Form Identitas Pasien
Form Identitas Pasien
KABUPATEN MALANG
NAMA : ..............................................................................................
UMUR : ..............................................................................................
AGAMA : ..............................................................................................
SUKU : ..............................................................................................
PEKERJAAN : ..............................................................................................
KEPERLUAN : ..............................................................................................*
Pasien,
(.........................................................)
Alamat :
4. Lain-lain : ..............................................
No. Telp/Hp :
Kasus Polisi : 1. Ya
2. Tidak
Pemeriksaan Fisik :
2. Nadi : .........................................X/mnt
5. Pemeriksaan Sistemik
Sistem jantung
Sistem Sistem Sistem saraf THT dan
dan pembuluh Keterangan
pencernaan pernapasan pusat kulit
darah
Diagnosa Utama :
Diagnosa Penyerta :
Kode ICD :
Dokter
Perawat
Petugas Admin