07-rujukan Eksternal Kbsr
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UPTD Puskesmas Kebonsari
UPTD Puskesmas Kebonsari
BPU/Form-07/2016
Jl. Brawijaya No. 1Tuban
BPU/Form-07/2016
Jl. Brawijaya No. 1Tuban
SURAT RUJUKAN
SURAT RUJUK BALIK
No........ /SR PKM-KS/...... /.........
No........ /SR PKM-KS/...... /.........
Kepada RS
: ......................................................
Kepada
: PUSKESMAS KEBONSARI
Poliklinik/ Unit
: ......................................................
Poliklinik/ Unit
: ......................................................
Teman Sejawat Yth.
Teman Sejawat Yth.
Memohon konsul dan penanganan lebih lanjut penderita :
Setelah kami lakukan pemeriksaan dan penanganan lebih lanjut pada penderita :
Nama
: ......................................................................................Umur : .................. tahun
Nama
: ......................................................................................Umur : .................. tahun
Jenis Kelamin
: Pria / Wanita
Jenis Kelamin
: Pria / Wanita
Alamat
: .......................................................................................................................................
Alamat
: .......................................................................................................................................
Keluhan
: ......................................................................................................................................
Keluhan
: ......................................................................................................................................
Diagnosa Sementara : .......................................................................................................................................
Diagnosa Kerja
: .......................................................................................................................................
Alasan merujuk
Terapi dan tindakan yang kami lakukan
: .......................................................................................................................................
Atas pertolongan sejawat terima kasih, serta mohon informasi selanjutnya atas penderita tersebut.
: ………………......................................................................
.............................................................................. ....................................................................................................... Saran untuk puskesmas : ....................................................................................................................... Demikian sejawat, terima kasih atas kepercayaan dan kerjasamanya.
Tuban, ............................................................. Hormat kami,
Tuban, ............................................................. Hormat kami,
( .......................................................................... ) NIP..........................................................................
( .......................................................................... ) NIP..........................................................................
UPTD Puskesmas Kebonsari
BPU/Form-07/2016
Jl. Brawijaya No. 1Tuban
BPU/Form-07/2016
Jl. Brawijaya No. 1Tuban
SURAT RUJUKAN
SURAT RUJUK BALIK
No........ /SR PKM-KS/...... /.........
No........ /SR PKM-KS/...... /.........
Kepada RS
: ......................................................
Kepada
: PUSKESMAS KEBONSARI
Poliklinik/ Unit
: ......................................................
Poliklinik/ Unit
: ......................................................
Teman Sejawat Yth.
Teman Sejawat Yth.
Memohon konsul dan penanganan lebih lanjut penderita :
Setelah kami lakukan pemeriksaan dan penanganan lebih lanjut pada penderita :
Nama
: ......................................................................................Umur : .................. tahun
Nama
: ......................................................................................Umur : .................. tahun
Jenis Kelamin
: Pria / Wanita
Jenis Kelamin
: Pria / Wanita
Alamat
: .......................................................................................................................................
Alamat
: .......................................................................................................................................
Keluhan
: ......................................................................................................................................
Keluhan
: ......................................................................................................................................
Diagnosa Sementara : .......................................................................................................................................
Diagnosa Kerja
: .......................................................................................................................................
Alasan merujuk
Terapi dan tindakan yang kami lakukan
: .......................................................................................................................................
Atas pertolongan sejawat terima kasih, serta mohon informasi selanjutnya atas penderita tersebut.
: ………………......................................................................
.............................................................................. ....................................................................................................... Saran untuk puskesmas : ....................................................................................................................... Demikian sejawat, terima kasih atas kepercayaan dan kerjasamanya.
Tuban, ............................................................. Hormat kami,
Tuban, ............................................................. Hormat kami,
( .......................................................................... ) NIP..........................................................................
( .......................................................................... ) NIP..........................................................................
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