Form Monitoring

 

PEMERINTAH KOTA PALEMBANG DINAS KESEHATAN

PUSKESMAS 1 ULU Jalan H. Faqih Usman No. 2329 Palembang, Provinsi Sumatera Selatan Selatan Telepon : (0711) 511497 Kode pos 30257 E-mail : [email protected] : [email protected]

FORM MONITORING TINDAKAN ANESTESI DAN BEDAH

Nama Pasien Umur Jenis Kelamin  Alamat

: : : :

............................ ........................................ ................. ..... ........... th L/P ......................... ........................................ .................... .....

Tanggal : .................... .................... No. RM : .................... ....................

ANESTESI Pre Anestesi

Gcs :........... TD :............

Durante Anestesi

Tindakan:

N :............ RR :............ Tax:............. Nyeri: + / Lain-lain:

Post Anestesi

Gcs :........... :.......... . TD :............ N :............ RR :............ Tax:............. Nyeri: + / Lain-lain:

PEMBEDAHAN

Pre Pembedahan Tindakan:

Durante Pembedahan

Post Pembedahan

Petugas

..............................