Review No.RM : 040206 No.

RM : 040207
A. Identifikasi sosial L TL TDK L TL TDK
1. Pribadi
a. No.RM 0 1 "-" 0 1 "-"
b. Nama Pasien 0 1 "-" 0 1 "-"
c. Umur 0 1 "-" 0 1 "-"
d. Jenis Kelamin 0 1 "-" 0 1 "-"
e. Tempat 0 0 1 0 0 1
f. Tangal Lahir 0 1 "-" 0 1 "-"
2. Sosial
a. Alamat 0 1 "-" 0 1 "-"
b. Agama 1 0 "-" 0 1 "-"
c. Pekerjaan 0 1 "-" 0 1 "-"
d. Status Perkawinan 1 0 "-" 1 0 "-"
e.Pedidikan 0 1 "-" 1 0 "-"
B. Pelaporan yang penting L TL TDK L TL TDK
1. Anamnesa 0 1 "-" 0 1 "-"
2. Pemeriksaan Fisik 0 1 "-" 0 1 "-"
3. Diagnosis Utama 0 1 "-" 1 0 "-"
4. Diagnosis Awal 0 0 1 0 0 1
5. Diagnosis Komplikasi 0 1 "-" 0 1 "-"
6. Formulir general concent 0 0 1 0 0 1
C. otentifikasi L TL TDK L TL TDK
1. Nama Terang Dokter 0 1 "-" 0 1 "-"
2. Tanda Tangan Dokter 1 0 "-" 0 1 "-"
3. Keaadaan Keluar Pasien 0 1 "-" 1 0 "-"
4. Nama Pasien 0 0 1 0 0 1
5. Tanda Tangan Pasien 0 0 1 0 0 1
6. Nama penanggung jawab pasien 0 1 "-" 1 0 "-"
7. Tanda Tangan Penanggung Jawab 0 0 1 1 0 "-"
8. Nama Perawat 1 0 "-" 1 0 "-"
9. Tanda Tangan Perawat 1 0 "-" 1 0 "-"
10. Nama Petugas Tppri 0 0 1 1 0 "-"
11. Tanda Tangan Petugas Tppri 0 0 1 1 0 "-"
D.Pecatatan yang benar B TB TDK B TB TDK
1. Cara Penulisan 0 1 "-" 0 1 "-"
2. Cara Pembetulan Kesalahan 0 1 "-" 0 0 1
3. Singkatan 1 0 "-" 1 0 "-"
4. Penutup 0 1 "-" 0 1 "-"
 AMR_12_KELOMPOK2_B

No.RM : 040208 No.RM : 040209 No.RM No.RM

L TL TDK L TL TDK L TL TDK L

0 1 "-" 0 1 "-" 0 1 "-" 0

1 0 "-" 1 0 "-" 1 0 "-" 1
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0

0 1 "-" 0 1 "-" 0 1 "-" 0

0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
L TL TDK L TL TDK L TL TDK L
0 1 "-" 0 1 "-" 0 1 "-" 0
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
0 0 1 0 0 1 0 0 1 0
0 0 1 0 0 1 0 0 1 0
0 1 "-" 0 1 "-" 0 1 "-" 0
L TL TDK L TL TDK L TL TDK L
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
B TB TDK B TB TDK B TB TDK B
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
1 0 "-" 1 0 "-" 1 0 "-" 1
0 1 "-" 0 1 "-" 0 1 "-" 0
 No.RM No.RM No.RM No.RM
TL TDK L TL TDK L TL TDK L TL

1 "-" 0 1 "-" 0 1 "-" 0 1

0 "-" 1 0 "-" 1 0 "-" 1 0
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1

1 "-" 0 1 "-" 0 1 "-" 0 1

1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
TL TDK L TL TDK L TL TDK L TL
1 "-" 0 1 "-" 0 1 "-" 0 1
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 1 0 0 1 0 0 1 0 0
0 1 0 0 1 0 0 1 0 0
1 "-" 0 1 "-" 0 1 "-" 0 1
TL TDK L TL TDK L TL TDK L TL
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
TB TDK B TB TDK B TB TDK B TB
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
0 "-" 1 0 "-" 1 0 "-" 1 0
1 "-" 0 1 "-" 0 1 "-" 0 1
No.RM No.RM No.RM No.RM
TDK L TL TDK L TL TDK L TL TDK

"-" 0 1 "-" 0 1 "-" 0 1 "-"

"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"

"-" 0 1 "-" 0 1 "-" 0 1 "-"

"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
TDK L TL TDK L TL TDK L TL TDK
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
1 0 0 1 0 0 1 0 0 1
1 0 0 1 0 0 1 0 0 1
"-" 0 1 "-" 0 1 "-" 0 1 "-"
TDK L TL TDK L TL TDK L TL TDK
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
TDK B TB TDK B TB TDK B TB TDK
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
 No.RM No.RM No.RM No.RM
L TL TDK L TL TDK L TL TDK L

