a}
{3} BRIsKesehat an Formulir Klaim Petayanan Primer
= 23011202 - PELANGAN
\dentias Pasion .
Kanon: NT SPORT
—— Modis: Tonggal Labi swans
er Kar Reser + ogcosersrrs2 vir 2 un 2 dan sa
NK 5201074305450001 Tanggal Pelayanan osmose022
Nama TAH Jenis Polayonan Promotit
Jens Ketamn Peempun sat sun aauanro
Nomor HP Enwty
‘etuhan pasion sat data ke PT
Arameese
PEMERIGSAAN Fis Pearson Gnarls Taba
Tanda Via: nx ans:
‘Kesadaran —_: Compos mentis ‘Suh 36.00 Hidung: Jontung.
Sse tommy Dale TOmmig Fi
Resp. Rate 29.00 imenit Heart Rate: 88.00 /opm Tsinga: eae
Tingp Bacon 155 ere BeratBadan : 50003 a isi sist:
Lingkat Pert : 68.00 em inet 2081 aoe is
inner tian a:
Pemertsaan Eenunlana
Radiologl: [7]
Laboratorium : (7)
Elektrocardiogram :{T)]
Riwayat Alergi 5
Pitan nai dopondont betes metus
Diagnosa Sekunder:
‘Tindakan (Prosedure)—S ~
rogné 7
{JENIS TAGIHAN NON KAPITASI
Pelayanan Gula Derah Puasa (GOP): Hast (80.0 } Range Noma - 130 mare)
Tenaga Kesehatan
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