Nama :........................................................................................
Alamat :.......................................................................................
1.______________________________________
2.______________________________________
3.______________________________________
TANDA TANGAN
Dengan tanda tangan saya dibawah ini, saya menyatakan bahwa saya telah membaca
dan memahami item persetujuan Umum/ General Consent.
Diagnosa
Rencana Tindakan ( Pemeriksaan Penunjang, Terapi, Tindakan / Prosedur
Khusus, Nutrisi, Konsultasi, Rehabiltasi ):
.................................... ..........................................
Klien / keluarga Klien Dokter
DISCHARGE PLANING
No. RM :................................
DISCHARGE PLANING Nama :................................
Jenis Kelamin :................................
Tanggal Masuk :................................ Tanggal Keluar :................................
Lain lain
Bojonegoro...............................
(................................................) (.....................................)
Nama :...................................................................................................
NO. RM :...............................................................................................
DIAGNOSA :...............................................................................................
Bojonegoro,............................
.................................... ...........................................