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PEMAKAIAN OBAT & BAHAN HABIS PAKAI

Nama : No. Rek. Medik :

Jenis Kelamin : L / P Tgl. Masuk/Jam :

TGL NAMA OBAT & BAHAN HABIS PAKAI JUMLAH POSTING PETUGAS
SEBAB-SEBAB KEMATIAN

Catatan:

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Lingga,…….……………………20….

Dokter yang merawat

Nama Jelas

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