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PEMERINTAH PROVINSI SULAWESI BARAT

RUMAH SAKIT UMUM DAERAH


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

RM 02e

Nama Lengkap :
PENGANTAR RAWAT INAP
No. RM :
Diisi oleh : Dokter Tanggal Lahir :

Dengan Hormat,
Mohon dilakukan perawatan atas pasien :
Nama : .......................................................................................................................................
Tanggal Masuk : .......................................................................................................................................
Alamat : .......................................................................................................................................
Diagnosis : .......................................................................................................................................
Ruangan : .......................................................................................................................................
Kelas : .......................................................................................................................................
Indikasi dirawat : ......................................................................................................................................
DPJP : ......................................................................................................................................

KETERANGAN :
Rencana Tatalaksana: .......................................................................................................................................
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LABORATORIUM : ....................................................................................................................................
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RO/USG/ENDOSKOPI/EKG : ......................................................................................................................
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Atas kerjasamanya diucapkan terima kasih.

Mamuju, .................................................
Hormat kami,