8/18/2019 Form Rekam Medis - Terpadu

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DINAS KESEHATAN KABUPATEN WONOGIRIUPT PUSKESMAS WONOGIRI II

 NAMA : ................................................................................................................................... L / P UMUR : .............................. ............................... ................

NAMA KK : ................................................................................................................................... AGAMA : .............................................................................

PEKERJAAN : .................................................................................................................... NO. KIS : .............................................................................

ALAMAT : ...................................................................................................................................

UMUM/ ASKES/ GAKIN/ JPKM/ DLL

TANGGAL

HASIL ANAMNESA, PEMERIKSAAN

FISIK, PEMERIKSAAN PENUNJANG

DAN DIAGNOSIS

TERAPI MEDIS & TINDAK LANJUT

NAMA

DOKTER &

TT

TIM INTERPROFESI (PERAWAT, BIDAN, SANITARIAN, FISIOTERAPIS, AHLI GIZI)

PENGKAJIAN PERENCANAAN PELAKSANAAN EVALUASINAMA

PETUGAS &

T T