PEMANTAUAN TERAPI OBAT

RIWAYAT KELUARGA :______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RIWAYAT PENGGUNAAN OBAT :

DATA PASIEN

Nama : (L/P). Tgl. Lahir : BB: kg. TB:

Alamat :

No. Telp: Tgl Masuk Rs: Ruang Rawat :

KELUHAN UTAMA :

RIWAYAT PENYAKIT SEKARANG:

RIWAYAT PENYAKIT TERDAHULU:

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HASIL PEMERIKSAAN DIAGNOSTIK :_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HASIL PEMERIKSAAN MIKROBIOLOGI :________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DIAGNOSIS :____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________