Alergi (Reaksi Obat) ______________________________________________________________ ______________________________________________________________ Hasil Laboratorium ______________________________________________________________ Belum selesai ______________________________________________________________ (Pending) ______________________________________________________________ ______________________________________________________________ Diet: ______________________________________________________________ ______________________________________________________________ Instruksi/Anjuran ______________________________________________________________ Dan Edukasi _____________________________________________________________ (Follow Up) : _____________________________________________________________ ______________________________________________________________ ______________________________________________________________ Kondisi Waktu Keluar: Sembuh Rujuk RS Meninggal Lain – lain ___________________________________________________________________ Pengobatan Dilanjutkan: Poliklinik Rumah Sakit Puskesmas lain Dokter Spesialis Lain – lain ____________________________________________________________________ Terapi Pulang:
Nama Obat
Jumlah
Dosis
Frekuensi
Cara Pemberian
Pilangkenceng, Dokter Penanggung Jawab Pelayanan
____________________________ Tanda Tangan Lembar 1: Pasien