PEMERINTAH KABUPATEN SERANG

DINAS KESEHATAN
UPT PUSKESMAS KECAMATAN JAWILAN
Jl. Raya Cikande – Rangkas Bitung Km. 10

FORMULIR MONITORING FISIOLOGIS PASIEN SELAMA

ANESTESI/SEDASI
Nama Pasien : .................................................
Umur : .................................................
Jenis Kelamin : .................................................
Diagnosa : .................................................
Poli : .................................................
Dokter Pelaksana / Pengawas : .................................................
Nama Perawat Pelaksana : .................................................
Jenis Anestesi/Sedasi : .................................................
Jam Mulai Anestesi/Sedasi : .................................................
Jam Mulai Tindakan : .................................................

Jam Selesai Tindakan : ...................................................

Keadaan umum pasien : ...................................................

Kesadaran : ...................................................
Riwayat Penyakit Terdahulu : ...................................................
Riwayat Allergi : ...................................................

MONITORING TANDA-TANDA VITAL

TD HR RR
Jam Keterangan
Mm Hg Kali / mnt Kali / mnt