RS. ISLAM JAKARTA PONDOK KOPI Nama : .................................................

Jl. Raya Pondok Kopi - Jakarta Timur Tanggal Lahir : .................................................

Telp. (021) 8610471 (Hunting)
No. RM : .................................................
(Label identitas pasien )

ASESMEN PRA ANESTESI

Tanggal : Jam : Ruangan :

1. Anamnesis : _______________________________________________________________

2. Pemeriksaan Fisik : _______________________________________________________________

3. Pemeriksaan Penunjang

a. Laboratorium : _______________________________________________________________

b. USG : _______________________________________________________________

c. Radiologi : _______________________________________________________________

d. Lain - lain : _______________________________________________________________

4. Diagnosis Pre Anestesi : _______________________________________________________________

5. Status ASA : _______________________________________________________________

6. Masalah yang berkaitan dengan anestesi : _______________________________________________________________

7. Rencana Tindakan Anestesi : _______________________________________________________________

8. Transfusi : _______________________________________________________________

9. Persiapan Anestesi : _______________________________________________________________

a. ___________________________________________________________________________________________________

b. ___________________________________________________________________________________________________

c. ___________________________________________________________________________________________________

d. ___________________________________________________________________________________________________

e. ___________________________________________________________________________________________________

Dokter Anestesi

(……………………………………………… )
Ttd & Nama Jelas