,

No :

SURAT PENGANTAR RAWAT INAP

Dokter Penanggungjawab : ...............................................................................

Nama Pasien : ...............................................................................
Usia : ...............................................................................
No. Rekam Medis :...............................................................................

Tanggal Masuk : ...............................................................................

Indikasi Rawat Inap : ...............................................................................
Diagnosa : ...............................................................................
Rencana Terapi/Tindakan yang diberikan: ...............................................................................
...............................................................................
Perkiraan Lama Rawat Inap
: ...............................................................................
Masuk Melalui
: IGD (emergency/non emergency) / Poli / Rujukan *lingkari salah satu

/ / /
Mengetahui,

Dokter Yang Bertanggungjawab

Nama & Tanda Tangan