RSU PURBOWANGI

Jl. Yos Sudarso Barat No. 01 Purbowangi Gombong

Form-RM 37 Rev.00
Telp (0287)471080, Fax (0287)472111

TRANSFER INTERN
No RM : Tgl Lahir/Umur : / (th/bl/hr)
Nama Pasien : L/P Ruang Asal :
Alamat : UMUM / BPJS

Kepada Perawat Ruang : ..................................................................................................

Berikut kami kirimkan pasien dengan alasan pemindahan :
Permintaan Pasien
Kondisi medis pasien

Hasil temuan yang berarti :

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Diagnosa :
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Prosedur yang telah diberikan :
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Obat yang telah diberikan :
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Kondisi pasien saat dipindahkan :
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Catatan penting :
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Tgl Pemindahan, ......................................Jam ..........................

Perawat Pengirim Perawat Penerima

( ....................................) ( ....................................)
Nama & Tanda Tangan Nama & Tanda Tangan

NB : Beri tanda ( √ ) pada tanda yang sesuai.

Coret yang tidak perlu