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STATUS PASIEN UMUM

NAMA

STATUS PASIEN UMUM

IDENTITAS PASIEN
: ......................................... UMUR :............... L/P

NAMA

STATUS PASIEN UMUM

IDENTITAS PASIEN
: ......................................... UMUR :............... L/P

NAMA

IDENTITAS PASIEN
: ......................................... UMUR :............... L/P

ALAMAT : ......................................................................

ALAMAT : ......................................................................

ALAMAT : ......................................................................

.........................................................................................

.........................................................................................

.........................................................................................

PEKERJAAN : .................................... ..
DOKTER UMUM
PERAWAT AHLI LUKA

PEKERJAAN : .................................... ..
DOKTER UMUM
PERAWAT AHLI LUKA

PEKERJAAN : .................................... ..
DOKTER UMUM
PERAWAT AHLI LUKA

dr. Ahmad Saiful Umam


SIP 10.01/402.102/SIPI/1.2/38/VIII/13

TGL

KELUHAN

Ns. Aine Artalia, CWCCA


SIPP 15.01/402.102/SIPP/241/15/IX/13

PEMERIKSAAN/
DIAGNOSA

TERAPI

dr. Ahmad Saiful Umam


SIP 10.01/402.102/SIPI/1.2/38/VIII/13

TGL

KELUHAN

Ns. Aine Artalia, CWCCA


SIPP 15.01/402.102/SIPP/241/15/IX/13

PEMERIKSAAN/
DIAGNOSA

TERAPI

dr. Ahmad Saiful Umam


SIP 10.01/402.102/SIPI/1.2/38/VIII/13

TGL

KELUHAN

Ns. Aine Artalia, CWCCA


SIPP 15.01/402.102/SIPP/241/15/IX/13

PEMERIKSAAN/
DIAGNOSA

TERAPI

TGL

KELUHAN

PEMERIKSAAN/
DIAGNOSA

TERAPI

TGL

KELUHAN

PEMERIKSAAN/
DIAGNOSA

TERAPI

TGL

KELUHAN

PEMERIKSAAN/
DIAGNOSA

TERAPI

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