PEMERINTAH KOTA SERANG

DINAS KESEHATAN
UPTD PUSKESMAS SINGANDARU
Jl. Letnan Djidun No. 04 Kel. Lontar Baru Kec. Serang Kota Serang 42115
Telp. (0254) 201775 E-mail : puskesmassingandaru@gmail.com

FORM MONITORING
STATUS FISIOLOGI PASIEN SELAMA PEMBERIAN ANESTESI LOKAL

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

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

No. Nama Obat yang Dosis Waktu Tanda vital

digunakan Tekana Nadi RR Suhu Skala
n Darah Nyeri
1 Sebelum
anestesi

2 Setelah
anestesi

3 Sebelum
pulang

Mengetahui
Serang, 2023
Perawat/Bidan Dokter