Nama pasien : WL
Nomor RM : 00.48.94.91
Rasionalitas
Dosis
Indikasi Obat Pasien Dosis Saat Interval Lama Rute
Tanggal Diagnosis Nama obat
pemberian pemberian pemberian pemberian pemberian
T
R R TR R TR R TR R TR R TR R TR R TR
R
1 3 4 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Rifampisin √ √ √ √ √ √ √ √
Isoniazid √ √ √ √ √ √ √ √
Pirazinamid √ √ √ √ √ √ √ √
Etambutol √ √ √ √ √ √ √ √
Seftriakson √ √ √ √ √ √ √ √
7 Oktober Tuberkulosis
Kodein √ √ √ √ √ √ √ √
2011 paru
Retaphyl® SR
√ √ √ √ √ √ √ √
(Teofilin)
Sohobion®
(vit. B 1 , vit. √ √ √ √ √ √ √ √
B 6 , vit. B 12 )
Rifampisin √ √ √ √ √ √ √ √
8-9 Oktober Tuberkulosis Isoniazid √ √ √ √ √ √ √ √
2011 paru Pirazinamid √ √ √ √ √ √ √ √
Etambutol √ √ √ √ √ √ √ √
Keterangan:
R = Rasional
TR = Tidak Rasional
a. Bagian Depan
Lampiran 1 :
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Rekomendasi :
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Apoteker :
(……………………..)
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Rekomendasi :
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
(……………………..) (………….…………………………....)
*Coret yang tidak perlu
Lampiran 5. Format Lembar Pelayanan Informasi Obat
1. Identitas Penanya
Nama : Status :
No Telp :
2. Data Pasien :
Kehamilan : Ya / Tidak…………………………………Minggu
3. Pertanyaan :
Uraian permohonan
.............................................................................................................................
.............................................................................................................................
Jenis Permohonan
o Stabilitas o Farmakokinetik/Farmakodinamik
4. Jawaban : ..............................................................................................................
.............................................................................................................................
5. Referensi : .............................................................................................................
Kekuatan sediaan
Jumlah obat
Stabilitas
Lampiran 6. Format Kartu Konseling Pasien Rawat Jalan RSUP H. Adam Malik
C. PERSYARATAN KLINIS:
JENIS SKRINING URAIAN
a Ketepatan indikasi
B Ketepatan obat
c Ketepatan pasien
d Ketepatan dosis Regimen: Saat pemberian: Lama pemberiaan: Interval pemberian: Cara pemberian:
e Duplikasi pengobatan
f Interaksi obat:
1. Obat >< Obat
2. Obat >< Makanan
3 Obat >< Hasil
Laboratorium
4 Obat >< Obat
Tradisional
g Kontraindikasi
i Efek Adiktif
D.KONSELING
Nasehat/Advice :