No.................

PROTOKOL TERAPI OBAT SITOSTATIKADiberikan kepada :Nama Pasien : .............................................................................................................. Umur ............... Tahun ............. Bulan ............Diagnosa : .............................................................................................................................................Pemberian Obat Sitostatika : ................................................................................................................ Kali, tiap .................... MingguResep yang diberikan : ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Dokter Pemeriksa

JADWAL PEMBERIAN OBAT SITOSTATIKANAMAOBATBULANMINGGU, TGL, PARAFBULANMINGGU, TGL, PARAFBULANMINGGU, TGL, PARAF

IIIIIIIVVIIIIIIIVVIIIIIIIVV

NAMAOBATBULANMINGGU, TGL, PARAFBULANMINGGU, TGL, PARAFBULANMINGGU, TGL, PARAF

IIIIIIIVVIIIIIIIVVIIIIIIIVV

Catatan :