Anda di halaman 1dari 1

PEMERINTAH PROVINSI SULAWESI BARAT

RUMAH SAKIT UMUM DAERAH


Alamat : Jl. R.E. Marthadinata, Simboro, Mamuju

RM 03

DATA DIRI PASIEN No RM :


PATIENT IDENTITY Nama Lengkap :
Diisi oleh : Petugas Rekam Medik Tanggal Lahir :

1. JENIS KELAMIN : ....................................................................................


2. ALAMAT LENGKAP : ....................................................................................
3. TELEPON : ....................................................................................
4. NOMOR KTP : ....................................................................................
5. SUKU / WARGA NEGARA : ....................................................................................
6. AGAMA : ....................................................................................
7. STATUS PERNIKAHAN : Belum Menikah/ Menikah / Janda / Duda *
8. PENDIDIKAN TERAKHIR : ....................................................................................
9. PEKERJAAN : ....................................................................................
10. NAMA AYAH / IBU/ SUAMI / : ....................................................................................
ISTRI /WALI *
▪ Pekerjaan : ....................................................................................
▪ Alamat : ....................................................................................
▪ No. Telepon : ....................................................................................
11. PENANGGUNG BIAYA
a. UMUM
▪ Nama : ....................................................................................
▪ Alamat : ....................................................................................
▪ No. Telepon : ....................................................................................
b. JAMINAN : BPJS / ASURANSI / LAIN-LAIN*
▪ No BPJS : ....................................................................................
▪ Nama / No ASURANSI : ....................................................................................
▪ LAIN-LAIN : ....................................................................................
12. MASUK RS
▪ Tanggal : ....................................................................................
▪ Jam : ....................................................................................
▪ Ruang : ....................................................................................
▪ Kelas : ....................................................................................
13. Cara Masuk RS : Rujukan / Datang Sendiri*
▪ Dokter / Rumah Sakit Perujuk *) :...................................................................................
▪ Diagnosis Rujukan :...................................................................................
Masuk RS Melalui : IRJ / IGD*

* Coret yang tidak perlu