PEMERINTAH KABUPATEN CIAMIS

UPTD PUSKESMAS SUKAMULYA

Jln. Raya Panjalu No. 24 Sukamulya Cihaurbeuti Tlp. (0265) 7526615
E-mail : pkm_sukamulya@yahoo.com

Kode Pos 46262

LAPORAN ANESTESI

Hari, Tanggal : ...........................................................

Ruang : ...........................................................
No. Rekam Medis : ...........................................................
Nama Lengkap : ...........................................................
Umur : ...........................................................
Petugas yang Melakukan Anestesi : ...........................................................
Petugas yang Melakukan Tindakan : ...........................................................
Diagnosis Sebelum Operatif : ...........................................................
Diagnosis Setelah Operatif : ...........................................................
Jenis Anestesi : ...........................................................
Resiko : ...........................................................
Riwayat Alergi : ...........................................................
Nama Operasi : ...........................................................
Jam Anestesi : Dimulai .................. WIB

MONITORING PASIEN SELAMA DIANESTESI

Berat Badan : ............. kg

Tinggi Badan : ............. cm

Tekanan
Jam Kesadaran Nadi Pernafasan Suhu Keterangan
Darah

Dokter Penanggung Jawab

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