PEMERINTAH KABUPATEN PEMALANG

DINAS KESEHATAN
PUSKESMAS WARUNGPRING

FORM MONITORING
STATUS FISIOLOGI PASIEN SELAMA PEMBERIAN ANESTESI LOKAL

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

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

No. Nama Obat Dosis Waktu Tanda

yang vital
Tensi Nadi RR Suhu
digunakan
1 Sebelum
anestesi

2 Setelah
anestesi

3 Sebelum
pulang

Perawat Dokter