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Monitoring Anestesi dan Informed Consent

Dokumen tersebut berisi tentang formulir monitoring evaluasi anestesi, persetujuan tindakan medis, persetujuan rujukan, dan pilihan tempat rujukan yang digunakan oleh Klinik Pratama Rawat Inap dan Bersalin Muhammadiyah Kemlagi.

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Herminofa Irsyad
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13 tayangan4 halaman

Monitoring Anestesi dan Informed Consent

Dokumen tersebut berisi tentang formulir monitoring evaluasi anestesi, persetujuan tindakan medis, persetujuan rujukan, dan pilihan tempat rujukan yang digunakan oleh Klinik Pratama Rawat Inap dan Bersalin Muhammadiyah Kemlagi.

Diunggah oleh

Herminofa Irsyad
Hak Cipta
© All Rights Reserved
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Format Tersedia
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KLINIK PRATAMA RAWAT INAP DAN BERSALIN

MUHAMMADIYAH KEMLAGI
JL. Raya Jetis – Kemlagi, Ds. Mojokumpul, Kec. Kemlagi, Kab Mojokerto.
Telp. (0321) 3714051, email : myclinicmujahidin1@[Link]

MONITORING EVALUASI ANESTESI

Nama Pasien :........................... L / P


No. RM
Tanggal Lahir :...................................

Diagnosa Medis :
Nama Tindakan :
Tanggal :
Tindakan
Obat Anestesi D Lidocaine 2 % Pehacain 2% Chlor ethyl spray
D D
D Lain-lain:
PRE TINDAKAN DURANTE TINDAKAN POST TINDAKAN
Keadaan Umum : Jam TD Nadi Keadaan Umum :
GCS : Tindakan (mmHg) (x/menit) GCS :
Tanda-tanda vital Tanda-tanda vital
TD : mmHg TD : mmHg
Nadi : x/menit Nadi : x/menit
Riwayat Alergi : Skala nyeri :
D Tidak ada nyeri : 0
D Nyeri ringan :1–3
D Nyeri sedang :4–6
D Nyeri berat :7–9
D Nyeri sangat : 10
berat
Tindak lanjut perawatan
D MRS
D Pulang
Kontrol :

Dokter Operator Perawat


KLINIK PRATAMA RAWAT INAP DAN BERSALIN
MUHAMMADIYAH KEMLAGI
JL. Raya Jetis – Kemlagi, Ds. Mojokumpul, Kec. Kemlagi, Kab Mojokerto.
Telp. (0321) 3714051, email : myclinicmujahidin1@[Link]

INFORMED CONSENT PERSETUJUAN / PENOLAKAN TINDAKAN MEDIS

Saya yang bertanda tangan dibawah ini :


Nama : ........................................................................................................................
Umur : ........................................................................................................................
Jenis Kelamin : ........................................................................................................................
Alamat : ........................................................................................................................
No. KTP : ........................................................................................................................

Dengan ini menyatakan dengan sesungguhnya telah memberikan :

PERSETUJUAN / PENOLAKAN*

Untuk dilakukan tindakan medis berupa ....................................................................................


terhadap : Diri Sendiri / Orang Tua / Istri / Suami / Anak* yang tersebut dibawah ini :
Nama : ........................................................................................................................
Umur : ........................................................................................................................
Jenis Kelamin : ........................................................................................................................
Alamat : ........................................................................................................................
No. KTP : ........................................................................................................................

Yang tujuan, sifat dan perlunya tindakan medis tersebut di atas, serta resiko yang dapat
ditimbulkan telah cukup dijelaskan oleh dokter ataupun petugas setempat dan telah saya
mengerti sepenuhnya.

Demikian pernyataan persetujuan ini saya buat dengan penuh kesadaran dan tanpa paksaan

Mojokerto , …………............
Dokter yang memeriksa Petugas Yang membuat pernyataan.

(………………………..) (………………………..) (………………………….)

Saksi I Keluarga paien/Saksi II

(………………………..) (………………………..)

*Coret yang tidak perlu


KLINIK PRATAMA RAWAT INAP DAN BERSALIN
MUHAMMADIYAH KEMLAGI
JL. Raya Jetis – Kemlagi, Ds. Mojokumpul, Kec. Kemlagi, Kab Mojokerto.
Telp. (0321) 3714051, email : myclinicmujahidin1@[Link]

INFORMED CONSENT RUJUKAN


Saya yang bertanda tangan dibawah ini :
Nama : ..................................................................................................................................
Umur : ..................................................................................................................................
Jenis Kelamin : ..................................................................................................................................
Alamat : ..................................................................................................................................

Dengan ini menyatakan dengan sesungguhnya telah memberikan :

PERSETUJUAN

Untuk dilakukan rujukan terhadap diri Sendiri / Orang Tua / Istri / Suami / Anak* yang tersebut
dibawah ini :
Nama : ..................................................................................................................................
Umur : ..................................................................................................................................
Jenis Kelamin : ..................................................................................................................................
Alamat : ..................................................................................................................................

