Anda di halaman 1dari 1

RUMAH SAKIT PETROKIMIA GRESIK DRIYOREJO

Jl. Raya Legundi Driyorejo


Telp. 031-8981778, 8981778 (Fax), 8981779 (UGD)

By. Jayd

FORMULIR LAPORAN HARIAN PASIEN RAWAT INAP


DATA PASIEN
Nama Pasien
: ............................................
No. Register
Umur
: ............................................
Status
Nama KK
: ............................................
Unit Kerja
NIK
: ............................................
Telepon
Alamat
: ............................................
Tanggal Keluar
Tanggal masuk
: ............................................
Diagnosa Keluar
Diagnosa masuk
: ............................................
Jenis Kunjungan
Keterangan Keluar : ............................................
Kasus

: ...................................................
: Kary.PG/Kelg/Umum/...............
: ...................................................
: ...................................................
: ...................................................
: ...................................................
: Lama / Baru
: Lama / Baru

Anda mungkin juga menyukai