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PEMERINTAH KABUPATEN PAMEKASAN

DINAS KESEHATAN
UPT PUSKESMAS SOPAAH
Jl. Raya Sopa’ah Kec. Pademawu (69323) Kab. Pamekasan
Telp. (0324) 331693 E-mail: pkmsopaah@gmail.com

PENGANTAR RAWAT INAP

No. Rekam Medis :


Nama Pengguna layanan : ......................................................................................................
Tgl. Lahir : ........................................................................................ (L / P)*

Alamat : ...........................................................................................................................................
No. JKN : ...........................................................................................................................................
Diagnosa : ...........................................................................................................................................
Tindakan / Therapy yang telah diberikan : ...........................................................................................
...........................................................................................
...........................................................................................
Ruang Pelayanan yang Mengirim : ...........................................................................................

Karena kondisinya pasien tersebut perlu dirawat.

Sopa’ah, .................................... Jam ...................

Dokter yang Merawat

.....................................................

* Coret yang tidak perlu

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