Rm Bpjs.docx

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UPT PUSKESMAS TANJUNG DALAM MEDICAL RECORD ASKES/BPJS/KIS/JKM No. MR : Nama Pasien Tanggal Lahir Jenis Kelamin Alamat Status Pasien No.

: : : : : ASKES/BPJS/JKM/KIS

Tanggal

No. HP Pekerjaan Pendidikan Agama No. Kartu

Anamnesa Umur Sekarang : Vital Sign : TD : P : N : S : BB : TB : Riwayat Penyakit Dahulu : Riwayat Penyakit Keluarga : Riwayat Alergi : ASKEP/ASKEB S:

O:

A: P: Anamnesa Dokter/Dokter Gigi : S:

O:

A:

P:

Kode Diagnosa :

-

: : : : : Therapy

Kontrol Ulang

Paraf

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