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NAMA :.....................................

NO. RM :.....................................
TGL LAHIR :.....................................

NAMA :.....................................
NO. RM :.....................................
TGL LAHIR :.....................................

ALERGI
NAMA :................................
RUMAH SAKIT
FALL RISK NO. RM :................................ UNIVERSITAS TANJUNGPURA

TANGGAL :................................

CAIRAN KE :................................

JENIS CAIRAN :................................

OBAT :................................
NAMA: EKO DWI PURNOMO

TETES / MENIT :................................


KEPALA
Ket: RUANGAN

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