INDIKATOR PENILAIAN FORMULIR REKAM MEDIS

INFORMED CONSENT

NO REKAM MEDIS 206998 103502 059826 020657 196330 205239

INDENTITAS PASIEN 1 1 1 1 1 1
PEMBERIAN INFORMASI 1 1 1 1 1 1
DIAGNOSIS 1 1 1 1 1 1
DASAR DIAGNOSIS 1 1 1 1 1 1
TINDAKAN KEDOKTERAN 1 1 1 1 1 1
INDIKASI TINDAKAN 1 1 1 1 1 1
TATA CARA 1 1 1 1 1 1
TUJUAN 1 1 1 1 1 1
RESIKO 1 1 1 1 1 1
KOMPLIKASI 1 1 1 1 1 1
PROGNOSIS 1 1 1 1 1 1
ALTERNATIF DAN RESIKO 1 1 1 1 1 1
TANDA TANGAN DPJP 1 1 1 1 1 1
TTD PENERIMA INFORMASI 1 1 1 1 1 1
PERSETUJUAN OPERASI 1 1 1 1 1 1
TTD SAKSI 1 1 1 1 1 1
1 1 1 1 1 1

1 LENGKAP
NOTE 0 TIDAK LENGKAP
KAM MEDIS
INFORMED CONSENT

209045 113561 207078 210080 111676 167684 053454 210033 155061 074054
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 0 0 0 0 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 0 0 0 0 1 1 1
209522 126372 127014 209986 110394 209957 196296 029169 203211 182868
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
210146 204385 181808 166392 200306 205155 207010 210327 210035 204305
1 1 1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
209901 203200 195268 209681 153208 057482 210507 210404 210036 208528
1 1 1 0 1 0 1 1 1 1
1 0 0 1 0 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 0 1 1 0 0 1 0 0 0
210394 210439 045826 143108 210506 210547 210534 118672 105919 .073475
1 1 1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 1 0 1
1 0 1 1 1 1 1 1 0 0
1 0 1 1 1 1 1 1 0 0
1 0 1 1 1 1 1 1 0 0
1 0 1 1 1 1 1 1 0 0
1 0 1 1 1 1 1 1 0 0
1 0 1 1 1 1 1 1 0 0
1 0 1 1 1 1 1 1 0 0
1 0 1 1 1 1 1 1 0 0
1 0 1 1 1 1 1 1 0 0
1 0 1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 1 0 0
207935 180373 210391 125764 51867 156643 179195 .029148 210630 086375
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 0 1
0 0 1 0 0 1 1 1 0 1
0 0 1 0 0 0 1 1 0 1
0 0 1 0 0 0 1 1 0 1
0 0 1 0 0 0 1 1 0 1
0 0 1 0 0 0 1 1 0 1
0 0 1 0 0 0 1 1 0 1
0 0 1 0 0 0 1 1 0 1
0 0 1 0 0 0 1 1 0 1
0 0 1 0 0 0 1 1 0 1
1 1 1 0 0 0 1 1 0 1
1 1 1 0 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 0 1 0 0 0 1 1 0 1
196673 197102 210642 210434 088770 210644 160585 196273 210712 163574
1 1 1 1 1 1 1 1 1 1
1 0 1 1 0 1 0 1 1 0
1 0 1 1 0 1 0 1 1 0
1 0 1 1 0 1 0 1 1 0
1 0 1 1 0 1 0 1 1 0
1 0 1 1 0 1 0 1 1 0
1 0 1 1 0 1 0 1 1 0
1 0 1 1 0 1 0 1 1 0
1 0 1 1 0 1 0 1 1 0
1 0 1 1 0 1 0 1 1 0
1 0 1 1 0 1 0 1 1 0
1 0 1 1 0 1 0 1 1 0
1 1 1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 0 1 1 0 1 0 1 1 0
210759 017244 203228 210416 197850 197588 142201 198829 204880 074181
1 1 1 1 1 1 1 1 1 1
0 1 1 0 1 1 1 1 0 1
0 1 1 0 1 1 1 1 0 1
0 1 1 0 1 1 1 1 0 1
0 1 1 0 1 1 1 1 0 1
0 1 1 0 1 1 1 1 0 1
0 1 1 0 1 1 1 1 0 1
0 1 1 0 1 1 1 1 0 1
0 1 1 0 1 1 1 1 0 1
0 1 1 0 1 1 1 1 0 1
0 1 1 0 1 1 1 1 0 1
0 1 1 0 1 1 1 1 0 1
1 1 1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 1 1 0 1 1 1 1 0 1
210907 086884 208466 068770 211019 210931 085995 180456 148015 207655
1 1 1 1 1 1 1 1 1 1
1 0 0 0 1 0 1 0 1 0
1 0 0 0 1 0 1 0 1 0
1 0 0 0 1 0 1 0 1 0
1 0 0 0 1 0 1 0 1 0
1 0 0 0 1 0 1 0 1 0
1 0 0 0 1 0 1 0 1 0
1 0 0 0 1 0 1 0 1 0
1 0 0 0 1 0 1 0 0 0
1 0 0 0 0 0 1 0 0 0
1 0 0 0 1 0 1 0 1 0
1 0 0 0 1 0 1 0 1 0
1 0 0 0 1 0 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 0 0 0 0 0 1 0 0 0
211064 081181 210977 136441 209961 134007 054036 209451 197511 204152
0 1 1 1 1 1 1 1 1 1
1 0 1 1 0 1 0 0 0 1
1 0 1 1 0 1 0 0 0 1
1 0 1 1 0 1 0 0 0 1
1 0 1 1 0 1 0 0 0 1
1 0 1 1 0 1 0 0 0 1
1 0 1 1 0 1 0 0 0 1
1 0 1 1 0 1 0 0 0 1
1 0 1 1 0 1 0 0 0 1
1 0 1 1 0 1 0 0 0 1
1 0 1 1 0 1 0 0 0 1
1 0 1 1 0 1 0 0 0 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 0 1 1 0 1 0 0 0 1
135958 211240 190410 .049521 .024998 211237 145091 153983 210768 188906
1 2 1 1 1 1 1 1 1 1
0 0 1 1 1 0 1 1 1 1
0 0 1 1 1 1 0 1 1 0
0 1 1 1 1 1 0 0 1 0
0 1 1 1 1 1 0 0 1 0
0 1 1 1 1 1 0 0 1 0
0 1 1 1 1 1 0 0 1 0
0 1 1 1 1 1 0 0 1 0
0 1 1 1 1 1 0 0 1 0
0 1 1 1 1 0 0 0 1 0
0 1 1 1 1 1 0 0 1 0
0 1 1 1 1 1 0 0 1 0
1 1 1 0 1 1 0 0 1 0
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 1 1 0 1 0 0 0 1 0
210947 057039 211050 124687 211271 203959 086365 210604 030483 211310
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 0 0 1 0
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 0 1 0
209126 211259 195668 092102 211269 149981
1 1 1 1 1 1 130 13000 419.3548 4.193548
0 0 1 0 0 1 93 0
0 0 1 0 0 1 86 0
0 0 1 0 0 1 85 0
0 0 1 0 0 1 85 0
0 0 1 0 0 1 85 0
0 0 1 0 0 1 85 0
0 0 1 0 0 1 85 0
0 0 1 0 0 1 84 0
0 0 1 0 0 1 78 0
0 0 1 0 0 1 85 0
0 0 1 0 0 1 88 0
1 1 1 0 1 1 119 0
1 1 1 1 1 1 132 0
1 1 1 1 1 1 132 0
1 1 1 1 1 1 132 0
0 0 1 0 0 1 79 53 TDK LENGKAP
 INDIKATOR PENILAIAN FORMULIR REKAM MEDIS
INFORMED CONSENT

NO REKAM MEDIS 211604 101178 211637 .047354 .028884 125085 211656

INDENTITAS PASIEN 1 1 1 1 1 1 1
PEMBERIAN INFORMASI 1 1 1 1 1 0 0
DIAGNOSIS 0 0 1 1 0 1 0
DASAR DIAGNOSIS 0 0 1 1 0 1 0
TINDAKAN KEDOKTERAN 0 0 1 1 0 1 0
INDIKASI TINDAKAN 0 0 1 1 0 1 0
TATA CARA 0 0 1 1 0 1 0
TUJUAN 0 0 1 1 0 1 0
RESIKO 0 0 1 1 0 1 0
KOMPLIKASI 0 0 0 0 0 0 0
PROGNOSIS 0 0 0 0 0 1 0
ALTERNATIF DAN RESIKO 0 0 0 0 0 1 0
TANDA TANGAN DPJP 0 0 1 1 0 1 0
TTD PENERIMA INFORMASI 1 1 1 1 0 1 1
PERSETUJUAN OPERASI 1 1 1 1 1 1 1
TTD SAKSI 1 1 1 1 1 1 1
0 0 0 0 0 0 0

