Mohon segera di isi dengan lengkap & huruf cetakFax Kembali ke No. 021-3926560 ( Jam Kerja )asuransiU.p: Adm Rawat Inapsinarmas

FORMULIR PELAPORAN RAWAT INAP (Indikasi Melahirkan)

Bersama ini diinformasikan bahwa Tertanggung / Pasien dengan data sebagai berikut :

Nama Pasien:Umur :Tanggal masuk:Nama Perusahaan pada kartu:No polis / Register:Hak Kelas di Kartu:................................................... Kelas Kamar diambil :.........................Harga Kamar di kartu :................................................... Harga Kamar diambil :.........................Nama RS:Tasik Medical CenterNama dokter yg merawat:...................................................------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------1.Keluhan Utama sehingga pasien memerlukan Rawat Inap :..............................................................................................................................................................................................................................................................................................................

2. Tanda Vital :-Suhu: .................................................... C-Heart Rate: ............................................................-Tekanan darah:..........................................................-Respiration Rate: ............................................................

3.Diagnosa :(mohon diisi dengan huruf cetak):....................................................................................................................................................................................................................................................................................................................................

4. Apakah Pasien melahirkan normal ?(mohon diisi dengan huruf cetak):......................................................................................................................................................................................................................................................................................

5.Apakah tindakanVakum/Forcep/Sectio Cesardilakukanpada saat persalinan ? :....................................................................................................................................................................................................................................................................

6. Umur kehamilan pada pasien:.............. MingguG.. P.. A..

7.Pemeriksaan Penunjang yang menunjang diagnosa :(hasil mohon dapat dilampirkan)..............................................................................................................................................................................................................................................................

8.Rencana Perawatan :

( ) Operasi :.................................( ) Konservatif( ) Therapy( ) Lain Lain

NAMA TINDAKAN:...............................................................................................................................................

KATEGORI OPERASI:...............................................................................................................................................

PERKIRAAN BIAYA:...............................................................................................................................................

Sewa OK:Rp ......................................Biaya Operator:Rp .......................................

Obat-obatan OK dll:Rp ......................................Biaya Anestesi (bius umum) :Rp .......................................

PERKIRAAN LAMA PERAWATAN :..............hari

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Tgl / bln/ thn:........./........./.................Yang membuat pernyataan ,

Nama jelas &ttd dokter / petugas pihak RS

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