RSUD Prof. Dr.

MARGONO SOEKARJO PURWOKERTO RM

INSTALASI FARMASI

Nama : ...................................................................... Nomor RM :

Tgl lahir/Umur : ......................... BB : ........... kg; TB : ............. cm; Kamar : .....................................
RPM : .................................................................. RPD : ...........................................................................
DPJP : .................................................. Diagnosis : ...............................................................................
Merokok : ....... batang/hr; Kopi : ....... gelas/hr; Lainnya : .............................................................................
Alergi : .............................................................................................................................................................

RIWAYAT PENGGUNAAN OBAT HARIAN

Diisi oleh Apoteker yang merawat :
Parameter Penyakit / Tanggal Nilai Normal 8/8 9/8 10/8 11/8
Tanda Vital

Tekanan Darah (mm Hg) 160/95 160/95 165/100 155/90

Nadi (kali per menit)
Suhu Badan (oC)
Respirasi (kali per menit)
Pusing +++ +++ +++
Batuk2 kering +++
KELUHAN

Laboratorium Rutin / Tanggal Nilai Normal

Laboratorium Rutin

Terapi (Nama Obat, Kekuataan) Aturan Pakai

RUTE PARENTERAL

Captopril 2 x 25 mg + + + +
HCT 2 x 1 tab + + + +
RUTE ORAL
I.V.F.D.

BB : Berat Badan; TB : Tinggi Badan; RPM : Riwayat Penyakit saat MRS; RPD : Riwayat Penyakit Dahulu