RM 1

KLINIK PRATAMA TABITA

Jl.Nilam No.06 Kota Gunungsitoli, Sumatera Utara
Kode Pos – 22815 Telp. 0639- 21921. Email: klinik.tabita@yahoo.com

FORMAT PASIEN RAWAT JALAN

Nama : ………………. tgl bln thn Agama : katolik protestan

Tempat/tgl lahir : ………………. islam lain-lain…

Jenis kelamin : laki-laki perempuan Pekerjaan : PNS wiraswsata lain-lain…

Alamat rumah : ………………. No.Telp./Hp : ___________________

No. RM : __ __ __ __ __ __

No. BPJS / KIS : _______________________________

Status Pasien : Umum JKN

Jenis Kunjungan : Kunjungan sakit Kunjungan sehat

Keluhan : ________________________________________________________________
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Pemeriksaan Fisik : ______________________________________________________

Tekanan darah : mmHg ______________________________________________________
Suhu Tubuh : °c ______________________________________________________
Respiratory Rate : x/menit ______________________________________________________
Heart Rate : Bpm
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Tinggi Badan : cm
Berat Badan : Kg ______________________________________________________
Kesadaran : ______________________________________________________
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Diagnosa : ______________________________________________________________
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Terapi : ______________________________________________________________
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Nama dan Tandatangan Dokter