1 LENGKAP
NOTE 0 TIDAK LENGKAP
MED CONSENT

198164 .087766 211574 175507 210485 104056 083804 205954 151403 180881
1 1 1 1 1 1 1 1 1 1
1 1 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 0
211938 047708 210815 207396 197681 058865 187721 211767 197145 166187
1 1 1 1 1 1 1 1 1 1
1 1 1 1 0 1 0 1 0 0
1 1 1 1 0 1 0 1 0 0
1 1 1 1 0 1 0 1 0 0
1 1 1 1 0 1 0 1 0 0
1 1 1 1 0 1 0 1 0 0
1 1 1 1 0 1 0 1 0 0
1 1 1 1 0 1 0 1 0 0
1 1 1 1 0 1 0 1 0 0
1 1 1 1 0 1 0 1 0 0
1 1 1 1 0 1 0 1 0 0
1 1 1 1 0 1 0 1 0 0
1 1 1 1 1 1 0 1 1 0
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 0 1 0 1 0 1
211819 211427 211765 141760 209993 .064626 158611 128875 211985 209999
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 0 0 1
1 1 1 1 1 1 0 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 0 0 0
212219 .099619 202636 211601 208282 191208 168311 209170 211121 212048
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 0 0 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 0 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 0 0 0 0 0 1 1 1 1
0 0 0 0 0 0 1 1 1 1
0 1 1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 1 1 1 1
145402 212353 203946 212364 212537 212380 209160 130475 .036784 212569
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 1 1 1
0 1 0 1 1 0 0 1 0 0
0 1 0 1 1 0 0 1 0 0
0 1 0 1 1 0 0 1 0 0
0 1 0 1 1 0 0 1 0 0
0 1 0 1 1 0 0 1 0 0
0 1 0 1 1 0 0 1 0 0
0 1 0 1 1 0 0 1 0 0
0 0 0 1 1 0 0 1 0 0
0 1 0 1 1 0 0 1 0 0
0 1 0 1 1 1 0 1 0 0
1 1 1 1 1 1 1 1 0 0
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 0 0 1 1 0 0 1 0 0
170072 212567 180751 133335 212504 142625 212718 181280 212827 210703
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 0
1 1 1 0 0 0 1 0 1 0
1 1 1 0 0 0 0 0 1 0
1 1 1 0 0 0 0 0 1 0
1 1 1 0 0 0 0 0 1 0
1 1 1 0 0 0 0 0 1 0
1 1 1 0 0 0 0 0 1 0
1 1 1 0 0 0 0 0 1 0
1 1 1 0 0 0 0 0 1 0
11 1 1 0 0 0 0 0 1 0
1 1 1 0 0 0 0 0 1 0
1 1 1 0 0 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 0 0 0 0 1 0
212840 201029 134358 169567 208074 210358 208952 212168 165214 125446
1 1 0 1 1 0 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
1 1 1 0 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 0 0 1 1 1 1 1 1
027686 092634 127077 067907 073100 064255 158733 182835 055473 213073
1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 1 1 0 1
1 0 0 0 0 0 1 1 0 1
1 0 0 0 0 0 1 1 0 1
1 0 0 0 0 0 1 1 0 1
1 0 0 0 0 0 1 1 0 1
1 0 0 0 0 0 1 1 0 1
1 0 0 0 0 0 1 1 0 1
1 0 0 0 0 0 1 1 0 1
1 0 0 0 0 0 1 1 0 1
1 0 0 0 0 0 1 1 0 1
1 0 0 0 0 0 1 1 0 1
0 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 0 1 0 1 0 1 0 0 1
140114 213143 213084 211875 213202 207130 149140 212176 080933 213128
1 1 1 1 1 1 1 1 1 1
0 1 1 1 1 0 1 1 0 1
0 1 1 1 1 0 1 1 0 1
0 1 1 1 1 0 1 1 0 1
0 1 1 1 1 0 1 1 0 1
0 1 1 1 1 0 1 1 0 1
0 1 1 1 1 0 1 1 0 1
0 1 1 1 1 0 1 1 0 1
0 1 1 1 1 0 1 1 0 1
0 1 1 1 1 0 1 1 0 1
0 1 1 1 1 0 1 1 0 1
0 1 1 1 1 0 1 1 0 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 1 1 1 1 0 1 1 0 1
212678 212722 084518 213312 213353 213088
1 1 1 1 1 1 101
1 1 0 1 1 0 72
1 1 0 1 1 0 54
1 1 0 1 1 0 53
1 1 0 1 1 0 53
1 1 0 1 1 0 53
1 1 0 1 1 0 53
1 1 0 1 1 0 53
1 1 0 1 1 0 51
1 1 0 1 1 0 48
1 1 0 1 1 0 60
1 1 0 1 1 0 49
1 1 1 1 1 1 83
1 1 1 1 1 1 100
1 1 1 1 1 1 103
1 1 1 1 1 1 103
1 1 0 1 1 0 48 55 TDK LENGKAP
B
 INDIKATOR PENILAIAN FORMULIR REKAM MEDIS
INFORMED CO

NO REKAM MEDIS .062698 .045626 213280 141091

INDENTITAS PASIEN 1 1 1 1

PEMBERIAN INFORMASI 0 1 1 0

DIAGNOSIS 0 0 0 0

DASAR DIAGNOSIS 0 0 0 0

TINDAKAN KEDOKTERAN 0 0 0 0

INDIKASI TINDAKAN 0 0 0 0

TATA CARA 0 0 0 0

TUJUAN 0 0 0 0

RESIKO 0 0 0 0

KOMPLIKASI 0 0 0 0

PROGNOSIS 0 0 0 0

ALTERNATIF DAN RESIKO 0 0 0 0

TANDA TANGAN DPJP 1 1 1 1

TTD PENERIMA INFORMASI 1 1 1 1

PERSETUJUAN OPERASI 1 1 1 1

TTD SAKSI 1 1 1 1
0 0 0 0
RMULIR REKAM MEDIS
INFORMED CONSENT

213346 213268 092353 212948 131547 090239 106104 213404 203977

1 1 1 1 1 1 1 1 1

1 1 1 1 0 0 0 0 1

1 1 1 1 0 0 0 0 1

1 1 1 1 0 0 0 0 1

1 1 1 1 0 0 0 0 1

1 1 1 1 0 0 0 0 1

1 1 1 1 0 0 0 0 1

1 1 1 1 0 0 0 0 1

1 1 1 1 0 0 0 0 1

1 1 1 1 0 0 0 0 1

1 1 1 1 0 0 0 0 1

1 1 1 1 0 0 1 0 1

1 1 1 1 0 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
1 1 1 1 0 0 0 0 1
182152 213253 177364 077886 213562 213465 144885 211709 165081

1 1 1 1 1 1 1 1 1

1 1 1 1 1 0 1 0 0

1 1 1 1 1 0 1 0 0

1 1 1 1 1 0 1 0 0

1 1 1 1 1 0 1 0 0

1 1 1 1 1 0 1 0 0

1 1 1 1 1 0 1 0 0

1 1 1 1 1 0 1 0 0

1 1 1 1 1 0 1 0 0

1 1 1 1 1 0 1 0 0

1 1 1 1 1 0 1 0 0

1 1 1 1 1 0 1 0 0

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
1 1 1 1 1 0 0 0 0
213605 213140 206041 147653 155462 192987 213075 213656 212646

1 1 1 1 1 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 0 0 1 1 1 1

1 1 1 1 0 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
1 1 1 0 0 1 1 1 1
129637 213457 130152 213696 213567 178745 081856 016611 134166

1 1 1 1 1 1 1 1 1

0 0 0 1 1 0 1 1 0

0 0 0 1 1 0 1 1 0

0 0 0 1 1 0 1 1 0

0 0 0 1 1 0 1 1 0

0 0 0 1 1 0 1 1 0

0 0 0 1 1 0 1 1 0

0 0 0 1 1 0 1 1 0

0 0 0 1 1 0 1 1 0

0 0 0 1 1 0 1 1 0

0 0 0 1 1 0 1 1 0

0 0 0 1 1 0 1 1 0

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
0 0 0 1 1 1 1 1 0
064346 213796 035279 178333 212153 208360 209148 121336 103010

1 1 1 1 1 1 1 1 1

0 1 1 0 0 1 1 0 1

0 1 1 0 0 1 1 0 1

0 1 1 0 0 1 1 0 1

0 1 1 0 0 1 1 0 1

0 1 1 0 0 1 1 0 1

0 1 1 0 0 1 1 0 1

0 1 1 0 0 1 1 0 1

0 1 1 0 0 1 1 0 1

0 1 1 0 0 1 1 0 1

0 1 1 0 0 1 1 0 1

0 1 1 0 0 1 1 0 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
0 1 1 0 0 1 1 0 1
213972 029532 105215 190607 190867 059922 213868 063630 100423

1 1 1 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

0 0 0 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
0 0 0 1 1 1 1 1 1
213596 026113 119880 212931 214059 213985 128532 144651 112672

1 1 1 1 1 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 0 0 0 1 1 1 1

1 0 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
1 0 0 0 0 1 1 1 1
214377 214165 214372 214325 214353 161086 136807 184277 210466

1 1 1 1 1 1 1 1 1

0 0 1 0 1 1 1 0 0

0 0 1 0 1 1 1 0 0

0 0 1 0 1 1 1 0 0

0 0 1 0 1 1 1 0 0

0 0 1 0 1 1 1 0 0

0 0 1 0 1 1 1 0 0

0 0 1 0 1 1 1 0 0

0 0 1 0 1 1 1 0 0

0 0 1 0 1 1 1 0 0

0 0 1 0 1 1 1 0 0

0 0 1 0 1 1 1 0 0

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
0 0 1 0 1 1 1 0 0
214402 214534 213187 052345 185533 214291 144496 214507 214013

1 1 1 1 1 1 1 1 1

0 1 0 0 1 1 0 0 0

0 1 0 1 0 1 1 0 0

0 1 0 1 1 1 1 0 0

0 1 0 1 1 1 1 0 0

0 1 0 1 1 1 1 0 0

0 1 0 1 1 1 1 0 0

0 1 0 0 1 1 1 0 0

0 1 0 0 1 1 0 0 0

0 1 0 1 1 1 0 0 0

0 1 0 1 1 1 0 0 0

0 1 1 0 1 1 1 1 0

1 1 1 0 1 1 1 1 0

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
0 1 0 0 0 1 0 0 0
162929 102031 214480 123387 214641 116495 214592 214699 214676

1 1 1 1 1 1 0 1 1

0 1 1 1 1 1 0 1 0

0 0 1 1 1 1 0 1 0

0 0 1 1 1 1 0 1 0

0 0 1 1 1 1 0 1 0

0 0 1 1 1 1 0 1 0

0 0 1 1 1 1 0 1 0

0 0 1 1 1 1 0 1 0

0 0 1 1 1 1 0 1 0

0 0 1 1 1 1 0 1 0

0 0 1 1 1 1 0 1 0

0 1 1 1 1 1 0 1 0

0 1 1 1 1 1 0 1 1

0 1 1 1 1 1 0 1 1

1 1 1 1 1 1 0 1 1

1 1 1 1 1 1 0 1 1
0 0 1 1 1 1 0 1 0
211730 214114 214703 101126 136275 054055 214790 150200 214795

1 1 1 1 1 1 1 1 1

1 1 0 1 0 0 1 1 0

1 1 0 1 0 0 1 1 0

1 1 0 1 0 0 1 1 0

1 1 0 1 0 0 1 1 0

1 1 0 1 0 0 1 1 0

1 1 0 1 0 0 1 1 0

1 1 0 1 0 0 1 1 0

1 1 0 1 0 0 1 1 0

1 1 0 1 0 0 1 1 0

1 1 0 1 0 0 1 1 0

1 1 0 1 0 0 1 1 0

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
1 1 0 1 0 0 1 1 0
160531 214853 214848 210015 214874 079761 120892 118505 087722

1 1 1 1 1 1 1 1 1

1 1 1 0 0 0 0 1 0

1 1 1 0 0 0 0 1 0

1 1 1 0 0 0 0 1 0

1 1 1 0 0 0 0 1 0

1 1 1 0 0 0 0 1 0

1 1 1 0 0 0 0 1 0

1 1 1 0 0 0 0 1 0

1 1 1 0 0 0 0 1 0

1 1 1 0 0 0 0 1 0

1 1 1 0 0 0 0 1 0

1 1 1 0 0 0 0 1 0

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
1 1 1 0 0 0 0 1 0
159426 214746 214927 166729 214998 067784 165097 124422 214117

