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PEMERINTAH KABUPATEN JEMBER

DINAS KESEHATAN
PUSKESMAS .............................

PENCATATAN LAPORAN OPERASI / PEMBEDAHAN


NO. REG : ....................................... POLI / UGD : ......................
NAMA : ....................................... LK / PR : ......................
ALAMAT : ........................................ UMUR : ......................
: ........................................ DIAGNOSIS : .....................
KAJIAN PRE OP
KELUHAN UTAMA : ...............................................................................................................
..............................................................................................................
RPS : ...............................................................................................................
................................................................................................................
RPD : ...............................................................................................................
...............................................................................................................

OPERATOR : ................................................ TEKNIK OPERASI : ...............................


ASISTEN :................................................. JENIS ANESTESI : ...............................
JENIS SEDATIF : ................................
TANGGAL OPERASI : ...........................................
MULAI JAM : ............................................... LAMA OPERASI : ...............................
SELESAI JAM : ............................................... ……….. JAM ………… MENIT

URAIAN OPERASI

OBSERVASI PASCA OPERASI / PEMBEDAHAN


JAM \ MENIT T N RR S KETERANGAN

TTD OPERATOR

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