No RM: RM 1

PROGRAM PENDIDIKAN PROFESI NERS

FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA Nama :
DI RUANG BOBO 2 Tgl lahir :
RUMAH SAKIT DR. SOETOMO SURABAYA

LEMBAR IDENTITAS

1. Nama Lengkap pasien : .............................................................................................

2. Jenis Kelamin : ( ) Laki-laki ( ) Perempuan
3. Tempat/ Tanggal Lahir : .............................................................................................
4. Alamat Domisili : .............................................................................................
5. No. Telp/Hp : .............................................................................................
6. No. Identitas : .............................................................................................
7. Status Perkawinan : .............................................................................................
8. Agama : .............................................................................................
9. Pendidikan : .............................................................................................
10. Pekerjaan : .............................................................................................

11. Nama Ayah/ Ibu/ Suami/ Istri *) : .............................................................................................

Pekerjaan : .............................................................................................
Alamat : .............................................................................................
No. Telp/ Hp : .............................................................................................
12. Nama Keluarga/ kenalan di Surabaya : .............................................................................................
Alamat : .............................................................................................
No. Telp/ Hp : .............................................................................................

13. Nama Penanggung Biaya

a. Umum: : .............................................................................................
Nama : .............................................................................................
Alamat : .............................................................................................
No. Telepon/ Hp : .............................................................................................
b. Jaminan (BPJS, BPJS Tenaga Kerja, SKTM, Kartu Sehat)
Nomor jaminan :

Jam :
14. Masuk Rumah Sakit : Tanggal : Kelas :
IRNA :
Dokter/Rumah Sakit Perujuk *) : .............................................................................................
Diagnosis Rujukan : .............................................................................................
Prosedur Masuk Melalui : a. IRD b. IRJ

16. Pindah Ruang : Tanggal Jam IRNA Lantai

1.
2.

18. Keluar Rumah Sakit : Tanggal :

Dari IRNA/Ruang :
Cara Keluar : Sembuh/Membaik/Pulang Paksa/Rujuk/Meninggal *)
Lama Perawatan : ...................hari

*) Coret yang tidak perlu