RM.

32

Nama Pasien : ...................................... No. RM :

Jenis Kelamin: L / P Tgl Lahir : ..................../ ........... Thn / Bln / Hr

Ruang / Kelas: ............... .../.............. Tgl Masuk : ................................. Jam :

............. ::.......................................................
RESUME MEDIS
Tgl Masuk : ........................................... Jam : .............. Dokter yang Merawat : .......................................................
Tgl Keluar : ........................................... Jam : .............. ..............................................................................................

Diagnosa Masuk : ...........................................................................................................................................................

Indikasi Rawat : ...........................................................................................................................................................

Diagnosa Keluar : ...........................................................................................................................................................

............................................................................................ Kode ICD-10 : .....................................

Komplikasi : ...........................................................................................................................................................

Komorbid : ...........................................................................................................................................................

Tindakan/ Operasi : ...........................................................................................................................................................

..................................Tgl Dilakukan: .......................................Kode ICD-9 CM : ...........................

Anamnesa

Keluhan Utama

: ................................................................................................................................................

Gejala Penyerta

: ................................................................................................................................................

Riwayat Penyakit Dahulu : .............................................................................................................................................

Temuan Penting

Pemeriksaaan Fisik : ................................................................................................................................................

Pemeriksaaan Penunjang : .............................................................................................................................................

Laboratorium

: ................................................................................................................................................

Pencitraan Diagnostik

: ................................................................................................................................................

Lainnya : ................................................................................................................................................

Konsultasi

: ................................................................................................................................................

Obat Selama Rawat

: ................................................................................................................................................

Kondisi Saat Pulang

1 2 3
: ................................................................................................................................................
Telah Diverifikasi Telah Dikode Legalisasi Severity
Tanggal Paraf Verifikator Tanggal Paraf Koder Komite Medis
Obat Pulang

: ................................................................................................................................................
Rangkap 1 : Arsip RS
2 : Untuk Pasien : ................................................................................................................................................
3 : Untuk Praktisi Kesehatan Lanjutan
Instruksi Lanjut

Kontrol Ulang