RUMAH SAKIT RIZANI

JL. Raya Surabaya Situbondo KM. 135 Desa Sumberrejo

Kecamatan Paiton Kabupaten Probolingo
Telpon (0335) 773444 Faximile (0335) 774556 Email : rizani.rs@gmail.com

FORMULIR LAPORAN PAPARAN BENDA TAJAM DN SUBSTANSI TUBUH

BAGIAN A (diisi oleh petugas/ staff yang terpapar)
Tgl. Laporan : ................................. Jam : .... : .... WIB Tgl. Laporan : ................................. Jam : .... : .... WIB
Unit/ instalasi: .............................................................. Tempat Kejadian : ........................................................
Koordinator : ............................................................... Bagian Tubuh Yang Terpapar (sebut dengan jelas) :
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IDENTITAS TERPAPAR
Nama : ............................................................... Jelaskan Kronologi Kejadian :
Alamat : ............................................................... ......................................................................................
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Memakai APD : Ya Tidak ......................................................................................
APD yang dipakai : ......................................................................................
HandScone Apron Masker ......................................................................................
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Google/ Kacamata/ Pelindung Wajah ......................................................................................
Lainnya : .................................................................. ......................................................................................

Staff Terpapar
Imunisasi Hepatitis B :
Ya (Lengkap) Ya (Tidak Lengkap) Tidak
Pertolongan Pertama :
Dilakukan Tidak Dilakukan (................................................)
BAGIAN B (diisi oleh IPCN/ Supervisor)
Tgl. Periksa : .................................. Jam : .... : .... WIB Jenis Paparan :
Diperiksa oleh : ............................................................
Kondisi Luka (besarnya luka/dalamnya luka) :
Jarum Suntik Pisau Bedah Gigitan
...................................................................................... Lainnya, sebutkan : .................................................
......................................................................................
...................................................................................... Hasil Pemeriksaan Laboratorium :
Materi dan Jumlah Paparan :
Darah : ........................... cc HBSAg : .....................................................................

Serum/ plasma : ........................... cc Anti HIV : .....................................................................

Lainnya, sebutkan : ................................................. Anti HCV : ....................................................................
Status Infeksius :
Resiko Paparan : SUMBER (PASIEN)
Hepatitis B HIV
Resiko Paparan Rendah Hepatitis C
Resiko Paparan Tinggi Tempel stiker ID disini
Tidak diketahui (+) ......................
Tidak diketahui (-) .......................
PENATALAKSANAAN
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HIV : .................. Rujuk ke RS : ...................................
FOLLOW UP
3 Bulan 6 Bulan
Hasil HBSAg : .............................................................. Hasil HBSAg : ..............................................................
SARAN :
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Paiton, .................................................
IPCN

Virnia Nourma Sutrisno, S.Kep.,Ners