Jl.

Pulau Putri Raya Perumahan Moderland

Kelurahan Kelapa Indah Kecamatan
Tangerang
Telp.: 021 2972 0201, 021 2972 0202

CATATAN ANASTESI Tempat Tindakan Dilakukan :   OK

Dokter Anestesi : Operator
Asisten : Asisten
Diagnostik Pra Tindakan : Diagnostik Pasca Tindakan

STATUS FISIK ASA : 1 / 2 /3 / 4 / 5 / 6 / E LOKASI

Karena : IV Line :

Assesmen Pra Induksi Arteri Line :

TD : HR : RR : BB:
CVP :
INDUKSI VENTILASI
Spontan Komtrol
Pressure Volume Control
VT......Paw..... PS.......BOR........
JENIS ANESTESI TEKNIK ANESTESI
SEDASI (RINGAN / SEDANG / BERAT)
REGIONAL SAB EA CSE PNB
GENERAL *ETT................
*LMA..............
*TRACHEA CANULE...........
JAM :
O2 / N2O / AIR.................
SPO2 / ETCO2
AGEN VOLATILE
........................................
........................................
TEMPERATUR :
ID
220

200

180
ERNAPASAN

160
IASTOLIK
ISTOLIK

NADI
  SISTO

 NAD
PER
 DIAS
140

0
120

100

80
AKHIR ANASTESI
AWAL ANASTESI

AKHIR BEDAH
AWAL BEDAH

60

40





20

0
POSISI PASIEN
PERDARAHAN
URINE
NGT
Beri tanda P pada jawaban yang dipilih
 PEMANTAUAN ANESTESI / SEDASI
ICU Endoscopy Radiologi Lain-lain.........
Tindakan:

Lama Operasi:

JENIS OBAT-OBATAN
1 ...................................................................................
2 ...................................................................................
3 ...................................................................................
4 ...................................................................................
5 ...................................................................................
6 ...................................................................................
SIMV 7 ...................................................................................
ntrol PEEP...... 8 ...................................................................................
........ 9 ...................................................................................
10 ...................................................................................
11 ...................................................................................
12 ...................................................................................
13 ...................................................................................
14 ...................................................................................
15 ...................................................................................
 :………………………………………Nama Lengkap
:………………………………………No. Rekam Medik
:………………………………………Tanggal Lahir
Jenis Kelamin :L/P
(Tempelkan stiker pasien jika tersedia )

Lama Anestesi

PREMEDIKSI

CAIRAN
1 ..........................................................................................
2 ..........................................................................................
3 ..........................................................................................
4 ..........................................................................................
5 ..........................................................................................
6 ..........................................................................................
7 ..........................................................................................
8 ..........................................................................................
9 ..........................................................................................
INPUT CAIRAN:
OUT PUT CAI :
BALANCE CAI:
 Jl. Pulau Putri Raya Perumahan Moderland
Kelurahan Kelapa Indah Kecamatan Tangerang
Telp.: 021 2972 0201, 021 2972 0202

Waktu tiba di Recovery Room :.............................................. WIB

CATATAN PASCA TINDAKAN (RECOVERY ROOM)
Jenis Tindakan Jenis Anestesi

220

200

180

160

140
 Diastole
˜ Nadi

120

100

80

60

40

20
Sistole
RR
 Sistole
RR


0

ALDERETE SCORE (BIUS UMUM) BROMAGE SCORE (SPINAL)

No Objek Kriteria Skor NO KRITERIA
Penilaian
1. Mampu menggerakan 4 anggota gerak
1 Aktifitas secara spontan/ sesuai perintah 2 1. Tidah ada blok, dapat melakukan fleksi pada kaki
2. Mampu menggerakan 2 anggota Blok parsial, cepat melakukan fleksi pada lutut, ta
gerak secara spontan 1 2. dapat mengangkat kedua tungkai dengan bebas
3. Belum bisa menggerakan anggota 0 Bila hampir lengkap, dapat melakukan fleksi pada
gerak secara spontan 3. tidak dapat fleksi pada lutut
2 Respirasi 1. Mampu bernafas dalam/batuk 2 4. Blok lengkap, tidak dapat melakukan gerakan oleh
2. Sesak 1 KetÆ Pasien dapat di pindah ke bangsal, jika score kura
3. Apnea 0
1.
Tekanan darah 20% dari tekanan darah STEWARD SCORE UNTUK P
3 Sirkulasi anestesi 2
2.
Tekanan darah 20%-50% dari tekanan TANDA KRI
darah anestesi 1
3.
Tekanan darah >50% dari tekanan Kesadaran 1. Bangun
darah pra anestesi 0
4 Kesadaran 1. Sadar penuh 2 2. Respon ter
2. Bila dipanggil/dibangunkan 1 3. Tidak ada r
3. Tidak 0 1. Batuk/ men
5 Warna kulit 1. Merah muda 2 Pernafasan 2. Pertahanka
2. Pucat Ikterus 1 3. Perlu bantu
3. Sianosis 0 1. Gerak bert
Ket : ● Pasien dapat di pindahkan ke bangsal, jika score minimal 8 pasien. Motorik 2. Gerak tanp
● Pasien di pindah ke ICU, jika score < 8 setelah di rawat selama 2 jam 3. Tidak berge
Ket Æ Score > 5 boleh keluar dari RR
 Waktu keluar di Recovery Room :.............................................. WIB
INSTRUKSI PASCA ANESTESI
nestesi/Anelgesia
Infus

