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No Tgl Anamnesis, Pemeriksaan Fisik & Diagnosis Penatalaksanaan Paraf

Pemeriksaan Penunjang (Kode Petugas


ICD X)
Anamnesis Terapi
Keluhan Utama : ........................................... ...............................................................
RPS : .............................................................. ...............................................................
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RPD : .............................................................. KIE
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Pemeriksaan Fisik ...............................................................
KU : Rujukan
TD : RR : BB : ...............................................................
N : S : Askep/Askeb/Asuhan Gizi/Kajian Sosial
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Pemeriksaan Penunjang ...............................................................
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Anamnesis Terapi
Keluhan Utama : ........................................... ...............................................................
RPS : .............................................................. ...............................................................
....................................................................... ...............................................................
....................................................................... ...............................................................
....................................................................... ...............................................................
RPD : .............................................................. KIE
........................................................................ ...............................................................
Pemeriksaan Fisik ...............................................................
KU : Rujukan
TD : RR : BB : ...............................................................
N : S : Askep/Askeb/Asuhan Gizi/Kajian Sosial
........................................................................ ...............................................................
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Pemeriksaan Penunjang ...............................................................
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Anamnesis Terapi
Keluhan Utama : ........................................... ...............................................................
RPS : .............................................................. ...............................................................
....................................................................... ...............................................................
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RPD : .............................................................. KIE
........................................................................ ...............................................................
Pemeriksaan Fisik ...............................................................
KU : Rujukan
TD : RR : BB : ...............................................................
N : S : Askep/Askeb/Asuhan Gizi/Kajian Sosial
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Pemeriksaan Penunjang ...............................................................
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