Tabel Monitoring Pengobatan Sendiri

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BUKTI MONITORING TERHADAP PENGOBATAN OLEH PASIEN SENDIRI

MONITORING PENGOBATAN SENDIRI DI RUANG PERAWATAN

RS PANTI WALUYO PURWOREJO

Ruang : Diagnosa : No

No

Tgl/ hari : Pagi Siang P Px P Px

Nama Obat

Jumlah Aturan Pakai

Nama Obat

Tgl/ hari : Siang Jumlah Aturan Pakai Pagi P Px P Px

Keterangan : P : Paraf Perawat

Px : Paraf Pasien

Kelas : Dokter : Riwayat Alergi : Tidak / Ya …………………………………………… Tgl/ hari : Tgl/ hari : Sore Malam Pagi Siang Sore Malam Pagi Siang P Px P Px P Px P Px P Px P Px P Px P Px

Sore Malam P Px P Px

Tgl/ hari : Pagi Siang P Px P Px

Sore Malam P Px P Px

Tgl/ hari : Pagi Siang P Px P Px

Sore Malam P Px P Px

Sore Malam P Px P Px

Pagi : jam 06.00 - 07.00 Sore : jam 20.00 - 21.00

Siang : jam 12.00 - 13.00 Malam : jam 22.00 - 23.00

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