Anda di halaman 1dari 3

No : ___________________ No : ___________________

DRG. KHOIRUL ANAM DRG. KHOIRUL ANAM


Klinik Insan Mulia Klinik Insan Mulia

REKAM MEDIS PASIEN REKAM MEDIS PASIEN

Nama : ________________________________ ( L / P ) ______ th Nama : ________________________________ ( L / P ) ______ th


Alamat : ________________________________________________ Alamat : ________________________________________________
Telp : ________________________________________________ Telp : ________________________________________________
Alergi : ________________________________________________ Alergi : ________________________________________________
Penyakit : ________________________________________________ Penyakit : ________________________________________________
Tgl Diagnosa Perawatan Tgl Diagnosa Perawatan

No : ___________________ No : ___________________

DRG. KHOIRUL ANAM DRG. KHOIRUL ANAM


Klinik Insan Mulia Klinik Insan Mulia

REKAM MEDIS PASIEN REKAM MEDIS PASIEN

Nama : ________________________________ ( L / P ) ______ th Nama : ________________________________ ( L / P ) ______ th


Alamat : ________________________________________________ Alamat : ________________________________________________
Telp : ________________________________________________ Telp : ________________________________________________
Alergi : ________________________________________________ Alergi : ________________________________________________
Penyakit : ________________________________________________ Penyakit : ________________________________________________
Tgl Diagnosa Perawatan Tgl Diagnosa Perawatan
Tgl Diagnosa Perawatan Tgl Diagnosa Perawatan

Tgl Diagnosa Perawatan Tgl Diagnosa Perawatan