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Nama Pasien : ______________________________L/P

Tanggal Lahir : ________________/Usia : ________Th


Monitoring pd Anestesi Lokal No. RM : _______________No Registrasi :______
Ruang Rawat / Kelas : _________________________________
Alamat : _________________________________
(Tempelkan Stiker Identitas Pasien)

FORMULIR PEMANTAUAN ANESTESI LOKAL


Jam mulai sedasi :
Tanggal :
Dosis Vital Sign TIME
No
Nama Obat yang RR HR TD 5' 10' 15' 20' 25' 30' 35' 40' 45' 50' 55' 60'
diberikan I II III
(o) () S(V) D(^)
8 220 220
10 200 200
12 180 180
14 160 160
16 140 140
18 120 120
20 100 100
22 80 80
24 60 60
26 40 40
28 20
Saturasi O2 :
Kesadaran :
Jam Selesai Operasi :
Perawat Anestesi DOKTER ANESTESI

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Monitoring
pd Operasi dgn Anestesi Lokal

MONITORING SEDASI RINGAN DAN LOKAL ANESTESI


Tanggal Jenis tindakan medis
LABEL PASIEN Ruang / Poliklinik Jenis sedasi / anstesi
Nama Pasien : ____________________________________
Diagnosa DPJP / Operator
Tgl. Lahir/Jenis Kel. : ____________________________________
No. RM : ____________________________________
Keadaan sebelum tindakan TD : mm/hg Nadi
Alamat : ____________________________________

(Harap diisi atau menempelkan stiker bila ada) Kesadaran Suhu : C RR

Jam mulai : Jam Selesai : Hb : mg / dl


jam
200

: sistole 180
: diastol
x : nadi 160

140

120

100

80

60
40

20

0
RR / obat
Komplikasi /temuan Tanda tangan operator

Kode RM : 2014 03 3 43 01
RINGAN DAN LOKAL ANESTESI

:
X / menit
: X / menit
Tanda tangan operator
Lap Operasi LAPORAN OPERASI Nama Pasien :
1/2 No. Rekam Medis :

Tanggal Lahir :
Jenis Kelamin : Lk Pr
Tanggal Operasi : Mulai Jam : Selesai Jam : Lama Operasi :
Dokter Ahli Bedah, Asisten, Perawat,

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Nama dan tanda tangan Nama dan tanda tangan Nama dan tanda tangan
Diagnosis Pra Bedah : ............................................................................................ Jenis Operasi :
.......................................................................................................................................... Kecil Sedang Besar Khusus
.......................................................................................................................................... Bersih Bersih Terkontaminasi
.......................................................................................................................................... Terkontaminasi Kotor
.......................................................................................................................................... Cito Elektif
.......................................................................................................................................... Anestasi
.......................................................................................................................................... Umum Regional Lokal
Diagnosis Pasca Bedah : ................................................................................................................................................................................................

LAPORAN OPERASI
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Tindakan Bedah : 1. ............................................................................................................................................................................................
2. ............................................................................................................................................................................................
3. ............................................................................................................................................................................................
4. ............................................................................................................................................................................................
Ahli Anestesi Obat Anestesi : Jumlah Perdarahan Kamar Operasi
1 2 3 4 5 6 7 8
Uraian Pembedahan
(uraian mulai dari bagian tubuh yang dioperasi, cara, penemuan-penemuan, tindakan yang dilakukan, eksplorasi yang dilakukan, drain yang digunakan, indikasi dan tindakan,
macamdan cara jahitan dengan lengkap dan jelas)
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Jaringan yang dikirim ke Histopatologi : Ahli Bedah
Ya Tidak
Macam Jaringan :
( ......................................................................)
Nama dan tanda tangan
Lanjutan Uraian Pembedahan
(uraian dimulai dari bagian tubuh yang dioperasi, cara, penemuan-penemuan, tindakan yang dilakukan, eksplorasi yang dilakukan dan tindakan, macam dan cara jahitan dengan lengkap dan
jelas)

Lap Operasi ................................................................................................................................................................................................................


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Ahli Bedah

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Nama dan tanda tangan