FORM PEMANTAUAN PENGGUNAAN OBAT RUMAH SAKIT UMUM

PENYANGGA PERBATASAN (RSUPP) BETUN

KAB/ KOTA : ………………………………………………….....

SARANA DIKUNJUNGI : …………………………………………………….

PEJABAT YG DIKUNJUNGI : .................................................................................

JUMLAH TENAGA APOTEKER : .................................................................................

TENAGA TTK ..................................................................................
NON FARMASI ..................................................................................

KEPALA INSTALASI FARMASI : .....................................................................

STATUS RSUD : BLUD/TIDAK BLUD

JUMLAH TEMPAT TIDUR :
AKREDITASI : A/B/C/D ........ PELAYANAN

A. PERENCANAAN DAN PENGADAAN:

1. Pemilihan obat berdasarkan Formularium Nasional ya / tidak

Berapa item :..........................................................................................................................
2. pemilihan Obat berdasarkan Daftar obat Esensial Nasional (DOEN) ya / tidak
Berapa Item : .......................................................................................................................
3. Pemilihan Obat berdasarkan Formularium Rumah Sakit ya / tidak
Berapa Item :.......................................................................................................................
4. Pengadaan obat berdasarkan E-Catalog ya / tidak
Jumlah dana dan Item :......................................................................................................
5. Pengadaan berdasarkan Tender/Lelang ya / tidak
Jumlah dana dan Item : ....................................................................................................
6. Pengadaan obat menggunakan Dana lain ya / tidak
Jumlah Dana dan Item :.....................................................................................................
6. Total Dana Pengadaan Obat Tahun 2015

A. PENYIMPANAN

1. Tempat penyimpanan di : Gudang/Apotek

2. Obat di letakkan pada : Palet/Rak/Lantai/Lemari

3. Obat disimpan berdasarkan Abjad/Sediaan lainnya : ya / tidak

4. Mutasi obat dicatat pada kartu stok : ya / tidak

5. Pencatatan dilakukan scr rutin jika terjadi mutasi : ya / tidak

6. Penyimpanan Obat dilakukan secara FIFO : ya / tidak

7. Penyimpanan Obat dilakukan secara FEFO : ya / tidak

B. PENDISTRIBUSIAN
 1. Pengeluaran Obat berdasarkan Resep/UDD : ya / tidak

2. Permintaan Ruangan menggunakan Form/Buku : ya / tidak

3. Jika tidak mekanisme yang digunakan :

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C. LAMPIRAN PEMAKAIAN OBAT TW 1,2 DAN 3 ( Januari – September 2015)
TAHUN 2015

D. PERMASALAHAN YANG DIHADAPI / DITEMUI PENGGUNAAN

FORMULARIUM NASIONAL DAN FORMULARIUM RUMAH SAKIT DALAM
PELAYANAN PENGOBATAN

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E. S A R A N

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