FORMULIR HAK DAN KEWAJIBAN/TANGGUNG JAWAB

PASIEN
Tgl/
Jam

Tanda tangan dan

Nama Jelas
Materi Edukasi
Pasien

Keluarga
(Hubungan)

Dijelaskan
tentang
Hak
dan
Tanggung Jawab Pasien:
1. Dijelaskan dan ditujukan Lembar
Informasi
Hak
dan
Kewajiban/Tanggung
Jawab
Pasien Rawat Inap di Rumah Sakit
Hi. Muhammad Yusuf
2. Pertanyaan Pasien:
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3. Tanggapan Pemberi Informasi:
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Rumah Sakit
Hi. Muhammad Yusuf

Nama pasien
: ....................................
No. Rekam Medis : ....................................

Staf
RS