Nama pasien : ....................................

No. Rekam Medis : ....................................

Rumah Sakit
Bersalin Masyita

FORMULIR HAK DAN KEWAJIBAN/TANGGUNG JAWAB

PASIEN
Tanda tangan dan
Nama Jelas
Tgl/
Materi Edukasi
Jam Keluarga Staf
Pasien
(Hubungan) RS

Dijelaskan tentang Hak dan

Tanggung Jawab Pasien:
1. Dijelaskan dan ditujukan Lembar
Informasi Hak dan
Kewajiban/Tanggung Jawab
Pasien Rawat Inap di Rumah Sakit
Hi. Muhammad Yusuf
2. Pertanyaan Pasien:
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3. Tanggapan Pemberi Informasi:
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