[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-id-113":3,"doc-seo-159223-113":53,"doc-detail-159223-id":128},{"code":4,"msg":5,"data":6},0,"success",[7,13,17,21,25,29,33,37,41,45,49],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},55,"Document","Agama & Spiritualitas",60,"religion-spirituality",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":11,"slug":16},48,"Cerita & Novel","story-novel",{"id":18,"doc_module":4,"doc_module_name":9,"category_name":19,"show_sort_weight":11,"slug":20},56,"Gaya Hidup","lifestyle",{"id":22,"doc_module":4,"doc_module_name":9,"category_name":23,"show_sort_weight":11,"slug":24},51,"Komik","comic",{"id":26,"doc_module":4,"doc_module_name":9,"category_name":27,"show_sort_weight":11,"slug":28},53,"Layanan Kesehatan","healthcare",{"id":30,"doc_module":4,"doc_module_name":9,"category_name":31,"show_sort_weight":11,"slug":32},54,"Penelitian & Laporan","research-report",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":11,"slug":36},49,"Sastra","literature",{"id":38,"doc_module":4,"doc_module_name":9,"category_name":39,"show_sort_weight":11,"slug":40},52,"Teknologi","technology",{"id":42,"doc_module":4,"doc_module_name":9,"category_name":43,"show_sort_weight":11,"slug":44},50,"Ujian","exam",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":47,"show_sort_weight":11,"slug":48},57,"Umum","general",{"id":50,"doc_module":4,"doc_module_name":9,"category_name":51,"show_sort_weight":4,"slug":52},181,"Formulir","formulir",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":121,"head_meta":123,"extra_data":125,"updated_unix":127},113,"id","doctors-statement-health-claim-attending-physicians-statement-form","Surat Keterangan Dokter Klaim Kesehatan - Formulir Attending Physician's Statement","","Surat Keterangan Dokter untuk klaim kesehatan berisi instruksi pengisian formulir oleh dokter yang merawat serta penjelasan kewajiban pengisian lengkap, menggunakan huruf cetak, dan memaraf setiap koreksi. Dokumen memuat bagian informasi administrasi pasien seperti nomor rekam medis, nama, tanggal lahir, dan jenis kelamin. Bagian medis merinci tanggal perawatan yang diajukan, diagnosis dan etiologi, kapan gejala pertama kali dirasakan, hasil pemeriksaan fisik (tensi, nadi, suhu, pernapasan, kesadaran), indikasi medis, serta pemeriksaan penunjang dan tindakan pengobatan yang diberikan. Terdapat pula pengisian terkait komplikasi/penyebab seperti kecelakaan, self-inflicted injury, bunuh diri, kehamilan/abortus/KB, gangguan jiwa atau psikososomatis, cacat lahir, alasan kosmetik, dan penyakit menular seksual/HIV/AIDS.",{"@graph":63,"@context":120},[64,81,103],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,72,75,78],{"item":68,"name":69,"@type":70,"position":71},"https://docshare.wps.com","Home","ListItem",1,{"item":73,"name":9,"@type":70,"position":74},"https://docshare.wps.com/id/document/",2,{"item":76,"name":27,"@type":70,"position":77},"https://docshare.wps.com/id/document/layanan-kesehatan/",3,{"item":79,"name":59,"@type":70,"position":80},"https://docshare.wps.com/id/document/doctors-statement-health-claim-attending-physicians-statement-form/159223/",4,{"url":79,"name":59,"@type":82,"image":83,"author":88,"headline":59,"publisher":91,"fileFormat":94,"inLanguage":57,"description":61,"dateModified":95,"datePublished":96,"encodingFormat":94,"isAccessibleForFree":97,"interactionStatistic":98},"DigitalDocument",{"url":84,"@type":85,"width":86,"height":87},"https://docshare.wps.com/thumbnails/doctors-statement-health-claim-attending-physicians-statement-form/159223.png","ImageObject",300,407,{"name":89,"@type":90},"Oliver Hayes","Person",{"url":68,"name":92,"@type":93},"DocShare","Organization","application/pdf","2026-09-20","2026-08-29",true,{"@type":99,"interactionType":100,"userInteractionCount":102},"InteractionCounter",{"@type":101},"ViewAction",6,{"@type":104,"mainEntity":105},"FAQPage",[106,112,116],{"name":107,"@type":108,"acceptedAnswer":109},"Siapa