PEMERINTAH KOTA BANJARMASIN RM. 5.

02
DINAS KESEHATAN
UPTD RSUD SULTAN SURIANSYAH
Jalan Rantauan Darat RT.04 RW.01 Kelurahan Kelayan Selatan Banjarmasin
Telp. (0511)6782000/(0511)6782222
e-mail : rsudsultansuriansyah@gmail.com Kode Pos 70246

PERMINTAAN PENDAFTARAN PASIEN RENCANA OPERASI CITO/EMERGENCY

1. NAMA PASIEN : ..........................................................................................................................

2. UMUR :...........................................................................................................................

3. NOMOR RM :...........................................................................................................................

4. Tanggal MRS :...........................................................................................................................

5. Alamat :...........................................................................................................................

6. Cara Pembayaran :...........................................................................................................................

7. Diagnosa :...........................................................................................................................

8. Rencana Tindakan :...........................................................................................................................

9. Jenis Pemeriksaan :...........................................................................................................................

10. Dokter Bedah / Operator :...........................................................................................................................

11. Tgl, bln, Thn, Jam Op :...........................................................................................................................

12. Persiapan Pra Op :...........................................................................................................................

13. Pemeriksaan Penunjang : Lab Radiologi EKG

- Konsul Anastesi :...........................................................................................................................

- Konsul Bagian Lain :...........................................................................................................................

- Persiapan obat-obatan bedah :...........................................................................................................................

- Persiapan obat-obatan anestesi :...........................................................................................................................

- Persiapan Implan :...........................................................................................................................

- Surat Izin Operasi / Anastesi :...........................................................................................................................

- Persiapan Pasien :...........................................................................................................................

Puasa Cukur

Petugas Ruangan, Mengetahui, Banjarmasin,……………….

IGD/VK/ ……….. Dokter Bedah Petugas kamar operasi

(………………………….) (………………………….) (………………………….)

N/B : Jika dalam 2 jam dari waktu yang ditentukan tidak dilaksanakan, operasi dicancel

jam operasi harus ditulis jelas

PENTING Pemberitahuan ke kamar operasi minimal 30 menit sebelum operasi