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LAPORAN PEMBEDAHAN



No. RM



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



Tanggal Lahir : ...................................................



Nama Pasien : .......................... .................................................



Jenis Kelamin : ....................................................



Dokter Ahli Bedah Asisten



: ......... ............................................ Dokter Ahli Anestesiologi : .............................................. :........ ............................................ Jenis Anestesi



Diagnosa Pra Bedah



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



: .......... ............................................ Tanggal Pembedahan



Diagnosa Pasca Bedah : ........... ............................................ Lama Pembedahan Tindakan Pembedahan :



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



Klasifikasi:



1 ............................................................ 2 ............................................................



□ Emergency



□ Mayor



3 ............................................................



□ Efektif



□ Medium



4 ..................................................



□ Poliklinik



□ Minor



URAIAN PEMBEDAHAN (Sesuai dengan Pedoman)



Jaringan ke Patologi



Asal Jaringan



Dokter Ahli Bedah



Ya, tanggal □



Tidak (



) Nama Jelas & Tanda Tangan