Nama : ......................................................................

Rumah Sakit PMC No. RM

Tgl Lahir
: .....................................................................
: .....................................................................
PEKANBARU MEDICAL CENTER Jenis Kelamin : .....................................................................
Jl. Lembaga Pemasyarakatan No. 25 Gobah Pekanbaru Ruang Rawat : .....................................................................
Telp. (0761) 848100, 859510 Fax. (0871) 859510 Tangal : .....................................................................
Dokter Anestesi : .....................................................................
(Mohon lengkapi/tempelkan label pasien)

LAPORAN ANESTESI
Diagnosa Prabedah : Ruangan :
Jenis Pembedahan : Jenis Operasi : Cito / Elektif
Diagnosis Pasca bedah :

Dokter Anestesi : Dokter Bedah :

Asisten Anestesi : Perawat Bedah :

A. CEK LIST PERSIAPAN ANESTESI

Informed consent Obat-obatan Anestesia Tata laksana jalan nafas Mesin Anestesi
Monitor Obat-obatan Emergensi Suction Aparatus Sirkuit Anestesi

B. PENILAIAN PRA INDUKSI

Jam : ................................................
Kesadara : ............................................. GCS : E M V
Airway : Terintubasi / tidak terintubasi
Respirasi : Spontan / Assist / Kontrol NASAL KANUL : O2 ............ L/m
Tekanan Darah : ........................... mmHg
Nadi : ................... x/mnt, reg/ ireg/ adekuat/ inadekuat
BB : ..................... Kg TB : .................... Cm
Puasa mulai jam : ........................................... ( ........................................... Jam pra Operasi)
EKG : ............................................................................................................................................
Thoraks foto : .............................................................................................................................................
Pemeriksaan lain-lain : ..............................................................................................................................................
Laboratorium :
HB : .............................................................................................................................................................
Leukosit : .............................................................................................................................................................
Lain-lain : ..............................................................................................................................................................

Penyakit penyerta
System saraf : ....................................................................................................................................
Sistem respirasi : ....................................................................................................................................
Sistem kardio vaskuler : ....................................................................................................................................
Sistem utinarius : ....................................................................................................................................
Sistem metabolic : ....................................................................................................................................
Lain-lain : ....................................................................................................................................
Obat-obatan yang sedang
Didapat : ....................................................................................................................................
Alergi :

STATUS FISIK : AS I / II / III / IV / V E

Pekanbaru, ............................ 20........
Dokter Anestesi Asisten Anestesi

( ................................................ ) ( ................................................ )
Tanda Tangan & Nama jelas Tanda Tangan & Nama jelas
C. ASSESMENT DURANTE ANESTESI
1. General Anestesi
Premedikasi : .................................................... Tanggal Operasi : ...................................................
Mulai Anestesi : ...................................................
Induksi : ................................................... Selesai Anestesi : ...................................................
Lama Anestesi : ..................................................

Jalan Nafas : ET / NT / Masker Muka / LMA No : ......................

Indukasi : Sempurna / eksitasi / muntah / batuk / spasme / ...........................................................
Pengaturan Nafas : Spontan / assist / control
Ventilator : Tidal Volume : ............... ml RR : ............ x/mnt 1:Erati ........................
PEEP : ......................................................
Teknik khusus : Hipotermi / hipotensi / bypass / ventilasi satu paru / ....................................................

2. Blokade Regional
Teknik : spinal / caudal / epidural /sadleblok / intravenous / blok syaraf / ..................................................
Lokasi Tusukan : ..........................................
Anestesi Lokal : ..........................................
Obat Tambahan : .......................................... dosis
Vasokontrikor : adrenalin / nonadrenalin / tidak pakai Konsentrasi : .....................
Waktu Mulai : Suntikan jam : ............................
Analgesia jam : ........................... lamanya : ................. Jam : ........... menit
Tindakan anestesi tambahan : ...........................................................................................................
...............................................................................................................................................................................
Posisi penderita : supine / prone / litomi / semi sitting / fowler / lateral dekubitus (R/L) trendelenberg – knee
Chest / jack – knife / telungkap .........................................................................................................................
MONITORING SELAMA ANESTESI
JAM : ..........................

MASALAH DURANTE OPERASI TINDAKAN

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2. ............................................................................ 2. ...........................................................................
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