FORMULIR HAK DAN TANGGUNG JAWAB PASIEN.docx

FORMULIR HAK DAN KEWAJIBAN/TANGGUNG JAWAB PASIEN Tgl/ Jam

Tanda tangan dan Nama Jelas Materi Edukasi Pasien

Keluarga (Hubungan)

Dijelaskan tentang Hak dan Tanggung Jawab Pasien: 1. Dijelaskan dan ditujukan Lembar Informasi Hak dan Kewajiban/Tanggung Jawab Pasien Rawat Inap di Rumah Sakit Hi. Muhammad Yusuf 2. Pertanyaan Pasien: ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ................................................ 3. Tanggapan Pemberi Informasi: ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................

Rumah Sakit Hi. Muhammad Yusuf

Nama pasien : .................................... No. Rekam Medis : ....................................

Staf RS