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RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2 x 24 JAM

LAPORAN INSIDEN(INTERNAL)

I. DATA PASIENNama : .........................................................................................................No MR : ......................................... Ruangan : .............................................Um! " : #$% &' * % &' + % -

* % - + - * - + % - * % - + /# - * /# - + 0 -

* 0 -J13 1'm : L$' P1!1m5P1666 &7 531 :

P!&8

A3!3 S93 ASKES P1m1!- P1!3-" JAMKESMAS

T66' M3 RS : ............................................................................Jm .....................................

II. RINCIAN KEJADIAN%. T66' 8 I381

T66' : ........................................................................................Jm ......................................

2.I381 : ....................................................................................................................................

......

/. K!;;';63 I381.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. J13 I381" :K1

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L$' .............................................................................................................(sebutkan)

8. Temat Ins!"enL;3 1

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4#a"!ng R!s!ko Ke$a"!an- (D3 ;'1- 3 51'5;!) : 5IR+ 6IJA+ K+NIN4 MERA6NB. " 5'- 3