Sensus Harian Kejadian Di Ruang Apotik ( Audit).docx
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SENSUS HARIAN INDIKATOR AREA KEJADIAN TIDAK DIHARAPKAN BULAN……………………….TAHUN………………… RUANG APOTIK ………………………. INSIDEN SERIUS AKIBAT EFEK SAMPING OBAT (KTD 2) NO
INSIDEN
NAMA PASIEN
NO.RM
TANGGAL/JAM
NAMA OBAT YANG
JENIS REAKSI
TINDAK
MENIMBULKAN EFEK
EFEK SAMPING
LANJUT
6
7
EVALUASI
KET
8
9
SAMPING 1
2
3
4
5
1. 2. 3. 4. 5. VERIFIKASI :
Kepala Instalasi
(
)
(
Kepala Ruangan
)
(
PIC
)
INSIDEN
NAMA PASIEN
NO.RM
TANGGAL/JAM
NAMA OBAT YANG
JENIS REAKSI
TINDAK
MENIMBULKAN EFEK
EFEK SAMPING
LANJUT
6
7
EVALUASI
KET
8
9
SAMPING 1
2
3
4
5
1. 2. 3. 4. 5. VERIFIKASI :
Kepala Instalasi
(
)
(
Kepala Ruangan
)
(
PIC
)
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