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    Formulir Penundaan Pelyanan

    Uploaded by

    syarmina

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    RM 112

    Nomor RM : ………………………………
    RSUP PERSAHABATAN
    Nama : ………………………………
    Jl. Persahabatan Raya No. 1
    Tanggal Lahir : ………………………………
    Jakarta Timur
    Jenis Kelamin :L/P
    Telp 4891708 /Fax 4711222 (Mohon diisi atau tempelkan stiker bila ada)

    FORMULIR PENUNDAAN PELAYANAN


    Tanggal : ……………………………………………………………………………………………
    Ruang Rawat/ Instalasi : ……………………………………………………………………………………………
    Diagnosa : ……………………………………………………………………………………………
    DPJP : ……………………………………………………………………………………………
    Tim Dokter : 1. …………………………………………………………………………………..
    2. …………………………………………………………………………………..
    3. …………………………………………………………………………………..
    Kondisi Terakhir Pasien : ……………………………………………………………………………………………
    ……………………………………………………………………………………………
    ……………………………………………………………………………………………
    Alasan Penundaan
    a. Medis : ……………………………………………………………………………………………
    ……………………………………………………………………………………………
    ……………………………………………………………………………………………
    b. Non Medis : ……………………………………………………………………………………………
    ……………………………………………………………………………………………
    ……………………………………………………………………………………………
    Instuksi Pengelolaan Pasein Selanjutnya : ……………………………………………………………………………………………
    ……………………………………………………………………………………………
    ……………………………………………………………………………………………

    Jakarta,………………………………pukul ………………
    Menyetujui,

    Keluarga Pasien DPJP

    (………………………………….) (…………………………………………………)
    November ‘14

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