No.

RM :
Nama :
Jenis Kelamin:
Tanggal Lahir :
(mohon diisi atau tempelkan stiker jika ada)

ASESMEN PRA ANESTESI DAN PRA SEDASI

ANAMNESA
● Riwayat Medis

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___________________________________________________________________________________________________
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● Riwayat Anastesi dan Operasi

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___________________________________________________________________________________________________
___________________________________________________________________________________________________

● Alergi
- Obat : _________________________________________________________________________________________

- Lainya : _________________________________________________________________________________________

● Riwayat Kebiasaan / Penggunaan Obat

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● Riwayat Keluarga
__________________________________________________________________________________________________
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Pemeriksaan Fisik
OBJEKTIF
Tanda-tanda vital :
Kesadaran :__________, GCS : E M V
TD :___________MmHg N :___________x/menit Suhu :__________x/menit RR :___________x/menit
Berat Badan : _____________ kg
Tinggi Badan : ______________cm
Temporoman dibular joint : ☐ Normal ☐ Abnormal
Jarak Thyromental : ☐ Normal ☐ Abnormal
Ekstensi Leher : ☐ Normal ☐ Abnormal
Jantung :_______________________________________________________________________________________________

Paru :_______________________________________________________________________________________________

Ginjal :_______________________________________________________________________________________________

Hepar :________________________________________________________________________________________________

GIT :________________________________________________________________________________________________
MED-BED.004.0818.00

Lainnya :_________________________________________________________________________________________________
Pemeriksaan Penunjang
● Laboratorium ( Pertanggal :____________________ )
Hb : _______ Ht :________ Leuko : _______ Trombo : ________
BT : _______ CT : ________ PT : _______ APTT : ________ INR : ________
Lain-lain :
_____________________________________________________________________________________________
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● EKG : __________________________________________________________________________________
● Radiologi
Foto Thorax : _________________________________________________________________________________
CT-Scan : _________________________________________________________________________________
MRI/MRA : _________________________________________________________________________________
USG : _________________________________________________________________________________
Lain-lain : _________________________________________________________________________________
● Hasil Konsultasi Bagian Lain :
__________________________________________________________________________________________________
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ASSASMENT

ASA 1 2 3 4 5 E
PLANNING

Setuju / tidak setuju untuk dilakukan tindakan Pasca Operatif :

anestesi/sedasi
Rencana penanganan Nyeri :
Preoperatif :
_____________________________________________
Puasa jam :
__________________________________
Perawatan Pasca Operasi :
Premedikasi :
☐ Ruang Rawat Inap
__________________________________
☐ Ruang HCU / NICU / PICU
Lain - lain :
☐ Pulang
__________________________________

Intraoperatif :
Jenis Anestesi : Anestesi umum / Regional / Kombinasi / Sedasi

Tanggal, ____________________, 20___ Jam : ________WIB

Dokter Anestesi

(____________________________)
MED-BED.004.0818.00
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