Lembar Formulir Rawat Jalan [PDF]

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LEMBAR FORMULIR RAWAT JALAN LAYANAN KEDOKTERAN FISIK DAN REHABILITASI I. Diisi oleh Pasien/Peserta



No. RM / Reg :



Nama Pasien



: ..........................................................................................



Tanggal Lahir



:..........................................................................................



Alamat



:..........................................................................................



Telp./ HP



: .........................................................................................



Hubungan dengan tertanggung :



Suami / Istri



Anak



II. Diisi oleh Dokter SpKFR Tanggal Pelayanan



: ............................................................................................



-Anamnesa



: ............................................................................................



-Pemeriksaan Fisik & Uji Fungsi : ............................................................................................ -Diagnosis Medis (ICD-10)



: ............................................................................................



-Diagnosis Fungsi (ICD-10)



: ............................................................................................



-Tata Laksana KFR (ICD 9 CM)



: ............................................................................................ .............................................................................................



-Anjuran



: ............................................................................................



-Evaluasi



: ............................................................................................



-Suspek Penyakit Akibat Kerja



:



Ya (………………………………………) Tidak



Tempat & Tanggal Tanda Tangan Pasien



Cap dan Tanda Tangan dr. SpKFR



(…………….………………………….)



(……………………………………………………..)