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İY.FR.001 - İLAÇ KIRILMA VE KAYIP OLAY FORMU (ECZANE)

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Demo Hastanesi (Prokalite.Com) İLAÇ KIRILMA VE KAYIP OLAY FORMU (ECZANE)

Doküman Kodu: İY.FR.001

Yayın Tarihi: 07.04.2016

Revizyon Tarihi: 18.02.2022

Revizyon No: 2

Sayfa: Otomatik

İLAÇ KIRILMA ve KAYIP OLAY FORMU (ECZANE İÇİN)
OLAYIN GERÇEKLEŞTİĞİ KLİNİĞİN ADI:	TARİH: / / SAAT:
İLACIN JENERİK ADI/FORM ŞEKLİ:
İLACIN MİKTARI:
OLAYIN GERÇEKLEŞME NEDENİ:
OLAYIN GERÇEKLEŞME NEDENİ:
KAYIP [ ]
KIRILMA [ ]
OLAYIN NASIL GERÇEKLEŞTİĞİNİN AÇIKLAMASI
OLAYA TANIK OLAN KİŞİ [ ] VAR [ ] YOK
OLAYI GÖREN KİŞİ/KİŞİLER ADI SOYADI	İMZA
1-
2-
3-
OLAYI/DURUMU TESPİT EDEN KİŞİ/KİŞİLER ADI-SOYADI-GÖREVİ	İMZA
1-
2-
3-
ONAYLAYAN KİŞİLER	İMZA
SORUMLU ECZACI
ECZANEDEN SORUMLU BAŞHEKİM YRD

<meta charset="utf-8"/>
<table style="border-collapse: collapse; width: 882px;" class=" cke_show_border" cellspacing="0"><tbody><tr><td colspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:top"><span style="font-size:15px"><strong><span style="color:black">İLAÇ KIRILMA ve KAYIP OLAY FORMU (ECZANE İÇİN)</span></strong></span></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><span style="font-size:15px"><strong><span style="color:black">OLAYIN GERÇEKLEŞTİĞİ KLİNİĞİN ADI:</span></strong></span></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; vertical-align: top; width: 262px;"><span style="font-size:15px"><span style="color:black">TARİH: / / SAAT:</span></span></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><span style="font-size:15px"><strong><span style="color:black">İLACIN JENERİK ADI/FORM ŞEKLİ:</span></strong></span><br></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; vertical-align: top; width: 262px;"><br></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><span style="font-size:15px"><strong><span style="color:black">İLACIN MİKTARI:</span></strong></span><br></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; vertical-align: top; width: 262px;"><br></td></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><p><span style="font-size:15px"><strong><span style="color:black">OLAYIN GERÇEKLEŞME NEDENİ:</span></strong></span><br></p></td><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 262px;"><br></td></tr><tr></tr><tr><td colspan="2" style="border-bottom:none; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:top"><span style="font-size:15px"><strong><span style="color:black">KAYIP [ ] </span></strong></span></td></tr><tr><td colspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:top"><span style="font-size:15px"><strong><span style="color:black">KIRILMA [ ] </span></strong></span></td></tr><tr><td colspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:top"><p><span style="font-size:15px"><strong><span style="color:black">OLAYIN NASIL GERÇEKLEŞTİĞİNİN AÇIKLAMASI</span></strong></span></p><p><br></p><p><br></p></td></tr><tr><td colspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:top"><span style="font-size:15px"><strong><span style="color:black">OLAYA TANIK OLAN KİŞİ [ ] VAR [ ] YOK </span></strong></span></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><span style="font-size:15px"><strong><span style="color:black">OLAYI GÖREN KİŞİ/KİŞİLER ADI SOYADI</span></strong></span></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; text-align: center; vertical-align: top; width: 262px;"><span style="font-size:15px"><strong><span style="color:black">İMZA</span></strong></span></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><p><span style="font-size:15px"><strong><span style="color:black">1-</span></strong></span></p></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; text-align: center; vertical-align: top; width: 262px;"><br></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><p><span style="font-size:15px"><strong><span style="color:black">2-</span></strong></span></p></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; text-align: center; vertical-align: top; width: 262px;"><br></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><p><span style="font-size:15px"><strong><span style="color:black">3-</span></strong></span></p></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; text-align: center; vertical-align: top; width: 262px;"><br></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><span style="font-size:15px"><strong><span style="color:black">OLAYI/DURUMU TESPİT EDEN KİŞİ/KİŞİLER ADI-SOYADI-GÖREVİ</span></strong></span></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; text-align: center; vertical-align: top; width: 262px;"><span style="font-size:15px"><strong><span style="color:black">İMZA</span></strong></span></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><p><span style="font-size:15px"><strong><span style="color:black">1-</span></strong></span></p></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; text-align: center; vertical-align: top; width: 262px;"><br></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><p><span style="font-size:15px"><strong><span style="color:black">2-</span></strong></span></p></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; text-align: center; vertical-align: top; width: 262px;"><br></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><p><span style="font-size:15px"><strong><span style="color:black">3-</span></strong></span></p></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; text-align: center; vertical-align: top; width: 262px;"><br></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><span style="font-size:15px"><strong><span style="color:black">ONAYLAYAN KİŞİLER</span></strong></span></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; text-align: center; vertical-align: top; width: 262px;"><span style="font-size:15px"><strong><span style="color:black">İMZA</span></strong></span></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><p><span style="font-size:15px"><strong><span style="color:black">SORUMLU ECZACI</span></strong></span></p></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; vertical-align: top; width: 262px;"><br></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid; border-width: medium 1px 1px; vertical-align: top; width: 612px;"><p><span style="font-size:15px"><strong><span style="color:black">ECZANEDEN SORUMLU BAŞHEKİM YRD</span></strong></span></p></td><td style="border-color: currentcolor black black currentcolor; border-style: none solid solid none; border-width: medium 1px 1px medium; vertical-align: top; width: 262px;"><br></td></tr></tbody></table>