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PEMERINTAH KABUPATEN SRAGEN No. RM : .....................................................

RSUD dr. SOEHADI PRIJONEGORO SRAGEN


Jln. Raya Sukowati No. 534 Telp. (0271) 891068 Sragen 57215 Nama Pasien : .....................................................
Website : http://rssoehadi.sragenkab.go.id
E-mail : rsudsragen1958@gmail.com Tanggal Lahir : .....................................................
Jenis Kelamin : Laki-laki Perempuan
SURAT BUKTI TINDAKAN DI IGD Alamat : .....................................................

Anamnesa : ....................................................................................................................

Kriteria Kegawatan : ....................................................................................................................

Diagnosis : ....................................................................................................................
Tindakan : ....................................................................................................................

Apabila Terkait Trauma (dilengkapi)


Tanggal Kejadian : ....................................................................................................................
Tempat Kejadian : ....................................................................................................................
Aktivitas yg sedang dilakukan : ......................................................................................................

Sragen, ....................................
Dokter

( ............................ )

RM : 13c/Rev.0/2020

PEMERINTAH KABUPATEN SRAGEN No. RM : .....................................................


RSUD dr. SOEHADI PRIJONEGORO SRAGEN
Jln. Raya Sukowati No. 534 Telp. (0271) 891068 Sragen 57215 Nama Pasien : .....................................................
Website : http://rssoehadi.sragenkab.go.id
E-mail : rsudsragen1958@gmail.com Tanggal Lahir : .....................................................
Jenis Kelamin : Laki-laki Perempuan
SURAT BUKTI TINDAKAN DI IGD Alamat : .....................................................

Anamnesa : ....................................................................................................................

Kriteria Kegawatan : ....................................................................................................................

Diagnosis : ....................................................................................................................
Tindakan : ....................................................................................................................

Apabila Terkait Trauma (dilengkapi)


Tanggal Kejadian : ....................................................................................................................
Tempat Kejadian : ....................................................................................................................
Aktivitas yg sedang dilakukan : ......................................................................................................

Sragen, ....................................
Dokter

( ............................ )

RM : 13c/Rev.0/2020

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