Formulir Monitoring Efek Samping Obat Apotek Laskar [PDF]

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APOTEK LASKAR



JL. Raya Ciamis-Banjar Ds Cisaga Kec. Cisaga Kab. Ciamis



FORMULIR MONITORING EFEK SAMPING OBAT (MESO) Nama Apotek Alamat Kabupaten/Kota Provinsi Triwulan/Tahun No



: APOTEK LASKAR : JL. Raya Ciamis-Banjar Ds Cisaga Kec. Cisaga : Kab. Ciamis : jawa barat :



Informasi pasien Nama/ Inisial Jenis pasien Kelam in



umur



Na ma Ob at



Informasi Obat Ben tuk No Bets Sedi aan



Obat yang digunakan bersamaan



Ca ra



Pemberian Dosis/ Tgl l Waktu Mulai



Tg l Akhir



Deskripsi



Tgl Mulai



KTD/ESO Tgl Akhir



Kesud ahan



Riwayat KTD/ESO yang pernah dialami



…….………….,...........20…....... Apoteker



(...........................................)



Nama Pelapor



APOTEK LASKAR



JL. Raya Ciamis-Banjar Ds Cisaga Kec. Cisaga Kab. Ciamis



DOKUMENTASI PEMANTAUAN TERAPI OBAT Nama Pasien Jenis Kelamin Umur Alamat No. Telepon No



Tanggal



: ............................................................................................................................... : ............................................................................................................................... : ............................................................................................................................... : ............................................................................................................................... : ............................................................................................................................... Catatan Pengobatan Pasien



Nama Obat, Dosis, Cara Pemberian



Identifikasi Masalah terkait Obat



Rekomendasi/ Tindak Lanjut



Riwayat penyakit



Riwayat penggunaan obat



Riwayat alergi



…….………….,...........20............… Apoteker



(...........................................)



APOTEK LASKAR



JL. Raya Ciamis-Banjar Ds Cisaga Kec. Cisaga Kab. Ciamis



DOKUMENTASI PELAYANAN KEFARMASIAN DI RUMAH (HOME PHARMACY CARE) Nama Pasien Jenis Kelamin Umur Alamat No. Telepon No



: ............................................................................................................................... : ............................................................................................................................... : ............................................................................................................................... : ............................................................................................................................... : ...............................................................................................................................



Tanggal kunjungan



Catatan Pelayanan Apoteker



…….………….,...........20......… Apoteker



(...........................................)



APOTEK LASKAR



JL. Raya Ciamis-Banjar Ds Cisaga Kec. Cisaga Kab. Ciamis



DOKUMENTASI KONSELING Nama Pasien Jenis Kelamin Umur Alamat No. Telepon



: ............................................................................................................................... : ............................................................................................................................... : ............................................................................................................................... : ............................................................................................................................... : ...............................................................................................................................



Tanggal konseling : Nama Dokter : Diagnosa : Nama obat, dosis dan cara pemakaian :



Riwayat alergi : Keluhan :



Pasien pernah datang konseling sebelumnya: : Tindak lanjut



Ya



/



tidak



Pasien



…….………….,...............................20.....… Apoteker



(...........................................)



(..................................................)



APOTEK LASKAR



JL. Raya Ciamis-Banjar Ds Cisaga Kec. Cisaga Kab. Ciamis



DOKUMENTASI PELAYANAN INFORMASI OBAT



APOTEK LASKAR



JL. Raya Ciamis-Banjar Ds Cisaga Kec. Cisaga Kab. Ciamis



CATATAN PENGOBATAN PASIEN Nama Pasien Jenis Kelamin Umur Alamat No. Telepon No



: ............................................................................................................................... : ............................................................................................................................... : ............................................................................................................................... : ............................................................................................................................... : ............................................................................................................................... Tanggal



Nama Dokter



Nama Obat / Dosis / Cara Pemberian



Catatan Pelayanan Apoteker



…….………….,...............................20…..... Apoteker



(..................................................)



ETIKET



APOTEK LASKAR



JL. Raya Ciamis-Banjar Ds Cisaga Kec. Cisaga Kab. Ciamis APOTEKER : Apt. Rizki mulia Insani S.Farm



NO : ...................



TGL : ..............................



APOTEK LASKAR



JL. Raya Ciamis-Banjar Ds Cisaga Kec. Cisaga Kab. Ciamis APOTEKER : Apt. Rizki mulia Insani S.Farm



NO : ...................



TGL : ..............................



Nam a Pasien : ..................................................................................... Bungkus / kapsul /tablet Aturan pakai : ........ X sehari ...............ml / tetes sendok obat / sendok makan ............ sebelum / sesudah makan Nama obat : ......................................................................................... Jumlah : ......................................................Ed ..............................