RM. 30
Diagnosa :..........................................................................................................................................
HASIL PEMERIKSAAN :
Kesan : ......................................................................................................................................
: ......................................................................................................................................
: ......................................................................................................................................
: .....................................................................................................................................
Kesimpulan : .....................................................................................................................................
: .....................................................................................................................................
Lahat, 20
Lembar : 1. rekam medis 2. administrasi klaim 3. pasien
Dokter Pemeriksa,
( .................................. )
NIP.