary health center to another health facility. It contains fields for patient identification details like name, ID number, medical record number, phone number. It also includes diagnosis, symptoms, medical history, treatment received and referral details. The form needs to be filled out for any patient being referred from one health facility to another.

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    Pengantar Rujukan Bpjs Uptd Puskesmas Lompoe Pengantar Rujukan Bpjs Uptd Puskesmas Lompoe

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    my chan
    5 views1 page
    This document is a referral form from a primary health center to another health facility. It contains fields for patient identification details like name, ID number, medical record number, phone number. It also includes diagnosis, symptoms, medical history, treatment received and referral details. The form needs to be filled out for any patient being referred from one health facility to another.

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    Bab 7.5

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    Bab 7.5

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    This document is a referral form from a primary health center to another health facility. It contains fields for patient identification details like name, ID number, medical record number, phone number. It also includes diagnosis, symptoms, medical history, treatment received and referral details. The form needs to be filled out for any patient being referred from one health facility to another.

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    5 views1 page

    Pengantar Rujukan Bpjs Uptd Puskesmas Lompoe Pengantar Rujukan Bpjs Uptd Puskesmas Lompoe

    Uploaded by

    my chan
    This document is a referral form from a primary health center to another health facility. It contains fields for patient identification details like name, ID number, medical record number, phone number. It also includes diagnosis, symptoms, medical history, treatment received and referral details. The form needs to be filled out for any patient being referred from one health facility to another.

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    © All Rights Reserved
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    PENGANTAR RUJUKAN BPJS UPTD PUSKESMAS LOMPOE PENGANTAR RUJUKAN BPJS UPTD PUSKESMAS LOMPOE

    Nama : ………………………………………………………………………………………………. Nama : ……………………………………………………………………………………………….


    No. BPJS : No. BPJS :

    No. RM : No. RM :

    No. HP : …………………………………………………………….……………………….. No. HP : …………………………………………………………….………………………..

    TGL PERIKSA : …………………………………………………………….JAM : ……………… TGL PERIKSA : …………………………………………………………….JAM : ………………

    DIAGNOSA : ………………………………………………………….. DIAGNOSA : …………………………………………………………..

    POLI : UMUM / KIA / MTBS / GIGI / UGD POLI : UMUM / KIA / MTBS / GIGI / UGD

    KELUHAN / : …………………………………………………………….……………………….. KELUHAN / : …………………………………………………………….………………………..


    ANAMNESA ANAMNESA
    …………………………………………………………….……………………….. …………………………………………………………….………………………..

    …………………………………………………………….……………………….. …………………………………………………………….………………………..

    RIW. ALERGI : makanan / udara / obat – obatan RIW. ALERGI : makanan / udara / obat – obatan

    …………………………………………………………..……………………………… …………………………………………………………..………………………………

    TERAPI OBAT / : …………………………………………………………………………………..... TERAPI OBAT / : ………………………………………………………………………………….....

    NON OBAT -------------------------------------------------------------------- NON OBAT --------------------------------------------------------------------


    TTV : TB : S: HR: TTV : TB : S: HR:
    BB : TD : BB : TD :
    LP : RR : LP : RR :
    RS : ………………………………………………………….. RS : …………………………………………………………..
    POLI : ………………………………………………………….. POLI : …………………………………………………………..

    PARAF : PARAF :

    __________________ __________________

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