Date Patient. No.

Patient's Name Patient's INP Physician's Name

244.03.24 Yara Kacho 623449 reva matta

 CPU Preparation L

Diagnostic TPP Start Time End Time Signature

 CPU Preparation Log Form

Drugs, diluents and acc

Prescription
Drug Batch No. Qty
Etoposide 200mg/500cc NS0.9% Etopex 100mg 2
 Drugs, diluents and accessories used
Remaining Qty Protector Injector Serum Remaining Qty
2 1 Sodium Chloride 0.9% 500cc
2 1
 Surplus Pharmacist
Surplus
Qty Review

PHA-Trial
May-22
Physican Name TTP
Dany Gholam Army
Elie Bechara COOP
Georges Hachem INS
Joseph Makdessi MOH
Mirna Hajj N+I
Mounir Khoury N+P
Nabil Chamseddine NSSF
Peter Noun N+Self
Sec
Self
Sec+Self
Serums
Dextrose In Water 5% 50 cc
Dextrose In Water 5% 100 cc
Dextrose In Water 5% 250cc
Dextrose In Water 5% 250cc (NPVC)
Dextrose In Water 5% 500cc
Dextrose In Water 5% 500cc (NPVC)
Dextrose In Water 5% 1000cc
Sodium Chloride 0.45% 500cc
Sodium Chloride 0.9% 50cc
Sodium Chloride 0.9% 100cc
Sodium Chloride 0.9% 250cc
Sodium Chloride 0.9% 250cc (NPVC)
Sodium Chloride 0.9% 500cc
Sodium Chloride 0.9% 500cc (NPVC)
Sodium Chloride 0.9% 1000cc
Baxter 2 Days