Lembar Konfirmasi Dpjp.docx

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LEMBAR KONFIRMASI

Nama

:

No RM/ No Kartu BPJS

:

No SEP

:

TanggalPelayanan

:

Diagnosis Primer

:

Diagnosis Sekunder

:

Tindakan

:

Hal yang dikonfirmasi

:

Jawabankonfirmasi

:

Menyatakanbahwaketerangan di atasadalahsudahbenardansesuaikondisiserta resume medis, wewenangdokterpenanngungjawab yang bertujuanuntukkepentinganmedis Medan, 2018 DokterPenanggungjawabpelayanan

Mei

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