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Nama Pasien Lengkap

Jenis Kelamin Pasien

Tanggal Lahir Pasien

No Rekam Medis

Tempat Tindakan

Tindakan :

Tanggal Tindakan :

Jam Tindakan :

Diagnosis Pra Tindakan

Diagnosisi Pasca Tindakan :

Operator

Asisten I :

Asisten II :

Rencana Tindakan :

Indikasi Tindakan :

Tindakan Terlaksana :

A. PRA TINDAKAN

B. MONITORING INTRA OPERASI

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 <tbody><tr style="mso-yfti-irow:0;mso-yfti-firstrow:yes;height:11.8pt">
 <td width="151" valign="top" style="width:112.95pt;border-top:solid windowtext 1.0pt;
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 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:11.8pt">
 Anestetikum                                                        
 <o:p></o:p>
 </td>
 <td width="151" colspan="3" valign="top" style="width:113.25pt;border:none;
 border-top:solid windowtext 1.0pt;mso-border-top-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:11.8pt">
 :  <span lang="IN" style="font-size:10.0pt;font-family:Symbol;mso-ascii-font-family:
 " times="" new="" roman";mso-hansi-font-family:"times="" roman";mso-bidi-font-family:="" "times="" roman";mso-ansi-language:in;mso-char-type:symbol;mso-symbol-font-family:="" symbol"="">ð  Pehacaine<o:p></o:p>
 </td>
 <td width="445" colspan="10" valign="top" style="width:333.75pt;border-top:solid windowtext 1.0pt;
 border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:11.8pt">
 :  -................................................................   Ampul / ml<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:1;height:11.95pt">
 <td width="151" valign="top" style="width:112.95pt;border:none;border-left:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:11.95pt">
  <o:p></o:p>
 </td>
 <td width="151" colspan="3" valign="top" style="width:113.25pt;border:none;
 padding:0cm 5.4pt 0cm 5.4pt;height:11.95pt">
    <span lang="IN" style="font-size:10.0pt;font-family:Symbol;mso-ascii-font-family:
 " times="" new="" roman";mso-hansi-font-family:"times="" roman";mso-bidi-font-family:="" "times="" roman";mso-ansi-language:in;mso-char-type:symbol;mso-symbol-font-family:="" symbol"="">ð  Lidocaine<o:p></o:p>
 </td>
 <td width="445" colspan="10" valign="top" style="width:333.75pt;border:none;
 border-right:solid windowtext 1.0pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:11.95pt">
 :  -.................................................................. Ampul / ml     
 </td>
 </tr>
 <tr style="mso-yfti-irow:2;height:13.75pt">
 <td width="151" valign="top" style="width:112.95pt;border:none;border-left:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.75pt">
  
 </td>
 <td width="151" colspan="3" valign="top" style="width:113.25pt;border:none;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
    <span lang="IN" style="font-size:10.0pt;font-family:Symbol;mso-ascii-font-family:
 " times="" new="" roman";mso-hansi-font-family:"times="" roman";mso-bidi-font-family:="" "times="" roman";mso-ansi-language:in;mso-char-type:symbol;mso-symbol-font-family:="" symbol"="">ð  Scandonest 2 %<o:p></o:p>
 </td>
 <td width="445" colspan="10" valign="top" style="width:333.75pt;border:none;
 border-right:solid windowtext 1.0pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
 :
 .-................................................................... Ampul / ml<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:3;height:13.75pt">
 <td width="151" valign="top" style="width:112.95pt;border:none;border-left:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.75pt">
  
 </td>
 <td width="151" colspan="3" valign="top" style="width:113.25pt;border:none;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
    <span lang="IN" style="font-size:10.0pt;font-family:Symbol;mso-ascii-font-family:
 " times="" new="" roman";mso-hansi-font-family:"times="" roman";mso-bidi-font-family:="" "times="" roman";mso-ansi-language:in;mso-char-type:symbol;mso-symbol-font-family:="" symbol"="">ð  Scandonest 3 % <o:p></o:p>
 </td>
 <td width="445" colspan="10" valign="top" style="width:333.75pt;border:none;
 border-right:solid windowtext 1.0pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
 :
 .-.................................................................    Ampul / ml<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:4;height:13.75pt">
 <td width="151" valign="top" style="width:112.95pt;border:none;border-left:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.75pt">
  
