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    Form PTO

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    octie
    This document contains a patient monitoring form for drug therapy. It collects information such as the patient's name, age, address, chief complaints, medical history, family history, social history, physical examination findings, and laboratory results. The form also documents the patient's medication history including any issues related to their medications, allergies, and the appointed pharmacist's notes and recommendations for follow-up.

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    Form PTO

    Uploaded by

    octie
    66 views5 pages
    This document contains a patient monitoring form for drug therapy. It collects information such as the patient's name, age, address, chief complaints, medical history, family history, social history, physical examination findings, and laboratory results. The form also documents the patient's medication history including any issues related to their medications, allergies, and the appointed pharmacist's notes and recommendations for follow-up.

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    This document contains a patient monitoring form for drug therapy. It collects information such as the patient's name, age, address, chief complaints, medical history, family history, social history, physical examination findings, and laboratory results. The form also documents the patient's medication history including any issues related to their medications, allergies, and the appointed pharmacist's notes and recommendations for follow-up.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    66 views5 pages

    Form PTO

    Uploaded by

    octie
    This document contains a patient monitoring form for drug therapy. It collects information such as the patient's name, age, address, chief complaints, medical history, family history, social history, physical examination findings, and laboratory results. The form also documents the patient's medication history including any issues related to their medications, allergies, and the appointed pharmacist's notes and recommendations for follow-up.

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    of 5

    PEMANTAUAN TERAPI OBAT

    DATA PASIEN
    Nama : ………………………………………….. (L/P), Tgl. Lahir : ……………………… BB : …….kg

    Alamat:
    …………………………………………………………………………………………………………………………………………………………….

    No. Telp. : ………………………………………………………. Tgl. Masuk RS : ………………………… Ruang Rawat :………………………

    KELUHAN UTAMA :
    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………

    RIWAYAT PENYAKIT SEKARANG :


    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………

    RIWAYAT PENYAKIT TERDAHULU :


    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………

    RIWAYAT KELUARGA :
    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………

    RIWAYAT SOSIAL :
    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………

    RIWAYAT PENGGUNAAN OBAT :


    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………………………………………………………………………………………………

    HASIL PEMERIKSAAN FISIK :


    Pemeriksaan Nilai NormTgl. Tgl. Tgl. Tgl. Tgl.
    HASIL PEMERIKSAAN LABORATORIUM :
    TB : ……cm

    Ruang Rawat :………………………

    ……………………………………………………
    ……………………………………………………
    ……………………………………………………

    ……………………………………………………
    ……………………………………………………
    ……………………………………………………

    ……………………………………………………
    ……………………………………………………
    ……………………………………………………

    ……………………………………………………
    ……………………………………………………
    ……………………………………………………

    ……………………………………………………
    ……………………………………………………
    ……………………………………………………

    ……………………………………………………
    ……………………………………………………
    ……………………………………………………
    DOKUMENTASI PEMANTAUAN TERAPI OBAT
    Nama Pasien :
    Jenis Kelamin :
    Umur :
    Alamat :
    No. Telepon :

    Nama Obat, Dosis, Cara Identifikasi Masalah


    No Tanggal Catatan Pengobatan Pasien
    Pemberian terkait Obat
    Riwayat penyakit

    Riwayat penggunaan obat

    Riwayat Alergi

    Candi, 20
    Apoteker/TTK

    (……………………….)
    BAT

    Rekomendasi/Tindak
    Lanjut

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