No Identitas Diagnosis Operasi Tanggal Jenis ILO Komplikasi
Operasi Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : .................. Superficial/Deep/Organ Dehiscence/Burst/Fistula/lain- lain : ..................