1 1 1 1 1 1 1 1 1

1 1 1 0 0 0 1 0 1

1 1 1 0 0 0 1 0 1

1 1 1 0 0 0 1 0 1

1 1 1 0 0 0 1 0 1

1 1 1 0 0 0 1 0 1

1 1 1 0 0 0 1 0 1

1 1 1 0 0 0 1 0 1

1 1 1 0 0 0 1 0 1

1 1 1 0 0 0 1 0 1

1 1 1 0 0 0 1 0 1

1 1 1 0 0 0 1 0 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1
1 1 1 0 0 0 1 0 1
114429 192656 215043 214357

1 1 1 1

0 1 0 0

0 1 0 0

0 1 0 0

0 1 0 0

0 1 0 0

0 1 0 0

0 1 0 0

0 1 0 0

0 1 0 0

0 1 0 0

0 1 0 0

1 1 1 1

1 1 1 1

1 1 1 1

1 1 1 1
0 1 0 0 124
64 60 TDK LENGKAP
 INDIKATOR PENILAIAN FORMULIR REKAM MEDIS
INFORMED CONSENT

NO REKAM MEDIS 133750 191027 175014 215063 190920 153893 215091

INDENTITAS PASIEN 1 1 1 1 1 1 1
PEMBERIAN INFORMASI 0 0 1 0 0 0 1
DIAGNOSIS 0 0 1 0 0 0 1
DASAR DIAGNOSIS 0 0 1 0 0 0 1
TINDAKAN KEDOKTERAN 0 0 1 0 0 0 1
INDIKASI TINDAKAN 0 0 1 0 0 0 1
TATA CARA 0 0 1 0 0 0 1
TUJUAN 0 0 1 0 0 0 1
RESIKO 0 0 1 0 0 0 1
KOMPLIKASI 0 0 1 0 0 0 1
PROGNOSIS 0 0 1 0 0 0 1
ALTERNATIF DAN RESIKO 0 0 1 0 0 0 1
TANDA TANGAN DPJP 1 1 1 1 1 1 1
TTD PENERIMA INFORMASI 1 1 1 1 1 1 1
PERSETUJUAN OPERASI 1 1 1 1 1 1 1
TTD SAKSI 1 1 1 1 1 1 1
0 0 1 0 0 0 1
ED CONSENT

210805 214818 181538 142004 214535 213650 195521 151718 207692 144138
1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 1
174783 022293 137370 043359 211750 114677 215121 211413 149770 131996
1 1 1 1 1 1 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 0 0 0 0 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 0 0 0 0 1 1 1 1
182819 215188 215181 026046 160450 090053 215313 215348 215165 212947
1 1 1 1 1 1 1 1 1 1
0 0 1 0 1 1 0 1 0 1
0 0 1 0 1 1 0 1 0 1
0 0 1 0 1 1 0 1 0 1
0 0 1 0 1 1 0 1 0 1
0 0 1 0 1 1 0 1 0 1
0 0 1 0 1 1 0 1 0 1
0 0 1 0 1 1 0 1 0 1
0 0 1 0 1 1 0 1 0 1
0 0 1 0 1 1 0 1 0 1
0 0 1 0 1 1 0 1 0 1
0 0 1 0 1 1 0 1 0 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 0 1 0 1 1 0 1 0 1
214732 215272 214783 147033 214620 215388 215392 215385 214819 52733
1 1 1 1 1 1 1 1 1 1
1 1 1 0 0 1 1 1 1 0
1 1 1 0 0 1 1 1 1 0
1 1 1 0 0 1 1 1 1 0
1 1 1 0 0 1 1 1 1 0
1 1 1 0 0 1 1 1 1 0
1 1 1 0 0 1 1 1 1 0
1 1 1 0 0 1 1 1 1 0
1 1 1 0 0 1 1 1 1 0
1 1 1 0 0 1 1 1 1 0
1 1 1 0 0 1 1 1 1 0
1 1 1 0 0 1 1 1 1 0
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 0 0 1 1 1 1 0
152061 151199 215448 215397 083217 214755 215177 215145 215346 088545
1 0 1 1 1 1 1 1 1 1
0 0 0 0 1 1 1 0 0 0
1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 0 0 0
1 1 1 0 1 1 1 0 0 0
1 1 0 1 1 1 1 0 0 0
1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 0 0 0 1 1 1 0 0 0
012813 205147 209165 183254 215605 075750 147946 174849 159603 117805
1 1 1 1 1 1 1 1 1 1
0 1 0 0 0 0 1 0 1 1
0 1 0 0 0 0 1 0 1 1
0 1 0 0 0 0 1 0 1 1
0 1 0 0 0 0 1 0 1 1
0 1 0 0 0 0 1 0 1 1
0 1 0 0 0 0 1 0 1 1
0 1 0 0 0 0 1 0 1 1
0 1 0 0 0 0 1 0 1 1
0 1 0 0 0 0 1 0 1 1
0 1 0 0 0 0 1 0 1 1
0 1 0 0 0 0 1 0 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 1 0 0 0 0 1 0 1 1
210521 163496 145763 141307 210600 111750 191211 167666 215722 215793
0 1 1 1 1 1 1 1 1 1
0 0 0 1 0 0 1 0 0 1
0 0 0 1 0 0 1 0 0 1
0 0 0 1 0 0 1 0 0 1
0 0 0 1 0 0 1 0 0 1
0 0 0 1 0 0 1 0 0 1
0 0 0 1 0 0 1 0 0 1
0 0 0 1 0 0 1 0 0 1
0 0 0 1 0 0 1 0 0 1
0 0 0 1 0 0 1 0 0 1
0 0 0 1 0 0 1 0 0 1
0 0 1 1 0 0 1 0 0 1
0 1 1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1 1 1
0 0 0 1 0 0 1 0 0 1
211830
1
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1 77
0 32 45 TDK LENGKAP
215926 210257 205930 216135 216109 213686 094006 110642 216054 215725
1 1 1 1 1 1 1 1 1 1
1 1 0 1 1 0 0 1 0 0
1 1 0 1 1 0 0 1 0 0
1 1 0 1 1 0 0 1 0 0
1 1 0 1 1 0 0 1 0 0
1 1 0 1 1 0 0 1 0 0
1 1 0 1 1 0 0 1 0 0
1 1 0 1 1 0 0 1 0 0
1 1 0 1 1 0 0 1 0 0
1 1 0 1 1 0 0 1 0 0
1 1 0 1 1 0 0 1 0 0
1 1 0 1 1 0 0 1 0 0
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
195090 215559 216203 216244 216145 215738 136485 216181 025151 210278
1 1 1 1 1 1 1 1 1 1
1 0 0 0 0 1 0 1 1 0
1 0 0 0 0 1 0 1 1 0
1 0 0 0 0 1 0 1 1 0
1 0 0 0 0 1 0 1 1 0
1 0 0 0 0 1 0 1 1 0
1 0 0 0 0 1 0 1 1 0
1 0 0 0 0 1 0 1 1 0
1 0 0 0 0 1 0 1 1 0
1 0 0 0 0 1 0 1 1 0
1 0 0 0 0 1 0 1 1 0
1 0 0 0 0 1 0 1 1 0
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
216255 216220 216334 214689 168246 211802 205686 027278 151976 205471
1 1 1 1 1 1 1 1 1 1
1 1 1 0 0 0 0 0 0 1
1 1 1 0 0 0 0 0 0 1
1 1 1 0 0 0 0 0 0 1
1 1 1 0 0 0 0 0 0 1
1 1 1 0 0 0 0 0 0 1
1 1 1 0 0 0 0 0 0 1
1 1 1 0 0 0 0 0 0 1
1 1 1 0 0 0 0 0 0 1
1 1 1 0 0 0 0 0 0 1
1 1 1 0 0 0 0 0 0 1
1 1 1 0 0 0 0 0 0 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
216536 216497 213539 216547 216637 216030 101433 216768 031848 175667
1 1 1 1 1 1 1 1 1 1
1 0 0 0 1 0 0 0 0 0
1 0 0 0 1 0 0 0 0 0
1 0 0 0 1 0 0 0 0 0
1 0 0 0 1 0 0 0 0 0
1 0 0 0 1 0 0 0 0 0
1 0 0 0 1 0 0 0 0 0
1 0 0 0 1 0 0 0 0 0
1 0 0 0 1 0 0 0 0 0
1 0 0 0 1 0 0 0 0 0
1 0 0 0 1 0 0 0 0 0
1 0 0 0 1 0 0 0 0 0
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
206666 070249 215710
1 1 1
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
1 1 1
1 1 1
1 1 1
1 1 1
 INDIKATOR PENILAIAN FORMULIR REKAM MEDIS
INFORMED CONSENT
6/3/2022
NO REKAM MEDIS 42559 217093 186292 027479 217154 147695
INDENTITAS PASIEN 1 1 1 1 1 1
PEMBERIAN INFORMASI 0 1 1 1 1 1
DIAGNOSIS 1 1 0 0 0 0
DASAR DIAGNOSIS 1 1 0 0 0 0
TINDAKAN KEDOKTERAN 1 1 0 0 0 0
INDIKASI TINDAKAN 1 1 0 0 0 0
TATA CARA 1 1 0 0 0 0
TUJUAN 1 1 0 0 0 0
RESIKO 1 1 0 0 0 0
KOMPLIKASI 1 0 0 0 0 0
PROGNOSIS 1 1 0 0 0 0
ALTERNATIF DAN RESIKO 1 1 0 0 0 0
TANDA TANGAN DPJP 1 1 1 1 1 1
TTD PENERIMA INFORMASI 1 1 1 1 1 1
PERSETUJUAN OPERASI 1 1 1 1 1 1
TTD SAKSI 1 1 1 1 1 1
0 0 0 0 0 0

