RS MUTIARA HATI MOJOKERTO NO.

RM

Ruang : Nama :
Kelas : Jenis Kelamin :
ASSESMEN PRA OPERASI
Tanggal Lahir :
Alamat :

Data subyektif : .............................................................................................................................

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Data Obyektif : .............................................................................................................................
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Diagnosa Pra Operasi : ............................................................................................................................
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Rencana Tindakan Operasi : ............................................................................................................................
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Dilaksanakan Tanggal : ......................................................... Jam : ...............................................
Antibiotik profilaksis : Ya, ........................................................................................

C Tidak
Persiapan Operasi : Laboratorium , ..............................................................................
C
Rontgen, .......................................................................................
C
C
EKG

C......................................................................................................
Berikan tanda pada gambar sesuai penandaan lokasi operasi pada tubuh pasien
Berikan penandaan (dengan Spidol Permanent) pada lokasi tubuh pasien dengan tanda panah(  )

Sisi Kiri Sisi Kanan Belakang Depan

Posisi Pasien dalam operasi :

Mojokerto, ...........................................
Dokter/ DPJP Pasien/ Keluarga

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RM 22 c K
RM 22 c K