Anda di halaman 1dari 1

DINAS KESEHATAN KABUPATEN TASIKMALAYA

UPT PUSKESMAS MANONJAYA


Jalan Tangsi No.6 Kecamatan Manonjaya Tlp. (0265) 381109 Tasikmalaya

FORM MONITORING
STATUS FISIOLOGI PASIEN SELAMA PEMBERIAN ANESTESI LOKAL

Nama Pasien :..................................................................................................


Tanggal Lahir :...............................................................................................L/P
Umur :..................................................................................................
No. RM :..................................................................................................
Alamat :..................................................................................................
Jenis Kasus :.................................................................................................

No. Nama Obat yang Dosis Waktu Tanda vital


Tensi Nadi RR Suhu
digunakan
1 Sebelum
anestesi

2 Setelah
anestesi

3 Sebelum
pulang

Perawat Dokter