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İY.FR.012 - ECZANEYE SOĞUK ZİNCİRE TABİİ İLAÇ TESLİM FORMU

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Demo Hastanesi (Prokalite.Com) ECZANEYE SOĞUK ZİNCİRE TABİİ İLAÇ TESLİM FORMU

Doküman Kodu: İY.FR.012

Yayın Tarihi: 18.01.2017

Revizyon Tarihi: 18.02.2022

Revizyon No: 2

Sayfa: Otomatik

İLAÇ SEVK TAKİP TARİHLERİ	İLAÇ İSMİ/MİKTARI	SOĞUK ZİNCİRİN KIRILMADIĞI KANITI
İLAÇ SEVK TAKİP TARİHLERİ	İLAÇ İSMİ/MİKTARI	DATA LOGGER	İNDİKATÖR
İlaç firmadan çıkış tarih/Saat;
	………………………………………………………………………………….

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Eczaneye teslim Tarih/Saat;
Eczaneye teslim Tarih/Saat;		*Data logger gibi dijital derecelerle gelen ilaçlar çıkış anından itibaren kayıtları alınmalı ve elektronik ortamda bir nüshası saklanmalıdır.

……………………………………………………………….... firmasından eczanemize teslim edilen soğuk zincire tabi yukarıda isim ve miktarları belirli ilaçların soğuk zincire uygunluğu /uygunsuzluğu tarafımızca tespit edilmiştir.

□ Soğuk Zincir Kırılmamıştır

□ Soğuk Zincir Kırılmıştır

					ECZANE SORUMLUSU/ECZANE DEPO GÖREVLİSİ

					AD SOYAD/İMZA

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			<td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><span style="font-size:18px"><span style="color:black">İLAÇ SEVK TAKİP TARİHLERİ</span></span></td>
			<td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><span style="font-size:18px"><span style="color:black">İLAÇ İSMİ/MİKTARI</span></span></td>
			<td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle"><span style="font-size:18px"><span style="color:black">SOĞUK ZİNCİRİN KIRILMADIĞI KANITI</span></span></td>
			<td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:middle"> </td>
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			<td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">DATA LOGGER</span></span></td>
			<td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">İNDİKATÖR</span></span></td>
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			<td rowspan="18" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">İlaç firmadan çıkış tarih/Saat;</span></span></td>
			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
			<td rowspan="19" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
			<td rowspan="19" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
			<td rowspan="18" style="border-bottom:none; border-left:1px solid black; border-right:none; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">………………………………………………………………………………….</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">………………………………………………………………………………….</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">………………………………………………………………………………….</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">………………………………………………………………………………….</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">………………………………………………………………………………….</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">………………………………………………………………………………….</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">………………………………………………………………………………….</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">………………………………………………………………………………….</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">………………………………………………………………………………….</span></span></td>
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			<td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">Eczaneye teslim Tarih/Saat;</span></span></td>
			<td style="border-bottom:none; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
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			<td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black"> </span></span></td>
			<td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><span style="font-size:18px"><span style="color:black">*<span style="color:black">Data logger gibi dijital derecelerle gelen ilaçlar çıkış anından itibaren kayıtları alınmalı ve elektronik ortamda bir nüshası saklanmalıdır.</span></span></span></td>
			<td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:middle"> </td>
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<p><span style="font-size:18px"> </span></p>

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			<td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">……………………………………………………………….... firmasından eczanemize teslim edilen soğuk zincire tabi yukarıda isim ve miktarları belirli ilaçların soğuk zincire uygunluğu /uygunsuzluğu tarafımızca tespit edilmiştir.</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">□ Soğuk Zincir Kırılmamıştır</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:middle"><span style="font-size:18px"><span style="color:black">□ Soğuk Zincir Kırılmıştır</span></span></td>
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	</tbody>
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<p><span style="font-size:18px"> </span></p>

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			<td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><span style="font-size:18px">                                                     </span></td>
			<td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><span style="font-size:18px"><span style="color:black">ECZANE SORUMLUSU/ECZANE DEPO GÖREVLİSİ</span></span></td>
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			<td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><span style="font-size:18px">                 </span></td>
			<td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"> </td>
			<td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><span style="font-size:18px"><span style="color:black">                   AD SOYAD/İMZA</span></span></td>
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