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RSUD SAWERIGADING KOTA PALOPO

Jl. Dr. Ratulangi Km.7 Rampoang Telp. (0471) 3312133 Fax. (0471) 33122

PROTOKOL PENGOBATAN

Nama Pasien : ..................................................................... No. Rekam Medis : .......................................................


Alamat : .................................................................... Tanggal Lahir : .......................................................
Berat Bada : .......................................................
Diagnosa : ....................................................................
Tinggi Badan : .......................................................

Uraian Penyakit : .....................................................................................................................................................................


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Pemberian Obat : .....................................................................................................................................................................
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Diagnosa : .....................................................................................................................................................................
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Prognosa : .....................................................................................................................................................................
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Palopo, ................................................., 20…............

Diketahui : ............................................................... Tim Onkologi : .....................................................


Direktur : ............................................................... SMF : .....................................................
Nama : ............................................................... Nama : .....................................................
Nip : ............................................................... Nip : .....................................................

P.H.B Rumah Sakit


Skema Pengobatan / Obat-obatan / Cairan

Jangka Waktu Pemberian Obat

2 Bulan (Siklus I)

Tanggal Tanggal Tanggal Tanggal Tanggal Tanggal

2 Bulan (Siklus II)

Tanggal Tanggal Tanggal Tanggal Tanggal Tanggal

2 Bulan (Siklus III)

Tanggal Tanggal Tanggal Tanggal Tanggal Tanggal

Tim Pengendali Dokter yang memberi obat,

. . . .
RSUD SAWERIGADING KOTA PALOPO
Jl. Dr. Ratulangi Km.7 Rampoang Telp. (0471) 3312133 Fax. (0471) 33122