0 1 "-" 0 1 "-" 0 1 "-" 0

1 0 "-" 1 0 "-" 1 0 "-" 1
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0

0 1 "-" 0 1 "-" 0 1 "-" 0

0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
L TL TDK L TL TDK L TL TDK L
0 1 "-" 0 1 "-" 0 1 "-" 0
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
0 0 1 0 0 1 0 0 1 0
0 0 1 0 0 1 0 0 1 0
0 1 "-" 0 1 "-" 0 1 "-" 0
L TL TDK L TL TDK L TL TDK L
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
B TB TDK B TB TDK B TB TDK B
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
1 0 "-" 1 0 "-" 1 0 "-" 1
0 1 "-" 0 1 "-" 0 1 "-" 0
 No.RM No.RM No.RM No.RM
TL TDK L TL TDK L TL TDK L TL

1 "-" 0 1 "-" 0 1 "-" 0 1

0 "-" 1 0 "-" 1 0 "-" 1 0
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1

1 "-" 0 1 "-" 0 1 "-" 0 1

1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
TL TDK L TL TDK L TL TDK L TL
1 "-" 0 1 "-" 0 1 "-" 0 1
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 1 0 0 1 0 0 1 0 0
0 1 0 0 1 0 0 1 0 0
1 "-" 0 1 "-" 0 1 "-" 0 1
TL TDK L TL TDK L TL TDK L TL
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
TB TDK B TB TDK B TB TDK B TB
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
0 "-" 1 0 "-" 1 0 "-" 1 0
1 "-" 0 1 "-" 0 1 "-" 0 1
No.RM No.RM No.RM No.RM
TDK L TL TDK L TL TDK L TL TDK

"-" 0 1 "-" 0 1 "-" 0 1 "-"

"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"

"-" 0 1 "-" 0 1 "-" 0 1 "-"

"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
TDK L TL TDK L TL TDK L TL TDK
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
1 0 0 1 0 0 1 0 0 1
1 0 0 1 0 0 1 0 0 1
"-" 0 1 "-" 0 1 "-" 0 1 "-"
TDK L TL TDK L TL TDK L TL TDK
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
TDK B TB TDK B TB TDK B TB TDK
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
"-" 1 0 "-" 1 0 "-" 1 0 "-"
"-" 0 1 "-" 0 1 "-" 0 1 "-"
 No.RM No.RM No.RM No.RM
L TL TDK L TL TDK L TL TDK L

0 1 "-" 0 1 "-" 0 1 "-" 0

1 0 "-" 1 0 "-" 1 0 "-" 1
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0

0 1 "-" 0 1 "-" 0 1 "-" 0

0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
L TL TDK L TL TDK L TL TDK L
0 1 "-" 0 1 "-" 0 1 "-" 0
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
0 0 1 0 0 1 0 0 1 0
0 0 1 0 0 1 0 0 1 0
0 1 "-" 0 1 "-" 0 1 "-" 0
L TL TDK L TL TDK L TL TDK L
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
1 0 "-" 1 0 "-" 1 0 "-" 1
B TB TDK B TB TDK B TB TDK B
0 1 "-" 0 1 "-" 0 1 "-" 0
0 1 "-" 0 1 "-" 0 1 "-" 0
1 0 "-" 1 0 "-" 1 0 "-" 1
0 1 "-" 0 1 "-" 0 1 "-" 0
 No.RM No.RM No.RM No.RM
TL TDK L TL TDK L TL TDK L TL

1 "-" 0 1 "-" 0 1 "-" 0 1

0 "-" 1 0 "-" 1 0 "-" 1 0
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1

1 "-" 0 1 "-" 0 1 "-" 0 1

1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
TL TDK L TL TDK L TL TDK L TL
1 "-" 0 1 "-" 0 1 "-" 0 1
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 1 0 0 1 0 0 1 0 0
0 1 0 0 1 0 0 1 0 0
1 "-" 0 1 "-" 0 1 "-" 0 1
TL TDK L TL TDK L TL TDK L TL
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
0 "-" 1 0 "-" 1 0 "-" 1 0
TB TDK B TB TDK B TB TDK B TB
1 "-" 0 1 "-" 0 1 "-" 0 1
1 "-" 0 1 "-" 0 1 "-" 0 1
0 "-" 1 0 "-" 1 0 "-" 1 0
1 "-" 0 1 "-" 0 1 "-" 0 1
No.RM No.RM Total
TDK L TL TDK L TL TDK

"-" 0 1 "-" 0 30 0
"-" 1 0 "-" 28 2 0
"-" 0 1 "-" 0 30 0
"-" 0 1 "-" 30
"-" 0 1 "-" 28 2
"-" 0 1 "-" 30

"-" 0 1 "-" 30
"-" 0 1 "-" 1 29
"-" 0 1 "-" 1 29
"-" 0 1 "-" 2 28
"-" 0 1 "-" 1 29
TDK L TL TDK L TL TDK
"-" 0 1 "-" 30
"-" 1 0 "-" 28 2
"-" 1 0 "-" 29 1
1 0 0 1 30
1 0 0 1 2 28
"-" 0 1 "-" 28 2
TDK L TL TDK L TL TDK
"-" 1 0 "-"
"-" 1 0 "-"
"-" 0 1 "-"
"-" 0 1 "-"
"-" 0 1 "-"
"-" 1 0 "-"
"-" 1 0 "-"
"-" 1 0 "-"
"-" 1 0 "-"
"-" 1 0 "-"
"-" 1 0 "-"
TDK B TB TDK B TB TDK
"-" 0 1 "-" 0 30 0
"-" 0 1 "-" 0 29 1
"-" 1 0 "-" 30 0 0
"-" 0 1 "-" 0 30 0