Nama Pasien :..................................................................................................
Tanggal Lahir :...............................................................................................L/P Umur :.................................................................................................. No. RM :.................................................................................................. Alamat :.................................................................................................. Jenis Kasus :.................................................................................................
No. Nama Obat Dosis Waktu Tanda vital
yang Digunakan Tensi Nadi RR Suhu 1 Sebelum anestesi 2 Setelah anestesi 3 Sebelum pulang