Alamat Lengkap : Jam Kunjungan : Cabang AAM : Hasil kunjungan : 1. Apakah terdapat praktek dokter di sarana relasi? Jika ya, pastikan jumlah dokter yang praktek & jadwal prakteknya ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... 2. Apakah terdapat RS / Klinik / Praktek dokter / Lab yang alokasinya berdekatan dengan sarana relasi? ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... 3. Berapa jumlah resep Psikotropika & Reguler yang masuk ke sarana per hari? ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... 4. Bagaimana kondisi daerah sekitar sarana : • Apakah ada pemukiman? .............................................................................................................................................................................................. • Apakah ada perkantoran? .............................................................................................................................................................................................. • Apakah sarana melayani layanan antar obat ke pasien / customer? .............................................................................................................................................................................................. 5. Apakah dokumen perizinan sarana kesehatan masih up date dan sesuai antara alamat pada dokumen perizinan dengan fisik dilapangan? ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... 6. Bagaimana hari dan jam operasional sarana kesehatan? ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... 7. Apakah pemilik sarana memiliki sarana kesehatan lainnya? Jika ya, sebutkan nama sarana beserta alamat pelengkapnya ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... 8. Apakah sarana kesehatan memiliki Apoteker Pendamping atau Tenaga Teknis Kefarmasian (TTK)? ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... 9. Bagaimana jam kerja / shift kerja APJ, APING & TTK di sarana kesehatan tersebut? ..................................................................................................................................................................................................... .....................................................................................................................................................................................................
Verifikasi Hasil Kunjungan Relasi oleh Apoteker AAM :
(Jelaskan apakah hasil kunjungan ke sarana kesehatan relasi sesuai dengan kewajaran jumlah & Frekuensi Order Relasi selama ini) ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... .....................................................................................................................................................................................................
Yang melakukan kunjungan: Kacab AAM Paraf / TTD & Stempel Relasi:
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No. Dokumen: AXIS-FRM-SQM.01-015 Tanggal Efektif: 4 Juli 2022