Resume Klinis Pasien Rujukan.docx

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RESUME KLINIS PASIEN RUJUKAN PUSKESMAS CILACAP SELATAN II

I

IDENTITAS PASIEN a. Nama pasien

:

b. Umur

:

c. Jenis Kelamin : d. Alamat

:

e. No. BPJS / Jamkesda : II

Keluhan Utama Pasien

III

Pemeriksaan Fisik

:

a. Keadaan Umum: b. GCS

:

c. Tanda-tanda Vital :  Tekanan darah  Nadi

: ……. / ………mmHg

: …………X/menit

 Pernafasan : …………X/menit  Suhu

: …………º C

d. Kelainan yang bermasalah :

IV

Diagnosa

:

V

Penatalaksanaan yang telah dilakukan : a. …………………………………………………………………………………………………. b. …………………………………………………………………………………………………. c. …………………………………………………………………………………………………. d. …………………………………………………………………………………………………. e. …………………………………………………………………………………………………. f. …………………………………………………………………………………………………. g. …………………………………………………………………………………………………. h. ………………………………………………………………………………………………….

VI

Alasan merujuk

:

Cilacap, Dokter yang merujuk

…………………………..

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