PEMERINTAH KABUPATEN BARITO KUALA

DINAS KESEHATAN
UPTD PUSKESMAS BANTUIL
Alamat Jl.HM.Yunus No 5 Rt.001 Desa Simpang Nungki Kec. Cerbon 70571

FORM MONITORING
STATUS FISIOLOGI PASIEN SELAMA PEMBERIAN ANESTESI LOKAL

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

Tanggal Lahir :...............................................................................................L/P
Umur :..................................................................................................
No. RM :..................................................................................................
Alamat :..................................................................................................
Diagnosa :.................................................................................................

No. Nama Obat yang Dosis Waktu Tanda vital

digunakan Tensi Nadi RR Suhu
1 Sebelum
anestesi

2 Setelah
anestesi

3 Sebelum
pulang

Perawat Dokter