FORMULIR SURVEILANS INFEKSI NOSOKOMIAL

Ruangan :.................................................................... Tanggal Masuk/Jam :......................./.............

Departemen :.................................................................... Cara dirawat : Emergency/Efektif

I. Identitas Pasien
1. No. Rekam Medis : .........................................
2. Nama Pasien : .........................................
3. Tanggal Lahir : .........................................
4. Jenis Kelamin :L/P
5. Alamat :

II. Diagnosa Waktu Masuk : .............................................................

III. Pindah Ke Ruangan 1. .............................................. tgl ................................................

2. .............................................. tgl ................................................

IV. Faktor Resiko Selamat Dirawat

Tanggal Pemesangan
No Jenis Tindakan/alkes Lokasi Total Hari Tanggal Infeksi Catatan
Mulai s/d
1 Intra Vena Kateter
Vena Sentral

Vena Perifer

Arteri

Umbilikal
2 Urine Kateter

Suprepuik Kateter
3 Ventilasi Mekanik
Tuba Endrotrakeal

Trakeostomi
4 Lain-lain ..............................
Drain/IABP/CVVH

Faktor Penyakit Hasil Laboratorium

 HBS Ag : Positif / Negatif/ Tidak diperiksa Leukocyt : .......................
 Anti HCV : Positif/ Negatif/ Tidak diperiksa LED : .......................
 Anti HIV : Positif/ Negatif/ Tidak diperiksa GDS : .......................
 Lain-lain : ...................................................

Hasil Radiologi : ............................................................................................

V. Tindakan / Operasi
1. Diagnosa : ..........................................................................................................................
2. Tanggal Operasi 1 ....................................lama Operasi .........................jam..........................mnt
2 ....................................lama Operasi .........................jam..........................mnt

UM 25.19
 3. Jenis Operasi : Bersih Bersih tercemar Tercemar Kotor
4. Tindakan Operasi : Cito Elektif
5. ASA Score :1 2 3 4 5

VI. Komplikasi / Infeksi Nosokomial

1. ILO Ada/ Tidak ada hari ke ..........................
Hasil kultur : .............................................................................................................................................

2. ISK Ada/ Tidak ada hari ke ..........................

Hasil kultur : .............................................................................................................................................

3. Pneumonia Ada/ Tidak ada hari ke ..........................

Hasil kultur : .............................................................................................................................................

4. IADP Ada/ Tidak ada hari ke ..........................

Hasil kultur : .............................................................................................................................................

5. Lain-lain (Plebilitis/dikubtus) Ada/ Tidak ada hari ke ..........................

Hasil kultur : .............................................................................................................................................

II. Pemakaian Antimikroba

1. ..........................................dosis..................................mulai tgl .......................................s/d.......................
2. ..........................................dosis..................................mulai tgl .......................................s/d.......................
3. ..........................................dosis..................................mulai tgl .......................................s/d.......................
4. ..........................................dosis..................................mulai tgl .......................................s/d.......................
Waktu Pemberian : Preoperasi / selama / sesudah operasi

III. Tanggal Pasien keluar RS / Meninggal : ...........................................................................

Pindah ke RS : ..................................................................................................................
Diagnosa Akhir : ..................................................................................................................

Perawat penanggung jawab / pengisi formulir Ka. Ruangan

........................................................ .......................................
Nama Jelas Nama Jelas

Catatan :
1. Formulir ini berada dalam dokumen medik pasien
2. Diisi oleh perawat yang bertanggung jawab pada pasien
3. Diperiksa oleh perawat pengendali infeksi setiap hari
4. Setelah pasien pulang formulir dikumpulkan sekretariat PIN RS

UM 25.19