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RUMAH SAKIT RM 6.

14
INSAN PERMATA Nomor RM :
Layanan Prima Sehat Paripurna Nama :
Tgl Lahir :

FORMULIR PENUNDAAN / KELAMBATAN PELAYANAN

Tanggal : ................................................................................
Ruang Rawat / Instansi : ................................................................................
Diagnosa : ................................................................................
DPJP : ................................................................................
Tim Dokter : 1. ............................................................................
2. ...........................................................................
3. ...................................................................................
Kondisi Pasien Terakhir : ........................................................................................
.........................................................................................
Alasan Penundaan
a. Medis : ...........................................................................................
...........................................................................................

b. Non Medis : ...........................................................................................


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Instruksi Pengolahan Pasien Selanjutnya : ................................................................................


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Tangerang Selatan, .....................................


Pukul ..........................................................

Menyetujui,

Keluarga Pasien Yang Memberi Penjelasan

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