yang harus mengisi formulir dan apa aturan pengisiannya?","Question",{"text":110,"@type":111},"Formulir diisi oleh dokter yang merawat. Pengisian harus lengkap dan benar sesuai fakta, menggunakan huruf cetak, serta setiap koreksi wajib diparaf oleh dokter yang merawat.","Answer",{"name":113,"@type":108,"acceptedAnswer":114},"Informasi medis apa saja yang diminta dalam formulir ini?",{"text":115,"@type":111},"Formulir meminta tanggal perawatan yang diajukan, diagnosis dan etiologi (termasuk sejak kapan diketahui), tanggal konsultasi awal, gejala/keluhan utama, tanggal gejala pertama kali, serta hasil pemeriksaan fisik seperti tensi, nadi, suhu, pernapasan, dan kesadaran.",{"name":117,"@type":108,"acceptedAnswer":118},"Apa yang harus dicantumkan terkait pemeriksaan penunjang dan tindakan pengobatan?",{"text":119,"@type":111},"Jika ada pemeriksaan penunjang untuk menentukan diagnosis, bagian tersebut perlu diisi dengan tanggal, nama pemeriksaan, dan hasil. Selain itu, tindakan pengobatan medis yang diberikan serta indikasi medis tindakan tersebut perlu dijelaskan.","https://schema.org",{"og:url":79,"og:type":122,"og:title":59,"og:site_name":92,"og:description":61},"article",{"robots":124,"canonical":79},"index,follow",{"doc_id":126,"site_id":56},159223,1788014734,{"code":4,"msg":5,"data":129},{"doc_id":126,"user_id":130,"nickname":89,"user_avatar":131,"doc_module":4,"category_id":26,"category_name":27,"doc_title":59,"doc_description":61,"doc_content":132,"file_id":133,"file_url":134,"file_type":135,"file_size":136,"view_count":102,"is_deleted":4,"is_public":71,"is_downloadable":71,"audit_status":71,"page_count":80,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":127,"read_time":102},687207020761,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","SURAT KETERANGAN DOKTER KLAIM KESEHATAN  \nATTENDING PHYCISIAN’S STATEMENT FOR HEALTH  \nDiisi oleh Dokter yang Merawat (Filled by Treating Doctor)  \nCatatan Penting (Note):  \n1. Mohon untuk mengisi formulir dengan lengkap dan benar sesuai dengan fakta yang sebenarnya / Please fill this form completely and correctly in accordance with the actual facts.  \n2. Mohon untuk mengisi formulir dengan huruf cetak / Please fill in the form in block letters  \n3. Apabila kolom yang ada tidak mencukupi, mohon di tuliskan di lembar lainnya / If the space is not enough, please written on other sheets.  \n4. Setiap koreksi di dalam formulir ini wajib di paraf oleh Dokter yang merawat / Any correction in this form must be initialed by the Treating Doctor.  \n5. Terima kasih atas kesediaan Anda untuk melengkapi dan mencantumkan tanda tangan, tanggal dan stempel pada formulir Klaim ini / Thank you for completing this medical Claim form with your signature, date and stamp on this form.  \nA. INFORMASI ADMINISTRASI / ADMINISTRATIVE DETAILS  \nNo. Rekam Medis / Medical Record Number Nama Pasien / Patient’s Name  \nTanggal Lahir / Date ofBirth  \nJenis Kelamin / Sex  \n:  \n:  \n:  \n:  \nB. INFORMASI MEDIS / MEDICAL DETAILS  \n1. Tanggal perawatan yang diajukan / Date of Hospitalization :  \n2. Tanggal Rawat Jalan/Perawatan Sebelum Sesudah Rawat Inap (jika perawatan bukan Rawat Inap)  \n3. Diagnosa / Diagnose :  \nDan sejak kapan terdiagnosa/ and since when it was  \nDiagnosed :  \n4. Etiologi Diagnosa / The Etiology of Diagnose :  \nDan sejak kapan etiologi diagnosa diketahui/ And since when the etiology of the diagnosis is known? :  \n5. Tanggal pertama kali konsultasi untuk penyakit yang diderita : Date of first consultation for this condition  \n6. Gejala / Keluhan utama yang muncul / Main Symptoms :  \n7. Tanggal Gejala / Keluhan pertama kali dirasakan : Date of first symptoms occurred  \n8. Bagaimana hasil Pemeriksaan Fisik pasien? (What is Physical examination results?)  \na. Tensi (Tension) :  \nb. Nadi (Pulse) :  \nc. Suhu (Temperature) :  \nd. Pernapasan (Respiration) :  \ne. Kesadaran (Awareness) :  \n9. Apakah indikasi medis dilakukannya perawatan tersebut? :(What is the medical indication for hospitalization/ treatment?)  \n\n| D | D | M | M | Y | Y | Y | Y |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\nto  \n\n| D | D | M | M | Y | Y | Y | Y |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n\n| D | D | M | M | Y | Y | Y | Y |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n| D | D | M | M | Y | Y | Y | Y |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n| D | D | M | M | Y | Y | Y | Y |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n\n| D | D | M | M | Y | Y | Y | Y |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n| D | D | M | M | Y | Y | Y | Y |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n\n|  |\n| --- |\n|  |\n|  |\n|  |\n|  |\n\n10. Apakah perawatan ini atas permintaan pasien?(Is the patient hospitalized upon his request?)  \nYa/Yes  \nTidak/No  \n11. Pada hari perawatan keberapa pasien diperbolehkan pulang? (On which days of hospitalization, patient was allowed to go home)?  \n1. Apakah ada pemeriksaan penunjang yang dilakukan untuk menentukan Diagnosis Any additional examination conducted to define Diagnose ?  \nJika “YA”, Mohon penjelasan / If “YES”, Please provide details:  \nYa/Yes  \nTidak/No  \n\n| Tanggal Pemeriksaan Penunjang / Date of Supporting Examination (dd/mm/yyyy) | Nama Pemeriksaan Penunjang / Name of Supporting Examination | Hasil / Result |\n| --- | --- | --- |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n\n2. Mohon dijelaskan tindakan pengobatan medis yang diberikan / Kindly describe the medical treatment measures has been given:  \n\n| Jenis Tindakan / Type of Treatment | Indikasi Medis Tindakan / Medical Treatment Indication |\n| --- | --- |\n|  |  |\n\n\n| D. KONDISI INI DISEBABKAN OLEH / KOMPLIKASI DARI / BERHUBUNGAN DENGAN / THIS CONDITION IS CAUSED BY / COMPLICATION OF /RELATED TO :\u003Cbr>|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | ---","cbCaircQXrRLWHuX","https://ap.wps.com/l/cbCaircQXrRLWHuX","pdf",337324,"Indonesian","# Informasi Administrasi\n## Identitas pasien\n# Informasi Medis\n## Detail perawatan dan diagnosis\n## Etiologi diagnosis dan konsultasi awal\n## Gejala utama dan pemeriksaan fisik\n## Indikasi medis dan persetujuan pasien\n## Pemeriksaan penunjang dan tindakan pengobatan\n# Komplikasi dan Penyebab Terkait\n## Kecelakaan dan cedera\n## Kehamilan, psikososomatis, serta kondisi bawaan\n## Alasan kosmetik dan penyakit menular seksual/HIV/AIDS","[{\"question\":\"Siapa yang harus mengisi formulir dan apa aturan pengisiannya?\",\"answer\":\"Formulir diisi oleh dokter yang merawat. Pengisian harus lengkap dan benar sesuai fakta, menggunakan huruf cetak, serta setiap koreksi wajib diparaf oleh dokter yang merawat.\"},{\"question\":\"Informasi medis apa saja yang diminta dalam formulir ini?\",\"answer\":\"Formulir meminta tanggal perawatan yang diajukan, diagnosis dan etiologi (termasuk sejak kapan diketahui), tanggal konsultasi awal, gejala/keluhan utama, tanggal gejala pertama kali, serta hasil pemeriksaan fisik seperti tensi, nadi, suhu, pernapasan, dan kesadaran.\"},{\"question\":\"Apa yang harus dicantumkan terkait pemeriksaan penunjang dan tindakan pengobatan?\",\"answer\":\"Jika ada pemeriksaan penunjang untuk menentukan diagnosis, bagian tersebut perlu diisi dengan tanggal, nama pemeriksaan, dan hasil. Selain itu, tindakan pengobatan medis yang diberikan serta indikasi medis tindakan tersebut perlu dijelaskan.\"}]","Surat Keterangan Dokter Klaim Kesehatan - Formulir Attending Physician's Statement | PDF"]