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RM234567</br>
<b>Permata Sari</b></br>
29 tahun / 23 Jan 1986
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<th>Kode</th>
<th>Deskripsi tindakan</th>
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<td>0210093</td>
<td>Bypass Coronary Artery, One Site from Coronary Artery with Autologous Venous Tissue, Open Approach</td>
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<td>2W20X4Z</td>
<td>Dressing of Head using Bandage</td>
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<td>4A0204Z</td>
<td>Measurement of Cardiac Electrical Activity, Open Approach</td>
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<td>83.8</td>
<td>Other plastic operations on muscle, tendon, and fascia</td>
<td><a href="#"><span class="glyphicon glyphicon-plus" aria-hidden="true"></span></a></td>
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<td>90.5</td>
<td>Microscopic Examination Of Blood</td>
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<td>99.04</td>
<td>Transfusion of packed cells</td>
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<td>23/Feb/15 - 11:15</td>
<td>90.5</td>
<td>Microscopic Examination Of Blood</td>
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<tr>
<td>23/Feb/15 - 15:06</td>
<td>99.04</td>
<td>Transfusion of packed cells</td>
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<tr>
<td>23/Feb/15 - 17:54</td>
<td>83.8</td>
<td>Other plastic operations on muscle, tendon, and fascia</td>
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<td>23/Feb/15 - 18:42</td>
<td>Inf. consent untuk plastic operations on muscle, tendon, and fascia</td>
<td><a href="#" data-toggle="modal" data-target="#informedConsentModal"> Belum ditandatangani</td>
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<h4 class="modal-title" id="myModalLabel">Informed Consent - Plastic operations on muscle, tendon, and fascia</h4>
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<p>
Saya yang bertanda tangan dibawah ini: </br>
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<p>
<b>Nama</b>: Susilo Santoso </br>
<b>TTL</b>: Semarang, 08 Jan 1973 </br>
<b>Alamat</b>: Jl. Surakarta 23, Semarang </br>
</p>
<p>
Bersama ini menyatakan kesediannya untuk dilakukan tindakan dan prosedur <i>plastic operations on muscle, tendon, and fascia</i> pada diri saya.
Persetujuan ini saya berikan setelah mendapat penjelasan oleh <i>dr. Silvia Nurahman</i>.
Dengan demikian terjadi kesepahaman diantara pasien dan dokter tentang upaya serta tujuan tindakan, untuk mencegah terjadinya masalah hukum dikemudian hari.
</p>
<p>
Demikian surat persetujuan ini saya buat tanpa ada paksaan dari pihak manapun dan agar dapat dipergunakan sebagaimana mestinya.
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<p class="text-right">
Semarang, 23/Feb/2015 - 18:46
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