Rekam Medis

Contoh2 Form
Bedah – Anestesi

NB. Pelajari contoh dan wajib baca SNARS 1.1.

dgn pola SEMILA

dr. Nico A. Lumenta, K.Nefro, MM, MHKes, FISQua

Komisi Akreditasi Rumah Sakit
2021
 Proses Asuhan Pasien
2 “blok” Patient Care
1 kegiatan

Asesmen Pasien
(Skrining, “Periksa Pasien”)
S
Profesinal Pemberi Asuhan

1. Pengumpulan Informasi : Anamnesa,

Asesmen Ulang
pemeriksaan, pemeriksaan lain / penunjang,
O
dsb
A 2. Analisis informasi : dihasilkan
Diagnosis / Problem / Kondisi, →
identifikasi Kebutuhan Yan Pasien
(PPA)

P 3. Susun Rencana Pelayanan/Care Plan :

untuk memenuhi Kebutuhan Yan
Pasien

2
*Implementasi Rencana
*Monitoring

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Form Anestesi 1/4

A
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 Monitoring Durante Sedasi/Anestesi

2/4

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2/4

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 h. 1/4 h. 2/4

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h. 3/4

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Durante Anestesi

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Asesmen Pra Anestesi/Sedasi

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Asesmen Pra Anestesi/Sedasi

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Asesmen Pra Anestesi/Sedasi

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Asesmen Pra Anestesi/Sedasi

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 RUMAH SAKIT ADVENT BANDUNG
JL. CIHAMPELAS 161
BANDUNG
LEMBAR PENGKAJIAN PRE OPERASI MEDIS DAN PENANDAAN LOKASI OPERASI
LABEL PASIEN

Dokter Operator
pengkajian Pra operasi

Jam..................WIB Tanggal.........................
o Data Subjektif (anamnesis)
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o Data Obyektif (pemeriksaan fisik)
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Diagnosis Praoperasi Rencana Operasi.............................................................
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Tanda tangan Dokter Operator

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Berikut tanda pada gambar sesuai dengan penandaan lokasi operasi pada tubuh pasien
Berikan penandaan pada lokasi tubuh pasien dengan * dan INISIAL DOKTER
Depan Belakang Sisi Kiri Sisi Kanan

Posisi pasien dalam operasi :

Diskripsi singkat apabila tidak dapat dilakukan pada tubuh pasien :

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Askep PeriOp
1/5

Askep PeriOp
2/5

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Askep PeriOp
3/5

Askep PeriOp
4/5

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Askep PeriOp
5/5

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 PERIOPERATIVE NCP
(Nursing Care Plan)
Pre-Op
1/3

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Intra-Op
2/3

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Post-Op
3/3

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 Contoh
Lap Operasi
1/2

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 Contoh
Lap Operasi
1/2

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Lap Operasi

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Monitoring Pasca Anestesi

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Informed Consent
→“Informed”/Edukasi
1/2

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Informed Consent
→“Consent”/Persetujuannya
2/2

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 Informed Consent
→“Consent”/Persetujuannya

Sutoto KARS 38
Informed Consent
→Penolakan

Sutoto KARS 39
 2/2
IC-Anestesi-Edukasi
1/2
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 CONTOH TINDAKAN ANESTESI DAN SEDASI YG PERLU
INFORMED CONSENT
Tindakan anestesi
• Anestesi Umum Tindakan sedasi
Sedasi sedang
• Anestesi Regional • Mengunakan midazolam 0,1 mg/kbgg
• Anastesi Infiltrasi • Mengunakan ketamin 0,5 mg/kgbb
• Mengunakan propofol 0,5 mg/kgbb
• Anastesi Blok Sedasi dalam
• Anastesi Spinal • Mengunakan ketamin 3-8 mg/kgbb
intramuskuler
• Blok Epidural • Mengunakan ketamin 1 mg/kgbb intravena
• Mengunakan midazolam oral 10 mg/kgbb
• Blok Pleksus Brakialis • Mengunakan flunitrazepam 0,1 mg/kgbb
• Anestesia Paravertebral • Mengunakan fentanil 0,5 – 1 ug/kgbb
• Mengunakan alfentanil 3-5 ug/kgbb
• Blok Transakral (Kaudal) • Mengunakan remifentanil 0,1 mg/kg/min
• Anastesi Regional Intravena

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 Contoh Form
Asesmen Pre Op

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Monitoring pd Anestesi Lokal

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 Monitoring
pd Operasi dgn Anestesi Lokal

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Form Operasi dgn Anestesi Lokal

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