INSTRUMEN EVALUASI AMBULANS DI PUSKESMAS

TAHUN 2022

PUSKESMAS : ............................................................................

ALAMAT : ............................................................................

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NO. TELP : ............................................................................

KEPALA PUSKESMAS : ............................................................................

NO.HP : ............................................................................

ALAMAT EMAIL : ............................................................................

KOORDINATOR AMBULANS : ............................................................................

NO.HP : ............................................................................
 Pelayanan Kesehatan Primer Bidang Pelayanan Kesehatan
Dinas Kesehatan Kota Depok

DAFTAR ISI

STANDAR INPUT
1. TENAGA PUSKESMAS
2. RUANGAN
3. JENIS PELAYANAN
4. SARANA DAN PRASARANA
5. PENCATATAN DAN PELAPORAN
6. PROTAP PELAYANAN/ BUKU PEDOMAN
7. PENGANGGARAN

STANDAR PROSES
1. JENIS PELAYANAN YANG DILAKSANAKAN
2. JENIS PENCATATAN YANG DILAKUKAN
3. PELAKSANAAN MANAJEMEN PERKESMAS

STANDAR OUTPUT
1. CAKUPAN PERKESMAS
1. TENAGA PELAYANAN AMBULANS

STATUS PENDIDIKAN PELATIHAN YG SUDAH DIIKUTI

NO NAMA DRIVER TENAGA
NON SAFETY DRIVING /
PNS SMU D3 S1 S2 BHD LAIN-LAIN
PNS DEVENSIVE DRIVING

4
JUMLAH

1 Sebutkan jam operasional ambulans ?

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2 Berapa jumlah armada ambulans?

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3 Apakah tersedia armada ambulans motor?

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4 Masalah yang berkaitan dengan ketenagaan :

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5 Pemecahan masalah yang telah dilakukan oleh Puskesmas :

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6 Saran :

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2. ALAT KESEHATAN

A. AMBULANS TRANSPORT
KETERSEDIAAN
NO JENIS ALAT NAMA ALAT
ADA TIDAK RUSAK
Tensimeter
Stetoskop
Reflex hammer
1 Pemeriksaan Umum Senter
Glucose Testing
Termometer digital

Cervical Collar
Oropharyngeal Airway
Nasopharyngeal Airway
2 Set jalan napas (Airway Set) Suction Cannula
Forsep Magill
Mesin suction elektrik

Bag Valve Mask (BVM)

Cannula konektor BVM
Nasal Cannule
3 Set pernapasan (Breathing Set) Simple Mask
Rebreathing Mask
Non Rebreathing Mask

Automated External Defibrillator (AED)

Infus set
Kateter intravena
Cairan infus
4 Set sirkulasi (Circulation Set)
Set alat bandaging
Disposable Syringe
Antiseptik

Wound toilet set

Set peralatan stabilisasi dan Splint/ Bidai
5
ekstrikasi Safety belt/ patient strapping

Stretcher/ Brankar
6
Peralatan transportasi dan Long Spine Board
evakuasi

Kunci Inggris (untuk tabung oksigen)

Alat Pelindung Diri (APD)
Penanda triase
7 Lain-Lain Pispot urinal
Apar
Sistem kelistrikan (Power Supply)
Lampu LED

* Keterangan : Di isi dengan jumlah ketersediaan

B. AMBULANS MOTOR
KETERSEDIAAN
NO JENIS ALAT NAMA ALAT
ADA TIDAK RUSAK
Tensimeter
Stetoskop
Reflex hammer
1 Pemeriksaan Umum Senter
Glucose Testing
Termometer digital

Cervical Collar
Oropharyngeal Airway
Nasopharyngeal Airway
2 Set jalan napas (Airway Set) Suction Cannula
Forsep Magill
Mesin suction elektrik
 2 Set jalan napas (Airway Set)

Bag Valve Mask (BVM)

Cannula konektor BVM
Nasal Cannule
Simple Mask
3 Set pernapasan (Breathing Set)
Rebreathing Mask
Non Rebreathing Mask
Tabung oksigen portable

Pulse Oximetry portable

Automated External Defibrillator (AED)
Infus set
Kateter intravena
4 Set sirkulasi (Circulation Set) Cairan infus
Set alat bandaging
Disposable Syringe
Antiseptik

Tas Emergency
5 Lain-Lain
Penanda triase

* Keterangan : Di isi dengan jumlah ketersediaan

 PELAKSANAAN
NO MENTENANCE AMBULANS
DILAKUKAN TIDAK DILAKUKAN
1 Kalibrasi Alat Kesehatan
2 Servis kendaraan
3. JENIS LAYANAN
DILAKSANAKAN JUMLAH
NO JENIS PELAYANAN
Januari Februari Maret April Mei Juni Juli KUMULATIF
Rujukan Pasien
1 Covid
Non Covid
2 Pengambilan Obat/ BMHP
3 P3K
4 Kegiatan Vaksinasi
5 Pengantaran Dokumen
Lainnya :
6 a. …………………………………………..
b. ………………………………………….

* Catatan : di isi dengan jumlah kasus

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