DR SAI DR SAI DR SAI DR SAI DR SAI

 M MEDIS
NFORMED CONSENT
2022 6/4/2022
090397 059686 186042 173042 165341 214758 217190 216584 210348
1 1 1 1 1 1 1 1 1
1 1 1 0 1 1 0 1 1
1 1 1 1 0 0 0 1 0
1 1 1 1 0 0 0 1 0
1 1 1 1 0 0 0 1 0
1 1 1 1 0 0 0 1 0
1 1 1 1 0 0 0 1 0
1 1 1 1 0 0 0 1 0
1 1 1 1 0 0 0 1 0
1 1 1 0 0 0 0 1 0
1 1 1 1 0 0 0 1 0
1 1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 1 1
1 1 1 0 0 0 0 1 0
0 0 0 1 0
DR PUR DR SAI DR PUR DR PUR DR SAI DR. SAI DR SAI DR PUR DR SAI
 6/6/2022
217111 073982 210636 217212 029256 101922 146749 078207 217099 216280
1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 1 1 1
1 0 1 1 0 1 1 0 1 1
1 0 1 1 0 1 1 0 1 1
1 0 1 1 0 1 1 0 1 1
1 0 1 1 0 1 1 0 1 1
1 0 1 1 0 1 1 0 1 1
1 0 1 1 0 1 1 0 1 1
1 0 1 1 0 1 1 0 1 1
1 0 1 1 0 1 1 0 1 1
1 0 1 1 0 1 1 0 1 1
1 1 1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 0 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1 0 1
0 0 1 1 0 0 1 0 0 1
0 0 DR INDRADR. PURW DR. SAIFDR. PURW DR. IRWANDR. SAIFUL ADR. PURWDR. PURW
DR PUR DR SAI 1 2 3 4 5 6 7 8
 6/7/2022
217238 217313 152790 216247 215147 207475 217062 102128 217293
1 1 1 1 1 1 1 1 1
0 0 1 1 1 1 1 0 1
1 1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 0 1
1 0 1 1 1 1 1 0 1
1 1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
0 0 1 1 1 1 1 0 1
DR. PUR DR. PURWAN DR. PURWA DR. PURWADR. PURWA DR. INDRA DR. PURWADR. SAIFUL
9 10 11 12 13 14 15
6/7/2022 6/8/2022
215834 217250 210751 110064 209610 207433 160476 217204 217242
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1 1
DR. INDRA DR. PURWA DR. PURWANDR. PUR DR. PUR DR. PUR DR. PUR DR. RUDI DR. PUR
2 6/9/2022
217386 185661 217061 99204 215942 166005 209456 217405 212899
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 1 1
0 0 0 1 1 0 1 1 1
0 0 0 1 1 0 1 1 1
0 0 0 1 1 0 1 1 1
0 0 0 1 1 0 1 1 1
0 0 0 1 1 0 1 1 1
0 0 0 1 1 0 1 1 1
0 0 0 1 1 0 1 1 1
0 0 0 1 1 0 1 1 1
0 0 0 1 1 0 1 1 1
1 1 1 1 1 1 1 1 1
0 1 0 1 0 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
0 0 0 1 0 0 0 1 1
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PUR DR. PUR DR. SAIFUL DR. PUR DR. PUR DR. PUR
 100727 217399 151017 191659 216624 208066 057316 146420
1 1 1 1 1 0 1 1
1 1 1 0 1 0 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 1 1 1 1 1 1
0 0 0 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 1 1 0 1 1
0 0 0 0 1 0 1 1
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. ANDRI DR. GAMAL DR. IRWAN DR. INDRA DR. PUR
 216666 113533 .045345 217478 070921 206444 039558 163839 217436
1 1 1 1 1 1 1 1 1
1 1 0 0 0 0 1 1 1
1 1 0 1 0 0 0 1 1
1 1 0 0 0 0 1 1 1
1 1 0 0 0 0 1 1 1
1 1 0 0 0 0 1 1 1
1 1 0 0 0 0 1 1 1
1 1 0 0 0 0 1 1 1
1 1 0 0 0 0 1 1 1
1 1 0 0 0 0 1 1 1
1 1 0 0 0 0 1 1 1
1 1 0 0 0 0 1 1 1
1 1 1 1 0 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 0 0 0 0 1 1 1
DR. INDRA DR PUR DR SAIFUL DR SAI DR SAIFUL DR SAIFUL DR PURWADR PURWA DR. IRWAN
 6/10/2022
214887 106186 179909 217540 207622 150376 099996 150414
1 1 1 1 0 1 1 1
1 1 1 1 0 1 1 1
1 0 0 1 1 1 0 1
1 0 0 1 1 1 0 1
1 0 0 1 1 1 0 1
1 0 0 1 1 1 0 1
0 0 0 1 1 1 0 1
1 0 0 1 1 1 0 1
0 0 0 1 1 1 0 1
0 0 0 1 0 1 0 1
0 0 0 1 1 1 0 1
1 1 1 1 1 1 1 1
1 1 0 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 1 0 1 0 1
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR PURWA DR PURWA DR PURWA DR PURWA DR PURWA
 6/15/2022
023061 157237 057377 20662 30818 071337 196700 058954 083669
1 1 1 1 1 1 1 1 0
1 1 1 0 1 1 1 1 0
0 0 0 0 1 1 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 1 1 0 0 0
0 1 1 1 1 1 0 0 0
1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
0 0 0 0 1 1 0 0 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. GAMAL DR PUR DR SAI DR PUR DR SAI
6/15/2022 6/17/2022
217520 066576 063436 91296 116173 217699 08858 176008
1 1 1 1 1 1 1 1
1 1 0 1 1 1 1 1
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 1 1 1 1 1
1 0 1 1 0 1 1 1
1 0 0 1 1 1 1 1
1 0 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 0 0 1 1 0
DR PUR DR SAI DR IRWAN DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL
 6/17/2022
176359 217280 142998 214250 216914 45526 028097 217783
1 1 1 1 1 1 1 1
0 1 1 0 1 1 1 1
0 1 0 0 1 0 1 0
0 1 0 0 1 0 1 0
0 1 0 0 1 0 1 0
0 1 0 0 1 0 1 0
0 1 0 0 1 0 1 0
0 1 0 0 1 0 1 0
0 1 0 0 1 0 1 0
0 1 0 0 1 0 1 0
1 1 0 0 1 0 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 0 0 1 0 1 0
DR. SAIFUL DR, PURWA DR. SAIFUL DR. SAIFUL DR. INDRA DR. SAIFUL DR. PURWA DR. SAIFUL
 6/18/2022
217808 084261 049311 217804 201077 077777 217778 217770
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
DR. PURWA DR. PURWA DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA DR. PURWA DR. PURWA
 217868 217424 194920 217843 217127 217753 093112 215787
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 1 1 1 0 0 0
0 0 1 1 1 0 0 0
0 0 1 1 1 0 0 0
0 0 1 1 1 0 0 0
0 0 1 1 1 0 0 0
0 0 1 1 1 0 0 0
0 0 1 1 1 0 0 0
0 0 1 1 1 0 0 0
0 0 1 1 1 0 0 0
1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 0
0 0 1 0 1 0 0 0
DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL
 6/20/2022
090245 089467 144098 206532 143083 072680 217605 178989
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
0 1 0 0 0 1 0 1
0 1 0 0 0 1 0 1
0 1 0 0 0 1 0 1
0 1 0 0 0 1 0 1
0 1 0 0 0 1 0 1
0 1 0 0 0 1 0 1
0 1 0 0 0 1 0 1
0 1 0 0 0 1 0 1
0 1 0 0 0 1 0 1
1 1 1 1 1 1 1 1
0 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1
0 1 0 0 0 1 0 1
DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA
6/20/2022
029557 217729 109686 206968 216833 185682 217906 217771
1 1 1 1 1 1 1 1
1 1 0 1 1 0 0 1
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
1 1 1 1 0 1 1 1
1 0 1 1 0 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL
 217767 161542 142276 216748 217241 215153 217847 24217
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
DR. PURWA DR. IRWAN DR. RUDI DR. INDRADR. INDRA DR. RUDI DR. IRWAN DR. ANDRI
 6/21/2022
217759 120906 217909 218059 217969 045109 125950 134767
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 0 1 0 1 1
1 1 1 0 1 0 1 1
1 1 1 0 1 0 1 1
1 1 1 0 1 0 1 1
1 1 1 0 1 0 1 1
1 1 1 0 1 0 1 1
1 1 1 0 1 0 1 1
1 1 1 0 1 0 1 1
1 1 1 0 1 0 1 1
1 1 1 1 1 1 1 1
1 1 1 0 1 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 1
1 0 1 0 1 0 1 1
DR. GAMAL DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA
 6/22/2022
146546 160587 218085 122841 218023 017991 216900 152002
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 0
1 1 1 1 1 1 0 0
1 1 1 1 1 1 0 0
1 1 1 1 1 1 0 0
1 1 1 1 1 1 0 0
1 1 1 1 1 1 0 0
1 1 1 1 1 1 0 0
1 1 1 1 1 1 0 0
1 1 1 1 1 1 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 0
DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. GAMAL DR. SAIFUL
 6/23/2022
23671 160180 218071 146721 179992 214690 129609 218063
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
1 1 1 1 1 1 1 1
0 1 0 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 0 0 1 1
DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR GAMAL
 6/24/2022 6/25/2022
218044 .056554 127894 216140 112526 218203 103032 071947 203739
1 1 1 1 1 1 1 1 1
1 1 1 1 0 0 1 1
1 1 0 1 0 1 0 0 0
1 1 0 1 0 1 0 0 0
1 1 0 1 0 1 0 0 0
1 1 0 1 0 1 0 0 0
1 1 0 1 0 1 0 0 0
1 1 0 1 0 1 0 0 0
1 1 0 1 0 1 0 0 0
1 1 0 1 0 1 0 0 0
1 1 0 1 0 1 0 0 0
1 1 0 1 0 1 1 1 1
1 1 0 1 0 1 1 1 0
1 1 1 1 0 1 1 1 1
1 1 1 1 0 1 1 1 1
1 1 1 1 0 1 1 1 0
1 1 0 1 1 0 0 0 0
DR IRWAN DR INDRA DR INDRA DR ARINI DR SAIFUL DR. PURWA DR.SAIFUL DR.SAIFUL DR.SAIFUL
 6/27/2022
164127 218288 218293 121575 218157 176179 218264 031029
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 0
0 1 1 1 0 1 0 1
0 1 1 1 0 1 0 1
0 1 1 1 0 1 0 1
0 1 1 1 0 1 0 1
0 1 1 1 0 1 0 1
0 1 1 1 0 1 0 1
0 1 1 1 0 1 0 1
0 1 1 1 0 1 0 1
0 1 1 1 0 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 1 1 0 1 0 0
DR. SAIFUL DR. PURWA DR. PURWA DR. PURWA DR. SAIFUL DR. RUDI DR. SAIFUL DR. PURWA
 6/28/2022 6/29/2022
108739 116233 134824 217944 158128 136328 218346 218393
1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 1
0 0 1 0 0 1 0 1
0 0 1 0 0 1 0 1
0 0 1 0 0 1 0 1
0 0 1 0 0 1 0 1
0 0 1 0 0 1 0 1
0 0 1 0 0 1 0 1
0 0 1 0 0 1 0 1
0 0 1 0 0 1 0 1
0 0 1 0 0 1 0 1
1 1 1 1 1 1 1 1
0 1 1 1 0 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 1 0 0 0 0 1
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA
 6/30/2022
216415 140446 187500 135195 218359 073614 217269 217300
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
1 1 1 1 1 1 1 1
0 0 0 1 0 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 0 1 1 1
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. IRWAN DR. INDRA
 218388 217460 164885 164524
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
0 0 0 1
0 0 0 1
DR. IRWAN DR. INDRA DR. IRWAN DR. IRWAN
 7/1/2022
NO REKAM MEDIS 202799 155453 055512 131744 218551
INDENTITAS PASIEN 1 1 1 1 1
PEMBERIAN INFORMASI 1 1 1 1 1
DIAGNOSIS 1 1 1 1 1
DASAR DIAGNOSIS 1 1 1 1 1
TINDAKAN KEDOKTERAN 1 1 1 1 1
INDIKASI TINDAKAN 1 1 1 1 1
TATA CARA 1 1 1 1 1
TUJUAN 1 1 1 1 1
RESIKO 1 1 1 1 1
KOMPLIKASI 1 1 1 1 1
PROGNOSIS 1 1 1 1 1
ALTERNATIF DAN RESIKO 1 1 1 1 1
TANDA TANGAN DPJP 1 1 1 1 1
TTD PENERIMA INFORMASI 1 1 1 1 1
PERSETUJUAN OPERASI 1 1 1 1 1
TTD SAKSI 1 0 1 1 1
1 0 1 1 1
DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. PURWA
 7/2/2022
128540 217139 115505 218223 218172 209672 196779 215708
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 0 1 1 0 1 1
1 0 0 1 1 0 1 1
1 0 0 1 1 0 1 1
1 0 0 1 1 0 1 1
1 0 0 1 1 0 1 1
1 0 0 1 1 0 1 1
1 0 0 1 1 0 1 1
1 0 0 1 1 0 1 1
1 0 0 1 1 0 1 1
1 1 1 1 1 1 1 1
1 0 0 1 1 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1
1 0 0 1 0 0 1 1
DR. PURWA DR. SAIFUL DR. SAIFUL DR, RUDI DR. IRWAN DR. GAMAL DR. GAMAL DR. GAMAL
 6/4/2022
217458 218630 085947 096648 204247 063446 185494 158824
