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RM 86

PENCATATAN TINDAKAN MEDIS

No. Rekam Medis : Ruang :


Nama Pasien : Kelas :
Tanggal Lahir :
NIK :

Diagnosa : ..................................................................................................................................................
Nama Tindakan : ..................................................................................................................................................
Tanggal Tindakan : .......................................... Jam Tindakan..............................WIB
Jenis Anastesi : □ Lokal □ ………………………………….

LAPORAN TINDAKAN

Dokter Operator Asisten Operator

( ............................................) ( ............................................)
Tanda Tangan & Nama Terang Tanda Tangan & Nama Terang

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