BLUD RSUD dr. BEN MBOY Kab. Manggarai NO.

RM
FORMULIR Nama: JK Unit/ ruangan/ kelas:
SURVEILANS
INFEKSI Umur:
NOSOKOMIAL

Tanggal Masuk / Jam :

Cara dirawat : Emergency / Elektif
I. DIAGNOSIS WAKTU MASUK :
II. PINDAH RAWAT : 1. Ruangan .............................tgl..............s/d tgl............ lama..............hari
2. Ruangan..............................tgl..............s/d tgl.............lama..............hari

Tanggal
Total Tanggal
No Tgl / Bln / Th Lokasi Pemasangan Catatan
Mulai s/d Hari Infeksi
1 Intra vena kateter
Vena sentral

Vena periver

Arteri

Umbilikal

2 Urine kateter

Suprabublik kateter

3 Ventilasi Mekanik

Tuba endotrakeal

Trakeostomi

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

III. HASIL LABORATORIUM TGL : 1..................................2. .........................3. ....................................

Hb :..........................................................................................................
Lekosit :..........................................................................................................
LED :..........................................................................................................
Gula Darah :..........................................................................................................
HBsAg :..........................................................................................................
Anti HCV :..........................................................................................................
Anti HIV :..........................................................................................................
IV. HASIL RADIOLOGI TGL :..........................................................................................................
V. TINDAKAN / OPERASI
 1. Diagnosa : ......................................................................................................................................
.
2. Tanggal Operasi : 1. ....................................Lama Operasi..........................Jam..............................Menit
2 .............................. ......Lama Operasi..........................Jam..............................Menit
Jenis Operasi : Bersih Bersih Tercemar Kotor
Tindakan Operasi
ASA Score : Cito Elektif
1. 2. 3. 4.

VI. PEMBERIAN ANTIBIOTIKA Ada/tidak ada Alasan...............................profilaksis/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......................
VII. 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. Infeksi Saluran Pernapasan/Pneumonia Ada/tidak ada Hari ke......................
Tgl/Hari Kultur 1.................................................................................................................................
2..................................................................................................................................
4. IADP Ada/tidak ada Hari ke......................
Tgl/Hari Kultur 1.................................................................................................................................
2.................................................................................................................................
5. Phlebitis Ada/tidak ada Hari ke.....................
Tgl/Hasil Kultur 1.................................................................................................................................
2.................................................................................................................................
6. Dekubitus Ada/tidak ada Hari ke.....................
Tgl/Hasil Kultur 1.................................................................................................................................
2.................................................................................................................................
VIII. TANGGAL PASIEN KELUAR RS / MENINGGAL
PINDAH KE RS................................................................................................................................................
DIAKNOSA AKHIR.........................................................................................................................................

Perawat Penanggung Jawab/Pengisi formulir Ka. Ruangan .....................

(.........................................................) (..............................................)
Nama Jelas Nama Jelas
Catatan:
1. Formulir ini berada pada setiap dokumen medic pasien (oleh CM)
2. Diisi oleh setiap perawat yang bertanggung jawab pada pasien tersebut
3. Diperiksa oleh perawat pengendali infeksi setiap hari
4. Setelah pasien pulang formulir di kirim ke sekertariat panitia PPI
 ALUR TERTUSUK JARUM
Tertusuk Jarum Terkontaminasi

Cuci dengan sabun antiseptik dan

dengan air yang mengalir tanpa
melakukan pemijatan

Lapor ke atasan/ kepala

Ruangan

Membuat Laporan

Bila terjadi diluar jam kerja segera Bila terjadi saat jam kerja segera ke
ke UGD untuk penatalaksanaan poli penyakit dalam (penatalaksana
lanjutan lanjutan)

Jika tidak diketahui sumber Jika status pasien bebas HIV, HBV,
paparannya petugas terpapan HCV dan bukan dalam masa inkubasi
diperiksa HBV, HCV, HIV tidak perlu tindakan khusus untuk
petugas bila dilanjutkan lakukan
konseling