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  • Contoh Formulir Rawat Jalan Rumah Sakit

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CLMASRI-02 FORMULIR ISIAN KLAIM ASURANSI RAWAT INAP RAWAT JALAN DAN SANTUNAN KRITIS Diisi oleh Tertanggung dan Pemegang Polis PENTING Syarat pengajuan klaim - Fotocopy identitas diri KTP/SIM/Passport Pemegang Polis - Surat kuasa bermeterai bila penerima dana bukan Pemegang Polis - Surat keterangan dari Kepolisian untuk penyebab klaim karena kecelakaan - Kwitansi asli pembelian obat disertai copy resep YANG BERTANDATANGAN DI BAWAH INI Nomor Polis Nama Pemegang Polis Nama Tertanggung Tempat Tanggal Lahir / tanggal Alamat Korespondensi wajib diisi Wajib diisi bila alamat yang diberikan berbeda dengan data Penanggung/Perusahaan maka Penanggung/Perusahaan akan lakukan perubahan alamat sesuai yang tertera dalam form ini bulan tahun Kompleks Jalan Blok/Gang Rt/Rw Kota Kelurahan Telepon Rumah Kode Pos - Hand Phone E-mail kode area Telepon Kantor DENGAN INI MENGAJUKAN MANFAAT ASURANSI UNTUK ASRI/Rawat Inap Rawat Jalan/Kecelakaan Santunan Kritis Lain-lain SEBAB - SEBAB PERAWATAN Telah dirawat di....

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Rekam Medis Rawat Jalan identitas pasien. tanggal dan waktu. hasil anamnesis berupa keluhan dan riwayat penyakit. hasil pemeriksaan fisis dan penunjang medik. diagnosis. rencana penatalaksanaan. pengobatan atau tindakan. pelayanan lain yang telah diberikan kepada pasien.

Pendaftaran pasien Rawat Jalan adalah untuk memberikan pelayanan dari rumah sakit kepada masyarakat untuk mendapatkan kesejahteraan dalam bidang kesehatan. Pelayanan Rekam Medis merupakan salah satu pelayanan penunjang medis di rumah sakit yang menjadi dasar peniliaian mutu pelayanan medik rumah sakit.

Rekam medis pasien rawat jalan ini sekurang-kurangnya harus memuat dokumen berisi: identitas pasien. tanggal dan waktu. hasil anamnesis berupa keluhan dan riwayat penyakit. hasil pemeriksaan fisis dan penunjang medik. diagnosis. rencana penatalaksanaan. pengobatan atau tindakan.

Alur Rekam Medis Rawat Jalan Dokter memeriksa dan mencatat hasil pemeriksaan, diagnosis serta terapi yang dilakukan. Petugas di poliklinik baik perawat maupun bidan membuat laporan harian pasien rawat jalan. Petugas poliklinik mengirimkan seluruh rekam medis pasien rawat jalan ke bagian Instalasi.

Berdasarkan Permenkes 269 Tahun 2008, isi rekam medis Gawat Darurat sekurang- kurangnya memuat: identitas pasien, kondisi saat pasien tiba di sarana pelayanan kesehatan, identitas pengantar pasien, tanggal dan waktu, hasil anamnesis, hasil pemeriksaan fisik dan penunjang medis, diagnosis, pengobatan/tindakan, ringkasan ...

Pasien mendaftar ke bagian Rekam Medik, staf MR menyiapkan berkas Rekam Medik diantaranya : memberi nomor Rekam Medik, mengisi KIUP, mengisi data sosial Pasien di lembaran Rawat Jalan kemudian petugas mencatat kunjungan Pasien di buku Register Rawat Jalan dan mengirimkan Rekam Medik ke : Klinik Spesialistik Dewasa.

Selanjutnya, rekam medis pasien rawat inap harus berisikan data identitas pasien, tanggal dan waktu perawatan, anamnesis (keluhan yang dirasakan pasien, riwayat penyakit pasien), hasil pemeriksaan fisik dan penunjang medis.

Formulir Rekam Medis Rawat Jalan Identitas pasien. Anamnesa/pemeriksaan fisik. Diagnosa. Terapi yang diberikan. Nama dan tanda tangan dokter. Rekam asuhan keperawatan. Formulir hasil-hasil penunjang medik. Copy resep.

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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232