Martapura, 01 April Nomor MR : ..................................................................................................................................................... Nama pasien 2014 : ..................................................................................................................................................... Umur : ………………Th/ …………………Bl/ ……….…….. Hr. BB : ......................................... Kg Jenis Kelamin Lampiran : -: L / P Kepada Yth. Ruangan : ……………………………………..... Kelas : ........................................................................... Perihal : Laporan Kehilangan BMDKepala BPKAD Kab. Banjar Tgl. MRS : ..................................................................................................................................................... Alamat Di : ..................................................................................................................................................... Cara pembayaran : ...........................................................................(BPJS/Umum/Tagihan/Jamkesda/Jamkesprov) Dokter Bedah / Operator Tempat : ..................................................................................................................................................... Diagnose Pre Operasi : ................................................................................................................................... Kanan/Kiri No : 800/ / Raza Martapura, 01 April Jenis Pembedahan : ..................................................................................................................................................... Jenis Pembiusan 2014 : ............................................................................................................................. Umum / Lokal Tanggal Operaasi : ............................................................................... Ronde : I / II / III Pk: ………………… Lampiran Diagnose Pasca Operasi : -: ..................................................................................................................................................... Kepada Yth. Perihal Operator, : Laporan Kehilangan BMDKepala BPKAD Kab. Banjar Ka. Ruangan / Perawat Di Nama : Nama : Tempat NIP : NIP : NB : * Mohon diisi dengan lengkap * Apabila tidak lengkap tidak akan dilayani
PEMERINTAH KABUPATEN BANJAR
RUMAH SAKIT UMUM DAERAH RATU ZALECHA Jl.Menteri Empat Martapura Kal-Sel Telp. ( 0511 ) 4789454-4789635 Fax. 4789454-4789635 Email : ratuzalecha@gmail.com
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BLANKO PENDAFTARAN PENDERITA CALON OPERASI
No : 800/ / Raza Tanggal : …………………….……………….
Martapura, 01 April Nomor MR : ..................................................................................................................................................... Nama pasien 2014 : ..................................................................................................................................................... Umur : ………………Th/ …………………Bl/ ……….…….. Hr. BB : ......................................... Kg Jenis Kelamin Lampiran : -: L / P Kepada Yth. Ruangan Perihal : ……………………………………..... : Laporan Kehilangan BMDKepala BPKAD Kab. Banjar Kelas : ........................................................................... Tgl. MRS : ..................................................................................................................................................... Alamat Di : ..................................................................................................................................................... Cara pembayaran : ...........................................................................(BPJS/Umum/Tagihan/Jamkesda/Jamkesprov) Dokter Bedah / Operator Tempat : ..................................................................................................................................................... Diagnose Pre Operasi : ................................................................................................................................... Kanan/Kiri No : 800/ / Raza Martapura, 01 April Jenis Pembedahan : ..................................................................................................................................................... Jenis Pembiusan 2014 : ............................................................................................................................. Umum / Lokal Tanggal Operaasi : ............................................................................... Ronde : I / II / III Pk: ………………… Lampiran Diagnose Pasca Operasi : -: ..................................................................................................................................................... Kepada Yth. Perihal Operator, : Laporan Kehilangan BMDKepala BPKAD Kab. Banjar Ka. Ruangan / Perawat Di Nama : Nama : Tempat NIP : NIP : NB : * Mohon diisi dengan lengkap * Apabila tidak lengkap tidak akan dilayani
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