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<text><![CDATA[Status perkawinan]]></text>
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<text><![CDATA[Suku Bangsa]]></text>
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<text><![CDATA[Sunda]]></text>
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<text><![CDATA[Madura]]></text>
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<text><![CDATA[Banjar]]></text>
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<text><![CDATA[Asing]]></text>
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<text><![CDATA[Lain-lain]]></text>
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<text><![CDATA[Agama/Kepercayaan]]></text>
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<text><![CDATA[:]]></text>
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<text><![CDATA[Kiriman dari]]></text>
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<text><![CDATA[:]]></text>
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<text><![CDATA[Status Pembayaran]]></text>
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<textFieldExpression><![CDATA[$F{stts_nikah}]]></textFieldExpression>
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<text><![CDATA[Keluarga Terdekat / Penanggung Jawab Pembayaran]]></text>
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<text><![CDATA[RS.Pemerintah]]></text>
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<text><![CDATA[Puskesmas]]></text>
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<text><![CDATA[Dokter]]></text>
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<text><![CDATA[RS.Swasta]]></text>
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<text><![CDATA[Alamat]]></text>
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<text><![CDATA[Telepon / HP]]></text>
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<text><![CDATA[DIISI OLEH REKAM MEDIS DIISI OLEH REKAM MEDIS]]></text>
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<text><![CDATA[Lama Dirawat :]]></text>
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<text><![CDATA[DIISI OLEH DOKTER]]></text>
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<text><![CDATA[Diagnosa Masuk :]]></text>
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<text><![CDATA[Diagnosa Utama :]]></text>
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<text><![CDATA[Diagnosa Komplikasi :]]></text>
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<text><![CDATA[Penyebab Kekerasan / Keracunan / Kecelakaan :]]></text>
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<text><![CDATA[Morfologi neoplasma / PA :]]></text>
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<text><![CDATA[Jenis Operasi :]]></text>
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<text><![CDATA[Sedang]]></text>
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<text><![CDATA[Besar]]></text>
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<text><![CDATA[Dokter Anastesi : 1.]]></text>
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<text><![CDATA[Hospital Acquired Infections :]]></text>
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<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
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<text><![CDATA[Tidak]]></text>
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<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
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<text><![CDATA[Ya :]]></text>
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<staticText>
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<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[IADP]]></text>
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<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[IDO]]></text>
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<staticText>
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<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[Riwayat Imunisasi :]]></text>
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<rectangle>
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<reportElement x="148" y="797" width="30" height="13" uuid="e8917615-21f6-4417-b220-939271630845"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[BCG]]></text>
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<rectangle>
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<staticText>
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<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[Polio]]></text>
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<rectangle>
<reportElement x="213" y="799" width="8" height="8" uuid="19513305-40e1-4836-8746-92e32ca48cf4"/>
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<staticText>
<reportElement x="226" y="797" width="20" height="13" uuid="9fb12f27-cec9-4c81-9bf2-466512a15e4f"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[TT]]></text>
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<staticText>
<reportElement x="259" y="797" width="22" height="13" uuid="0640111f-439d-415b-9769-dedc76c02460"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[DPT]]></text>
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<rectangle>
<reportElement x="246" y="799" width="8" height="8" uuid="a157f7f1-81b8-4f95-89e4-3a70b73cde11"/>
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<pen lineWidth="0.75"/>
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<rectangle>
<reportElement x="284" y="799" width="8" height="8" uuid="6dbae084-2fa6-441e-a97d-c491c2f777b9"/>
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<staticText>
<reportElement x="297" y="797" width="22" height="13" uuid="f3b7fdd0-099a-4695-9d87-e9995eb5ef74"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
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<text><![CDATA[DT]]></text>
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<rectangle>
<reportElement x="317" y="799" width="8" height="8" uuid="4b8533ca-a0aa-4a68-8153-3ec15683363c"/>
<graphicElement>
<pen lineWidth="0.75"/>
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<staticText>
<reportElement x="330" y="797" width="40" height="13" uuid="26cbff7a-085f-4951-b3d3-3fd083fc5cc7"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[Hepatitis]]></text>
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<rectangle>
<reportElement x="372" y="799" width="8" height="8" uuid="a3ef0c8f-6c34-458f-a60a-bf12dc8b02c5"/>
<graphicElement>
<pen lineWidth="0.75"/>
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</rectangle>
<staticText>
<reportElement x="385" y="797" width="40" height="13" uuid="cd7a257a-e769-4881-9b69-f1637b5a9240"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[Lain-lain]]></text>
</staticText>
<line>
