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KLINIK PRATAMA

DEA
REKAM MEDIS
PASIEN RAWAT JALAN

NAMA :...…………………...……...................
BPJS PBI NO. KARTU BPJS :
NAMA KK :...…………………..……....................
LK/PR/UMUR :............................................................. BPJS NON PBI
AGAMA :...………………………….................. UMUM
PEKERJAAN :...……………………..................…… RIWAYAT ALLERGI :
ALAMAT :......………………………...............… LAINNYA
TELP./HP :...........................................................

Tgl (S) (O) (A) (P) (Tx) Ket


Subyektif Obyektif Assesment Planning Tindakan
Tgl (S) (O) (A) (P) (Tx) Ket
Subyektif Obyektif Assesment Planning Tindakan

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