FORM MONITORING

STATUS FISIOLOGI PASIEN SELAMA PEMBERIAN ANESTESI LOKAL

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

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

No. Nama Obat yang Dosis Waktu Tanda vital

digunakan Tensi Nadi RR Suhu
1 Sebelum
anestesi

2 Setelah
anestesi

3 Sebelum
pulang

Perawat Dokter