Form Pengantar Rawat Inap 191z5i
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RS.HARAPAN BUNDA JL. T.UMAR No.181-211 BANDA ACEH
FORM PENGANTAR RAWAT INAP
NAMA
: .............................................................................................
UMUR
: .............................................................................................
JENIS KELAMIN
: .............................................................................................
NO. REKAM MEDIS
: ............................................................................................
MASUK MELALUI
:
DIAGNOSIS SEMENTARA
: ............................................................................................
RUANGAN
: ............................................................................................
PEMBIAYAAN/ASURANSI
: ............................................................................................
PETUGAS PEMESAN KAMAR
: ............................................................................................
KONFIRMASI PEMESAN KAMAR
: ............................................................................................
KETERANGAN
: ............................................................................................
IGD
Rujukan
Pengantar RI
Petugas istrasi
(
Poliklinik Spesialis
Dokter Pengirim
)
(
RS.HARAPAN BUNDA JL. T.UMAR No.181-211 BANDA ACEH
)
FORM PENGANTAR RAWAT INAP
NAMA
: .............................................................................................
UMUR
: .............................................................................................
JENIS KELAMIN
: .............................................................................................
NO. REKAM MEDIS
: ............................................................................................
MASUK MELALUI
:
DIAGNOSIS SEMENTARA
: ............................................................................................
RUANGAN
: ............................................................................................
PEMBIAYAAN/ASURANSI
: ............................................................................................
PETUGAS PEMESAN KAMAR
: ............................................................................................
KONFIRMASI PEMESAN KAMAR
: ............................................................................................
KETERANGAN
: ............................................................................................
IGD
Rujukan
Pengantar RI
Petugas istrasi
(
Poliklinik Spesialis
Dokter Pengirim
)
(
)
FORM PENGANTAR RAWAT INAP
NAMA
: .............................................................................................
UMUR
: .............................................................................................
JENIS KELAMIN
: .............................................................................................
NO. REKAM MEDIS
: ............................................................................................
MASUK MELALUI
:
DIAGNOSIS SEMENTARA
: ............................................................................................
RUANGAN
: ............................................................................................
PEMBIAYAAN/ASURANSI
: ............................................................................................
PETUGAS PEMESAN KAMAR
: ............................................................................................
KONFIRMASI PEMESAN KAMAR
: ............................................................................................
KETERANGAN
: ............................................................................................
IGD
Rujukan
Pengantar RI
Petugas istrasi
(
Poliklinik Spesialis
Dokter Pengirim
)
(
RS.HARAPAN BUNDA JL. T.UMAR No.181-211 BANDA ACEH
)
FORM PENGANTAR RAWAT INAP
NAMA
: .............................................................................................
UMUR
: .............................................................................................
JENIS KELAMIN
: .............................................................................................
NO. REKAM MEDIS
: ............................................................................................
MASUK MELALUI
:
DIAGNOSIS SEMENTARA
: ............................................................................................
RUANGAN
: ............................................................................................
PEMBIAYAAN/ASURANSI
: ............................................................................................
PETUGAS PEMESAN KAMAR
: ............................................................................................
KONFIRMASI PEMESAN KAMAR
: ............................................................................................
KETERANGAN
: ............................................................................................
IGD
Rujukan
Pengantar RI
Petugas istrasi
(
Poliklinik Spesialis
Dokter Pengirim
)
(
)
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