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PEMERINTAH KABUPATEN SITUBONDO

RUMAH SAKIT UMUM DAERAH dr. ABDOER RAHEM

Jl. Anggrek No.68 Telp (0338)673293-675116 Fax (0338)671028

SITUBONDO 68312

FORMULIR TIMBANG TERIMA

UNIT PERAWATAN INTENSIF

 Nama Pa!en " ################# $m%r " ########..

Aal " ################# No. &' "

CHECK IN  " Tanggal ##########. P%k%l #######.. *

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##############. +PJP "

&en/ana T!nakan a T!ak 2.

*!la a ################### 2.

Jen! Am!! 4lek!

+ar%ra

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I. EVALUASI PRA ICU

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'akan Terak:!r " ###### * '!n%m Terak:!r " ########.*&!;aa Alerg!

" Aa T!ak Aae%kan

aa "###########.

II. DAFTAR TILIK KELENGKAPAN PASIEN

A. Adm!"#r$#% B. F"&  

a% Pa!en 1. Pol!kl!n!k =!g! pal% !lepa

2. =+ An!ng-an!ng !lepa3. &NA ,!n/!n !lepa

%ra Pere%

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I. EVALUASI KELUAR  

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&!;aa Alerg! " Aa T!ak Aa e%kan

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