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1
1 1 0 1 0 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 0 0 0 0 0 0
DR. INDRA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL
 INDIKATOR PENILAIAN FORMULIR RE
INFORMED CONSE
7/5
031976 214576 126942 218311 218577 218384 124044 218649
1 0 1 1 1 1 1 1
1 0 1 1 1 1 1 0
0 0 1 0 0 1 0 0
0 0 1 0 0 1 0 0
0 0 1 0 0 1 0 0
0 0 1 0 0 1 0 0
0 0 1 0 0 1 0 0
0 0 1 0 0 1 0 0
0 0 1 0 0 1 0 0
0 0 1 0 0 1 0 0
0 0 1 0 0 1 0 0
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 0
1 0 1 1 1 1 1 1
1 0 1 1 1 1 1 1
1 0 1 1 1 1 1 1
0 0 1 0 0 1 0 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. IRWAN DR SAIFUL DR SAIFUL
LAIAN FORMULIR REKAM MEDIS
INFORMED CONSENT
7/5/2022 7/6/2
178741 150835 207986 218696 126650 218684 209039 130337
1 1 1 1 1 1 1 1
0 1 1 1 0 0 0 1
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1
1 1 0 0 0 0 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 1
0 0 0 0 0 0 0 0
DR. PURWA DR SAIFUL DR SAIFUL DR SAIFUL DR SAIFUL DR SAIFUL DR. SAIFUL DR. PURWA
 7/6/2022 7/7/2022
217041 218753 218717 218716 33087 142258 120313 162795
1 1 1 1 1 1 1 1
1 1 1 0 0 1 0 1
0 1 0 0 0 0 0 1
0 1 0 0 0 0 0 1
0 1 0 0 0 0 0 1
0 1 0 0 0 0 0 1
0 1 0 0 0 0 0 1
0 1 0 0 0 0 0 1
0 1 0 0 0 0 0 1
0 1 0 0 0 0 0 1
0 1 0 0 0 0 0 1
1 1 1 1 1 1 1 1
0 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 0 0 0 0 0 1
DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA
7/7/2022 7/8/2022
218797 218781 120313 45856 218049 132193 218625 208618
1 1 1 1 1 1 1 1
1 1 0 1 1 1 1 1
0 1 1 1 0 0 1 0
0 1 1 1 0 0 1 0
0 1 1 1 0 0 1 0
0 1 1 1 0 0 1 0
0 1 1 1 0 0 1 0
0 1 1 1 0 0 1 0
0 1 1 1 0 0 1 0
0 1 1 1 0 0 1 0
0 1 1 1 0 0 1 0
0 1 1 1 1 1 1 1
1 1 1 1 0 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
0 1 0 1 0 0 1 0
DR. SAIFUL DR.PURWA DR.PURWA DR. GAMAL DR. SAIFUL DR. SAIFUL DR. IRWAN DR. SAIFUL
095801 095854 129450 107091 218618 139245 181448 088886 180371
1 1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 0 1
0 0 0 1 1 0 1 1 0
0 0 0 1 1 0 1 1 0
0 0 0 1 1 0 1 1 0
0 0 0 1 1 0 1 1 0
0 0 0 1 1 0 1 1 0
0 0 0 1 1 0 1 1 0
0 0 0 1 1 0 1 1 0
0 0 0 1 1 0 1 1 0
0 0 0 1 1 0 1 1 0
1 1 1 1 1 1 1 1 1
1 0 1 1 1 0 1 1 0
1 1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1 1
1 1 1 1 1 1 1 1 1
0 0 0 0 1 0 1 0 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. IRWAN DR. IRWAN dr irwan DR. INDRA dr irwan DR. SAIFUL
 7/11/2022
189730 039167 095967 219010 28924 087269 219043 164277
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 1 0 0 0 0
1 0 1 1 0 0 0 0
1 0 1 1 0 0 0 0
1 0 1 1 0 0 0 0
1 0 1 1 0 0 0 0
1 0 1 1 0 0 0 0
1 0 1 1 0 0 0 0
1 0 1 1 0 0 0 0
1 0 1 1 0 0 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 1 1 0 0 0
DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL
 217544 218838 218562 218545 115548 217550 217586 219031
1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 0 0
1 1 1 1 1 1 1 0
1 1 1 1 1 0 0 0
1 1 1 1 1 0 0 0
1 1 1 1 1 0 0 0
1 1 1 1 1 0 0 0
1 1 1 1 1 0 0 0
1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 1 1 1 1 0 1
0 0 1 1 1 0 0 0
DR. IRWAN DR. PURWA DR. PRAMITA DR. IRWAN DR. IRWAN DR. INDRA DR. INDRA DR. SAIFUL
 7/12/2022
218205 218886 179604 210346 218899 218027 216922 218964
1 1 1 1 1 1 1 1
1 0 1 1 0 1 1 1
0 1 1 0 0 0 0 1
0 1 1 0 0 0 0 1
0 1 1 0 0 0 0 1
0 1 1 0 0 0 0 1
0 1 1 0 0 0 0 1
0 1 1 0 0 0 0 1
0 1 1 0 0 0 0 1
0 1 1 0 0 0 0 1
0 1 1 0 0 0 0 1
1 1 1 1 1 1 1 1
0 1 1 0 1 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 1 0 0 0 0 1
DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA
095373 088702 218920 219062 217177 219097 216960 088659
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 1
0 1 1 0 0 1 1 1
0 1 1 0 0 1 1 1
0 1 1 0 0 1 1 1
0 1 1 0 0 1 1 1
0 1 1 0 0 1 1 1
0 1 1 0 0 1 1 1
0 1 1 0 0 1 1 1
0 1 1 0 0 1 1 1
0 1 1 0 0 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 0
0 1 1 0 0 1 0 0
DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA DR. PURWA
 7/13/2022
069678 219133 029403 219106 217140 141732 219103 078451
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 0 1 0 1 1
DR. PURWA DR. PURWA DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA
 7/14/2022
215851 161612 170232 219115 211147 076331 176221 148736
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0
1 1 1 1 1 1 1 1
1 1 0 0 1 0 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1
0 0 0 0 0 0 0 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. IRWAN DR. SAIFUL DR. SAIFUL DR. SAIFUL
14/2022 7/15/2022
093139 218096 1 219123 219120 219229 219230 219211
1 1 1 1 1 1 1 1
1 1 0 1 1 1 0 1
0 1 0 1 1 1 1 0
0 1 0 1 1 1 1 0
0 1 0 1 1 1 1 0
0 1 0 1 1 1 1 0
0 1 0 1 1 1 1 0
0 1 0 1 1 1 1 0
0 1 0 1 1 1 1 0
0 1 0 1 1 1 1 0
0 1 0 1 1 1 1 0
1 1 1 1 1 1 1 1
0 1 0 1 1 1 1 1
1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 0 1 1 1 0 0
DR. SAIFUL DR. INDRA DR. GAMAL DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. SAIFUL
 7/16/2022
219182 219235 136550 216875 029986 219286 175559 218876
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 1 1 1 1
1 1 1 1 0 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 0 1 0 0
DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL
 7/18/2022
167559 057545 199868 157327 159355 207473 181064 033233
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0
1 1 1 1 1 1 1 1
1 0 1 1 0 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 1 1 1 1 1
0 0 0 1 0 1 0 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL
 7/19/2022
158497 08769 059528 060079 149842 029588 218626 144159
1 1 1 1 1 1 1 1
1 1 1 1 0 0 1 1
1 1 0 0 0 0 1 0
1 1 0 0 0 0 1 0
1 1 0 0 0 0 1 0
1 1 0 0 0 0 1 0
1 1 0 0 0 0 1 0
1 1 0 0 0 0 1 0
1 1 0 0 0 0 1 0
1 1 0 0 0 0 1 0
1 1 0 0 0 0 1 0
1 1 1 1 1 1 1 1
1 1 0 0 1 0 1 0
1 1 1 1 1 0 1 1
1 1 1 1 1 1 1 1
1 1 0 0 1 1 1 1
1 1 0 0 0 0 1 0
DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. GAMAL DR. RUDI DR. GAMAL
 7/20/2022
217568 172937 209593 219375 194257 162154 028666 075095
1 1 1 1 1 1 1 1
1 1 0 1 0 0 1 1
1 1 1 1 1 0 0 1
1 1 1 1 1 0 0 1
1 1 1 1 1 0 0 1
1 1 1 1 1 0 0 1
1 1 1 1 1 0 0 1
1 1 1 1 1 0 0 1
1 1 1 1 1 0 0 1
1 1 1 1 1 0 0 1
1 1 1 1 1 0 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 1 0 1 1 1
1 1 0 1 0 0 0 1
DR. INDRA DR. IRWAN DR. RUDI DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA
7/20/2022 7/21/2022
137332 161053 219493 202622 216662 160424 219495 141634 134035
1 1 1 1 1 1 0 1 1
1 0 1 0 0 0 1 1
0 1 1 0 0 0 1 0 1
0 1 1 0 0 0 1 0 1
0 1 1 0 0 0 1 0 1
0 1 1 0 0 0 1 0 1
0 1 1 0 0 0 1 0 1
0 1 1 0 0 0 1 0 1
0 1 1 0 0 0 1 0 1
0 1 1 0 0 0 1 0 1
0 1 1 0 0 0 1 0 1
1 1 1 0 0 0 1 0 1
0 1 1 0 0 0 1 0 1
0 1 1 0 0 0 1 0 1
1 1 1 0 0 0 1 0 1
1 1 1 1 1 1 1 1 1
0 0 1 0 0 0 1 0 1
DR. SAIFUL DR. PURWA DR PUR DR SAI DR SAI DR SAI DR PUR DR SAI DR IRWAN
 7/22/2022
143032 201678 095396 090779 179446 218768 219507 199848 197021
1 1 1 1 1 1 1 1 1
1 1 0 1 1 1 1 1 1
1 1 1 0 0 1 0 1 0
1 1 1 0 0 1 0 1 0
1 1 1 0 0 1 0 1 0
1 1 1 0 0 1 0 1 0
1 1 1 0 0 1 0 1 0
1 1 1 0 0 1 0 1 0
1 1 1 0 0 1 0 1 0
1 1 1 0 0 1 0 1 0
1 1 1 0 0 1 0 1 0
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1
1 1 0 0 0 1 0 1 0
DR INDRA DR IRWAN DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. PUR DR. SAIFUL
 7/23/2022
218169 219545 160114 186699 086579 165255 219563 219041
1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 1
1 0 1 0 0 0 1 1
1 0 1 0 0 0 1 1
1 0 1 0 0 0 1 1
1 0 1 0 0 0 1 1
1 0 1 0 0 0 1 1
1 0 1 0 0 0 1 1
1 0 1 0 0 0 1 1
1 0 1 0 0 0 1 1
1 0 1 0 0 0 1 1
1 1 1 1 1 1 1 1
1 0 1 1 0 0 1 1
1 1 1 1 0 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 0 0 0 1 1
DR. INDRA DR. GAMAL DR. SAIFUL DR. SAIFUL DR. SAIFULDR. PURWA DR. PURWA DR. PURWA
 7/25/2022
219546 152333 205611 131988 072306 171651 217802 219216
1 1 1 1 1 1 1 1
1 1 0 1 0 1 1 1
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 0 1 0 0 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 0 0 0 1 1 0
DR. PURWA DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL
25/2022
197599 159864 219568 127257 131663 219641 120996 024279
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 0 0 1 0 1 1
1 0 0 0 1 0 1 1
1 0 0 0 1 0 1 1
1 0 0 0 1 0 1 1
1 0 0 0 1 0 1 1
1 0 0 0 1 0 1 1
1 0 0 0 1 0 1 1
1 0 0 0 1 0 1 1
1 0 0 0 1 0 1 1
1 1 0 1 1 1 1 1
1 0 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 0 0 1 0 1 1
DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA
 7/26/2022 7/27/2022
219690 219676 052693 219618 219673 214235 172054 184493
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 0 0 1 1 0 0 0
1 0 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 0 1 0 0 0 0
DR. PURWA DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL
 7/28/2022 7/29/2022
000237 219531 044814 211605 079510 153041 041564 219797
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 1 1 0 0
0 0 0 0 1 1 0 0
0 0 0 0 1 1 0 0
0 0 0 0 1 1 0 0
0 0 0 0 1 1 0 0
0 0 0 0 1 1 0 0
0 0 0 0 1 1 0 0
0 0 0 0 1 1 0 0
0 0 0 0 1 1 0 0
1 1 1 1 1 1 1 1
0 1 0 0 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 1 1 0 0
DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL
 7/29/2022
219525 219823 219195 215359 124947 050786
1 1 1 1 1 1
1 1 1 1 1 1
0 0 0 0 1 0
0 0 0 0 1 0
0 0 0 0 1 0
0 0 0 0 1 0
0 0 0 0 1 0
0 0 0 0 1 0
0 0 0 0 1 0
0 0 0 0 1 0
0 0 0 0 1 0
1 1 1 1 1 1
0 0 0 0 1 0
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
0 0 0 0 1 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL
 INFORMED CONSENT BULAN JUNI
RAB KAM JUM SAB MING SEN SEL RAB KAM JUM SAB MING SEN SEL RAB KAM JUM SAB MING SEN SEL RAB KAM JUM SAB MING SEN SEL RAB KAM
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
TOTAL 10 9 6 15 3 13 13 6 7 13 9 28 8 7 8 5 4 10 3 2 13 192
TDK LENGKAP 7 6 5 6 2 4 7 4 4 0 2 2 2 1 7 2 3 6 1 2 8 82
LENGKAP 3 3 1 9 1 9 6 2 3 13 7 26 6 6 1 3 0 4 2 0 5 110

