PEMERINTAH KABUPATEN OGAN ILIR N0.

Slip :
RSUD KAB.OGAN ILIR
INDRALAYA
BUKTI PERMINTAAN dan TINDAKAN PELAYANAN
PENUNJANG DIAGNOSTIK/ TINDAKAN MEDIS CANGGIH

Nama Dokter : ..................................................∕ .......................................... Nama Tindakan :

Nama /Umur : ..................................................... ..............∕ ............... Thn 1. ....................................................

No.Reg. / No.Rekam Medis : ..................................................∕ .......................................... 2. ....................................................

No.Kartu BPJS (JKN)/Kepesertaan : ..................................................∕ .......................................... 3. ....................................................

Ruang / Kelas : ..................................................∕ .......................................... 4. ....................................................

Diagnose : ...................................................................................................

Hari / Tgl. : ..................................................∕ .......................................... Tgl. Dilakukan : ................................

Dokter ybs, Keluarga pasien ybs, Petugas,

...................................... ...................................... ......................................

NIP. : Hub. Dengan Pasien NIP. :
1. Orang Tua
2. Suami / Istri
3. Saudara Kandung