RUMAH SAKIT UMUM ORMULIR EDUKASI |
QL MITRASEMATYOGYAKARTA ——__-PEMERIKSAANDENGAN RADIASL
| Nama pemberi | Mo sa Setodes | Nama pasien Tb Almayra a
Lpersetujuan ae an | ee
Hubungan dengan | | Tg Cahir | 3/- 12-2000 |
_pasien | ieee
No Foto I NoRM SoFOTe
| 1. Penjelasan tentang pemantaatan pemeriksaan clengan radiasi pengion
| .2. Ada persiapan / tidak ada persiapan
| 3. denis pemeriksaan .... 72644... dengan pemakaian kV
| 4. Pemakaian APD (APRON)
58
| Keterangan
| 1, Pemeriksaan radiologi merupakan pemeriksaan penunjang dengan menggunakan radiasi pengion
(sinar — X) yang dapat merekam organ-organ tubuh,
Radiasi pengion bisa menycbubkan kematian sel-sel
Akan tetapi penggunaan sinar ~ X di RSU Mitra Sehat masih dalam ambang batas yang ditentukan
dengan adanya ijin operasional dari BAPETEN dimana jumlah dosis radiasi maksimum yang boleh
diterima untuk seluruh tubuh S0mSv ($000mRem) peitahun (PP No. 63 Tahun 2000 dan SK
Ka.BAPETEN No, 01/Ka-BAPETEN/V-99)
4. Oleh karena itu pemeriksuan radiologi harus ada pengantar dari dokter pemeriksa pasien
Tanggal [et okies teh Tam [Lao
Penerima persetujuan
,
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