Contoh Surat Permohonan Izin Hemodialisa.doc

RUMAH SAKIT PERMATA BUNDA Jl. Hayam Wuruk Wuruk No. 24 Telp. ( 0292 ) 422 838 – 422839 Fax ( 0292 ) 423 892 PURW!"!# $ %R&%"N

 No ' 03  03  R*.P&  #+  20,. -am -amp '  er erka/ ka/. Hal Hal ' Perm Permo oo1 o1a1 a1 #1 #1 Pe1y Pe1yel ele1 e1 ar araa aa1 1 Pelaya1a1 Hemo5al/a. Kepada Yth. Kepala Dinas Kesehatan Kabupaten Grb!an "l. Ga#ah$ada N. %& Di Pur'dadi.

!e1a orma67 !e1 !e1a1 a1 1 kam kam /ampa ampaka1 ka1 a aaa u16u u16uk k meme1 eme1u u per per/yar /yara6 a6a1 a1 rum uma a /ak ak6 5apa 5apa66 me1yel me1yele1 e1ara araka1 ka1 pera/ pera/o1 o1al al Pelaya Pelaya1a1 1a1 Hemo5 Hemo5al al/a /a perlu perlu a5a1ya a5a1ya 1 1 opera/ opera/o1 o1al al ya1 5keluarka1 ole !1a/ e/ea6a1 aupa6e1. *euu1a1 al 6er/eu6 5a6a/7 er/ama 1 kam me1a:uka1 permoo1a1 #1 Pe1yele1araa1 Pelaya1a1 Hemo5al/a 5 R*. Perma6a &u15a Puro5a5 aupa6e1 %rooa17 *eaa aa1  per6ma1a1 kam lamprka1 kele1kapa1 erka/ pe15uku1 5a1 /ura6 rekome15a/ 5ar P;RN;FR# J"T;N%. !emka1 a6a/ pera6a1 5a1 6erkaul1ya permoo1a1 p ermoo1a1 1 kam /ampaka1 6erma ka/.

Puro5a57 2 "prl 20,. !rek6ur R*. Perma6a &u15a

Dr. H. I$an Santsa( M.Kes

Tembusan : 1. Arsip.

Data pendu)un! per$hnan i*in perasinal he$dialisa RS. Per$ata Bunda

 N A.  2 3 4

= ,

B.  2 3

4 = , 

2

3

3

4

R#T;R#" SARANA + PRASARANA Rua1 perala6a1 me/1 emo5al/a Rua1 pemerk/aa1 5ok6er Rua1 615aka1 Rua1 peraa6a17 /6erl/a/7  pe1ympa1a1 oa67 pe1u1:a1 me5k  Rua1 "5m1/6ra/ Rua1a1 la11ya

PERA,ATAN
*T"N!"RT <1. 4 (empa6 ) me/1 *e/ua keu6ua1 *e/ua keu6ua1 *e/ua keu6ua1

4 ( empa6 ) me/1 H! "5a "5a "5a

*e/ua keu6ua1 *e/ua keu6ua1

"5a Pemur1 ar7 re$u/e7 u5a17 l1e1.

<1mal 4 me/1 *e/ua *6a15ar6 *e/ua *6a15ar6

4 ( empa6 ) me/1 H! "5a "5a

*e/ua *6a15ar6 *e/ua *6a15ar6 *e/ua *6a15ar6

KETENAGAAN  Se)uran! / )urann0a 1 !ok6er *p. P!$%H !r. *p.P!$%H ya1 ( o1/ul6a1 %1:al Hper6e1/ ) /eaa  eker:a 5 R*. 6/. *uper>/or U16 !al// !ok6er *p. P! /eaa pe1a1u1
Te1aa la11ya ( T;<7 T&R )

N!#*# R*

*e/ua *6a15ar6

"5a "5a

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!r. Pu: "r/ R 

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e6era1a1 ' . "ar 5ua6 5e1a rua1a1. 2. "ar 5ua6 ?o6o perala6a1 ke/ea6a1 ya1 a5a 3. "ar 5ua6 ?o6o rua1a1 ya1 a5a 4. "ar 5ua6 5a?6ar ala6 ke/ea6a1 ya1 5peru1aka1 5 /e6ap rua1a1. =. "ar 5ua6 5a?6ar 1ama 6e1aa
DA2TAR A,AT KESEHATAN + N3N KESEHATAN RUANG HEM3DIA,ISA RS. PERMATA BUNDA N3

NAMA RUANG

2UNGSI RUANGAN



Rua1 Hemo5al/a

Rua1a1 6empa6 pa/e1 me15apa6ka1 615aka1 @u@ 5ara.

