ASSESMEN PRA BEDAH

No RM :
Nama :
Umur :
Jenis Kelamin :L/P
Assemen Pra Operasi

Jam................................WIB Tanggal.........................................................................................

Data Subjektif (anamnesis) :

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Data Obyektii (pemeriksaan fisik) :
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Diagnosis pra operasi :..................................................................................................................................

Estimasi waktu yang dibutuhkan :.................................................Jam.................................................................Menit

Rencana Operasi :..................................................................................................................................

Riwayat Alergi : Tidak ada  Ada

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Berikan tanda pada gambar sesuai penandaan lokasi operasi tubuh pasien
Berikan penandaan (dengan spidol permanen) pada lokasi Deskripsi singkat apabila tidak dapat dilakukan
tubuh pasien dengan tanda garis ( - ), tanda lingkar ( o ) atau penandaan pada tubuh pasien
tanda panah ( )
JANGAN menggunakan ( x )
Sisi Kiri Sisi Kanan Belakang Depan

Posisi pasien dalam operasi:

Dokter Operator Pasien/ Keluarga

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