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PEMERINTAH PROVINSI JAWA TIMUR

RUMAH SAKIT JIWA MENUR


JL. Menur No.120, Telp. (031) 5021635, 5021637
SURABAYA

NASEHAT PASIEN PULANG

1. NAMA LENGKAP : ..............................................................................................................


2. NO. REKAM MEDIS : ..............................................................................................................
3. TANGGAL LAHIR : ..............................................................................................................
4. RUANG : ...............................................................................................................
5. ALAMAT : ...............................................................................................................
6. TANGGAL MASUK : ..............................................................................................................
7. TANGGAL PULANG : ..............................................................................................................
8. DOKTER YANG MERAWAT : ...............................................................................................................
9. DIAGNOSA : ..............................................................................................................
10. OPERASI/TINDAKAN : ..............................................................................................................
11. KONTROL KEPADA : ..............................................................................................................
12. HARI/TANGGAL : ..............................................................................................................
13. OBAT YANG DISERAHKAN
 …………………………………………………………………………………………………………………..
 …………………………………………………………………………………………………………………...
14. HASIL PEMERIKSAAN
 ……………………………………………………………………………………………………………………
 ……………………………………………………………………………………………………………………
15. NASEHAT
 DIET
 ………………………………………………………………………………………………………………………
 ……………………………………………………………………………………………………………………….

Yang Menerima Obat Surabaya, ………………………..


Perawat Ruang …………………

(…………………………………) (…………………………………)

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