resume medis rawat jalan

2
 RUMAH SAKIT SARI ASIH RESUME MEDIS RAWAT JALAN No. Rekam Medis Nama Pasien  T anggal Lahir  T anggal Peme riksaan Klinik / Dokter Lembar untuk diisi dokter Anamnesa Diagnosa  T erapi Anjuran : : : : : : : : : ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ Dengan ini saya selaku pasien / tertanggung, mengizinkan RS. Sari Asih Karawaci untuk memberikan keterangan lengkap mengenai keadaan penyakit / data medis kepada pihak ketiga yang ditunjuk secara sah. ( ____________________ ) Pasien / Tertanggung ( ____________________ ) Dokter Pasien Arsip Perusahaan

Upload: wawan

Post on 04-Nov-2015

39 views

Category:

Documents


0 download

DESCRIPTION

OO

TRANSCRIPT

  • RUMAH SAKITSARI ASIH

    RESUME MEDIS RAWAT JALAN

    No. Rekam Medis

    Nama Pasien

    Tanggal Lahir

    Tanggal Pemeriksaan

    Klinik / DokterLembar untuk diisi dokter

    Anamnesa

    Diagnosa

    Terapi

    Anjuran

    :

    :

    :

    :

    :

    :

    :

    :

    :

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    ................................................................................................................................................................

    Dengan ini saya selaku pasien / tertanggung, mengizinkan RS. Sari Asih Karawaci untuk memberikan keterangan lengkap mengenai keadaan penyakit / data medis kepada pihak ketiga yang ditunjuk secara sah.

    ( ____________________ )Pasien / Tertanggung

    ( ____________________ )DokterPasien

    ArsipPerusahaan

    Page 1