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LEMBAR PENGUMPULAN DATA

1. No. RM : ......................................................... 4. Diagnosa : ............................................................... .....


2. Nama Pasien : ......................................................... ....................................................................
3. Usia/Jenis Kelamin : .............................................. L / P ............................................................... .....
Terapi
Keterangan (Waktu)
Waktu Rute
Pem
Tgl
No. Nama Obat Dosis & beri- Tgl : Tgl : Tgl : Tgl : Tgl :
frek an
6- 12- 18- 6- 12- 18- 6- 12- 18- 6- 12- 18- 6- 12- 18-
Mulai Stop 0-6 12 18 24 0-6 12 18 24 0-6 12 18 24 0-6 12 18 24 0-6 12 18 24

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