FORM PEMESANAN
MAKANAN UNTUK PASIEN RAWAT INAP
TANGGAL : - -
2013
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No. |
JENIS MAKANAN |
Nama Ruang |
JUMLAH |
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Sakinah |
Ibnu Sina |
Rufaida |
Safa |
VK |
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1. |
Makanan
Biasa (MB) |
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2. |
Makanan
Lunak (ML) |
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3. |
Bubur Kasar Lauk Lunak (BKLL) |
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3. |
Makanan
Diet : |
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a.
Diabetes Melitus (DM) |
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b.
Rendah Lemak (RL) |
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c.
Rendah Garam (RG) |
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d.
Rendah Purin (RP) |
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e.
Tinggi Energi Tinggi Protein (TETP) |
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f.
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g.
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h.
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Mengetahui : Ka UPTD Puskesmas Selomerto 1 DEWI YULIANA.S,SSiT,M.Kes NIP.19710724 199103 2 007 |
PETUGAS JAGA
: ……………………………. NIP. |
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