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PEMANTAUAN TERAPI OBAT (PTO)

FARMASI UPT Puskesmas


Sanankulon

No. RM :................................................ DPJP :..........................................


Nama Pasien :................................................ Bangsal :..........................................
Jenis Kelamin :................................................ Riwayat Penyakit :..........................................
Tgl Lahir/umur :................................................ TB/BB :.........................................
Diagnosis ................................................. Alergi Obat :..........................................
KELUHAN pasien Tanggal 
SUBYEKTIF (S)

Vital Sign Nilai Normal


Tekanan Darah 120 /80 mmHg
Nadi 60-100 x/mnt
Respirasi 16-20 x/mnt
Suhu Badan 36,5-37 oC
Hasil Laboratorium Nilai Normal
OBYEKTIF (O )

Terapi (Nama Obat, Aturan Pakai


Dosis,rute)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10
ASESSMEN (A)
PLAN (P)

Apoteker :

(………………………………………….)

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