 </td>
 <td width="151" colspan="3" valign="top" style="width:113.25pt;border:none;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
   <span lang="IN" style="font-size:10.0pt;font-family:Symbol;mso-ascii-font-family:
 " times="" new="" roman";mso-hansi-font-family:"times="" roman";mso-bidi-font-family:="" "times="" roman";mso-ansi-language:in;mso-char-type:symbol;mso-symbol-font-family:="" symbol"="">ð...............................<o:p></o:p>
 </td>
 <td width="445" colspan="10" valign="top" style="width:333.75pt;border:none;
 border-right:solid windowtext 1.0pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
 :
 .....................................................................Ampul / ml<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:5;height:13.75pt">
 <td width="151" valign="top" style="width:112.95pt;border:none;border-left:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.75pt">
 Tehnik Anestesi<o:p></o:p>
 </td>
 <td width="151" colspan="3" valign="top" style="width:113.25pt;border:none;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
 :  <span lang="IN" style="font-size:10.0pt;font-family:Symbol;mso-ascii-font-family:
 " times="" new="" roman";mso-hansi-font-family:"times="" roman";mso-bidi-font-family:="" "times="" roman";mso-ansi-language:in;mso-char-type:symbol;mso-symbol-font-family:="" symbol"="">ð Blok<o:p></o:p>
 </td>
 <td width="445" colspan="10" valign="top" style="width:333.75pt;border:none;
 border-right:solid windowtext 1.0pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
 <span lang="IN" style="font-size:10.0pt;font-family:Symbol;
 mso-ascii-font-family:" times="" new="" roman";mso-hansi-font-family:"times="" roman";="" mso-bidi-font-family:"times="" roman";mso-ansi-language:in;mso-char-type:="" symbol;mso-symbol-font-family:symbol"="">ð  Perisemental / Intraligamen<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:6;height:13.75pt">
 <td width="151" valign="top" style="width:112.95pt;border:none;border-left:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.75pt">
  
 </td>
 <td width="151" colspan="3" valign="top" style="width:113.25pt;border:none;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
    <span lang="IN" style="font-size:10.0pt;font-family:Symbol;mso-ascii-font-family:
 " times="" new="" roman";mso-hansi-font-family:"times="" roman";mso-bidi-font-family:="" "times="" roman";mso-ansi-language:in;mso-char-type:symbol;mso-symbol-font-family:="" symbol"="">ð Infiltrasi<o:p></o:p>
 </td>
 <td width="445" colspan="10" valign="top" style="width:333.75pt;border:none;
 border-right:solid windowtext 1.0pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
 <span lang="IN" style="font-size:10.0pt;font-family:Symbol;
 mso-ascii-font-family:" times="" new="" roman";mso-hansi-font-family:"times="" roman";="" mso-bidi-font-family:"times="" roman";mso-ansi-language:in;mso-char-type:="" symbol;mso-symbol-font-family:symbol"="">ð  Intrapulpa<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:7;height:13.75pt">
 <td width="151" valign="top" style="width:112.95pt;border-top:none;border-left:
 solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt;border-right:
 none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
 Lokasi<o:p></o:p>
 </td>
 <td width="151" colspan="3" valign="top" style="width:113.25pt;border:none;
 border-bottom:solid windowtext 1.0pt;mso-border-bottom-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
 : Perut
 </td>
 <td width="445" colspan="10" valign="top" style="width:333.75pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.75pt">
  
 </td>
 </tr>
 <tr style="mso-yfti-irow:8;height:13.5pt">
 <td width="160" colspan="2" valign="top" style="width:119.95pt;border-top:none;
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 mso-background-themecolor:background1;mso-background-themeshade:217;
 padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
 Waktu <o:p></o:p>
 </td>
 <td width="38" valign="top" style="width:28.3pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
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 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 <td width="157" colspan="2" valign="top" style="width:117.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 <td width="74" valign="top" style="width:55.25pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:#D9D9D9;mso-background-themecolor:background1;mso-background-themeshade:
 217;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
  
