Form Formulir Pra Anestesi Dan Sedasi Diisi Dokter
Form Formulir Pra Anestesi Dan Sedasi Diisi Dokter
PEMERIKSAAN FISIK
Tekanan darah: _____mmHg Nadi: ____kali/menit Suhu: ___°C RR:____ kali/menit
Tinggi : ____cm Berat : ____k
KEADAAN UMUM
Skor Mallampati:______________________________________ Gigi palsu : ______________
Jantung: ______________________________________________________________________
Paru-paru: ____________________________________________________________________
Abdomen : ____________________________________________________________________
Tulang belakang: _______________________________________________________________
Ekstremitas : __________________________________________________________________
Neurologi (bila dapat diperiksa) : __________________________________________________
Keterangan:_____________________________________________________________________________
______________________________________________________________________________
Alat khusus :
Bronchoscopy
Glidescope
USG
Lain-lain: ___________________________________________________________________
Perawatan pasca anestesia :
Rawat inap
Rawat jalan
Rawat khusus : ICU ICCU HCU PICU Lain-lain : ________________
( dr. ……………………………)