REFFERALL LETTER

PATIENT’S DATA VITAL SIGN

Nama/Usia : SpO2/Heart rate :
Alamat : Tekanan darah :
No. Telepon : Gula Darah (Puasa/Acak/2JPP) :
Alergi : Kolesterol :
Asam Urat :
ASSESSMENT
1. AVPU (Alert – Verbal – Pain – Unresponse) :
Jika UNRESPONSIVE/UNCONSCIOUS (Pingsan/Tidak sadar), Lakukan CABD dan Rujuk Dokter/RS segera
2. FAST (Face – Arms – Speech – Time) :
Jika menunjukkan gejala stroke berdasarkan FAST, hitung ABCD2
3. ABCD2 (Age – BP – Clinical Feature – Duration – Diabetes) Score 0 – 7 :
Jika score > 3, Rujuk Dokter/RS segera
4. SAMPLE OPQRST : RECOMMENDATION
● Sign and Symptom : Apa yang sudah apoteker lakukan?

➢ Onset :
➢ Provocation :

➢ Quality :
➢ Region/Radiating :
➢ Severity : FOLLOW-UP SCHEDULE
➢ Time :
● Medication History
FOLLOW-UP PLAN

● Medical History

● Family History
FOLLOW-UP RESULT
● Social History

● Last Meal

● Event

● Doctor’s Note to Pharmacist :