RABU KAMIS JUMAT SABTU MINGGU SENIN SELASA RABU KAMIS JUMAT SABTU MINGGU SENIN SELASA RABU KAMIS JUMAT SABTU MINGGU SENIN SELASA RABU KAMIS JUMAT SABTU MINGGU SENIN SELASA RABU RABU
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

TD TD
TDK TDK TDK TDK TDK TDK TDK TDK TDK TDK TDK TDK TDK TDK TDK TDK TDK TDK TDK LE TDK TDK TDK TDK TDK
TDK LEN LEN TDK LEN LEN LEN LEN LEN TDK LEN LEN LEN LEN LEN LEN LEN LEN LEN K LEN K LEN LEN TDK LEN LEN
LEN LEN LEN LEN LENG LEN LEN LENG LEN LEN LEN LEN LENG LEN LEN LEN LEN LEN LENG LEN LENG LEN LEN LEN NG LEN LENG LEN LENG LEN LEN LEN LENG
LENG GKA GKA LENG GKA GKA GKA GK GKA LENG GKA GKA GKA GK GKA GKA GKA GKA GKA LEN GKA LEN GK GKA LENG GK GKA
GKA GKA GKA GKA KAP GKA GKA KAP GKA GKA GKA GK KAP GKA GKA GKA GKA GK KAP GK KAP GKA GK GKA KA GK KAP GK KAP GKA GKA GKA KAP
KAP P P KAP P P P AP P KAP P P P AP P P P P P GK P GK AP P KAP AP P
P P P P P P P P P AP P P P P AP AP P AP P P AP AP P P P
AP AP

DR PUR 2 1 1 4 7 1 9 1 3 2 1 2 0 4 0 7 2 6 2 3 0 6 1 1 1 0 1 3 1 0 0 2
DR SAIFUL 6 1 4 2 2 3 4 4 3 0 0 8 2 0 0 15 0 1 6 0 1 0 3 0 5 0 1 2 1 0 5 0
DR IRWAN 1 1 1 0 1 0 1 0 1 2 2
DR RUDI 0 2 0 1
DR INDRA 1 1 2 0 1 0 2 1 1 1 1
DR GAMAL 1 0 1 1 0 0 1
DR ARINI
ORMED CONSENT BULAN JUNI
JUM SABTMING SEN SEL RAB KAM JUM SAB MING SEN SEL RAB KAM JUM SAB
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
TOTAL 6 2 18 9 7 8 9 15 17 18 5 7 5
TDK LENGKAP 1 2 13 8 6 4 8 9 10 12 4 2 1
LENGKAP 5 0 5 1 1 4 1 6 7 6 1 5 4

JUM SABTU MINGGU SENIN SELASA RABU KAMIS JUMAT

1 2 3 4 5 6 7 8
TL L TL L TL L TL L TL L TL L TL L TL L
DR PUR 1 5 1 0 1 1 2 3 1 0
DR SAIFUL 2 0 11 1 7 0 5 0 2 0 6 0
DR IRWAN 1 0 0 1 1 1
DR RUDI 0 1
DR INDRA 0 1
DR GAMAL 1 2 0 1
DR ARINI
dr. Paramita
MING SEN SEL RABKAMJUM SABMINGSEN SEL RAB KAM JUM SAB MING
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 TOTAL
15 10 6 8 7 9 12 8 2 5 10 218
15 6 2 4 5 4 8 4 2 4 7 141
0 4 1 4 2 5 4 4 0 1 3 77

SABTU MINGGU SENIN SELASA RABU KAMIS JUMAT SABTU MINGGU SENIN SELASA
9 10 11 12 13 14 15 16 17 18 19
TL L TL L TL L TL L TL L TL L TL L TL L TL L TL L TL
0 3 2 4 3 5 1 4 03 4 0 1
5 1 6 0 8 1 4 0 1 0 11 11 0 2
4 1 0 2 1 0 0
1
0 1 2 0 0 1 0
0 1 2

