KARTU MONITORING OBAT

Nama Pasien : ..............................................................No.telp/HP............................................

No. Register : ............................................................................................................................
Alamat : ............................................................................................................................
Jenis Kelamin : L P Umur : th BB : kg TB : cm

Diagnosis :
Riwayat Penyakit :
Riwayat Penggunaan Obat :
Riwayat Alergi :
Dosis Monitoring
Tanggal Nama Dokter Hasil Lab Terapi
(Aturan Pakai & Rute Pemberian) (Catatan Pelayanan Apoteker)
 KARTU MONITORING OBAT

Nama Pasien : ..............................................................No.telp/HP............................................

No. Register : ............................................................................................................................
Alamat : ............................................................................................................................
Jenis Kelamin : L P Umur : th BB : kg TB : cm

Nama Dokter :
Diagnosis :
Riwayat Penyakit :
Riwayat Penggunaan Obat :
Riwayat Alergi :
Hasil lab :
Waktu Minum Obat Tanggal Minum Obat (Checklist ✓)
No Nama Obat Dosis Sebelum Sesudah Waktu Catatan Pelayanan Apoteker
Makan Makan Makan

......................20........

Apoteker