RSUP DR WAHIDIN SUDIROHUSODO MAKASSAR DR WAHIDIN SUDIROHUSODO PUBLIC GENERAL HOSPITAL PERSETUJUAN PERSETUJUAN TINDAKAN PEMBIUSAN
I&'O*+ ,O&-*&T 'O !&!*-T*-I! I.
II. II.
Consent Bersama ini saya .................................! "r. yan# men#e$a%&asi 'ra anestesia ( memint meminta a 'erset 'erset&)& &)&an an "an *e*en *e*enan# an# &nt&+ &nt&+ me%a+ me%a+&+ &+an an 'em,i& 'em,i&san san &m&m &m&m re#iona% I..................................... hereby request consent consent to authorize authorize the administration of general regional anesthesia during the pending procedure/surgery/treatment procedure/surgery/treatment T&)&an T&)&an tin"a+an +e"o+teran +e"o+teran yan# "i%a+&+an a"a%a///////// ........................................................ The purpose of medical acts performed ////////////............................................................ A%ternati0 %ain &nt&+ 'em,i&san ini a"a%a ............................................................................ Other alternative alternative for for anesthesia anesthesia is : ............................................................................ Resi+ esi+o o "an "an Meto Meto"e "e A%te A%terrnati nati0 0 A%ternati$e Meto"s - Ris+ 1. Saya Saya meny menya" a"ar arii ,a* ,a*a a 'e%a 'e%aya yana nan n "i r&ma r&ma sa+i sa+itt ini ini mer&' mer&'a+ a+an an s&at s&at& & +er)a +er)a tim ! termas termas&+ &+ "o+ter "o+ter "an 'era*a 'era*att aneste anestesi( si( "an ,a*a ,a*asan sanya ya anestesi &nt&+ tin"a+an o'erasi ini a+an "i%a+&+an "i ,a*a 'en#a*asan I uderstand that a team approach for anesthesia care ( included physician and and nurs nurse e anes anesth thes esia ia assi assist stan ance ce ) is used used at this this hosp hospit ital al and and that that anaesthesia for my operation ill be provided under the supervision of "r. "r. /////////////////////S'An Do+ter A%i Anestesi - !nesthesiologist - !nesthesiologist 2. Saya Saya menya" menya"ari ari "an men#er men#erti ti se'en&n se'en&nya ya 'en)e%as 'en)e%asan an "o+ter "o+ter s'esia s'esia%is %is anes aneste tesi si ,a* ,a*a a )eni )enis s 'em, 'em,i& i&sa san n a'a' a'a'&n &n yan# yan# "i%a "i%a+ +&+an &+an se%a se%a%& %& men#an"&n# men#an"&n# ,e,era'a ,e,era'a +onse+ +onse+&ensi &ensi "an resi+o resi+o.. Resi+o esi+o 'otensia% 'otensia% yan# m&n#+in ter)a"i termas&+ 'er&,aan te+anan "ara3 rea+si o,at !a%er#i(3 enti enti )ant&n )ant&n#3 #3 +er&sa+ er&sa+an an ota+3 ota+3 +e%&m +e%&m'& '&an3 an3 +er&s +er&sa+a a+an n sara0 sara0 ,a+a ,a+an n +ematian. Saya menya"ari a% ini "an resi+o serta +om'%i+asi %ain yan# m&n#+in )&#a "a'at ter)a"i. I understand that" regardless of the type of anaesthesia used" there are a number of ris# and consequences that may occur. The ris# include but are not limited to changes in blood pressure" drug reactions" crdiac arrest" brain damage" paralysis" nerve damage and death. I understand that these or other ris# or complications may occur. 