Surat Rujukan ASKES
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Transcript of Surat Rujukan ASKES
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✄..............................................................................................................................................................................................
PT. Askes (Persero) Kantor Regional/Kantor Cabang.........................
Rujukan Puskesmas / Dokter Keluarga
SURAT RUJUKAN PESERTA ASKES
No. Rujukan :
Puskesmas/Dokter Keluarga :................................... Kode : .........................
Kabupaten/Kota :.................................. Kode : .........................
Kepada Yth : TS dr. Poli .....................................
Di RSU : ........................................................
Mohon pemeriksaan dan penanganan lebih lanjut penderita :
Nama : ....................................................... Umur :.........................( L / P)
No. Kartu Askes : Status : P / S / I / 1 / 2
Diagnosa : ..........................................................................................
Telah diberikan : ..........................................................................................
..........................................................................................
Demikian atas bantuannya banyak terima kasih.
SURAT RUJUKAN BALIK
Teman sejawat Yth.
Mohon kontrol selanjutnya penderita :
Nama : ......................................................................................
Diagnosa : ......................................................................................
Tindak lanjut yang dianjurkan
Pengobatan dengan obat-obatan : Perlu rawat inap
............................................................ Konsultasi selesai
Kontrol kembali ke RS tanggal : ...................tgl.....................
Lain-lain :
No. Urut Bulan Tahun
Salam Sejawat
(...................................)
Dokter RS,
(...................................)
Pedoman Administrasi Pelayanan Kesehatan Askes Sosial