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RUMAH SAKIT BAPTIS BATU

KEU 07

Jl. Raya Tlekung No. 1 Batu Tromol Pos 100


Telp. (0341) 594161, 598192, 598191 Fax. (0341) 598911

LEMBAR PELAYANAN RAWAT INAP PASIEN ASKES SOSIAL


No. MR
Nama Pasien
Alamat

:
No. Reg. IRNA :
: ..................................................................................... L / P
: ......................................................................................

1. TABEL PELAYANAN.

PAKET

HARI KE : .....
TANGGAL :................................
RUANG :................................

KETERANGAN

TTD
PX

HARI KE : .....
TANGGAL :................................
RUANG :................................
TTD
PRWT

KETERANGAN

PAKET
IIA
PAKET
IIB
PAKET
IIC
PAKET
IIIA
PAKET
IIIB
PAKET
IIIC
KLP
I
KLP
II
KLP
III

2. VERIFIKASI.
PASIEN KRS

(.............................)

DOKTER IRNA

(.............................)

PERAWAT

(.............................)

TTD
PX

HARI KE : .....
TANGGAL :................................
RUANG :................................
TTD
PRWT

KETERANGAN

TTD
PX

TTD
PRWT