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Form Rujukan Ke RS SMC
Form Rujukan Ke RS SMC
Form Rujukan Ke RS SMC
RS SMC
RUMAH SAKIT SINGAPARNA MEDIKA CITRA UTAMA
Jl. Raya Rancamaya Singaparna
Telp. (0265) 543456 – 543238 Fax 543237.
Nama : ....................................................................................
Tgl. Lahir/Umur : ....................................................................................
No RM : ....................................................................................
Diagnosa : ....................................................................................
Alasan Rujuk : ....................................................................................
ada saat diserah-terimakan keadaan pasien tersebut dibawah ini :
1. Keadaan Umum:.......................................................................................................................................
2. Kesadaran: Compos mentis / apatis / sopor / somnolen / soporocoma / coma *)
3. Tanda Vital : TD :................../.....................mmHg Nadi : ..................................x/menit
Resep :...................................x/menit Suhu : ..................................oC
4. Alat-alat yang terpasang pada tubuh pasien (beri tanda