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III.

PENGKAJIAN MEDIS
Pemeriksaan Dokter, Pukul :
Subjective :
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Objective :
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Pemeriksaan Penunjang :

EKG
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Radiologi : _____________________________________________________________________
Laboratorium : _____________________________________________________________________
Assessment :

Diagnosa Kerja
Diagnosa Banding

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Palanning : Penatalaksanaan / Pengobatan / Rencana Tindakan / Konsultasi


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Nama / Tanda Tangan Dokter

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