FORMULIR SURVEILENS INFEKSI NOSOKOMIAL

Ruangan : ................................ Instalasi : ............................. Tgl. Masuk/Jam ..................................

No. RM :..............................................................................................................................................

I. IDENTITAS PASIEN
Nama Pasien :........................................................... cara dirawat : emergency/elektif
Umur : ................................................................................................................................
Jenis Kelamin : L/P
II. DIAGNOSA WAKTU MASUK : ......................................................................................................
III. PINDAH RAWAT : 1. Ruang .................tgl.............s/d..............lama.............hari
2. Ruang .................tgl.............s/d..............lama.............hari
3. Ruang .................tgl.............s/d..............lama.............hari

Tgl/Bln/Th Tanggal Pemasangan Total Tanggal

NO Lokasi Catatan
mulai s/d Hari Infeksi
1 Intra Vena Cateter
Vena Sentral

Vena Perifer

Arteri

Umbilikal

2 Urine Kateter

Suprapubik Kateter

3 Ventilasi Mekanik

Tuba endotrakeal

Trakeostomi

4 Lain-lain ..........................
Drain/IABP/CVVH
NGT
IV.HASIL LABORATORIUM TGL : 1. ............................ 2............................. 3...................................
Hb : ......................................................................................................
Leukosit : ......................................................................................................
LED : ......................................................................................................
Gula Darah : .....................................................................................................
HbsAG : .....................................................................................................
Anti HCV : ......................................................................................................
Anti HIV : ......................................................................................................
Urine : .....................................................................................................
V .HASIL RADIOLOGI TGL : .....................................................................................................
......................................................................................................
VI .TINDAKAN/OPERASI
1 .Diagnosa : ................................................................................................................................
2 .Tanggal Operasi : 1. ............................. Lama Operasi ............................ Jam ..................... Mnt
2. ............................. Lama Operasi ............................ Jam ..................... Mnt
Jenis Operasi : Bersih Bersih Tercemar Kotor
Tindakan Operasi : Cito Elektif
ASA Score : 1 2 3 4

VII. PEMBERIAN ANTIBIOTIKA Ada/Tidak Ada Alasan : Propilaksis/Pengobatan

Nama/Jenis : 1..................................... Dosis.............................. Mulai Tgl ................. s/d ...................
2.................................... Dosis.............................. Mulai Tgl ................. s/d ...................
3.................................... Dosis.............................. Mulai Tgl ................. s/d ...................
4.................................... Dosis.............................. Mulai Tgl ................. s/d ...................
VIII. KOMPLIKASI DAN INFEKSI NOSOKOMIAL
1. Infeksi luka Operasi ada/tidak ada Hari ke .......................................
Tgl/Hasil Kultur 1..................................................................................................................
2...................................................................................................................
2. Infeksi Saluran Kemih ada/tidak ada Hari ke .......................................
Tgl/Hasil Kultur 1..................................................................................................................
2...................................................................................................................
3. Lain-lain (Plebitis) ada/tidak ada Hari ke .......................................
Tgl/Hasil Kultur 1..................................................................................................................
2...................................................................................................................
4. Infeksi Saluran Pernafasan / Pneumonia ada/tidak ada Hari ke .......................................
Tgl/Hasil Kultur 1...................................................................................................................
2...................................................................................................................
5. IADP ada/tidak ada Hari ke .......................................
Tgl/Hasil Kultur 1....................................................................................................................
2...................................................................................................................

IX . TGL PASIEN PKELUAR RS/MENINGGAL ........................................................................................

PINDAH RS ............................................................................................................................................
DIAGNOSA AKHIR ..............................................................................................................................

IPCLN DPJP Ka. Ruangan

.................................................. ..................................................... ...................................................

Catatan :
1. Formulir ini berada pada setiap dokumen medik pasien
2. Diisi oleh setiap perawat yang bertanggung jawab pada pasien tersebut
3. Diperiksa oleh perawat pengendali infeksi setiap hari (IPCN)
4. Setelah pasien pulang formulir dikirim ke sekretariat komite PPI