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PEMERINTAH KABUPATEN BANYUASIN

DINAS KESEHATAN
UPT PUSKESMAS PENGUMBUK
Jl. Raya Pengumbuk Tebing Abang Kecamatan Rantau Bayur Kode Pos 30753
E-mail : puskesmaspengumbuk@gmail.com

SURAT RUJUKAN
NO : 445 / / PKM-Pgbk / / 2018

Kepada,
Yth,............................................................
RS..............................................................

Dengan Hormat,
Mohon Pemeriksaan dan Pengobatan lebih lanjut terhadap penderita :
Nama Pasien :............................................................................
Jenis Kelamin : Laki – laki / Perempuan
Umur : ..............Tahun
Alamat : ............................................................................
Keluhan : ............................................................................
............................................................................
Pemeriksaan yang telah dilakukan : ............................................................................
. ............................................................................
Pengobatan / Tindakan yang telah dilakukan : ...........................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...............................................................................................................

Pengumbuk, 2018
Kepala Upt. Puskesmas Pengumbuk
Dokter yang Memeriksa

dr. Ricky Dwi Putra


STATUS PASIEN BPJS
UPT PUSKESMAS PENGUMBUK
Jl. Raya Pengumbuk Tebing Abang Kecamatan Rantau Bayur Kode Pos 30753
E-mail : puskesmaspengumbuk@gmail.com

TGL : / 2018

NAMA PESERTA :
UMUR :
NO. KARTU BPJS : (000..................................) ASKES/BPJS/ JAMKESMAS/TNI/POLRI
POLI TUJUAN :( )
KELUHAN :( )
PEMERIKSAAN FISIK
● TB : CM
● BB : KG
●TD : MMHG
●RR : X/M
●HR : X/M
DIAGNOSA KODE PENYAKIT: ( ).........................................................................................
TERAPI : ...............................................................................................
...............................................................................................
...............................................................................................
...............................................................................................
TENAGA MEDIS : ...............................................................................................
STATUS PULANG : 1. BEROBAT JALAN ( )
2. RUJUK LANJUT ( )
3. RUJUK INTERNAL ( )

PPK RUJUKAN :
NO RUMAH SAKIT POLI RUJUKAN
1 RSUD BANYUASIN POLI ANAK
2 RS. BHAYANGKARA POLI PENYAKIT DALAM
3 RS. MATA PALEMBANG POLI BEDAH
4 RS. PARU POLI SYARAF
5 RS. MYRIA POLI THT
6 RS ERNALDI BAHAR POLI OBGYN
7 RS. AR-RASYID POLI KULIT KELAMIN
8 POLI JIWA
POLI MATA
POLI JANTUNG
POLI FISIOTERAPI

STATUS PASIEN BPJS


UPT PUSKESMAS PENGUMBUK
Jl. Raya Pengumbuk Tebing Abang Kecamatan Rantau Bayur Kode Pos 30753
E-mail : puskesmaspengumbuk@gmail.com

TGL : / 2018

NAMA PESERTA :
UMUR :
NO. KARTU BPJS : (000..................................) ASKES/BPJS/ JAMKESMAS/TNI/POLRI
POLI TUJUAN :( )
KELUHAN :( )
PEMERIKSAAN FISIK
● TB : CM
● BB : KG
●TD : MMHG
●RR : X/M
●HR : X/M
DIAGNOSA KODE PENYAKIT: ( )..........................................................................
TERAPI : ...............................................................................................
...............................................................................................
...............................................................................................
...............................................................................................
TENAGA MEDIS : ...............................................................................................
STATUS PULANG : 1. BEROBAT JALAN ( )
2. RUJUK LANJUT ( )
3. RUJUK INTERNAL ( )

PPK RUJUKAN :
NO RUMAH SAKIT POLI RUJUKAN
1 RSUD BANYUASIN POLI ANAK
2 RS. BHAYANGKARA POLI PENYAKIT DALAM
3 RS. MATA PALEMBANG POLI BEDAH
4 RS. PARU POLI SYARAF
5 RS. MYRIA POLI THT
6 RS ERNALDI BAHAR POLI OBGYN
7 RS. AR-RASYID POLI KULIT KELAMIN
8 POLI JIWA
POLI MATA
POLI JANTUNG
POLI FISIOTERAPI

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