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  • Mojokerto Health Clinic Referral Monitoring Card

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    Kasnan
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    This document is a referral monitoring card from the Kutorejo Community Health Center in Mojokerto Regency, East Java, Indonesia. The card collects key identifying and medical information about a referred patient, including their name, gender, date of birth, address, referral date and time, origin of referral, destination, diagnosis, and notes. Spaces are provided for signatures of the referring party and receiving party to acknowledge the patient handoff.

    Original Description:

    rujukan

    Original Title

    Monitoring Ambulan

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    This document is a referral monitoring card from the Kutorejo Community Health Center in Mojokerto Regency, East Java, Indonesia. The card collects key identifying and medical information about a referred patient, including their name, gender, date of birth, address, referral date and time, origin of referral, destination, diagnosis, and notes. Spaces are provided for signatures of the referring party and receiving party to acknowledge the patient handoff.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    11 views1 page

    Mojokerto Health Clinic Referral Monitoring Card

    Uploaded by

    Kasnan
    This document is a referral monitoring card from the Kutorejo Community Health Center in Mojokerto Regency, East Java, Indonesia. The card collects key identifying and medical information about a referred patient, including their name, gender, date of birth, address, referral date and time, origin of referral, destination, diagnosis, and notes. Spaces are provided for signatures of the referring party and receiving party to acknowledge the patient handoff.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    PEMERINTAH KABUPATEN MOJOKERTO

    DINAS KESEHATAN
    UPT PUSKESMAS KUTOREJO
    Jl. Raya Mayjend Soemadi No 112 Telepon. (0321) 511836
    MOJOKERTO 61383
    Email : uptpuskesmaskutorejo@gmail.com

    KARTU MONITORING RUJUKAN

    No. Kartu peserta : …………………………………………………………………………


    Nama pasien : …………………………………………………………………………
    Jenis kelamin : …………………………………………………………………………
    Tanggal lahir / umur : …………………………………………………………………………
    Alamat : …………………………………………………………………………
    : …………………………………………………………………………
    Tanggal dan jam dirujuk : …………………………………………………………………………
    Tempat asal rujukan : …………………………………………………………………………
    Tempat tujuan rujukan : …………………………………………………………………………
    Jumlah kilometre : …………………………………………………………………………
    Diagnosa : …………………………………………………………………………
    Keterangan : …………………………………………………………………………
    : …………………………………………………………………………
    : …………………………………………………………………………

    yang merujuk yang menerima rujukan

    ( …………………………………………… ) ( …………………………………………… )

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