<reportElement x="422" y="807" width="121" height="1" uuid="dc793411-f4b2-4554-94a5-f636e19e1197"/>
<graphicElement>
<pen lineWidth="0.5"/>
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</line>
<line>
<reportElement x="42" y="810" width="509" height="1" uuid="afb0f3e5-9191-451a-8a70-b77b2a1754e9"/>
<graphicElement>
<pen lineWidth="0.5"/>
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</line>
<rectangle>
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<staticText>
<reportElement x="44" y="812" width="80" height="13" uuid="0bbbe2b1-dfaa-45f3-81a2-51048c9f1698"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[Keadaan Keluar :]]></text>
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<staticText>
<reportElement x="137" y="812" width="40" height="13" uuid="22f13252-7939-47d4-babe-bda7c9c3363d"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
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<text><![CDATA[Sembuh]]></text>
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<staticText>
<reportElement x="192" y="812" width="80" height="13" uuid="9039bd7a-4ef1-45ef-b2a7-c75c2e0a03c0"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
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<text><![CDATA[Dalam Perbaikan]]></text>
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<rectangle>
<reportElement x="179" y="814" width="8" height="8" uuid="e013a714-80de-4c49-95ac-92e2a49842d5"/>
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<staticText>
<reportElement x="285" y="812" width="70" height="13" uuid="412d4f8b-e30d-4153-9c44-cf85b90ee171"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
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<text><![CDATA[Belum Sembuh]]></text>
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<rectangle>
<reportElement x="272" y="814" width="8" height="8" uuid="40752b26-6b77-49c4-b2a6-0affacccbaa5"/>
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<staticText>
<reportElement x="369" y="812" width="40" height="13" uuid="485301a7-da05-49cc-adf2-72f63e2f6f80"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[Cacat]]></text>
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<rectangle>
<reportElement x="356" y="814" width="8" height="8" uuid="dab53c32-7f3f-4d6d-a552-7baad7287cc3"/>
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<staticText>
<reportElement x="137" y="825" width="100" height="13" uuid="fed098d6-7c51-4455-a5b2-2f15bfea2161"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
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<text><![CDATA[Meninggal < 48 jam]]></text>
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<rectangle>
<reportElement x="124" y="827" width="8" height="8" uuid="972f687e-529d-4621-af2c-b4c2a40873a7"/>
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<rectangle>
<reportElement x="245" y="827" width="8" height="8" uuid="4e7e96b9-1952-4fcb-8006-b388ab2a3e3d"/>
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<staticText>
<reportElement x="258" y="825" width="120" height="13" uuid="36d98484-5f33-49f7-8137-d500abad2f28"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
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<text><![CDATA[Meninggal > 48 jam]]></text>
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<line>
<reportElement x="42" y="839" width="509" height="1" uuid="19168865-500a-485d-a0ea-045bdfa21e38"/>
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<pen lineWidth="0.5"/>
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</line>
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<reportElement x="44" y="840" width="80" height="13" uuid="8bc4250e-8f39-48c1-ba88-ff01139f976f"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
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<text><![CDATA[Cara Keluar :]]></text>
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<staticText>
<reportElement x="137" y="841" width="60" height="13" uuid="561a993f-281c-40d6-8b9e-d776f4d369a6"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
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<text><![CDATA[Dipulangkan]]></text>
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<rectangle>
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<staticText>
<reportElement x="226" y="841" width="60" height="13" uuid="93cc1e72-8107-49a4-ab1e-86ca18b8dc81"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
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<text><![CDATA[Dirujuk]]></text>
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<rectangle>
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<staticText>
<reportElement x="287" y="841" width="120" height="13" uuid="96309531-3104-46ac-81af-dc67a41bb3bd"/>
<textElement textAlignment="Left">
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<paragraph lineSpacing="Single"/>
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<text><![CDATA[Atas Permintaan Sendiri]]></text>
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<rectangle>
<reportElement x="274" y="843" width="8" height="8" uuid="95cf500d-beb5-4e2a-8492-b68e6880bd6a"/>
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<staticText>
<reportElement x="426" y="841" width="60" height="13" uuid="a1d8d251-fff9-4813-8f6e-6001073e6d77"/>
<textElement textAlignment="Left">
<font fontName="Tahoma" size="10"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[Lari]]></text>
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<rectangle>
<reportElement x="413" y="843" width="8" height="8" uuid="14113acc-5b03-4aea-b5cf-69cccd7affe7"/>
<graphicElement>
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<staticText>
<reportElement x="418" y="855" width="120" height="13" uuid="011076c9-f058-476d-9f21-5c921d382e5a"/>
<textElement textAlignment="Center">
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<paragraph lineSpacing="Single"/>
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<text><![CDATA[Dokter yang merawat]]></text>
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<staticText>
<reportElement x="418" y="882" width="120" height="13" uuid="f7fa32e4-0191-4435-8e4c-9a51f7d388b0"/>
<textElement textAlignment="Center">
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<paragraph lineSpacing="Single"/>
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<text><![CDATA[ttd & nama terang]]></text>
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<staticText>
<reportElement x="38" y="882" width="350" height="13" uuid="523cc330-e72b-4ff8-aee2-c8eca6edbd13"/>
<textElement>
<font fontName="Tahoma" size="9"/>
<paragraph lineSpacing="Single"/>
</textElement>
<text><![CDATA[NB : Tulis lengkap dengan huruf cetak, jelas dan terbaca (tidak disingkat)]]></text>
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<line>
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