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No. RM : ...................................................

Nama : ..................................................

Jl.Raya. Kosambi-Telagasari Km 3 Klari – Karawang Jenis Kelamin : ..................................................


(41371) Umur : ..................................................
Telepon (0267) 437507 Fax (0267) 438681
(mohon diisi atau tempelkan stiker jika ada)
Email :rs_citrasarihusada@yahoo.co.id Website :
www.rscitrasarihusada.com

ASSESMEN PRA BEDAH

1. Anamnesa :
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2. Pemenriksaan Fisik:
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3. Pemeriksaan Penunjang
a. Laboratorium :..........................................................................................................
b. USG :..........................................................................................................
c. CT-Scan / RO / MRI :..........................................................................................................
d. Lain-lain :..........................................................................................................
4. Diagnosa
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5. Rencana Operasi
a. Tindakan /prosedur :..........................................................................................................
b. Waktu dan Tempat :..........................................................................................................
6. Alternatif :..........................................................................................................
7. Resiko dan Rencana Prosedur Operasi
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8. Potensial Komplikasi :...........................................................................................................
9. Keuntungan dari Prosedur Operasi ini :..........................................................................................................
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10. Transfusi (optional) :..........................................................................................................
11. Catatan
a. Telah dijelaskan kepada :.........................................................................................................
b. Sebagai (pasien/wali/keluarga), hubungan :........................................................................................
c. Tentang diagnosis, rencana operasi, berikut resiko, alternatif, komplikasi serta keuntungan prosedur
operasi.

Karawang, .............................20...........
Dokter Operasi

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