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FORMULIR PERMOHONAN
PEMERIKSAAN BAKTERIOLOGI TB

 Nama Unit Yankes  PU!"#!$%!


PU!"#!$%! D&'&DU& D&'&DU& No. (e)* (e)* Pasien .......................
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 Nama Dokter
Dokter Pengirim  ........................................
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 Nama (er+ga
(er+ga -Pasien
-Pasien (  .................................
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.......... Umr  (hn
 Nomor In+k
In+k "e*en++kan
"e*en++kan  .................................
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/enis "e)amin  'aki  'aki Perem*an
%)amat 'engka*  ...............................................................
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/enis (er+ga - Pasien (
"a*aten - "ota  o)aang $ongon+ow ( ( %nak  
Proinsi  !)awesi Utara ( 3I ( 5&

 N&. I+entitas
I+entitas !e+iaan !esai
!esai +atar ter+ga
ter+ga +i (
( 06 (. 06 5&
5&   - -
(angga)
angga) Pengam
Pengami)
i)an
an onto
ontohh U:i ......
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(angga)
angga) Pengir
Pengirima
imann ontoh
ontoh U:i ......
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(an+a (anga
(angann Pengami)
Pengami) ontoh
ontoh U:i ............
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Alaa! Pe!eri"aan #
Diagnosa ( Diagnosis ( 5&
Pemantaan "ema:an Pengoatan  )an "e
Pemeriksaan U)ang Pas;a Pengoatan ( 5&  )an "e
 No. 5eg (-
(- ( 5& <askes  ................................................................
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 No. 5eg (
( - ( 5& "a-"ota  ................................................................
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Jeni Dan Ju!la$ Pe!eri"aan L%"ai Ana&%!i


(%  ................................................................. Par
(est e*at => #kstra *ar
(est e*at 'P% 'okasi  ...................................
iakan ? ........................................................... '%n&%$ U(i
U:i "e*ekaan 'ini 1  ....................................... Dahak 
U:i "e*ekaan 'ini 2  ....................................... 'ain@a  .......................

!e;ara isa) Daha tam*ak  eri (an+a A *a+a "otak 


 Nanah 'en+ir
'en+ir er;ak Darah
Darah %ir 'ir  Ikhwan, ……………………2017
Dokter Pengirim
!ewakt-*agi

!ewakt-*agi
Dr. Jaqueline Olivia Lapian
!ewakt-*agi NIP.
NIP. 19870107 201704 2 006
HASIL PEMERIKSAAN BAKTERIOLOGI TB
 No. 5egister 'aoratorim  !esai k 5egister 'a ( 04 - ( 04 5&   ……………………….
'%n&%$ U(i )* Tan++al Pe!eri"aan Hail pe!eri"aan Mi,r%"%pi BTA ))

!ewakt - Pagi --- -- -  / 0))) Ne+

!ewakt - Pagi

!ewakt - Pagi

Hail Te& 'epa&


'%n&%$ U(i )* Tan++al Hail Te& 'epa& E1per& MTB2RIF))*
Lain 3 LPA*)))*
Ne+ Ri4 Sen Ri4 Re Ri4 In5en Invali5 Err%r N% Reul& INH Ri4 MTB
!ewakt - Pagi

'%n&%$ U(i )* Tan++al Hail Bia"an ))*


6- 7- 8- - /0)))* Ne+ NTM K%n&a!inai
!ewakt - Pagi

3asi) U:i "e*ekaan BBBBB


ontoh U:i B (angga) 3asi)
3 5 # ! "m %mk &?

!ewakt - Pagi

Di*eriksa &)eh  $engetahi


(an+a (angan Pemeriksa,
Dokter P/ Pemeriksaan 'aoratorim

NI N9OMAN SURITI
……………………………………………….
 NIP.198C1210 200701 2 001

B Diisi sesai +engan ko+e hr sesai i+entitas se+ian wakt *engami)an +ahak 
BB eri tan+a rm*t A *a+a hasi) *emeriksaan - tingkat *ositi @ang sesai
BBB Isi +engan /m)ah (% - k)oni @ang +itemkan
BBBB Untk ko)om IN3 +an 5I< +iisi 5  5esisten, !  !ensiti 
Untk "o)om $( +iisi $(  $@;roakterim (er;)osa, N(  Non $@;roakterim (er;)osa
BBBBB Disis 5  5esisten, !  !ensiti