Anda di halaman 1dari 1

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

INSTALASI BEDAH SENTRAL


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 : ……………………………………..... 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

INSTALASI BEDAH SENTRAL


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