PEMERINTAH KABUPATEN JEMBER

DINAS KESEHATAN
UPTD . PUSKESMAS SILO 1
Alamat : Jl. A. Yani No. 154 Silo, Jember Telp. 0331-521169
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PENCATATAN PELAPORAN OPERASI / PEMBEDAHAN

No. REG : .............................................................. POLI UGD : ........................................................

NAMA : ............................................................. LK/PR : ........................................................
ALAMAT : ............................................................. UMUR : ....................................... ...............
: ............................................................. DIAGNOSIS : ......................................................
KAJIAN PRE OP

KELUHAN UTAMA : ................................................................................................................................

................................................................................................................................
RPS : .................................................................................................................................
................................................................................................................................
RPD : ................................................................................................................................
................................................................................................................................

OPERATOR : .................................................. TEKNIK OPERASI : ............................................

ASISTEN : ................................................. JENIS ANASTESI : ..............................................

TANGGAL OPERASI : ................................................ JENIS SEDATIF : ..............................................

MULAI JAM : ................................................. LAMA

OPERASI : ...................................JAM ......................
SELESAI JAM : ................................................. MENIT ........................................

URAIAN OPERASI

OBSERVASI PASCA OPERASI / PEMBEDAHAN

 WAKTU T N RR S KETERANGAN

SEBELUM TINDAKAN

SAAT TINDAKAN

SESUDAH TINDAKAN

TTD OPERATOR

..........................................

PEMERINTAH KABUPATEN JEMBER

DINAS KESEHATAN
UPTD . PUSKESMAS SILO 1
Alamat : Jl. A. Yani No. 154 Silo, Jember Telp. 0331-521169

Kode
Pos :
68184

FORMULIR PENANDAAN AREA OPERASI (SITE MARKING )

NAMA : NO REKAM MEDIK :

UMUR : RUANG :

TANGGAL OPERASI : JAM :

JENIS OPERASI : OPERATOR :

Saya menyatakan bahwa lokasi operasi yang telah di tetapkan pada diagram adalah benar

PASIEN/ KELUARGA PETUGAS

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