Download - Departemen Kesehatan Republik Indonesia
Download - Departemen Kesehatan Republik Indonesia
Download - Departemen Kesehatan Republik Indonesia
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
Form 3 :<br />
REKAPITULASI PASIEN CALON/JEMAAH HAJI<br />
Propinsi :<br />
Kabupaten/Kota :<br />
Rumah Sakit :<br />
Embarkasi/Debarkasi :<br />
No<br />
Nama<br />
Pasien<br />
No<br />
Rekam<br />
Medik<br />
Umur<br />
Sex<br />
L/P<br />
Kloter<br />
Embar/<br />
Debar<br />
Diag<br />
nosa<br />
Rawat<br />
Inap<br />
Jalan (....<br />
hari)<br />
Biaya<br />
Rawat<br />
Biaya<br />
Lab<br />
Biaya<br />
Radiologi<br />
(Ro &<br />
USG)<br />
Biaya<br />
EKG<br />
Biaya<br />
Transport<br />
asi<br />
Biaya<br />
Obat<br />
Jumlah<br />
JUMLAH TOTAL<br />
..................................., ......................................20....<br />
Mengetahui Direktur RS......................................................<br />
Kepala Dinas <strong>Kesehatan</strong> ...........................................<br />
(........................................................) (...................................................................)
Change language