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  • Form PIO 2022

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    Putu Oka Suartama
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    This document is a request form for drug information from the Pharmacy Installation of RS BaliMed Karangasem Hospital. It requests information from pharmacists about a patient's condition, including age, pregnancy status, kidney and liver function, and culture results. The requester can select the type of information needed, such as indications, dosing, interactions, or regulations. Pharmacists will provide a written response with references to support the answers.

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    form PIO 2022

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    This document is a request form for drug information from the Pharmacy Installation of RS BaliMed Karangasem Hospital. It requests information from pharmacists about a patient's condition, including age, pregnancy status, kidney and liver function, and culture results. The requester can select the type of information needed, such as indications, dosing, interactions, or regulations. Pharmacists will provide a written response with references to support the answers.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    2 views1 page

    Form PIO 2022

    Uploaded by

    Putu Oka Suartama
    This document is a request form for drug information from the Pharmacy Installation of RS BaliMed Karangasem Hospital. It requests information from pharmacists about a patient's condition, including age, pregnancy status, kidney and liver function, and culture results. The requester can select the type of information needed, such as indications, dosing, interactions, or regulations. Pharmacists will provide a written response with references to support the answers.

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    © All Rights Reserved
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    of 1

    PELAYANAN INFORMASI OBAT

    Instalasi Farmasi – Panitia Medik Farmasi dan Terapi RS BaliMed Karangasem


    Jl. Nenas, Kecicang, Bebandem, Karangasem
    Telp. (0363) 4301618
    email : farmasiRSBMK@gmail.com

    Permohonan No. () : Tanggal : / / Jam : BBWI


    Pemohon :  Dokter Keperawatan
    Farmasis Asisten Apoteker
    Lain – lain
    Nama Pemohon :
    Unit Kerja : Telp.

    Uraian Permohonan :

    Latar Belakang Permohonan :

    Kondisi Klinis Pasien : Usia : Hamil / Menyusui :


    Fungsi ginjal : Fungsi hati :
    Hasil kultur :
    Jenis Permohonan :
    Indikasi Harga Obat Lama pemberian Perhitungan Farmasi
    Farmakoterapi Dosis Stabilitas Identifikasi
    Farmakologi Frekuensi pemberian Interaksi obat Ketersediaan obat
    Farmakokinetik Saat Pemberian Kompabilitas Perundang-undangan
    Farmakodinamik Cara pemberian ESO Lain-lain

    Referensi () :

    Jawaban () :

    Jawaban diberikan oleh () :


    ()
    Tanggal : / / Jam : BBWI ()
    ()
    Catatan : = Diisi oleh tim PIO

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