Surat Keterangan Medis.docx

SURAT KETERANGAN MEDIS

1. No. RM

:..............................................................

2. Nama

:.............................................................

3. Tgl. Lahir

:.............................................................

4. Jenis Kelamin

: Laki-Laki / Perempuan

5. Diaknosa Awal

:.............................................................

6. Peserta

: PBI / Non PBI

7. Kelas Rawatan

:.............................................................

8. R.Rawatan Terakhir

:.............................................................

9. Tanggal Masuk

:.............................................................

10. Tanggal Keluar

:.............................................................

11. Tanggal Meninggal

:.............................................................

12. Dokter Yang Merawat

:.............................................................

13. Ringkasan Riwayat Paisen

:.............................................................

14. Kondisi Pasien Saat Dirujuk

:.............................................................

15. Diagnosa Saat Dirujuk

:.............................................................

16. Terapi Yang Sudah di Berikan

:.......................................................................................... :......................................................................................... :.........................................................................................

Bagan Batu, ......../............./ 2015 `

Dokter yang Merawat

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