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    Informed Consent/ Tindakan Kedokteran: Pemberian Informasi

    Uploaded by

    morning
    This document is an informed consent form for a medical procedure. It contains fields for patient information like name, date of birth, medical record number, and gender. It lists the type of procedure, the doctor performing it, and who provided the informed consent information. There are 11 categories of information provided to the patient, including diagnosis, basis for diagnosis, procedure details, risks, complications and alternatives. Spaces are provided for signatures of the doctor and patient or guardian to acknowledge the information was received and understood.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    Informed Consent/ Tindakan Kedokteran: Pemberian Informasi

    Uploaded by

    morning
    2 views2 pages
    This document is an informed consent form for a medical procedure. It contains fields for patient information like name, date of birth, medical record number, and gender. It lists the type of procedure, the doctor performing it, and who provided the informed consent information. There are 11 categories of information provided to the patient, including diagnosis, basis for diagnosis, procedure details, risks, complications and alternatives. Spaces are provided for signatures of the doctor and patient or guardian to acknowledge the information was received and understood.

    Original Description:

    INFORM CONSENT

    Original Title

    Inform

    Copyright

    © © All Rights Reserved

    Available Formats

    XLSX, PDF, TXT or read online from Scribd

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    This document is an informed consent form for a medical procedure. It contains fields for patient information like name, date of birth, medical record number, and gender. It lists the type of procedure, the doctor performing it, and who provided the informed consent information. There are 11 categories of information provided to the patient, including diagnosis, basis for diagnosis, procedure details, risks, complications and alternatives. Spaces are provided for signatures of the doctor and patient or guardian to acknowledge the information was received and understood.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    2 views2 pages

    Informed Consent/ Tindakan Kedokteran: Pemberian Informasi

    Uploaded by

    morning
    This document is an informed consent form for a medical procedure. It contains fields for patient information like name, date of birth, medical record number, and gender. It lists the type of procedure, the doctor performing it, and who provided the informed consent information. There are 11 categories of information provided to the patient, including diagnosis, basis for diagnosis, procedure details, risks, complications and alternatives. Spaces are provided for signatures of the doctor and patient or guardian to acknowledge the information was received and understood.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 2

    Nama :

    Tgl Lahir/Umur :
    INFORMED CONSENT/ No.RM :
    TINDAKAN Jenis Kelamin :
    KEDOKTERAN Tgl Masuk
    DPJP
    :
    :
    PPJP :
    NAMA TINDAKAN:
    PEMBERIAN INFORMASI
    DOKTER PELAKSANA TINDAKAN :
    PEMBERI INFORMASI :
    PENERIMA INFORMASI/PEMBERI :
    PERSETUJUAN :
    DIBERIKAN PADA TANGGAL/JAM :

    NO JENIS INFORMASI ISI INFORMASI

    1 DIAGNOSIS
    (DIAGNOSIS KERJA&DIAGNOSIS
    BANDING)
    2 DASAR DIAGNOSIS
    3 TINDAKAN KEDOKTERAN
    4 INDIKASI TINDAKAN
    5 TATA CARA
    6 TUJUAN
    7 RISIKO
    8 KOMPLIKASI
    9 PROGNOSIS
    10 ALTERNATIF & RESIKO
    11 LAIN LAIN
    DENGAN INI MENYATAKAN BAHWA SAYA TELAH MEREANGKAN HAL-HAL DI ATAS TANDA TANGAN DOKTER
    SECARA BENAR DAN JELAS DAN MEMBERIKAN KESEMPATAN UNTUK BERTANYA
    DAN/ATAU BERDISKUSI

    DENGAN INI SAYA MENYATAKAN BAHWA SAYA TELAH MENERIMA INFORMASI TANDA TANGAN PENERIMA
    SEBAGAIMANA DI ATAS YANG SAYA BERI TANDA/PARAF DI KOLOM KANANNYA, DAN INFORMASI
    TELAH MEMAHAMINYA

    BILA PASIEN TIDAK BERKOMPETEN ATAU TIDAK MAU MENERIMA INFORMASI, MAKA PENERIMA INFORMASI
    ADALAH WALI ATAU KELUARGA TERDEKAT
    Ruang :
    Kelas :

    TANDA (v) /
    PARAF
    PENERIMA
    INFORMASI

    TANDA TANGAN DOKTER

    TANDA TANGAN PENERIMA


    INFORMASI

    NERIMA INFORMASI

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