Nama Lengkap :

Tanggal Lahir :
No. RM :
(mohon diisi atau tempelkan stiker)

CHARGE SLIP OPERATING THEATER (OT)

RSD MADANI KOTA PEKANBARU

TANGGAL OPERASI : TIME I :

GOLONGAN OPERASI :KECIL/SEDANG/BESAR/KHUSUS/CANGGIH TIME II :
DIAGNOSA : TIME III :

TINDAKAN :
OT ROOM : I / II /III / IV dr. OPERATOR : dr.
ASISTEN : dr. ANASTESI : dr.
INSTRUMEN : dr. ANAK : dr.
SIRKULER :
PENATA :

No NAMA OBAT Sat JML No ALAT KESEHATAN Sat JML

1 Atropin Sulfat Amp 1 DYNASCAST PCS
2 Bupivacaine / REGIVEL Amp 2 ELASTIS PERBAN 3inci/4inci/6inci PCS
3 Cortidek / Dexamethason Amp 3 GIP PERBAN 3inci/4inci/6inci PCS
4 Ecron Injeksi 10 mg Amp 4 SOFBAN PERBAN 3inci/4inci/6inci PCS
5 Ephedrine HCL Injeksi 50 mg/mIL Amp 5 URIN BAG PCS
6 Ephineprin Injeksi 1 mg/ml Amp 6 FOLLEY CHATETER NO PCS
7 Asam Traneksamat Amp 7 MY JELLY PCS
8 Fentanyl Amp 8 NGT NO PCS
9 Gentamisin Amp 9 LEUMATUL PCS
10 Flamicort Amp 10 CURASPON PCS
11 Induxin Injeksi 10 IU /mL Amp 11 TRANSOFIK PCS
12 Lasix / URESIX / Furosemide Amp 12 PISAU CUKUR PCS
13 Lidocaine Injeksi 2 % Amp 13 UNDERPAD PCS
Miloz Injeksi 15 mg / ml &5 mg/mln Amp 14 SPON CUci tangan
14 PCS
/ Midozolam
15 Morphine KF Injeksi 10 mg/mL Amp 15 APRON PCS
Nokoba Injeksi 0,4 mg/mL dalam 2 Amp 16 GLOVE STERIL MPM 6/6,5/7/7,5/8 PCS
16
MI
17 Ondansetron Injeksi 8 mg/ 2mL Amp 17 GLOVE GAMEX 6/6,5/7/7,5/8 PCS
Pehacain Injeksi 2 mL Amp 18 BISTURI PCS
18
NO;10/11/15/20/21/22/24
19 Pethidine KF Injeksi 100mg/2 MI Amp NO BENANG Sat JML
20 Pospargin Injeksi 0,2 mg/mL Amp 1 CROMIC PCS
21 PRONALGES SUPP Amp 2 CROMIC PCS
Keterolak / Ketesse / Amp 3 MERSILK
22 PCS
Dexketoprofen
23 Ranitidine Amp 4 MERSILK PCS
24 Recofol / LIPURO / Profol Amp 5 SILK PCS
25 Roculax Injeksi 50 ml Amp 6 SILK PCS
26 Tramadol Injeksi 50 mg/ml Amp 7 VICRYL PCS
27 Tramus Amp 8 VICRYL PCS
28 Valisanbe/Stesolid injeksi Amp 9 MONOCRIL PCS
29 Vit C Amp 10 PROLEN PCS
30 Vit K[PHYTOMENADION) Amp 11 PROLEN PCS
31 Parcetomol infus Amp No DICASHKAN FARMASI Sat JML
32 Parracetomol supp Amp 1 PENSIL COUTER REUSE PCS
33 Levobuvipacan inj Amp 2 KASSA HIDROFIL PCS
34 Calcrum Glukonat Amp 3 KASS TAMPON PCS
35 nalokson Amp 4 CUTTON BUD PCS
36 Penitom inj Amp 5 KASS X-RAY PCS
37 Ahractrium kesilat Amp 6 BIG KASSA PCS
38 Ketalar/ketami Amp
No CAIR INFUS Sat JML No GAS ANASTESI OT YG CHASKAN Sat JML
1 D5%NS OTSU INFUS500 ml kolf 1 Isoflirane inhalasi cair 250ml PCS
Dextrose OTSU[D5%]500 ml Sevoflurane larutan
2 kolf 2 PCS
250ml/Sevodex
3 Dextrose OTSU [D5%]500ml kolf 3 N20 PCS
4 Manitol 500ml kolf 4 02 PCS
5 Asering OTSU Infus 500ml kolf No ALMED TO YG CHASKAN Sat JML
6 Gelofusal 500ml kolf 1 MONITOR Unit
7 Nacl 0,9%100ml kolf 2 ELECTROCOUTER Unit
8 Nacl 0,9%100ml kolf 3 INFANT WARMER Unit
9 Rl,500 ml kolf 4 SUCTOIN Unit
10 Water For Injektion 25 ml kolf 5 BLANKED WARMER Unit
11 Water for Injektion 100 ml kolf NO BHP OT YG CHASKAN Sat JML
No ALAT KESEHATAN Sat JML 1 MASA COUTER PCS
1 Adult infus seet/ blood seet PCS 2 PENSIL COUTER YANG BARU PCS
2 IV Catheter No PCS 3 ALKOHOL70% PCS
IV FILM DRESSING BETHADIN
3 PCS 4 PCS
SOLUTION/POVIDONELODINE
4 ETT No PCS 5 FORMALIN PCS
5 Spinocan No PCS 6 H202 PCS
6 LMA No PCS 7 ULTRAFIX/FIXOMUL 15x5/10x5 CM
7 Suction Tube No PCS
8 Syringe TERUMO1/3/5/10/20/50 PCS
9 Syringe ONE MED 1/3/5/10/20/50 PCS
10 Kanul Nassal /SIMPLEK MASK PCS
11 GUDEL /OPA PCS
12 ALkohol swap PCS
13 PLesterin/Handsaplast PCS

Dipersiapkan oleh DIketahui Oleh PETUGAS OT YG INPUT

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