DINAS KESEHATAN KABUPATEN WAY KANAN
UPT PUSKESMAS NEGERI BARU
JalanLintas [Link]. [Link] – Way Kanan 34764
E-Mail : pkmnegeribaru@[Link]
SURAT RUJUKAN UMUM
NO. / PKM-NB / / 2019
RS KonfirmasiRujukan Petugas JamBerang Jam PetugasPeneri
TujuanRujuk (call) kat SampaiRs ma
an
Jam Penerima Perawat/ Sopir
Bidan
Kepada :
Dokter :..................................................Bagian..............................................................................
Denganinimohonpemeriksaandanpengobatanlebihlanjutpadapenderita / Pasien :
Nama : ..............................................No kartu : ..................................................................
Umur : ...............................................JenisKelamin :...................................................................
Alamat :............................................................................................................................................
Denganhasilpemeriksaansebagaiberikut :
Anamnesa :.........................................................................................................................
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PemeriksaanFisik :........................................................................................................................
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PemeriksaanLaboratorium :
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Diagnosa :..............................................................................................................................
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Obat yang telahdiberikan :...............................................................................................................
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Tindakan yang telahdilakukan :.......................................................................................................
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Atasbantuandanperhatiansejawatdiucapkanterimakasih.
NegeriBaru, 2019
DokterJaga
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NIP/NRPTT