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CEK LIST RAWAT INAP

NAMA PASIEN : .....................................................


NO. RM : .....................................................
KAMAR : .....................................................

No URAIAN MRS KRS


1 Bed Cover
2 Selimut
3 Bantal + sarung bantal
4 Bunga Meja
5 Remote AC
6 Remote TV
7 Pigura
8 Charge Lamp

Pamekasan, .......................................

Bidan/Perawat Jaga Penanggung jawab Pasien

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

CEK LIST RAWAT INAP

NAMA PASIEN : ..............................................................


NO. RM : ..............................................................
KAMAR : ..............................................................

No URAIAN MRS KRS


1 Bed Cover
2 Selimut
3 Bantal + sarung bantal
4 Bunga Meja
5 Remote AC
6 Remote TV
7 Pigura
8 Charge Lamp

Pamekasan, .......................................

Bidan/Perawat Jaga Penanggung jawab Pasien

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

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