Jam..................WIB Tanggal.........................
Data Subjektif (anamnesis)
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Data Obyektif (pemeriksaan fisik)
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Rencana Operasi
Diagnosis Praoperasi .....................................................................
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.Tgl/Jam ...............................................................
Tanda tangan Dokter Operator .....................................................................
Berikut tanda pada gambar sesuai dengan penandaan lokasi operasi pada tubuh pasien
Berikan penandaan pada lokasi tubuh pasien dengan INISIAL DOKTER