0 1
SELASA RABU KAMIS JUMAT SABTU MINGGU SENIN SELASA RABU KAMIS JUMAT
19 20 21 22 23 24 25 26 27 28 29
L TL L TL L TL L TL L TL L TL L TL L TL L TL L TL
1 1 1 1 1 1 2 1 3 0 4 2 4 1 0 0
0 1 0 3 0 4 0 2 1 8 0 2 0 2 0 3 1 7
1 0 2
1
1 0 1 0 1
0 1 0
JUMAT SABTU MINGGU
29 30 31
L TL L TL L
3
 NO REKAM MEDIS 219868 209885 134088 219752 219802
INDENTITAS PASIEN 1 1 1 1 1
PEMBERIAN INFORMASI 1 1 1 1 1
DIAGNOSIS 0 0 1 0 1
DASAR DIAGNOSIS 0 0 1 0 1
TINDAKAN KEDOKTERAN 0 0 1 0 1
INDIKASI TINDAKAN 0 0 1 0 1
TATA CARA 0 0 1 0 1
TUJUAN 0 0 1 0 1
RESIKO 0 0 1 0 1
KOMPLIKASI 0 0 1 0 1
PROGNOSIS 0 0 1 0 1
ALTERNATIF DAN RESIKO 1 1 1 1 1
TANDA TANGAN DPJP 0 1 1 0 1
TTD PENERIMA INFORMASI 1 1 1 1 1
PERSETUJUAN OPERASI 1 1 1 1 1
TTD SAKSI 1 1 1 1 1
0 0 1 0 1
DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA
 8/1/2022
218742 219915 218384 146043 153227 155263 219919 125805
1 1 1 1 1 1 1 1
0 1 0 1 1 1 1 1
1 1 1 0 0 0 1 0
1 1 1 0 0 0 1 0
1 1 1 0 0 0 1 0
1 1 1 0 0 0 1 0
1 1 1 0 0 0 1 0
1 1 1 0 0 0 1 0
1 1 1 0 0 0 1 0
1 1 1 0 0 0 1 0
1 1 1 0 0 0 1 0
1 1 1 1 1 1 1 1
1 1 1 1 0 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 0 0 0 0 1 0
DR. PURWA DR. PURWA DR. IRWAN DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL
 165000 164793 178378 173159 212670 098819 189218 016180
1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 1
1 1 0 1 0 1 1 1
1 1 0 1 0 1 1 1
1 1 0 1 0 1 1 1
1 1 0 1 0 1 1 1
1 1 0 1 0 1 1 1
1 1 0 1 0 1 1 1
1 1 0 1 0 1 1 1
1 1 0 1 0 1 1 1
1 1 0 1 0 1 1 1
1 1 1 1 1 1 1 1
1 1 0 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 0
1 0 0 1 0 1 1 0
DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. RUDI
 8/2/2022 8/3/2
219956 038073 219961 179605 162206 217151 148847 118704
1 1 1 1 1 1 1 1
1 1 1 0 0 1 1 1
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 0 0 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 0 0 1 0 1
1 1 1 0 0 1 0 0
DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. IRWAN DR. GAMAL DR. SAIFUL
 8/3/2022 8/4/2022
219969 219985 078453 219764 205281 020369 220077 218816
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 0 0 0 1 0 1
1 0 0 0 0 1 0 1
1 0 0 0 0 1 0 1
1 0 0 0 0 1 0 1
1 0 0 0 0 1 0 1
1 0 0 0 0 1 0 1
1 0 0 0 0 1 0 1
1 0 0 0 0 1 0 1
1 0 0 0 0 1 0 1
1 1 1 1 1 1 1 1
1 0 1 0 0 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 0 0 0 1 0 1
DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. GAMAL DR. SAIFUL DR. PURWA
022 8/5/2022
219633 064251 220138 220159 013468 219590 085948 120630
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 1 0 1 0 0
1 0 1 1 0 1 0 0
1 0 1 1 0 1 0 0
1 0 1 1 0 1 0 0
1 0 1 1 0 1 0 0
1 0 1 1 0 1 0 0
1 0 1 1 0 1 0 0
1 0 1 1 0 1 0 0
1 0 1 1 0 1 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 1 0 1 0 0
DR. IRWAN DR. SAIFUL DR.PURWA DR. PURWA DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL
 8/5/2022
220102 044543 211419 049305 197801 040412 145391 088175
1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 1 1 0 1 1 0
0 0 1 1 0 1 1 0
0 0 1 1 0 1 1 0
0 0 1 1 0 1 1 0
0 0 1 1 0 1 1 0
0 0 1 1 0 1 1 0
0 0 1 1 0 1 1 0
0 0 1 1 0 1 1 0
0 0 1 1 0 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 0
0 0 1 1 0 1 1 0
DR. SAIFUL DR, SAIFUL DR. IRWAN DR. INDRA DR. GAMAL DR. IRWAN DR. RUDI DR. RUDI
 8/8/2022
134035 220206 180195 176120 026097 220164 215170 219852
1 1 1 1 1 1 1 1
1 1 0 1 1 1 1 0
1 1 0 1 1 1 0 0
1 1 0 1 1 1 0 0
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 0 1 1 0 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 1 1 0 0 0
DR. IRWAN DR.PURWA DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL
 8/9/2022
139457 210289 133929 188212 218858 220096 220172 171371
1 1 1 1 1 1 1 1
1 0 0 1 1 1 1 0
1 0 0 1 1 1 1 0
1 0 0 1 1 1 1 0
1 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 1 1 1 1 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. INDRA DR. PRAMITA DR. IRWAN DR. IRWAN DR. SAIFUL
 220313 193611 209101 220139 217654 168202 164824 218967
1 1 1 1 1 1 1 1
0 1 1 1 0 0 1 1
0 1 0 0 0 0 1 1
0 1 0 0 0 0 1 1
0 1 0 0 0 0 1 1
0 1 0 0 0 0 1 0
0 1 0 0 0 0 0 0
0 1 0 0 0 0 0 0
0 1 0 0 0 0 0 0
0 1 0 0 0 0 0 0
0 1 0 0 0 0 0 0
1 1 1 1 1 1 1 1
0 1 1 1 1 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 0 0 0 0 0 0
DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL
 8/10/2022
173366 025918 066534 219022 220246 136163 220231 073617
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
1 1 0 1 0 1 1 0
1 1 0 1 0 1 1 0
1 1 0 1 0 1 1 0
1 1 0 1 0 1 1 0
1 1 0 1 0 1 1 0
1 1 0 1 0 1 1 0
1 1 0 1 0 1 1 0
1 1 0 1 0 1 1 0
1 1 0 1 0 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 0 0 1 1 0
DR. PURWA DR. PURWA DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL
 8/11/2022
219580 219655 104760 151830 088494 195912 134619 180143
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 0 1 0 0
0 0 0 0 0 1 0 0
0 0 0 0 0 1 0 0
0 0 0 0 0 1 0 0
0 0 0 0 0 1 0 0
0 0 0 0 0 1 0 0
0 0 0 0 0 1 0 0
0 0 0 0 0 1 0 0
0 0 0 0 0 1 0 0
0 1 0 1 1 1 0 1
0 1 0 1 1 1 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 0 1 0 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. GAMAL DR. SAIFUL DR. SAIFUL
8/11/2022 8/15/2022
132220 219818 194969 130317 120892 087753 220445 209970
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 1 1 0 1 1 0
0 1 1 1 0 1 1 0
0 1 1 1 0 1 1 0
0 1 1 1 0 1 1 0
0 1 1 1 0 1 1 0
0 1 1 1 0 1 1 0
0 1 1 1 0 1 1 0
0 1 1 1 0 1 1 0
0 1 1 1 0 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 0 0 1 1
0 1 1 1 0 0 1 0
DR. SAIFUL DR.IRWAN DR.IRWAN DR. PURWA DR. INDRA DR. RUDI DR. RUDI DR. SAIFUL
 217945 204299 220520 052243 220615 057039 218733 215344
1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 0 1 0 1 1
0 1 1 0 1 0 1 0
DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. INDRA DR. SAIFUL
 INDIKATOR PENILAIAN FORMULIR REKAM MEDIS
INFORMED CONSENT
8/16/2022
209727 122365 220580 134324 193272 039137 027421 135491
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
0 0 0 0 0 1 1 1
1 1 1 1 1 1 1 1
1 0 0 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 0 0 1 1 1
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA DR. PURWA
ULIR REKAM MEDIS
NT
8/18/2022
138943 217920 1 104869 220688 210852 217600 171234
1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 0
0 1 1 0 0 1 0 1
0 1 1 0 0 1 0 1
0 1 1 0 0 1 0 1
0 1 1 0 0 1 0 1
0 1 1 0 0 1 0 1
0 1 1 0 0 1 0 1
0 1 1 0 0 1 0 1
0 1 1 0 0 1 0 1
0 1 1 0 0 1 0 1
1 1 1 1 1 1 1 1
0 1 1 0 0 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 1 1 1 1 1
0 1 0 0 0 0 0 0
DR. SAIFUL DR. PURWA DR. IRWAN DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL
056673 220720 182322 220678 220671 162286 219754 171337
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 1 1 0 0 0
1 0 1 1 1 0 0 0
1 0 1 1 1 0 0 0
1 0 1 1 1 0 0 0
1 0 1 1 1 0 0 0
1 0 1 1 1 0 0 0
1 0 1 1 1 0 0 0
1 0 1 1 1 0 0 0
1 0 1 1 1 0 0 0
1 1 1 1 1 1 1 1
1 0 1 1 1 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 1 1 0 0 0
DR. PURWA DR. SAIFUL DR. PURWA DR.PURWA DR.PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL
 8/19/2022
124641 219579 211873 166364 220701 097311 220779 084550
1 1 1 1 1 1 1 1
1 1 0 1 1 0 1 1
0 0 1 0 0 0 0 1
0 0 1 0 0 0 0 1
0 0 1 0 0 0 0 1
0 0 1 0 0 0 0 1
0 0 1 0 0 0 0 1
0 0 1 0 0 0 0 1
0 0 1 0 0 0 0 1
0 0 1 0 0 0 0 1
0 0 1 0 0 0 0 1
1 1 1 1 1 1 1 1
1 0 1 0 0 0 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 1
0 0 0 0 0 0 0 1
DR. SAIFUL DR. GAMAL DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA
 218721 175770 215959 028320 093097 122021 217608 171326
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
0 1 1 0 1 1 1 1
DR. SAIFUL DR. PRAMITA DR. RUDI DR.INDRA DR.INDRA DR. IRWAN DR. IRWAN DR. PURWA
 8/20/2022
220858 220829 220257 167977 220818 218865 058504 220770
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 0 1 1 1 1
DR. PURWA DR. PURWA DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA DR. PURWA DR. PURWA
160288 169791 201526
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
DR. PURWA DR. PURWA DR. PURWA
088393 176150 217167 220869
1 1 1 1 1
1 1 0 1 1
1 1 1 0 0
1 1 1 0 0
1 1 1 0 0
1 1 1 0 0
1 1 1 0 0
1 1 1 0 0
1 1 1 0 0
1 1 1 0 0
1 1 1 0 0
1 1 1 1 1
1 1 1 1 0
1 1 1 1 1
1 1 1 1 1
1 1 1 1 1
1 1 1 0 0
DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL
130628 167117 220856 218160 213209 220883 219113 213792
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
0 0 0 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 1 0 1 1 1
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA DR. PURWA DR. INDRA DR. INDRA
 8/22/2022
220709 220681 203126 220762 068252 218635 083381 220956
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 0 1 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 0 1 0 0
DR. IRWAN DR. IRWAN DR. ARINI DR. GAMAL DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL
 8/23/2022
165674 214023 124675 159031 220911 117122 220926 220890
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
1 1 0 0 0 1 0 0
1 1 0 0 0 1 0 0
1 1 0 0 0 1 0 0
1 1 0 0 0 1 0 0
1 1 0 0 0 1 0 0
1 1 0 0 0 1 0 0
1 1 0 0 0 1 0 0
1 1 0 0 0 1 0 0
1 1 0 0 0 1 0 0
1 1 1 1 1 1 1 1
1 1 0 0 0 1 0 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 0 0 1 0 0
DR. PURWA DR.PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. GAMAL
8/23/2022 8/24/2022
019064 220736 091666 074653 146554 179401 147767 220918
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
1 1 0 1 0 0 0 1
1 1 0 1 0 0 0 1
1 1 0 1 0 0 0 1
1 1 0 1 0 0 0 1
1 1 0 1 0 0 0 1
1 1 0 1 0 0 0 1
1 1 0 1 0 0 0 1
1 1 0 1 0 0 0 1
1 1 0 1 0 0 0 1
1 1 1 1 1 1 1 1
1 1 1 1 0 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 1
0 1 1 0 0 0 0 1
DR. IRWAN DR. IRWAN DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA
 8/25/2022
172602 091422 203019 136213 077402 156417 191163 177396
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 1 0 0 1 1
0 0 0 1 0 0 1 1
0 0 0 1 0 0 1 1
0 0 0 1 0 0 1 1
0 0 0 1 0 0 1 1
0 0 0 1 0 0 1 1
0 0 0 1 0 0 1 1
0 0 0 1 0 0 1 1
0 0 0 1 0 0 1 1
0 1 1 1 1 1 1 1
1 0 0 1 1 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 1 0 0 1 1
DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL DR. SAIFUL DR. INDRA DR. INDRA
 8/26/2022
220477 212185 221114 221177 221146 213372 221184 221204
1 1 1 1 1 1 1 1
1 1 0 1 1 0 1 1
1 0 0 0 0 1 0 0
1 0 0 0 0 1 0 0
1 0 0 0 0 1 0 0
1 0 0 0 0 1 0 0
1 0 0 0 0 1 0 0
1 0 0 0 0 1 0 0
1 0 0 0 0 1 0 0
1 0 0 0 0 1 0 0
1 0 0 0 0 1 0 0
1 1 1 1 1 1 1 1
1 1 0 0 1 1 1 0
1 1 0 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1
1 0 0 0 0 0 0 0
DR. RUDI DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL
 8/29/2022
148583 221055 061398 220507 154164 154249 217815 192130
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 0 1 1 0 1 1
1 1 1 1 1 1 1 1
1 1 0 1 1 0 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 1 1 0 1 1
DR. PURWA DR. IRWAN DR. INDRA DR. IRWAN DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA
 8/30/2022
220249 210943 151148 089061 221327 144722 211583 221334
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 0 1 1 1 1
1 1 0 0 1 1 1 1
1 1 0 0 1 1 1 1
1 1 0 0 1 1 1 1
1 1 0 0 1 1 1 1
1 1 0 0 1 1 1 1
1 1 0 0 1 1 1 1
1 1 0 0 1 1 1 1
1 1 0 0 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 0 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 0 1 1 1 1
DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA DR. PURWA DR. PURWA
 8/31/2022
221379 056600 212185 221096
1 1 1 1
1 0 1 1
1 0 1 1
1 0 0 1
1 0 0 1
1 0 0 1
1 0 0 1
1 0 0 1
1 0 0 1
1 0 0 1
1 0 0 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 0 0 1
DR. PURWA DR. SAIFUL DR. SAIFUL DR. IRWAN
 NO REKAM MEDIS 208081 077686 181735 160060 221377
INDENTITAS PASIEN 1 1 1 1 1
PEMBERIAN INFORMASI 1 1 1 0 1
DIAGNOSIS 0 1 0 1 1
DASAR DIAGNOSIS 0 1 0 1 1
TINDAKAN KEDOKTERAN 0 1 0 1 1
INDIKASI TINDAKAN 0 1 0 1 1
TATA CARA 0 1 0 1 1
TUJUAN 0 1 0 1 1
RESIKO 0 1 0 1 1
KOMPLIKASI 0 1 0 1 1
PROGNOSIS 0 1 0 1 1
ALTERNATIF DAN RESIKO 1 1 1 1 1
TANDA TANGAN DPJP 0 1 0 1 1
TTD PENERIMA INFORMASI 1 1 1 1 1
PERSETUJUAN OPERASI 1 1 1 1 1
TTD SAKSI 1 1 1 1 1
0 1 0 1 1
DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA
 9/1/2022
157938 219077 147380 221433 221445 212377 213301 152342
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 1 0 0 1 0
0 0 0 1 0 0 1 0
0 0 0 1 0 0 1 0
0 0 0 1 0 0 1 0
0 0 0 1 0 0 1 0
0 0 0 1 0 0 1 0
0 0 0 1 0 0 1 0
0 0 0 1 0 0 1 0
0 0 0 1 0 0 1 0
1 1 1 1 1 1 1 1
0 1 1 1 1 1 1 0
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 1 0 0 1 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL
 9/2/2022 8/3/2022
221425 221200 221412 136423 166282 210372 072971
1 1 1 1 1 1 1
1 1 1 1 1 1 1
0 1 0 0 1 0 1
0 1 0 0 1 0 1
0 1 0 0 1 0 1
0 1 0 0 1 0 1
0 1 0 0 1 0 1
0 1 0 0 1 0 1
0 1 0 0 1 0 1
0 1 0 0 1 0 1
0 1 0 0 1 0 1
1 1 1 1 1 1 1
1 1 1 1 1 0 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
0 1 0 0 1 0 1
DR. SAIFUL DR. IRWAN DR. SAIFUL DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA
 9/5/2022
221559 144599 221534 221518 183507 221572 216519 218349
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 0 1 1 1 1
1 0 1 0 0 1 1 1
1 0 1 0 0 1 1 1
1 0 1 0 0 1 1 1
1 0 1 0 0 1 1 1
1 0 1 0 0 1 1 1
1 0 1 0 0 1 1 1
1 0 1 0 0 1 1 1
1 0 1 0 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 0 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 0 1 0 0 1 1 1
DR. PURWA DR, SAIFUL DR. PURWA DR. SAIFUL DR. SAIFULDR. GAMAL DR. INDRA DR. INDRA
 152929 221424 221478 213713 101425 146726 219820 209933
1 1 1 1 1 1 1 1
1 1 0 0 1 1 1 1
1 1 1 1 0 0 0 1
1 1 1 1 0 0 0 0
1 1 1 0 0 0 0 0
1 1 1 0 0 0 0 0
1 1 1 0 0 0 0 0
1 1 1 0 0 0 0 0
1 1 1 0 0 0 0 0
1 1 1 0 0 0 0 0
1 1 1 0 0 0 0 0
1 1 1 1 1 1 1 1
1 1 1 1 0 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 0 0 0 0 0
DR. RUDI DR. RUDI DR, IRWANDR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL
 9/8/2177
219182 061993 221688 221728 191101 187034 155607
1 1 1 1 1 1 1
1 1 1 1 1 0 1
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 1
1 1 1 1 1 0 1
1 1 1 1 1 0 0
DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. PURWA DR. SAIFUL
187760 221618 217131 208873 080002 210999 221586 177554
1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0
1 1 1 1 1 1 1 1
0 1 0 0 0 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 0 1 1
0 0 0 0 0 0 1 0
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFULDR. SAIFUL DR. PURWA DR. SAIFUL
 9/8/2022
168553 166141 091761 191358 197843 221724 113350 103611
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 0 1 0 1 1 1
1 0 0 1 0 1 1 1
1 0 0 1 0 1 1 1
1 0 0 1 0 1 1 1
1 0 0 1 0 1 1 1
0 0 0 1 0 1 1 1
0 0 0 1 0 1 1 1
0 0 0 1 0 1 1 1
1 0 0 1 0 1 1 1
1 1 1 1 1 1 1 1
1 1 0 1 0 1 0 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1
0 0 0 1 0 1 0 1
DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA DR. SAIFUL DR. PURWA DR. PURWA DR. RUDI
 INDIKATOR PENILAIAN FORMULIR REKAM MEDIS
INFORMED CONSENT
9/9/2022 9/10/2022
080229 204151 220030 145977 000116 41870 174054
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 0
1 1 1 1 1 1 1
1 0 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 0 1 1 1 1 0
DR. INDRA DR. INDRA DR. INDRA DR. INDRA DR. INDRA DR. GAMAL DR. SAIFUL
AM MEDIS