 </td>
 </tr>
 <tr style="mso-yfti-irow:9;height:13.5pt">
 <td width="160" colspan="2" valign="top" style="width:119.95pt;border-top:none;
 border-left:solid black 1.0pt;mso-border-left-themecolor:text1;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;mso-border-left-alt:
 solid black .5pt;mso-border-left-themecolor:text1;background:white;
 mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;height:
 13.5pt">
 Nadi<o:p></o:p>
 </td>
 <td width="38" valign="top" style="width:28.3pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="157" colspan="2" valign="top" style="width:117.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="74" valign="top" style="width:55.25pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 </tr>
 <tr style="mso-yfti-irow:10;height:13.5pt">
 <td width="160" colspan="2" valign="top" style="width:119.95pt;border-top:none;
 border-left:solid black 1.0pt;mso-border-left-themecolor:text1;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;mso-border-left-alt:
 solid black .5pt;mso-border-left-themecolor:text1;background:white;
 mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;height:
 13.5pt">
 Respirasi<o:p></o:p>
 </td>
 <td width="38" valign="top" style="width:28.3pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="157" colspan="2" valign="top" style="width:117.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="74" valign="top" style="width:55.25pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 </tr>
 <tr style="mso-yfti-irow:11;height:13.5pt">
 <td width="160" colspan="2" valign="top" style="width:119.95pt;border-top:none;
 border-left:solid black 1.0pt;mso-border-left-themecolor:text1;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;mso-border-left-alt:
 solid black .5pt;mso-border-left-themecolor:text1;background:white;
 mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;height:
 13.5pt">
 Tekanan Darah<o:p></o:p>
 </td>
 <td width="38" valign="top" style="width:28.3pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="157" colspan="2" valign="top" style="width:117.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="74" valign="top" style="width:55.25pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 </tr>
 <tr style="mso-yfti-irow:12;height:13.5pt">
 <td width="160" colspan="2" valign="top" style="width:119.95pt;border-top:none;
 border-left:solid black 1.0pt;mso-border-left-themecolor:text1;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;mso-border-left-alt:
 solid black .5pt;mso-border-left-themecolor:text1;background:white;
 mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;height:
 13.5pt">
 Suhu<o:p></o:p>
 </td>
 <td width="38" valign="top" style="width:28.3pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="157" colspan="2" valign="top" style="width:117.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="74" valign="top" style="width:55.25pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 </tr>
 <tr style="mso-yfti-irow:13;height:13.5pt">
 <td width="160" colspan="2" valign="top" style="width:119.95pt;border-top:none;
 border-left:solid black 1.0pt;mso-border-left-themecolor:text1;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;mso-border-left-alt:
 solid black .5pt;mso-border-left-themecolor:text1;background:white;
 mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;height:
 13.5pt">
 Skala Nyeri<o:p></o:p>
 </td>
 <td width="38" valign="top" style="width:28.3pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="157" colspan="2" valign="top" style="width:117.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="36" valign="top" style="width:27.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="42" valign="top" style="width:31.5pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 <td width="74" valign="top" style="width:55.25pt;border-top:none;border-left:
 none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid windowtext .5pt;
 mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 background:white;mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
  
 </td>
 </tr>
 <tr style="mso-yfti-irow:14;mso-yfti-lastrow:yes;height:6.95pt">
 <td width="747" colspan="14" valign="top" style="width:559.95pt;border-top:none;
 border-left:solid black 1.0pt;mso-border-left-themecolor:text1;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;mso-border-left-alt:
 solid black .5pt;mso-border-left-themecolor:text1;background:white;
 mso-background-themecolor:background1;padding:0cm 5.4pt 0cm 5.4pt;height:
 6.95pt">
 
