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Jl. Syamsu Biya, Kel. Kayubulan, Kec. Limboto, Kab.

Gorontalo – Kode Pos 96181


Email : klinik.panipi@yahoo.com Hp /Whatsapp : 08114333556

FORM MONITORING
STATUS FISIOLOGI PASIEN SELAMA PEMBERIAN ANESTESI
LOKAL

Nama Pasien :..................................................................................................


Tanggal Lahir :...............................................................................................L/P
Umur :..................................................................................................
No. RM :..................................................................................................
Alamat :..................................................................................................
Jenis Kasus :.................................................................................................

No. Nama Obat yang Dosis Waktu Tanda vital


digunakan Tensi Nadi RR Suhu
1 Sebelum
anestesi

2 Setelah
anestesi

3 Sebelum
pulang

Perawat Dokter

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