Formulir Denda.docx
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FORMULIR KETERANGAN DIAGNOSA AWAL
KETERANGAN PASIEN RAWAT INAP Nama Pasien
:
Nomor Kartu JKM-KIS
:
Tanggal Masuk FKRTL
:
Diagnosa Awal
:
Keterangan
:
Nama Dokter Penanggungjawab Pasien (DPJP) :
............./......../..............
DPJP
(..............................)
KETERANGAN PASIEN RAWAT INAP Nama Pasien
:
Nomor Kartu JKM-KIS
:
Tanggal Masuk FKRTL
:
Diagnosa Awal
:
Keterangan
:
Nama Dokter Penanggungjawab Pasien (DPJP) :
............./......../..............
DPJP
(..............................)
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