4. Saya menya"ari "an men#erti ,a*a "a%am 'ra+te+ i%m& +e"o+ +e"o+ter teran3 an3,&+ ,&+an an mer&'a mer&'a+an +an i%m& i%m& 'en#et 'en#eta& a&an an yan# yan# 'asti 'asti "an saya saya men#erti men#erti ti"a+ seoran#'&n seoran#'&n "a'at men)an)i+an men)an)i+an ata& men)amin ses&at& ses&at& yan# ,er&,&n#an "en#an tin"a+an me"is termas&+ 'em,i&san. I am aare that the practice of anaesthesiology" medicine and surgery is not an e$act science and ac#noledge that no one has given to me any promises or guarantees regarding the e%ectiveness or ris# relating to the administration of anaesthesia. 5. Saya Saya menya"ar menya"arii "an men#ert men#ertii ,a*a ,a*a o,at o,atan o,atan yan# saya saya "a'at+a "a'at+an n se,e%&m 'rose"&r 'em,e"aan "an 'em,i&san "a'at sa)a menim,&%+an +om'%i+a +om'%i+asi si ,a#i 'em,i&san "an 'em,e"aan 'em,e"aan.. O%e +arena it& men)a"i men)a"i +e*a)i,an "an tan##&n# )a*a, saya &nt&+ mem,eri+an in0ormasi +e'a"a "o+ter tentan# sem&a o,at 6 o,atan yan# saya min&m3 termas&+ as'irin3 +ontrase'i3 +ontrase'i3 o,at6o,at 7&3 nar+oti+3 mari)&ana3 +o+ain +o+ain "an %ain %ain. I understand that any medication I am ta#ing may cause complications ith anaesthesia and surgery" I ac#noledge that is my responsibility and
RSUP DR WAHIDIN SUDIROHUSODO MAKASSAR DR WAHIDIN SUDIROHUSODO PUBLIC GENERAL HOSPITAL
in my best interest" to inform my physicians of any medications I am ta#ing including but not limited to aspirin" contraceptives" cold remedies" narcotics" mariuana" and cocaine. 0. Saya te%a mem,a8a 0orm&%ir ini se8ara te%iti3 men#erti "an menyet&)&i 'en)e%asan tentan# tin"a+an yan# a+an "i%a+&+an termas&+ +em&n#+inan +om'%i+asi 9 +om'%i+asi yan# m&n#+in
ter)a"i. O%e se,a, it& saya men#ata+an men#erti isinya "an menerima 'ersyaratan yan# ter8ant&m. Do+ter a%i anestesi te%a ,er"is+&si "en#an saya "an +e%&ar#a tentan# ren8ana anestesia "an a%ternati0 %ain yan# mem&n#+in+an sem&a 'ertanyaan saya te%a ter)a*a, "en#an ,ai+. I have read this form carefully and it has been fully e$plained to me and I certify that I understand its contents and I accepts its terms. y anaesthesiologist has discussed ith me and my family the anesthesia plan and applicable alternatives. !ll my questions have been ansered to my satisfaction.
III. KOMPLIKASI, KONDISI YANG TAK TERDUGA & HASIL YANG DIPEROLEH COMPLICATIONS UNFORSEEN CONDITIONS & RESULTS
Saya menya"ari se'en&nya ,a*a 'a"a tin"a+an me"is3 ,er,a#ai resi+o "an +om'%i+asi yan# ti"a+ "i"&#a se,e%&mnya m&n#+in "a'at tim,&%. Saya )&#a menya"ari ,a*a se%ama ,er%an#s&n#nya tin"a+an terse,&t3 a"a +em&n#+inan tim,&%nya +on"isi +on"isi yan# ti"a+ ter"&#a "imana a% terse,&t memer%&+an tin"a+an tin"a+an 'er%&asan o'erasi yan# ,er&,&n#an "en#an o'erasi yan# se"an# "i%a+&+an: &nt&+ it& saya menyet&)&i "i%a+&+annya tin"a+an terse,&t a'a,i%a "i'er%&+an. Se%an)&tnya3 saya menya"ari ,a*a ti"a+ a"a )aminan ata& )an)i6)an)i yan# "i,eri+an +e'a"a saya se&,&n#an "en#an asi% "ari se#a%a tin"a+an "an ata& 'era*atan. I