Minum /makan obat

Analgetik

Antibiotika

Bila mual/muntah

Obat-obat lain

Posis Pasien

Pemantauan
 Instruksi lainnya

SCORE

0
da kaki dan lutut
utut, tapi belum 1
bebas
si pada kaki, tapi 2

an oleh kedua tungkai 3

re kurang dari 2

NTUK PASCA ANESTHESI ANAK

KRITERIA SCORE

pon terhadap ransang Nama &

k ada responj
k/ menangis
ahankan jalan nafas
u bantuan nafas
ak bertujuan
ak tanpa tujuan
k bergerak
dari RR
NESTESI

obat : Puasa sampai...............................................................................................................

Boleh minum bila........................................................................................................
Boleh makan bila........................................................................................................

: 1. .....................................................................................................................................................................
2. .....................................................................................................................................................................
3. .....................................................................................................................................................................
4. .....................................................................................................................................................................
5. .....................................................................................................................................................................

: Kesadaran, setiap..........................................., selama............................................

Tekanan darah, setiap...................................., selama............................................
Nadi, setiap....................................................., selama...........................................
Pernapasan, setiap........................................., selama...........................................
Suhu, setiap....................................................., selama...........................................
 :

Tangerang,.......................................
Dokter Anastesi, Perawat Anastesi

(................................................) (..........................................)
Nama & Tanda Tangan Nama & Tanda Tangan
 Jl. Pulau Putri Raya Perumahan Moderland
Kelurahan Kelapa Indah Kecamatan Tangerang
Telp.: 021 2972 0201, 021 2972 0202

CATATAN ANASTESI Tempat Tindakan Dilakukan :   OK

Dokter Anestes: Operator
Asisten : Asisten
Diagnostik Pra Tindakan : Diagnostik Pasca Tindakan

STATUS FISIK ASA : 1 / 2 /3 / 4 / 5 / 6 / E LOKASI

Karena : IV Line :

Assesmen Pra Induksi Arteri Line :

TD : HR : RR : BB:
CVP :
INDUKSI VENTILASI
Spontan Komtrol
Pressure Volume Control
VT......Paw..... PS.......BOR........
JENIS ANESTESI TEKNIK ANESTESI
SEDASI (RINGAN / SEDANG / BERAT)
REGIONAL SAB EA CSE PNB
GENERAL *ETT................
*LMA..............
*TRACHEA CANULE...........
JAM :
O2 / N2O / AIR.................
SPO2 / ETCO2
AGEN VOLATILE
........................................
........................................
TEMPERATUR :
ID
220

200
PERNAPASAN

180
 DIASTOLIK
 SISTOLIK

 NADI

160
0
 



0
140

120

100
AKHIR ANASTESI
AWAL ANASTESI

AKHIR BEDAH
AWAL BEDAH

80

60





40

20

0
POSISI PASIEN
PERDARAHAN
URINE
NGT
Beri tanda P pada jawaban yang dipilih
 :……

Jenis K
(Temp

PEMANTAUAN ANESTESI / SEDASI

ICU Endoscopy Radiologi Lain-lain.........
Tindakan:

Lama Operasi: Lama Anestesi

JENIS OBAT-OBATAN PREMEDIKSI

1 ...................................................................................
2 ...................................................................................
3 ...................................................................................
4 ...................................................................................
5 ...................................................................................
6 ................................................................................... CAIRAN
SIMV 7 ................................................................................... 1 ..................
ntrol PEEP...... 8 ................................................................................... 2 ..................
........ 9 ................................................................................... 3 ..................
10 ................................................................................... 4 ..................
11 ................................................................................... 5 ..................
12 ................................................................................... 6 ..................
13 ................................................................................... 7 ..................
14 ................................................................................... 8 ..................
15 ................................................................................... 9 ..................
INPUT CAIRAN
OUT PUT CAIRAN
BALANCE CAIRAN
 :………………………………………Nama Lengkap
:………………………………………No. Rekam Medik
:………………………………………Tanggal Lahir
Jenis Kelamin :L/P
(Tempelkan stiker pasien jika tersedia )

stesi

SI

...................................................................................
...................................................................................
...................................................................................
...................................................................................
...................................................................................
...................................................................................
...................................................................................
...................................................................................
...................................................................................
AN :
AIRAN :
AIRAN :
FORM-PMD-15-01