Hospital : Margono Soekarjo Hospital

Ward / Clinic : dahlia ward

Contact Number for enquiries : (0281) 390234

Name of Nurse making referral : Nurse Tanu seherly

Signed :

District Number : 53318

GP Name and surgery address: Doctor Abdul Hadi and Mersi st number 05
Date of discharge : April 20rd 2011
First Visit Requested For : he was convalesce stage
Patients Name and Full Home Address including Post Code :
Mr. bejo and kocar, binanguCilacap, 53281
Telephone Number : 085747313933
Date of Birth : January 30st 1970
Does the patient live alone? No, he doesnt
Name of main career and telephone number : Mr. bejo and 085365588436
Discharge address if different : Name and Address of Temporary General Practitioner :
Doctor Abdul H and Mersi st number 05
Reason for admission :
He is hepatitis.
Diagnosis : Intolerance activity related to decrease of power with manifested patients ,
SD : Patient said that he feel tired, anorexia, diarrhea, cramp abdomen
OD : Patient look so pale and fever, abnormal function of liver, and
color brown of feces

Date and nature of recent surgery : Is the patient / family aware of Diagnosis / Prognosis : Yes / No / Not Sure