BLANKO PEMAKAIAN OBAT DAN BHP FARMASI

PASIEN OPERASI OK CENTRAL

NAMA PASIEN : ......................................................

HARI/TGL OPERASI : ......................................................

NO. MR : ......................................................

ALAMAT : ......................................................

NAMA DPJP : ......................................................

TINDAKAN OPERASI : ......................................................

JENIS ANESTESI : ......................................................

NO. NAMA BARANG PERMINTAAN PEMAKAIAN SISA KET.

1 BUNASCAN
2 SPINOCAN NO.
3 DEXAMETHASON
4 RANITIDINE
5 KETOROLAC
6 ONDANCENTRON
7 TRAMADOL
8 ETT NO.
9 LMA NO.
10 FRESOFOL
11 METHERGIN
12 OXYTOCIN
13 RINGER LACTAT
14 NACL
15 LIDOCAIN
16 HEPARIN
17 KETAMINE
18 BELNIUM
19 PROTOFEN
20 ASAM TRANEXAMAT
21 CDL
22 EPHEDRIN
23 MIDAZOLAM
24 FENTANIL
25 HANDSCOOND NO.
26 VIT K
27 NEOSTIGMIN
28 ATROPIN SULFATE
29 NALOXON
30

Pariaman, .....................
Yang menerima
Petugas anestesi

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NO. NAMA BARANG PERMINTAAN PEMAKAIAN SISA KET.