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PEMERINTAH KABUPATEN SERUYAN PEMERINTAH KABUPATEN SERUYAN PEMERINTAH KABUPATEN SERUYAN

RSUD KUALA PEMBUANG CM-2.2 RSUD KUALA PEMBUANG CM-2.2 RSUD KUALA PEMBUANG CM-2.2
Jl. A. Yani No. 30 Kuala Pembuang 74211 Kalimantan Tengah Jl. A. Yani No. 30 Kuala Pembuang 74211 Kalimantan Tengah Jl. A. Yani No. 30 Kuala Pembuang 74211 Kalimantan Tengah
Telepon (0538) 21017 Faximile (0538) 21566 Telepon (0538) 21017 Faximile (0538) 21566 Telepon (0538) 21017 Faximile (0538) 21566

SURAT PERINTAH MASUK DIRAWAT SURAT PERINTAH MASUK DIRAWAT SURAT PERINTAH MASUK DIRAWAT

Nama Pasien : ................................................................... Nama Pasien : ................................................................ Nama Pasien : ................................................................


Tgl Lahir : ........................................................*(L/P) Tgl Lahir : .....................................................*(L/P) Tgl Lahir : ................................................*(L/P)
Alamat : ................................................................... Alamat : ................................................................ Alamat : ................................................................
................................................................... ................................................................ ................................................................
Tanggal periksa : ………./………../………... Tanggal periksa : ………./………../……….. Tanggal periksa : ………./………../……….
Ruang : ........................................... Ruang : ........................................... Ruang : ...........................................
Diagnosa masuk : ................................................................... Diagnosa Masuk : ................................................................ Diagnosa Masuk : ................................................................
Terapi : ................................................................... Terapi : ................................................................ Terapi : ................................................................
................................................................... ................................................................ ................................................................
................................................................... ................................................................ ................................................................
................................................................... ................................................................ ................................................................
................................................................... ................................................................ ................................................................
Pernyataan Pasien : ................................................................... Pernyataan Pasien : ................................................................ Pernyataan Pasien : ................................................................
(Setuju dirawat) ................................................................... (Setuju dirawat) ................................................................ (Setuju dirawat)

Dokter yang memeriksa, Dokter yang memeriksa, Dokter yang memeriksa,

(……………………………………) (……………………………………) (……………………………………)

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