Kami telah mendapatkan penjelasan dan telah mengerti mengenai alasan dilakukan rujukan,
kemungkinan yang terjadi selama rujukan dan resiko jika rujukan tidak dilakukan. Demikian
pernyataan ini kami buat dengan sebenar-benarnya tanpa ada paksaan dari siapapun.

Mojokerto,............................

Petugas Yang Membuat Pernyataan

(........................................) (........................................)

Saksi/ Keluarga

(........................................)

*Coret yang tidak perlu


KLINIK PRATAMA RAWAT INAP DAN BERSALIN
MUHAMMADIYAH KEMLAGI
JL. Raya Jetis – Kemlagi, Ds. Mojokumpul, Kec. Kemlagi, Kab Mojokerto.
Telp. (0321) 3714051, email : myclinicmujahidin1@[Link]

INFORMED CHOICE PILIHAN TEMPAT RUJUKAN


Saya yang bertanda tangan dibawah ini :
Nama : ..................................................................................................................................
Umur : ..................................................................................................................................
Jenis Kelamin : ..................................................................................................................................
Alamat : ..................................................................................................................................

Dengan ini menyatakan setuju terhadap diri Sendiri / Orang Tua / Istri / Suami / Anak* yang
tersebut dibawah ini :
Nama : ..................................................................................................................................
Umur : ..................................................................................................................................
Jenis Kelamin : ..................................................................................................................................
Alamat : ..................................................................................................................................
Diagnosa : ........................................................................................................................

Dirujuk ke Rumah Sakit : 1. RSI Hasanah 3. RS Mutiara Hati


2. RS Gatoel 4. RS Emma
3. RSUD Basoeni 5. .....................................................

Mojokerto,............................

Petugas I Yang Membuat Pernyataan


(Dokter/Bidan/Perawat)

(........................................) (........................................)

Petugas II

(........................................)

*Coret yang tidak perlu

Common questions

Didukung oleh AI

If a patient does not follow through with a recommended referral, potential risks include deterioration of their medical condition, delayed treatment, and complications due to lack of specialized care available at the referral institution. These outcomes can lead to increased healthcare costs and diminished quality of life, as well as possible legal ramifications if non-compliance results in preventable harm .

Consenting to a medical procedure involves understanding the nature, risks, and benefits of the treatment and giving voluntary approval for it to proceed. On the other hand, choosing a referral hospital involves evaluating multiple potential hospitals based on criteria such as specialization in the required treatment, location, and available facilities, ensuring the patient receives appropriate care based on their diagnosis .

When assessing a patient's condition before, during, and after a medical procedure, elements such as general condition, Glasgow Coma Scale (GCS), vital signs like blood pressure (TD) and pulse rate (nadi), and pain scale should be considered. Pre, durante, and post-procedure evaluations include monitoring these parameters to ensure patient safety and to evaluate the need for further medical intervention .

The absence of informed consent can adversely affect patient care by violating patient autonomy and potentially subjecting them to unauthorized treatments, which might lead to mistrust and harm. Legally, it can result in lawsuits against healthcare providers for performing procedures without documented patient approval, increasing liability and reputational risks for the healthcare institution .

Informed consent protects patients by ensuring they understand the purpose, nature, risks, and benefits of a medical procedure, thereby enabling them to make an informed decision. It protects healthcare providers by serving as a documented agreement that the patient was given adequate information and agreed to the procedure voluntarily, reducing legal liability risks .

Documenting a patient's choice for a referral hospital is important as it ensures that the referral aligns with the patient's preferences and medical needs. This transparency in the decision-making process helps in maintaining trust, accountability, and continuity of care. It reduces misunderstandings and legal disputes about whether the chosen institution was appropriate for the patient's condition .

A patient's decision to allow or deny consent for a medical procedure could be influenced by factors such as their level of understanding of the procedure, perceived risks versus benefits, personal and cultural beliefs, past medical experiences, trust in the healthcare provider, and advice from family or friends .

To grant informed consent for a medical procedure, a patient must provide their name, age, gender, address, and identification number. Additionally, the consent must clarify whether it pertains to themselves or a relative and confirm the patient's understanding of the nature, purpose, and risks of the procedure .

Witnesses during the informed consent process are responsible for verifying that the patient has been duly informed and is voluntarily consenting without coercion. They confirm the authenticity of the patient's signature, ensuring the integrity of the consent process. Witnesses also provide a neutral observation that can be pivotal in legal contexts to affirm that all procedural requirements were met .

Healthcare providers should clearly explain the procedure, including its purpose, risks, and benefits, ensuring that the patient comprehends the information. Documentation should include the patient's name, age, gender, address, and an affirmation of understanding. The patient should sign the consent form in the presence of witnesses and healthcare staff to legitimize the document .

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