FORMULIR PENGGUNAAN VENTILATOR

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

TANGGAL LAHIR : ................................................................................
NO REKAM MEDIS : ................................................................................
ALAMAT : ................................................................................

DIAGNOSA MEDIS : ................................................................................

DPJP : ................................................................................
MERK VENTILATOR : ................................................................................

HARI, TANGGAL, & PARAF / TANDA

JAM PASANG INDIKASI KETERANGAN TANGAN

Cikalongwetan,............….................

PERAWAT DPJP DOKTER ANASTESI

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