7/17/2019 Form Penundan Operasi Pab

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PEMERINTAH PROVINSI JAWA TIMUR

DINAS KESEHATAN

UPT RUMAH SAKIT KUSTA SUMBERGLAGAH

Dsn. Sumberglagah, Ds. Tanjungen!ng! " Pa#e$ , M!j!er$! Tel% &'()*+ -'*, -'*' /a0.&'()*+ -'*(1 2!3e P!s *(1

FORMULIR PENUNDAAN OPERASI

Pembatalan untuk

rencana operasi   : ..................................................................................................................:ari : ..................................... : !an""al: : .....................................

Nama : ..................................... #am : .....................................!an""al La$ir : ..................................... Umur : ......................L%PAsal Ruan"an : ..................................... No.RM : .....................................Dia "nosa : ..................................... :!in&akan : ..................................... Anast$esi : .....................................Operator : ..................................... :Alasan ' alasan penun&aan :

Menstruasi (elainan kar&iolo"i

Panas !i&ak &atan")atuk% Pilek )elum masuk ruan" pera*atan!ensi tin""i !i&ak ter&a+tar&alam acara  Menolak Sala$ men"a,ukan rencana  ) - / "r 0 ...................................................................

OperatorDinas luar% ber$alan"an ..................................................................!erlambat &atan" ..................................................................

Fasilitas(amar Operasi A1 mati :................................................................................................

Listrik mati :..........................................................................................O2 $abis.................................................................................................Ruan" Pera*atan

Surat i3in operasi ti&ak a&a Persiapan operasi belum len"kap

!i&ak a&a Pemeriksaan $asil labPemeriksaan pen4akit &alamasil +oto ront"enPersiapan &ara$)elum &icukur

(e$abisan pakaian operasi(e$abisan 5as% &eppers sterilLain6lain...................................................................................................................

)eri tan&a 7

Sumber"la"a$8...............................................Penan""un",a*ab O(

9.................................................................  NIP

/M4RM4 '5 4