9/12/2022
034826 202851 221807 221727 221823 194823 110745
1 1 1 1 1 1 1
1 1 1 1 1 0 1
0 0 1 1 1 1 1
0 0 1 1 1 1 1
0 0 1 1 1 1 1
0 0 1 1 1 1 1
0 0 0 1 1 1 1
0 0 0 1 0 1 1
0 0 0 1 0 1 1
0 0 0 1 0 1 1
0 0 0 1 0 1 1
1 1 1 1 1 1 1
1 0 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
0 0 0 1 0 0 1
DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. GAMAL DR. SAIFUL DR. PURWA DR. PURWA
 211412 221654 175717 221852 221690 177542 122939
1 1 1 1 1 1 1
1 0 1 1 1 1 1
1 1 1 1 1 0 1
1 1 1 1 1 0 1
1 1 1 1 1 0 1
1 1 1 1 1 0 1
1 0 1 0 1 0 1
1 0 1 0 1 0 1
1 0 1 0 1 0 1
1 0 1 0 1 0 1
1 0 1 0 1 0 1
1 1 1 1 1 1 1
1 1 1 1 1 0 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 0 1 1 1 1 1
1 0 1 0 1 0 1
DR. PURWA DR. PURWA DR. PURWA DR. SAIFUL DR. IRWAN DR. SAIFUL DR. PURWA
 9/13/20
130856 183152 117875 222006 221766 127711 221079
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 0 1 1 1 1
1 1 0 1 1 1 1
1 1 0 1 1 1 1
1 1 0 1 1 1 1
1 1 0 1 1 1 1
1 1 0 1 1 1 1
1 1 0 1 1 1 1
1 1 0 1 1 1 1
1 1 0 1 1 1 1
1 1 1 1 1 1 1
1 1 0 0 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 0 0 1 1 1
DR. PURWA DR. SAIFUL DR. SAIFUL DR. PURWA DR. PURWA DR. PURWA DR. PURWA
 9/13/2022
100832 221952 216224 148058 221496 120667 151286
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 0 1 1
1 1 1 1 0 1 1
1 1 1 1 0 1 1
1 1 1 1 0 1 1
1 1 1 1 0 1 1
1 1 1 1 0 1 1
1 1 1 1 0 1 1
1 1 1 1 0 1 1
1 1 1 1 0 1 1
1 1 1 1 1 1 1
1 1 1 1 0 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 0 1 1
DR. PURWA DR. PURWA DR. PURWA DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA
 9/14/2022
222041 221983 101845 181992 217593 221962 221904
1 1 1 1 1 1 1
1 1 1 1 1 1 1
0 1 1 1 1 1 1
0 1 1 1 1 1 1
0 1 1 1 1 1 1
0 1 1 1 1 1 1
0 1 1 1 1 1 1
0 1 1 1 1 1 1
0 1 1 1 1 1 1
0 1 1 1 1 1 1
0 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
0 1 1 1 1 1 1
DR. SAIFUL DR. PURWA DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. SAIFUL DR. IRWAN
9/14/2022 9/15/2022
219002 216105 222114 106482 220646 221111 202783
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
DR. PRAMITA DR. INDRA DR. SAIFUL DR. PURWA DR. SAIFUL DR. PURWA DR. SAIFUL
022 9/16/2022
221511 222202 213576 220523
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
DR. PURWA DR. PURWA DR. SAIFUL DR. INDRA