LAPORAN TINDAKAN (LASER

PHOTOCOAGULATION)
Name
: ........................................
of Birth : ..........................

Patien Number

Date

Eye : ..................................

: ........................................

: ....................................

Diagnosis : ............................................................................ Procedure

: .............................................................

Patterns Used

: ..................................................

Contact Lens

: ..................................................

Spot Size (m)

Exposure (ms)
[Median, Range]
Power (mW)
[Median, Range]
Number of Spots
Fluence (J/cm) [Median, Range] : ......................
Notes :

.............................................................. MD

.............................................................. Signature

Date

.............../.............../...................... Date