2

Nur/e *6a6o1

Rua1 u16uk melakuka1  pere1@a1aa17  pe1ora1/a/a17 a/ua1 5a1 pelaya1a1 keperaa6a17 5okume16a/ 5a1 e>alua/.

3

Rua1 Re$u/e

4

Rua1 a6er 6rea6me1 E R

Rua1 u16uk me1@u@ ala6 ke/ea6a1 5a1 /6erl/a/ ala6 ke/ea6a1. Rua1 u16uk pemur1a1 ar

=

Rua1 l1e1

Rua1 u16uk keu6ua1 l1e1

,

Rua1 !ok6er

B

Rua1 Peraa6

8

Rua1 "5m1/6ra/ E R<

9

Rua1 Tu1u

Rua1 u16uk ko1/ul6a/ 5ok6er. Rua1 u16uk keperlua1  peraa6. Rua1 u16uk me1yele1araka1 kea6a1 a5m1/6ra/ H! 5a1 6empa6  pe1ympa1a1 erka/ pa/e1. Rua1 u16uk keluara   pe1a16ar pa/e1

,UAS

2ASI,ITAS

B7= x =7, TT Pa/e175a1 4 C 98 <2. me/1 H!7 T+.

2x3C , <2.

2x=C 0 <2 4x=C 20 <2

7= x 4 C , <2 =x3C = <2 =x2C 0 <2 2x3C , <2

22= <2

"A7 e /a>1 eDupme167 5e?rla6or7 ala6 re/u/6a/ pa/e17 oa6$oa6 l>e /a>17 6e1/me6er7 6ermome6er7perala6a1 ke/ea6a1 ekal H!7 /6e6o/@ope 5ll. *poel o@k7 ........

/7 kpa/ a11.

DA2TAR NAMA TENAGA MEDIS( PARAMEDIS N3N PARAMEDIS UNIT HEM3DIA,ISA RS. PERMATA BUNDA4PUR53DADI

N3

NAMA

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Pe1a1u1 :aa u16 5al// !ok6er pelak/a1a

4

<. Po1@o Pur1omo7 "<

Peraa6 pelak/a1a

=

R1a ! 7 "<

Peraa6 pelak/a1a

,

*u/a16o7 "<

Peraa6 pelak/a1a

B

*u1ar6o7 "<

Peraa6 pelak/a1a

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Te1aa ;lek6ro
*er6?ka6 !kla6 !al// *er6?ka6 !kla6 !al// *er6?ka6 !kla6 !al// *er6?ka6 !kla6 !al// *er6?ka6 Pela6a1

*er6?ka6 Per1e?r

STRUKTUR 3RGANISASI INSTA,ASI HEM3DIA,ISA RS. PERMATA BUNDA KEPA,A BIDANG MEDIK  !r. Pu: "r/ R/maa1

KEPA,A SEKSI PE,AYANAN MEDIK  !r. Herl1a P.-

KEPA,A INSTA,ASI HEM3DIA,ISA !r. H. "u/ ur1a7 *p.P!

ADMINISTRASI M. Pn6( AMK 

!T;R  !r. Pu: "r/ R 

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!"FT"R ;UR"N%"N ##N H;<!#"-#*#* R*. P;R<"T" &UN!"

. *#P !r. -e/6ar /u5a 3 6empa67 *P per6ama 5 R*U!. *oe5:a67 ma/a erlaku a/ 20. !1ke/ %ro aka1 erko1/ul6a/ ke !1ke/ Prop1/. 2. *#P !r "r/ ula1
Puro5a57 2= "prl 20,.

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RUMAH SAKIT PERMATA BUNDA Jl. Hayam Wuruk No. 24 Telp. ( 0292 ) 422 838 – 422839 Fax ( 0292 ) 423 892

PURW!"!# $ %R&%"N

TANDA TERIMA

Pa5a ar 1 ................7 ...................................... 20=. am me1yeraka1 erka/ permoo1a1 perpa1:a1a1 1 Ruma *ak6 Perma6a &u15a 6au1 20=. e a16or &PPT a. %rooa1 /ea1yak ( /a6u ) uku.

!emka1 a6a/ pera6a11ya kam u@apka1 6erma ka/.

Puro5a57 ......................................

Ga1 me1erma

Ga1 me1yeraka1

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Kepada Yth. Sdri. "ett0 Helena Peru$ Ala$ Sutra -luster. "l. Sutera Intan II( N. 78( Serpn! Tan!eran! / Selatan.  89%7 %&:% 9%;8 1