PEMERINTAH KABUPATEN MALANG

DINAS KESEHATAN
UPTD PUSKESMAS WONOKERTO
Jl. Diponegoro No 10 Wonokerto Bantur (0341) 879495
Email :pkmwonokerto@gmail.com
MALANG - 65181

FORM MONITORING TINDAKAN ANSTESI DAN BEDAH

Nama Pasien : ..................................... No. RM : .........................................
Tanggal lahir : ......./........./......... Tanggal : .........................................
Jenis Kelamin : L/P
Alamat : ......................................

ANASTESI
Pre Anastesi Durante Anastesi Post Anastesi
GCS : ........................... Tindakan : GCS : ............................
TD : . TD : ............................
Nadi : ........................... Nadi : ............................
RR : . RR : ............................
Tax : ........................... Tax : ............................
Nyeri : . Nyeri : +/-
Lain-lain : ........................... Lain-lain : ............................
.
...........................
.
+/-
...........................
.

PEMBEDAHAN
Pre Anastesi Durante Anastesi Post Anastesi
Tindakan : Tindakan : Tindakan :

Petugas / Paramedis

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