Blangko Status Rawat Inap Revisi

N% Reg.

PUSKESMAS RAWAT INAP MANDOR

1. DAT DATA DASAR PASIEN Nama Pasien

:……………………………..

Tanggal / Jam Masuk

: ……………………………………….

Umur

: …………………………….

Tanggal / Jam Keluar

: ……………………………………….

Jenis Kelamin

: …………………………….

Ruang / Be

: ……………………………………….

Agama

: …………………………….

UMUM

Penaggun Penaggungg !a"a# !a"a# $asien $asien

: …………………… ……………………………. ……….

N%. &el$/ 'P (g #s i)u#

: …………………………….

Alama&

: …………………………….**

ASKES

JAMKESMAS

N%. ASKES / JAMKESMAS

+. TANDA DAN ,EJA-A PENAKIT PENAKIT DS :.............................................. :........................................................................................................ ..................................................................................................................... ................................................................................ .......................... ..... ................................................................................................................. ....................................................... .................................................................................................................... ............................................................................. ................... ........................................................................................................................................................................... ................................................................................................................. ............................................................................. ................... ................................................................................................................. ....................................................... .................................................................................................................... ............................................................................. ................... ................................................................................................................. ....................................................... .................................................................................................................... ............................................................................. ...................

D : ……………………………………………………………………………………………………………………………………….. °

TD : 0000000000000mm'g Tem$ :0000000000   Res$irasi Ra&e 2RR3 :0000000004/meni& :0000000004/meni& Nai : 000000004/meni& 000000004/meni&

5. DIA,NSA MEDIK................................................................................... MEDIK.............................................................................................................................................. .................................................................................. ....................... ................................................................................................................... ......................................................... ..................................................................................................................... ........................................................................ ..................... ........ 6. T'ER T'ERAP AP   

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

7. TIND TINDAK AKAN AN .................................................................................................................................................................................................... .................................................................................................................................................................................................... .................................................................................................................................................................................................... 8. PEMERIKS PEMERIKSAAN AAN PENUNJAN PENUNJAN, , .................................................................................................................................................................................................... ....................................................................................................................................................................................................

CATATAN PERAWATAN

Nama Pasien

:……………………………..

Agama

: …………………………….

Umur

: …………………………….

Alama&

: …………………………….

Jenis Kelamin

: …………………………….

Ruang / Be

: ……………………………

Penaggung !a"a# $asien

: …………………………….

PARAF & NAMA TANGGAL

JAM

CATATAN PERKEMBANGAN DAN KEPERAWATAN PETUGAS

C A TA TA N V I S I T E D O K T E R

Nama Pasien

:……………………………..

Agama

: …………………………….

Umur

: …………………………….

Alama&

: …………………………….

Jenis Kelamin

: …………………………….

Ruang / Be

: ……………………………

Penaggung !a"a# $asien

: …………………………….

PARAF & NAMA TANGGAL

JAM

CATATAN MEDIK PETUGAS