NOMOR REKAM MEDIS : __________________________________________________
NAMA : __________________________________________________ TANGGAL LAHIR : __________________________________________________ ALASAN MASUK RS : __________________________________________________ INDIKASI MASUK RS : __________________________________________________ DIAGNOSA KERJA : __________________________________________________ DOKTER PJP : __________________________________________________ RUANG / KELAS : __________________________________________________
HARI & TGL : ______________________
JAM : ______________________
DOKTER : ______________________
SURAT PENGANTAR DIRAWAT
NOMOR REKAM MEDIS : __________________________________________________
NAMA : __________________________________________________ TANGGAL LAHIR : __________________________________________________ ALASAN MASUK RS : __________________________________________________ INDIKASI MASUK RS : __________________________________________________ DIAGNOSA KERJA : __________________________________________________ DOKTER PJP : __________________________________________________ RUANG / KELAS : __________________________________________________