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No Reg.

P U S K E S M A S R AWAT I N A P M A N D O R
1. DATA DASAR PASIEN
Nama Pasien

:..

Tanggal / Jam Masuk

: .

Umur

: .

Tanggal / Jam Keluar

: .

Jenis Kelamin

: .

Ruang / Bed

: .

Agama

: .

UMUM

Penaggung jawab pasien

: .

No. telp/ HP yg bs dihub

: .

Alamat

: .

ASKES

JAMKESMAS

No. ASKES / JAMKESMAS

2. TANDA DAN GEJALA PENYAKIT


DS :.............................................................................................................................................................................................
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DO : ..
TD : _____________mmHg Temp :__________C Respirasi Rate (RR) :_________x/menit Nadi : ________x/menit
3. DIAGNOSA MEDIK.....................................................................................................................................................................
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4. THERAPY
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.. .........................................................................................................................................................................................
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5. TINDAKAN
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6. PEMERIKSAAN PENUNJANG
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C ATATA N P E R AWATA N
Nama Pasien

:..

Agama

: .

Umur

: .

Alamat

: .

Jenis Kelamin

: .

Ruang / Bed

Penaggung jawab pasien

: .

TANGGAL

JAM

CATATAN PERKEMBANGAN DAN KEPERAWATAN

PARAF & NAMA


PETUGAS

C ATATA N V I S I T E D O K T E R
Nama Pasien

:..

Agama

: .

Umur

: .

Alamat

: .

Jenis Kelamin

: .

Ruang / Bed

Penaggung jawab pasien

: .

TANGGAL

JAM

CATATAN MEDIK

PARAF & NAMA


PETUGAS

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