 </td>
 </tr>
</tbody></table>

C. PASKA TINDAKAN

<table class="MsoTableGrid" border="1" cellspacing="0" cellpadding="0" width="747" style="margin-left: -8.8pt; border: none;">
 <tbody><tr style="mso-yfti-irow:0;mso-yfti-firstrow:yes;height:15.75pt">
 <td width="132" valign="top" style="width:99.15pt;border-top:solid windowtext 1.0pt;
 border-left:solid windowtext 1.0pt;border-bottom:none;border-right:none;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt">
 Jam                                                             <o:p></o:p>
 </td>
 <td width="271" valign="top" style="width:203.05pt;border:none;border-top:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:15.75pt">
 : -....................................................<o:p></o:p>
 </td>
 <td width="69" valign="top" style="width:52.0pt;border:none;border-top:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:15.75pt">
 Tekanan Darah<o:p></o:p>
 </td>
 <td width="274" valign="top" style="width:205.75pt;border-top:solid windowtext 1.0pt;
 border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.75pt">
 : -............................mmHg<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:1;height:15.75pt">
 <td width="132" valign="top" style="width:99.15pt;border:none;border-left:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:15.75pt">
 Kesadaran<o:p></o:p>
 </td>
 <td width="271" valign="top" style="width:203.05pt;border:none;padding:0cm 5.4pt 0cm 5.4pt;
 height:15.75pt">
 : .-.................................................<o:p></o:p>
 </td>
 <td width="69" valign="top" style="width:52.0pt;border:none;padding:0cm 5.4pt 0cm 5.4pt;
 height:15.75pt">
 Suhu<o:p></o:p>
 </td>
 <td width="274" valign="top" style="width:205.75pt;border:none;border-right:solid windowtext 1.0pt;
 mso-border-right-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:15.75pt">
 :.-............................... 0C<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:2;height:13.5pt">
 <td width="132" valign="top" style="width:99.15pt;border:none;border-left:solid windowtext 1.0pt;
 mso-border-left-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
 Respirasi<o:p></o:p>
 </td>
 <td width="271" valign="top" style="width:203.05pt;border:none;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
 : .-.......................................... x/menit<o:p></o:p>
 </td>
 <td width="69" valign="top" style="width:52.0pt;border:none;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
 Skala Nyeri<o:p></o:p>
 </td>
 <td width="274" valign="top" style="width:205.75pt;border:none;border-right:solid windowtext 1.0pt;
 mso-border-right-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;
 height:13.5pt">
   : .-........................<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:3;height:16.5pt">
 <td width="132" valign="top" style="width:99.15pt;border:none;border-left:solid black 1.0pt;
 mso-border-left-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;padding:0cm 5.4pt 0cm 5.4pt;height:16.5pt">
 Nadi<o:p></o:p>
 </td>
 <td width="271" valign="top" style="width:203.05pt;border:none;padding:0cm 5.4pt 0cm 5.4pt;
 height:16.5pt">
 : .-..........................................  x/menit<o:p></o:p>
 </td>
 <td width="344" colspan="2" valign="top" style="width:257.75pt;border:none;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-right-alt:
 solid black .5pt;mso-border-right-themecolor:text1;padding:0cm 5.4pt 0cm 5.4pt;
 height:16.5pt">
  
 </td>
 </tr>
 <tr style="mso-yfti-irow:4;mso-yfti-lastrow:yes;height:13.5pt">
 <td width="747" colspan="4" valign="top" style="width:559.95pt;border-top:none;
 border-left:solid black 1.0pt;mso-border-left-themecolor:text1;border-bottom:
 solid windowtext 1.0pt;border-right:solid black 1.0pt;mso-border-right-themecolor:
 text1;mso-border-left-alt:solid black .5pt;mso-border-left-themecolor:text1;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid black .5pt;
 mso-border-right-themecolor:text1;padding:0cm 5.4pt 0cm 5.4pt;height:13.5pt">
 Tindak Lanjut 
 :   <span lang="IN" style="font-size:10.0pt;font-family:Symbol;mso-ascii-font-family:" times="" new="" roman";="" mso-hansi-font-family:"times="" roman";mso-bidi-font-family:"times="" mso-ansi-language:in;mso-char-type:symbol;mso-symbol-font-family:symbol"="">ð  Pulang       <span lang="IN" style="font-size:
 10.0pt;font-family:Symbol;mso-ascii-font-family:" times="" new="" roman";mso-hansi-font-family:="" "times="" roman";mso-bidi-font-family:"times="" roman";mso-ansi-language:="" in;mso-char-type:symbol;mso-symbol-font-family:symbol"="">ð  Rawat Inap di-   ....................................................<o:p></o:p>
 </td>
 </tr>
</tbody></table>

INTRUKSI PASCA TINDAKAN

PEMANTAUAN ANESTESI LOKAL