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DINAS KESEHATAN KABUPATEN WONOGIRI

UPT PUSKESMAS WONOGIRI II

KARTU RAWAT JALAN TERPADU


NAMA
NAMA KK
PEKERJAAN
ALAMAT

UMUR : .............................................................................
AGAMA : .............................................................................
NO. KIS : .............................................................................

: ................................................................................................................................... L / P
: ...................................................................................................................................

: ....................................................................................................................
: ...................................................................................................................................

UMUM/ ASKES/ GAKIN/ JPKM/ DLL

TANGGAL

HASIL ANAMNESA, PEMERIKSAAN


FISIK, PEMERIKSAAN PENUNJANG
DAN DIAGNOSIS

TERAPI MEDIS & TINDAK LANJUT

NAMA
DOKTER &
TT

TIM INTERPROFESI (PERAWAT, BIDAN, SANITARIAN, FISIOTERAPIS, AHLI GIZI)


PENGKAJIAN

PERENCANAAN

PELAKSANAAN

EVALUASI

NAMA
PETUGAS &
TT