25. FORM RUJUKAN PASIEN.pdf
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DIREKTORAT KESEHATAN ANGKATAN DARAT RSPAD GATOT SOEBROTO RUJUKAN PASIEN Kepada Yth : ...................................................... ........................................................... ........................................................... Kami mengirimkan pasien untuk perawatan selanjutnya, dengan alasan : Tempat tidur penuh Sesuai permintaan pasien / keluarga Fasilitas Tidak Tersedia .............................................................. Dokter yang dituju : ..................................... Nama Pasien : ....................................... Jenis kelamin : ..................................... Tanggal Lahir : ....................................... No. RM : ..................................... Alamat : ............................................................................................................ Nama Pengantar / Keluarga Terdekat : ........................................................................ No. Telepon / HP : ………………………………………...................................................... Penanggung Jawab Biaya : …………………………………………………….. Keluhan Utama : .................................................................................................. ............................................................................................................................. ...................... ................................................................................................................................................... Pemeriksaan Fisik : .................................................................................................. .................................................................................................................................................. . ……………………………………………………………………………………………………………. Pemeriksaan Penunjang : .................................................................................................. ............................................................................................................................. ...................... ................................................................................................................................................... Diagnosis : .................................................................................................. ................................................................................................................................................... Terapi / Tindakan : .................................................................................................. ............................................................................................................................. ...................... .......................................................................................................... ......................................... ……………………………………………………………………………………………………………. Terima kasih atas kerjasamanya. Jakarta, .................................... Dokter yang merawat ( .......................................... ) Tanda tangan dan nama jelas RM-025/RI
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Transcript of 25. FORM RUJUKAN PASIEN.pdf
DIREKTORAT KESEHATAN ANGKATAN DARATRSPAD GATOT SOEBROTO
RUJUKAN PASIEN
Kepada Yth : ......................................................
...........................................................
...........................................................
Kami mengirimkan pasien untuk perawatan selanjutnya, dengan alasan :
Tempat tidur penuh
Sesuai permintaan pasien / keluarga
Fasilitas Tidak Tersedia
..............................................................
Dokter yang dituju : .....................................
Nama Pasien : ....................................... Jenis kelamin : .....................................
Tanggal Lahir : ....................................... No. RM : .....................................
Alamat : ............................................................................................................
Nama Pengantar / Keluarga Terdekat : ........................................................................
No. Telepon / HP : ………………………………………......................................................
Penanggung Jawab Biaya : ……………………………………………………..
Keluhan Utama : ..................................................................................................
...................................................................................................................................................
...................................................................................................................................................
Pemeriksaan Fisik : ..................................................................................................
...................................................................................................................................................
…………………………………………………………………………………………………………….
Pemeriksaan Penunjang : ..................................................................................................
...................................................................................................................................................
...................................................................................................................................................
Diagnosis : ..................................................................................................
...................................................................................................................................................
Terapi / Tindakan : ..................................................................................................
...................................................................................................................................................
...................................................................................................................................................
…………………………………………………………………………………………………………….
Terima kasih atas kerjasamanya.
Jakarta, ....................................
Dokter yang merawat
( .......................................... )
Tanda tangan dan nama jelas
RM-025/RI
