CHECKLIST PEMBERIAN TERAPI OLEH DOKTER

Nama Pasien : ......................................................................................

Umur : ...................................................................... (L/P)

Alamat : .......................................................................................

Diagnosis : .......................................................................................

TERAPI

Jenis Terapi Nama Obat Aturan Pakai Jumlah Kesesuaian Terapi dengan Diagnosis

o Oralo Injeksi

i.m./i.v.o Suppositori

ao Topikal

1. .........................

2. .........................

3. .........................

4. ..........................

5. ..........................

6. ..........................

7. ..........................

1. ...........................

2. ...........................

3. ...........................

4. ...........................

5. ...........................

6. ...........................

7. ...........................

1. ........

2. ........

3. ........

4. ........

5. ........

6. ........

7. ........

Alasan:....................................................................................................................................................................................................................................................................................................

Keterangan: Alasan diisi jika ada ketidaksesuaian antara diagnosis dan terapi.

Ya

Tidak