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RSUD BOLMUT

Nomor RM : …………….........................................
Jl. Talaga tomoagu kec.bolangitang barat
Kodepos 95764

ANESTHESIA RECORD
Nama Pasien :
Tanggal Lahir :

DATE REMARKS MONITORING


TIME am pm
Stethoscope:Eshoph Pre
ECG Doppler Dinamap
Bp Cuff Radial Line
T Esoph Rectal Tymp
CVP Sp02 ETC0

CHART CODE ⁰C 240

42 220
Oper
41 200
Anesth ×
40 180
Resp.
39 160
Pulse
38 140
BP
37 120
Intub T
36 100
Extub _I_
35 80

34 60

33 40

32 20

PREMEDICATION
FLUIDS

Position :
Regional Block :
Urine cc Spinal Epidural
NG Tube cc Caudal Axillary
Proposed Operation Agent :
Operation
Pre- op Daignosis Needle Gauge :
Post-op Diagnosis Interspace :
Surgeons Dermatome Level :
Anesthetist Paresthesia: Yes No
INTAKE TOTAL
Dokter Anestesi
OUTPUT TOTAL

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(Tanda tangan dan nama jelas)

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