Berkas Mr No 3.xlsx

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CATATAN DOKTER GIGI No. Medical Record

:

Alergi :

Nama Pasien (Patient's name :

1.

Tanggal Lahir (Date of Birth)

:

2.

Umur (Age)

:

3.

Jenis Kelamin

:

Laki-laki Perempuan

Anamnesa

Tanggal (date)

:

Diagnosis

Uraian Tindakan, Pemeriksaan Penunjang, Terapi, dll

NAMA/T.Tangan KODE ( ICD ) (Name/Signature)

No Form : 03/MR/I/13 Hal 1 dari 2 No. Rev : 01

Tanggal (date)

Diagnosis

Uraian Tindakan, Pemeriksaan penunjang, Terapi, dll NAMA/T.Tangan (Name/Signature)

KODE (ICD)

No Form : 03/MR/VI/11 Hal 2 dari 2 No. Rev : 00

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