FORM MONITORING TINDAKAN ANESTESI DAN BEDAH

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

Umur : ........ th No. RM : ....................
Jenis Kelamin :L/P
Alamat : ...................................

ANESTESI

Pre Anestesi Durante Anestesi Post Anestesi

Jam : Tindakan : Jam :
Gcs :........... Gcs :...........
TD :............ TD :............
N :............ N :............
RR :............ RR :............
HR :............. HR :.............
Nyeri: + / - Nyeri: + / -
Lain-lain: Lain-lain:

PEMBEDAHAN

Pre Pembedahan Durante Pembedahan Post Pembedahan

Jam : Dilakukan hecting Jam :

Tindakan: Tutup sofratul, dressing

Petugas/Paramedis

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