NAMA : ...................................................... (L/P)

UMUR : ......................................................

BAGIAN / KAMAR: ...................................................... NO RM :..........................................................

LEMBAR OBSERVASIALERGI

TANGGAL

HARI PERAWATAN

TNSRP

250 160 41 50 10200 140 40 40 8150 120 39 30 6100 100 38 20 4 50 80 37 10 2 0 60 36 0 0

PERDARAHAN

LABORATORIUM

RADIOLOGI

USG

EKG

TINDAKAN

TERAPI O2

IV CATH/ NGT / F.CATH

OBAT INJEKSI

OBAT ORAL

INTRA DERMAL

SUPOSITORIA

LAIN-LAIN