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[{"$nulls":3},"FORMULIR VERIFIKASI"]
[{"$nulls":3},"SISTEM CASE-MIX / INA-CBG"]
[" "]
["1.","Nama RS",":","RSUD. Dr. SAIFUL ANWAR MALANG"]
["2.","Nomor Kode Rs",":",3573011,null,null,"3.","Kelas RS",":","A"]
["4.","Nomor Rekam Medik",":"," ",{"$nulls":5}," "]
["5.","Nama Pasien",":"]
["6.","Jenis Perawatan",":",null,"a.","Rawat Inap","b.","Rawat Jalan","c.","IGD"]
["7.","Kelas Perawatan",":",null,"a.","Kelas 1","b.","Kelas 2","c.","Kelas 3","d.","Kelas VIP"]
["8.","Total Biaya",":"]
["9.","Tanggal Masuk",":",null,"10.","Tanggal Keluar : "]
["11.","Jumlah Hari Perawatan",":",null,"Tgl. Keluar - Tgl. Masuk + 1"]
["12.","Tanggal Lahir",":",null,"13.","Usia Dalam Tahun : ",null,null,"14.","Usia Dalam Hari :"]
["15.","Jenis Kelamin",":"]
["16.","Cara Pulang",":"]
["17.","Berat Lahir",":"]
["18.","Diagnosa Utama",":"," ",{"$nulls":5},"ICD-10",":"," "]
["19.","Diagnosa Sekunder",":"]
["No.","DIAGNOSA",{"$nulls":6},"ICD-10"]
[" "," ",{"$nulls":6}," "]
[" "," ",{"$nulls":6}," "]
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[" "," ",{"$nulls":6}," "]
[" "," ",{"$nulls":6}," "]
[" "," ",{"$nulls":6}," "]
[" "," ",{"$nulls":6}," "]
[" "," ",{"$nulls":6}," "]
["20.","Prosedur / Tindakan",":"]
["NO","TINDAKAN / PROSEDUR",{"$nulls":4},"ICD-9-CM",null,null,"TGL TINDAKAN"]
[" "," ",{"$nulls":4}," ",null,null," "]
[" "," ",{"$nulls":4}," ",null,null," "]
[" "," ",{"$nulls":4}," ",null,null," "]
[" "," ",{"$nulls":4}," ",null,null," "]
[" "," ",{"$nulls":4}," ",null,null," "]
[" "," ",{"$nulls":4}," ",null,null," "]
[" "," ",{"$nulls":4}," ",null,null," "]
[" "," ",{"$nulls":4}," ",null,null," "]
[" "," ",{"$nulls":4}," ",null,null," "]
[" "," ",{"$nulls":4}," ",null,null," "]
["Catatan : Diagnosis diisi oleh dokter yang merawat/ yang memeriksa dengan huruf \"Cetak\"\n              Untuk pasien yang dilakukan tindakan, disertakan \"tanggal\" dilakukannya tindakan tersebut"]
[{"$nulls":6},"Malang, Tgl. "]
[null,"DPJP / Dokter yang merawat",{"$nulls":5},"Pasien / Keluarga Pasien"]
[null," \n\n",{"$nulls":5}," \n\n"]
[]
[]
[" ","NIP.  ……………………………………",{"$nulls":5}," ……………………………………"]

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