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  • Form Permintaan PX Radiologi

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    radiologi syifa
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    This document is a request form for radiology examinations from Syifa Medina General Hospital. It contains the patient's name, date of birth, address, doctor's name and signature. It also lists various examination options under headings like Head, Vertebrae, Thorax-Abdomen, Extremities (Upper and Lower). The form allows the referring doctor to select the specific radiological tests needed based on the patient's diagnosis and clinical information.

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    412912843 Form Permintaan Px Radiologi

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    This document is a request form for radiology examinations from Syifa Medina General Hospital. It contains the patient's name, date of birth, address, doctor's name and signature. It also lists various examination options under headings like Head, Vertebrae, Thorax-Abdomen, Extremities (Upper and Lower). The form allows the referring doctor to select the specific radiological tests needed based on the patient's diagnosis and clinical information.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    34 views3 pages

    Form Permintaan PX Radiologi

    Uploaded by

    radiologi syifa
    This document is a request form for radiology examinations from Syifa Medina General Hospital. It contains the patient's name, date of birth, address, doctor's name and signature. It also lists various examination options under headings like Head, Vertebrae, Thorax-Abdomen, Extremities (Upper and Lower). The form allows the referring doctor to select the specific radiological tests needed based on the patient's diagnosis and clinical information.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 3

    RUMAH SAKIT No.

    Rekam Medis:
    UMUM
    SYIFA MEDINA
    Jl. Bantar No.15A Tasikmalaya
    Telp. 0265-334544
    FORMULIR PERMINTAAN PEMERIKSAAN RADIOLOGI
    Tgl :
    Nama Pasien :
    Tanggal Lahir : Dokter :
    Alamat :
    Tanda Tangan dokter pengirim:

    No. Telp :

    Diagnosa / Keterangan KlinikRONTGEN


    : Cito/ Biasa
    USG

    HEAD ESKTREMITAS ATAS  USG Abdomen

     Skull AP-LAT (2 posisi)  Manus DEX AP-Oblique  Urologi


     Sinus Parasinalis (Waters)  Manus SIN AP-Oblique  Thorax Marker
     Sinus Parasinalis (3 posisi)  Wrist Dex AP-LAT  Mammae Dex-Sin
     Mastoid (Schuller) DEX/SIN  Wrist Sin AP-LAT  Muskuloskeletal
     Antebrachii DEX AP-  (regio ..........................
     Nasale
    LAT ... )
     Adenoid Ratio  Antebrachii SIN AP-LAT  FAST
     Vascular Ext Atas Dex
    VERTEBRAE  Elbow Dex AP-LAT
    / Sin
     Vascular Ext Bawah
     Cervical AP-LAT (2 posisi)  Elbow Sin AP-LAT
    Dex / Sin
     Cervical Open Mouth  Humerus Dex AP-LAT  USG Leher (COLLI)
     Cervical AP-LAT, Oblique
     Humerus Sin AP-LAT  USG Testis
    Dex-Sin
     Thoracal AP-LAT  Shoulder Dex True AP
     Thoracal AP-LAT, Oblique
     Shoulder Sin True AP
    Dex-Sin
     Shoulder Dex AP(/ + Y
     Thoracolumbal AP-LAT
    View)
     Shoulder Sin AP(/ + Y
     Lumbal AP-LAT
    View)
     Lumbal AP-LAT, Oblique  Shoulder Dex Exo-Endo
    Dex-Sin Rotation
     Shoulder Sin Exo-Endo
     Lumbosacral AP-LAT
    Rotation
     Shoulder Dex Axillary
     Lumbosacral Dynamic X-ray
    view
     Thoracolumbosacral AP-  Shoulder Sin Axillary
    LAT(Errect) view
     Thoracolumbosacral AP
     Clavicula Dex AP-LAT
    Bending Kiri-kanan (supine)
     Pelvis Inlet & Outlet View  Clavicula Sin AP-LAT
     Pelvis AP  Scapular Dex Y view
     Scapular Sin Y view
     Pelvis Obturator & Illiac view
    THORAX-ABDOMEN EXTREMITAS BAWAH
    Thorax PA-AP Femur Dex AP-LAT
    Thorax Lateral FEMUR Sin AP-LAT
    Genu Dex AP-LAT
    Thorax RLD
    (/+Skyline View )
    Genu Sin AP-LAT
    Thorax LLD
    (/+ Skyline View )
    Top Lordotic Cruris Dex AP-LAT
    Abdomen Polos (BNO) Cruris Sin AP-LAT
    Abdomen RLD Ankle Dex AP-LAT
    Abdomen LLD Ankle Sin AP-LAT
    Abdomen 3 posisi Ankle Dex Mortise View
    Ankle Sin Mortise View
    Pedis Dex AP-LAT/Oblique
    Pedis Sin AP-LAT/Oblique
    Varus / Valgus Genu

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