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SURAT PENGANTAR OPERASI ELEKTIF

No RM : ..........................................................................................................................
Nama : .........................................................................................................................
Tanggal lahir : .........................................................................................................................
Alamat : .........................................................................................................................
Jaminan :  Umum  BPJS Kesehatan  Lainnya............
Diagnosis : .........................................................................................................................
Nama Operasi : ................................................................. Kriteria : ...................................
Tanggal : .................................................................. Jam : ..............................
Perawatan Post-Op :  ODC  Rawat Inap Biasa  ICU
Instruksi Pre-Op : .........................................................................................................................
.........................................................................................................................

Lamongan, .................................
Perawat Dokter

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

SURAT PENGANTAR OPERASI ELEKTIF

No RM : ..........................................................................................................................
Nama : .........................................................................................................................
Tanggal lahir : .........................................................................................................................
Alamat : .........................................................................................................................
Jaminan :  Umum  BPJS Kesehatan  Lainnya............
Diagnosis : .........................................................................................................................
Nama Operasi : ................................................................. Kriteria : ..........................
Tanggal : .................................................................. Jam : ..............................
Perawatan Post-Op :  ODC  Rawat Inap Biasa  ICU
Instruksi Pre-Op : .........................................................................................................................
.........................................................................................................................

Lamongan, .................................
Perawat Dokter

(.........................................) (.............................................)