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FAB 05.

a
RS KHUSUS MATA MEDAN BARU
Jl. Abdullah Lubis No. 67 Medan Telp (061) 4530989 Fax (061) 4532924
Email: mmbc.mata@yahoo.com

No. RM : ……………………………………………………
STATUS SEDASI Nama : ……………………………………………………
Tgl. Lahir / Umur : ……………………………………. ( Lk/Pr )

Tanggal Prosedur : Rencana Sedasi : sedang / dalam


Nama Prosedur : Pelaku Sedasi :
Pelaku Prosedur : Asisten Sedasi :
Diagnosis : Jam Mulai :
Alergi : Jam Selesai :
Mallampati :1 2 3 4
ASA :1 2 3 4 E

Pemantauan (Monitoring) :
 EKG lead  NIBP
 SpO2  Lain-lain : _________________
Ceklist Persiapan Sedasi :
 Penilaian Prasedasi  Obat-obat Sedasi
 Persetujuan Tindakan Medis  Perlengkapan Emergensi
 Time Out
Penilaian Pra tindakan : Jam :____________
 Tekanan Darah : …………………………..  Frekuensi Napas : …………………………….
 Frekuensi Nadi : …………………………..  Suhu : ………………………………….
 SpO2 : …………………………..  Kesadaran : …………………………………..
Akses intravena, tempat dan ukuran : _________________________________
Obat dan Pemantauan Selama Prosedur dengan Sedasi :

Derajat Kedalaman Sedasi:


0 = sadar penuh ;
1 = sedasi minimal (mengantuk, respon percakapan adekuat) ;
2 = sedasi sedang (mengantuk/tidur, terbangun dengan rangsangan sentuh) ;
3 = sedasi dalam (tidur dalam, terbangun dengan rangsangan fisik bermakna) ;
4 = tidak dapat dibangunkan FAB 05.a1

Pemantauan Pasca Sedasi :


RS KHUSUS MATA MEDAN BARU
Jl. Abdullah Lubis No. 67 Medan Telp (061) 4530989 Fax (061) 4532924
Email: mmbc.mata@yahoo.com
Jam Masuk Ruang Pulih : ____________________

R N TD VAS/FLACC/
Skor Adrette
FACES
60 220 Aktivitas
10
55 200 Sirkulasi

50 180 9 Pernapasan

N 45 160 8 Kesadaran

V Sis 40 180 140 7 Warna Kulit

ʌ Dis 35 160 120 6

+R 30 140 100 5

25 120 80 4

20 100 60 3

15 80 40 2

10 60 20 1

5 0 0 Total

Post Anesthetic Discharge Scoring System (untuk pasien rawat jalan dewasa dan anak) :

Tanda vital Perdarahan surgical


Aktivitas, Status Mental Input dan Output
Nyeri, mual, muntah Skor Total

Jam Keluar Ruang Pulih : ____________________

Instruksi Pasca Sedasi:


Obat-obatan : _______________________________________________________________________________
_______________________________________________________________________________
Mobilisasi : ________________________________________________________________________________
Diet & Nutrisi : _____________________________________________________________________________
Edukasi & Follow up : ________________________________________________________________________
Lain-lain : __________________________________________________________________________________

Medan, …………………………..
Tanda Tangan DPJP

( _____________________ )
FAB 05.a2

KOLOM TINDAK LANJUT :

…………………………………………………………………………………………………………………
RS KHUSUS MATA MEDAN BARU
Jl. Abdullah Lubis No. 67 Medan Telp (061) 4530989 Fax (061) 4532924
Email: mmbc.mata@yahoo.com
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FAB 05.a3

CATATAN PERSIAPAN PRA ANASTESI :


RS KHUSUS MATA MEDAN BARU
Jl. Abdullah Lubis No. 67 Medan Telp (061) 4530989 Fax (061) 4532924
Email: mmbc.mata@yahoo.com
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Tanda tangan DPJP Anastesiologi

( Dr. …………………………… )

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