FKK UNIVERSITAS MUHAMMADIYAH JAKARTA

Jl. Cempaka Putih Tengah I/1

STATUS PASIEN
ANESTESIA

No RM:
Nama Pasien :
Umur :
Nama Dokter Muda :

I. IDENTITAS
Nama Lengkap

Tempat dan Tanggal lahir

Usia

Jenis Kelamin

Pekerjaan

Alamat

Masuk RS tanggal

Diagnosis saat masuk

No Rekam Medis

Diagnosis Prabedah

Jenis Pembedahan

Lama Operasi

diagnosis pascabedah

jenis Anastesi

Lama Anastesia

Keadaan pribadi :
TB: ..BB:
Gol darah :.RH :. T.D :....
Nadi :..Suhu :..Hb :..Ht :..
Sirkulasi

Respirasi

Saraf
Gastrointestinal
Renal
Metabolic
Status Fisik : ASA : 1
Medikasi Para bedah

Komplikasi prabedah
Keadaan piskhe sesudah pramediksi
Anestesia / analgesi dengan:
Relaksasi dengan
teknik anestesia / analgesia

Respirasi :
posisi :
Infus :
komplikasi selama pembedahan
Keadaan akhir pembedahan
keadaan bayi pada seksio sesaria
terapi khusus pada pasca bedah

Komplikasi Prabedah

hipersensitivitas/alergi

kematian
Sebab kematian
Tehnik khusus :

Pramedikasi

Medikasi
1.
pemberian: SK...IM/IV P. Oval 2.
waktu jam.................................. 3.
Efek :.......................................... 4.
5.

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STATUS PASIEN
PROGRAM DARI POSU OPERASI

No RM:
Nama Pasien :
Umur :
Nama Dokter Muda

Instruksi
Bila kesakitan

: .............................................................................................................
..........
bila mual/ muntah : .............................................................................................................
Antibiotika
: .............................................................................................................
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Obat-obatan lain
: .............................................................................................................
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minum
: .............................................................................................................
infus
: .............................................................................................................
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monitor
a. tensi
:
b. nadi
:
c. nafas
:
d. suhu
:
lain-lain
: .............................................................................................................
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