FORM CHECKLIST BEDAH UMUM

NO. NAMA BHP JUMLAH KETERANGAN CHECKLIST

1 Apron 3
2 Aquabidest 2
3 Benang T-Chromic No. 1-0 3
4 Benang T-Chromic No. 3-0 3
5 Benang T-Nylon No. 2-0 3
6 Benang T-Nylon No. 3-0 3
7 Benang T-Vio No. 1-0 3
8 Benang T-Vio No.3-0 3
9 Handscoon Nitril 12
10 Handscoon Steril No. 6½ 1
11 Handscoon Steril No. 7½ 4
12 Handscoon Steril No. 8 1
13 Infusan Nacl 500ml 2
14 Infusan RL 500ml 2
15 Masker Karet 7
16 Nasal Kanul O2 Dewasa 1
17 NGT No. 16 1
18 Spinocan No. 25G 1
19 Spuit 10 cc 3
20 Spuit 3 cc 2
21 Spuit 5 cc 2
22 Surgical Blade No. 15 1
23 Surgical Blade No.21 1
24 ThreeWay Biasa 1
25 Topi Operasi 4
26 T-Scrub Brush 3
27 Under Pad 2
28 Urin Kateter No. 16 1
29 Urine Bag 1
30 Hernia Mesh 1 additional

NO. NAMA OBAT JUMLAH KETERANGAN CHECKLIST

1 Atracurium Inj 1 Kulkas
2 Atropin Sulfas Inj 5
3 Bucain Inj 1
4 Dexamethason Inj 2
5 Ephedrin Inj 1 Lemari narkotik
6 Fenthanyl Inj 2 Lemari narkotik
7 Fortanes Inj 1 Lemari narkotik
8 Infusan Fimahest 2
9 Kalnex Inj 1
10 Ketamin Inj (KTM) 1 Lemari narkotik
11 Ketorolac Inj 3
12 Nokoba Inj 1
13 Ondansetron 4mg Inj 2
14 Phetidin Inj 1 Lemari narkotik
15 Pronalges Suppo 1 Kulkas
16 Ranitidine Inj 2
17 Recofol Inj 1 Kulkas
Pangkalan Bun..................................
Mengetahui,
Perawat/Bidan Apoteker/Asisten Apoteker

............................ ................................
 FORM CHECKLIST BEDAH OBGYN
NO. NAMA BHP JUMLAH KETERANGAN CHECKLIST
1 Apron 3
2 Aquabidest 2
3 Benang T-Chromic No. 1-0 3
4 Benang T-Chromic No. 3-0 3
5 Benang T-Mono No. 0-0 3
6 Benang T-Mono No.3-0 3
7 Dermafix-T 10x25cm 1
8 Gurita Ibu 1
9 Handscoon Nitril 12
10 Handscoon Steril No. 7 1
11 Handscoon Steril No. 7½ 3
12 Handscoon Steril No. 8 1
13 Infusan Nacl 500ml 2
14 Infusan RL 500ml 2
15 Jarik 1
16 Kendi 1
17 Masker Karet 8
18 Nasal Kanul O2 Dewasa 1
19 NGT No. 16 1
20 Spinocan No. 25G 2
21 Spuit 10 cc 3
22 Spuit 3 cc 2
23 Spuit 5 cc 2
24 Surgical Blade No.21 1
25 ThreeWay Biasa 1
26 Topi Operasi 3
27 T-Scrub Brush 3
28 Under Pad 2
29 Urin Kateter No. 16 1
30 Urine Bag 1

NO. NAMA OBAT JUMLAH KETERANGAN CHECKLIST

1 Atropin Sulfas Inj 5
2 Bleedstop Inj 2 Kulkas
3 Bucain Inj 1
4 Dexamethason Inj 2
5 Ephedrin Inj 1 Lemari narkotik
6 Fenthanyl Inj 2 Lemari narkotik
7 Fortanes Inj 1 Lemari narkotik
8 Infusan Fimahest 2
9 Kalnex Inj 1
10 Ketamin Inj 1 Lemari narkotik
11 Ketorolac Inj 3
12 Nokoba Inj 1
13 Oksitosin Inj 2 Kulkas
14 Ondansetron 4mg Inj 2
15 Phetidin Inj 1 Lemari narkotik
16 Pronalges Suppo 1 Kulkas
17 Ranitidine Inj 2
18 Recofol Inj 1 Kulkas
Pangkalan Bun..................................
Mengetahui,
Perawat/Bidan Apoteker/Asisten Apoteker

........................................... ......................................
BEDAH UMUM

BEDAH OBGYN