FORM K.

03

No. RM
RESUME PULANG
Nama Pasien :

Tanggal : …………………………………. Jam : …………… WITA

1. Diagnosa utama : .................................................................................................................
2. Diagnosa Komplikasi : a. .......................................................................................................
b. ......................................................................................................
c. ......................................................................................................
3. Obat-obat yang dibawa pulang : .................................................................................................
.............................................................................................................................................................
...........................................................................................................................................................
4. Tindak lanjut : Konsultasi Selesai Dirujuk Balik Dirujuk Ke Poli ..................
Di Rujuk Ke RS Lain Pemeriksaan Penunjang.................................
Perlu Rawat Inap Kontrol Ulang Hari/Tanggal ...........................
5. Kondisi saat pulang : .....................................................................................................................

Sumbawa,
Dokter Penanggung Jawab Pasien

(………………………….…………............................)
Tanda Tangan dan Nama Terang

Beri tanda √ yang dikehendaki