CHECK-LIST BIMBINGAN TEKNIS/ SUPERVISI RUMAH SAKIT

DI KABUPATEN MALANG
Nama Fasyankes : RS Prasetya Husada
Tanggal Supervisi : 2 November 2023
Petugas yang disupervisi : 1.
2.
3.

1. Penemuan Kasus

NO. KEGIATAN TAHUN 2023

1. Jumlah rata-rata kunjungan pasien per hari semua poli 100
2. Jumlah Penemuan Terduga 220
3. Jumlah Penemuan Kasus 220
4. Jumlah Penderita TBC yang ditemukan 22
5. Jumlah Penderita TBC yang diobati 6
6. Jumlah Penderita TBC diobati yang berhasil pengobatan 9
(pengobatan lengkap/ sembuh)
7. Jumlah Pasien Lost to Follow Up 0
8. Jumlah pengobatan gagal/ meninggal 0

2. Proses Penjaringan Terduga

Melalui Poliklinik dan IGD....................................................................................................
.............................................................................................................................................
.............................................................................................................................................
3. Proses Penemuan Kasus
Pasien Per Igd dan Poli Rawat Jalan ..................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
4. Tatalaksana Pasien Mangkir/ Drop Out/ LTFU
Menghubungi bagian kader dan bekerjasama dengan yayasan..........................................
.............................................................................................................................................
.............................................................................................................................................
5. Akses TCM
Sudah ada Sputumboot.......................................................................................................
.............................................................................................................................................
6. Pelaksanaan Jejaring Internal
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
7. