TEKNIK ANESTESI :
Sedasi _____________ Anestesia Umum : _____________
Spiral Epidural Kaudal Perifer : __________
Lain – lain : ________________
MONITORING :
EKG Lead ________ SpO2 EtCO2 NIBP Temp Stetoskop
CVP _____________ Arteri Line ____________ PA Catheter Urine Catheter NGT
PENILAIAN PRA-INDUKSI :
Jam : ______________
Kesadaran : ___________________Tekanan Darah : ________________ Nadi : ______________ RR : ____________
Suhu : _____________ Saturasi O2 : _____________________ Lain – Lain : ________________________________
Catatan :
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