am a*are tat in te 'ra8ti8e o0 me"i8ine3 oter ≠'e8te" ris+s or 8om'%i8ations not "is8&sse" may o88&r. I a%so &n"erstan" tat "&rin# te 8o&rse o0 te 'ro'ose" 'ro8e"&re!s( &n0oreseen 8on"itions may ,e re$ea%e" re<&irin# te 'er0orman8e o0 'ro8e"&res s'e8i=8a%%y re%ate" to te 8on"ition an" I a&tori>e s&8 'ro8e"&res to ,e 'er0orme".i 0&rter a8+no*%e"#e tat no #&arantee or 'romise a$e ,een #i$en to me 8on8ernin# te res&%ts o0 any 'ro8e"&re. Diset&)&i o%e 'asien - ,onsent/ efuse by patient1 Tem'at- 2lace3 Tan##a% - +ate 33333333"33333333333333333 3333333333333333333333333 33333333333333333333333333 Tan"a Tan#an "an nama ?e%as ! H&r&0 Ba%o+ ( "an Nama ?e%as -ignature and 'ull &ame ( 4loc# 5etter ) 'ull name
33333333333333333333333333.. 3333333333333333333333333
Tan"a Tan#an Sa+si Ke%&ar#a -ignature of 'amily 6itness and
RSUP DR WAHIDIN SUDIROHUSODO MAKASSAR DR WAHIDIN SUDIROHUSODO PUBLIC GENERAL HOSPITAL
Tanda Tangan do#ter dan nama elas dan &ama 7elas
Tanda Tangan -a#si 2iha# -
-ignature of doctor and full bame ( 4loc# 5etters) and full name
-ignature of hospital itness
Bi%a 'asien ,er&sia "i ,a*a 21 ta&n ata& ti"a+ "a'at mem,eri+an 'erset&)&an +arena a%asan %ain!@( ti"a+ "a'at menan"atan#ani s&rat "i atas3 'ia+ R&ma Sa+it men#am,i% +e,i)a+sanaan "en#an mem'ero%e tan"atan#an "ari oran# t&a3 'asan#an3 an##ota +e%&ar#a ter"e+at ata& *a%i "ari 'asien. If the patient is belo 89 years old or nvalid for some other reason(s) unable to sign above consent" the hospital reserves the discretion to obtain the signature of parent" spouse" ne$t of #in or guardian of the patient 17elas#an alasan lainya/-pecify other reasons(s) 6666666666666666666666666666666666666666666666666666666666666666666666666666
Saya oran# t&a-'asan#an-+e%&ar#a ter"e+at-*a%i !8oret yan# ti"a+ 'er%&( "ari 'asien ///////// I te 'arent-s'o&se-ne;t o0 +in" #&ar"ian ! "e%ete *ere a''%i8a,%e ( o0 te 'atient//////////
Mem,enar+an ,a*a saya memi%i+i a+ &nt&+ menerima se#a%a +on"isi %an)&tan atas nama 'asien Con=rm tat I a$e te a&tority to so#n te 8onsent 0orm on ,ea%0 o0 te 'atient Te%a mem,a8a3 memaami "an menerima sem&a in0ormasi 'a"a 0orm 'erset&)&an ini. Ha$e rea"3 &n"erstan" an" a88e't a%% in0ormation on tis 8onsent 0orm Memasti+an ,a*a saya te%a "i,eri 'en)e%asan "an men#erti "en#an ,ai+ tentan# tin"a+an terse,&t Co=rm tat I a$e ,een e;'%aine" an" 0&%%y &n"erstan" a,o&t te treatent-'ro8e"&re to ,e 'er0orme". Tem'at-P%a8e3 Tan##a%-Date /////.3////////////// //////////////////// ///////////////////.. Tan"a Tan#an "an Nama ?e%as ! &r&0 ,a%o+( Sa+si 1 "an Nama ?e%as -iganture and 'ull &ame ( 4loc# 5etter ) and full name
3333333333333333333333.. 3333333333333333333333
Tan"a Tan#an -ignature of itness 9
RSUP DR WAHIDIN SUDIROHUSODO MAKASSAR DR WAHIDIN SUDIROHUSODO PUBLIC GENERAL HOSPITAL
Tanda Tangan +o#ter dan &ama 7elas ( huruf balo#) -a#si 8 dan &ama 7elas -ignature of +octor and 'ull &ame ( 4loc# 5etter ) and full name
Tanda Tangan -ignature of itness 8
