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  • Form Monitoring Pasien Rujukan Pasca Rawat Inap

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    14 tayangan1 halaman

    Form Monitoring Pasien Rujukan Pasca Rawat Inap

    Diunggah oleh

    octavia tri wulandari

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 1

    RUMAH SAKIT IBU DAN ANAK

    MUHAMMADIYAH MALANG
    Jl. KH. WAHID HASYIM NO 26, 30 TELP. (0341) 326222 – 351549 Fax (0341) 354480

    FORMULIR MONITORING PASIEN RUJUKAN PASCA RAWAT INAP

    Nama Pasien : ................................................................................................... (L / P)


    No. Rekam Medis : ................................................................................................................
    Tanggal Lahir / Umur : ................................................................................................................
    Alamat : ................................................................................................................
    .................................................................................................................
    Tanggal Keluar Rawat Inap : ................................................................................................................
    Nama DPJP : ................................................................................................................
    Diagnosis : ................................................................................................................

    Nama Petugas RS : ................................................................................................................


    Tanggal Monitoring : ................................................................................................................
    Asal FKTP : ................................................................................................................
    No. Telp. FKTP / Media : ............................................................... /...............................................
    Nama Petugas FKTP : ................................................................................................................
    Hasil Monitoring : ................................................................................................................
    .................................................................................................................
    .................................................................................................................
    .................................................................................................................
    .................................................................................................................
    .................................................................................................................
    .................................................................................................................

    Petugas

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

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