DINAS KESEHATAN
UPT PUSKESMAS GASING
Jl. Tanjung Api-api Desa Gasing Kecamatan Talang Kelapa
Email : gasing.pkm@gmail.com
I. IDENTITAS PASIEN
a. Nama Pasien :
b. Umur :
c. Jenis Kelamin :
d. Alamat :
e. No BPJS/Jamkesda :
a. Keadaan Umum :
b. GCS
c. Tandatanda Vital :
d. Kelainan yang
bermasalah : ......................................................................................
...................................................................................
...
IV Diagnosa :
a. .................................................................................................................................
......
b. .................................................................................................................................
......
c. .................................................................................................................................
......
d. .................................................................................................................................
.....
Gasing,
Dokter yang merujuk
(....................................................)
PEMERINTAH KABUPATEN BANYUASIN
DINAS KESEHATAN
UPT PUSKESMAS GASING
Jl. Tanjung Api-api Desa Gasing Kecamatan Talang Kelapa
Email : gasing.pkm@gmail.com