Resume MEdis Rawat Jalan

RUMAH SAKIT

SARI ASIH

RESUME MEDIS RAWAT JALAN

No. Rekam Medis

:

Nama Pasien

:

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 Tanggal  T anggal Lahir

:

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 Tanggal  T anggal Pemeriksaan Pemeriksaan :

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Klinik / Dokter

:

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Anamnesa

:

Diagnosa

:

 Terapi  T erapi

:

Anjuran

:

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Lembar untuk diisi dokter 

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 Arsip Perusahaan

( ____________________ ) Pasien / Tertanggung

( ____________________ ) Dokter