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Alergi (Reaksi Obat) _______________________________________________________________
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Hasil Laboratorium ________________________________________________________________
Belum selesai _______________________________________________________________
(Pending) ________________________________________________________________
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Diet: _______________________________________________________________
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Instruksi/Anjuran ________________________________________________________________
Dan Edukasi _______________________________________________________________
(Follow Up): _______________________________________________________________
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Terapi Pulang:
Nama Obat Jumlah Dosis Frekuensi Cara Pemberian
Jakarta,
Dokter Penanggung Jawab Pelayanan
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Tanda Tangan
Lembar 1: Pasien
Lembar 2: Rekam Medis