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

No. Rekam Medis :...................................................

FORMULIR HAK DAN KEWAJIBAN/TANGGUNG JAWAB PASIEN

Tanda tangan dan Nama Jelas

Tgl/ Materi Edukasi Keluarga
Jam Pasien Staf RS
(Hubungan)
Dijelaskan tentang Hak dan Tanggung
Jawab Pasien :
1. Dijelaskan dan ditunjukan
lembar informasi hak dan
kewajiban pasien rawat inap di
RSB Nabasa
2. Pertanyaan pasien :
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3. Tanggapan pemberi informasi :
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