A. IDENTITAS PASIEN
Nama : ……………………….. Penanggung jawab pasien
Umur : ……………………….. Nama : …………………………...
Jenis kelamin : ……………………….. Umur : …………………………...
Agama : ……………………….. Jenis kelamin : …………………………...
Pendidikan : ……………………….. Pendidikan : …………………………...
Pekerjaan : ……………………….. Pekerjaan : …………………………...
Suku/ bangsa : ……………………….. Status hub : …………………………...
Alamat : ……………………….. Alamat : …………………………...
Status perkawinan : ………………………..
D. TERAPI OBAT
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E. TINDAKAN PEMBEDAHAN
Rencana akan dilakukan operasi
Hari : ……… Tanggal : ………… Jam : ………… Jenis operasi: ……………………
Pre operasi
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Post operasi
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PEMERIKSAAN PENUNJANG
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