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Anamnesis
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Keadaan umum :
Alasan dirujuk :
Kebutuhan pelayanan:
V. LAIN-LAIN
Dokter Pengirim
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KATEGORI DAN PENDAMPING PASIEN TRANSFER
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V. KONDISI PASIEN
Kesadaran : Kesadaran :
Pemeriksaan tanda-tanda vital : Pemeriksaan tanda-tanda vital :
Tensi : MmHg Tensi : mmHg
Suhu : ⁰C Suhu : ⁰C
Nadi : x/mnt Nadi : x/mnt
Catatan penting : Catatan penting :
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