RS WAVA HUSADA
Jl. Panglima Sudirman No.99A. SURAT RUJUKAN
Kepanjen Malang
Telp. 0341-393000 Fax. 0341-398398
Kepada Yth.
Pengirim ....................................................
Dokter pengirim : .....................................................
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Instalasi/Unit : .....................................................
Tanggal : .............................. Pukul:............ ....................................................
Mohon penatalaksanaan lebih lanjut pada pasien :
Identitas
Tindakan yang telah diberikan :
No. Rekam medis : ............................................................
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Nama pasien : ............................................. L / P
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Tanggal lahir : ............................................................
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Alamat : ............................................................
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Resume Medis
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Diagnosa : ....................................................................
.................................................................... Terapi yang telah diberikan :
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Pemeriksaan : GCS ...........................................
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TD :.................... RR :..............
N :.................... S :.............. .............................................................................................................
Temuan lain : .............................................................................................................
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Alasan dirujuk : .............................................................................................
Dokter,
Dokumen yang disertakan : Lab Rontgen ECG USG CT Scan MRI ................
Keterangan tambahan : .............................................................................................
dr..............................................
* Staf yang menyetujui pengiriman ...................................... (Tanda Tangan & Nama Terang)
KOLOM OBSERVASI PASIEN SAAT RUJUKAN
Jam Tensi Nadi RR Suhu SPO2 GCS Terapi & Tindakan
Keterangan :
Serah Terima Pasien
Kepanjen, .........................................
Penerima Rujukan Petugas Perujuk
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(Tanda Tangan & Nama Terang) (Tanda Tangan & Nama Terang)