PEMANTAUAN TERAPI OBAT (PTO)

DATA PASIEN:
Nama:__________________
(L/P). Tgl. Lahir:_______________ BB:___kg, TB:____cm
_
Alamat:_____________________________________________________________________
No. Telp:________________ Tgl Masuk Klinik:______________ Ruang Rawat:_______

KELUHAN UTAMA:
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____________________________________________________________________________
__________________

RIWAYAT PENYAKIT SEKARANG:

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____________________________________________________________________________
__________________

RIWAYAT PENYAKIT TERDAHULU:

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__________________

RIWAYAT KELUARGA:
____________________________________________________________________________
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__________________

RIWAYAT SOSIAL:
____________________________________________________________________________
____________________________________________________________________________
__________________
RIWAYAT PENGGUNAAN OBAT:
____________________________________________________________________________
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__________________

HASIL PEMERIKSAAN FISIK:

Pemeriksaan Nilai normal Tanggal Tanggal Tangga Tanggal Tanggal
l

HASIL PEMERIKSAAN LABORATORIUM:

Pemeriksaan Nilai normal Tanggal Tanggal Tangga Tanggal Tanggal
l
HASIL PEMERIKSAAN DIAGNOSTIK:
____________________________________________________________________________
____________________________________________________________________________
__________________

HASIL PEMERIKSAAN MIKROBIOLOGI:

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____________________________________________________________________________
__________________

DIAGNOSIS:
____________________________________________________________________________
____________________________________________________________________________
__________________

PENGGUNAAN OBAT SAAT INI:

Nama Obat Regimen Indikasi

PEMANTAUAN (S.O.A.P)