Surat Dokter Form PDF Details

Do you need to fill out a Surat Dokter Form, but aren't sure how or where to start? You're not alone! Filling out these forms can be confusing and time-consuming. In this post, we will review the purpose of Surat Dokter Forms, why they are important, and all the information you need to provide when completing them correctly. Keep reading to learn everything you need to know about successfully filling out your Surat Dokter Form.

QuestionAnswer
Form NameSurat Dokter Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessurat sakit dokter, surat sakit dokter pdf, surat sakit online, surat dokter kosong pdf

Form Preview Example

SURAT KETERANGAN DOKTER

KHUSUS UNTUK KLAIM SEQUIS LADY PROTECTION RIDER

PENYAKIT KANKER

HARUS DIISI DENGAN LENGKAP OLEH DOKTER YANG MENGOBATI / MERAWAT SI SAKIT

Mohon dapat diberikan secara rinci hal-hal yang berhubungan dengan penyakit di atas pada pasien :

Nama

: _______________________________________________________ No. MR_______________________________

Umur

: _______________________________________________________________________________________________

Jenis Kelamin

:

 

Perempuan

 

Pekerjaan

: _______________________________________________________________________________________________

Alamat

: _______________________________________________________________________________________________

 

 

 

 

Diagnosa penyakit ini didasarkan atas hal-hal tersebut dibawah ini :

a.Jenis/diagnosa kanker yang diderita : _________________________________________________________________________________

Tanggal diagnosa : ____/____/_______ dd/mm/yyyy

Stadium : T ____ N ____ M ____

Lokasinya : __________________________________________________________________________________________________________

Bagaimana Klasifikasinya ? __________________________________________________________________________________________

Apakah telah meluas ke kelenjar getah bening dan telah terjadi anak sebar /metastase ? _______________________________

_______________________________________________________________________________________________________________________

b.Apakah penyakit yang diderita termasuk di bawah ini ?

Mohon berikan tanda centang ( ) pada pilihan berikut :

Stadium CIN (Cervical Intraepithelial Neoplasia)

Tumor yang belum dikategorikan ganas

Kanker yang belum menyebar (kanker in-situ)

Tumor ganas sebagai akibat terdapatnya Human Immunodeficiency Virus

Lain-lain ___________________________________________________________________________________

c.Hasil Patologi Anatomi (makroskopik dan mikroskopik)

d.Kapan pertama kali gejala penyakit tersebut dirasakan ?

e.Tindakan / pembedahan yang telah dilakukan dan kapan dilaksanakannnya ?

!"#$ % & !!' ! !()#$ % &* + $",-./0.12-3330.

f.Selain tindakan pembedahan, apakah diperlukan terapi lain ? Bila Ya, mohon disebutkan jenis terapi tersebut ?

g.Bagaimana prognosa dan harapan hidup dari pasien

Ya

Tidak

h.Apakah pasien merupakan rujukan dari dokter atau rumah sakit lain ?

Ya

Tidak

Jika Ya, nama dokter : ___________________________ rumah sakit ______________________________________

_______________________________________________________________________________________________

i.Hal lain yang masih dianggap perlu untuk dijelaskan

Untuk memperlancar proses klaim ini, mohon dokter dapat melampirkan laporan medis, hasil pemeriksaan patalogi anatomi, hasil laboratorium, pemeriksaan penunjang lainnya yang mendukung ditegakkannya diagnosis penyakit di atas.

Tempat & tanggal dibuat, _________________________

Dokter yang merawat,

(_________________________________________________)

nama jelas, tandatangan & cap stempel

Mohon surat keterangan ini tidak diberikan kepada pasien atau keluarganya, tetapi dikirim langsung kepada

PT AJ Sequis Life yang akan memperlakukan informasi ini dengan penuh kerahasiaan

!"#$ % & !!' ! !()#$ % &* + $",-./0.12-3330.

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1. To start with, while completing the surat dokter, begin with the form section that includes the following fields:

surat dokter pdf completion process detailed (stage 1)

2. Once your current task is complete, take the next step – fill out all of these fields - Name and address of referral doctor, Jenis dan hasil pemeriksaan, hasil PA dll Physiscal, Diagnosa atau dugaan diagnosa, Final diagnosis or Working, Kode ICD X ICD Code X, Terapi atau tindakan Therapy or, Indikasi medis rawat inap rawat, Medical indication for inpatient, Rawat inap rawat jalan atas, Inpatient outpatient requested by, Dokter Doctor rawat inap selama, CHDSKDVer, PUSAT LAYANAN NASABAH, and Page of with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

surat dokter pdf completion process outlined (portion 2)

3. The next step is usually simple - complete every one of the empty fields in Diagnosa di atas berhubungan, applicable, Kesuburan Fertility, Penggunaan kontrasepsi, Penyakit kejiwaan Psychiatry, Kelainan bawaan Congenital, Kecelakaan Accident, AIDS HIV Pekerjaan Occupation, Diagnosa tersebut akibat dari, Kecelakaan accident, Penyalahgunaan obat bius drug, Konsumsi alcohol alcoholism, Olahraga berbahaya dangerous sport, Percobaan bunuh diri suicide, and Perang atau huru hara war or riot to conclude this process.

surat dokter pdf writing process outlined (part 3)

Many people generally get some points incorrect while completing AIDS HIV Pekerjaan Occupation in this section. You should review whatever you type in here.

4. The next subsection will require your attention in the subsequent areas: Faktor Penyakit lain yang, penyakit kelainan tersebut, Bila dilakukan tindakan bedah, If surgery was done please, Tanggal pembedahan, Date of, surgery, tglblnthn ddmmyyy, Saya sebagai dokter yang, Nama dokter Name of doctor, Spesialisasi Specialization, and Alamat Address. Make certain you type in all required info to go forward.

surat dokter pdf completion process described (stage 4)

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