LAPORAN VISITE

Periode Bulan : MARET 2021

NO NAMA PASIEN NO RM KLASIFIKASI / DRP REKOMENDASI PETUGAS

Mengetahui,
Kepala Instalasi Farmasi Jampangkulon, 2021
RSU Jampangkulon Koordinator Visite

NIP NIP
LAPORAN VISITE PASIEN RAWAT INAP RSUD JAMPANGKULON

Jumlah Pasien yang di visite : ………Orang

Uraian Masalah pasien terhadap Obat (Drug Related Problem)
Pasien/RM :
Diagnosa:
Ruangan :
Hari/ Tgl/ Bln/ Thn :
Masalah Obat Pasien :

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Rekomendasi :
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Apoteker :

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FORMAT KONSULTASI DENGAN *(DOKTER/PERAWAT/TENAGA MEDIS ) LAINNYA

Pasien/RM :
Diagnosa:
Hari/ Tgl/ Bln/ Thn:
Masalah Obat Pasien:

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Rekomendasi :
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 Apoteker : *(Dokter/Perawat/Tenaga Medis Lainnya)

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*Coret yang tidak perlu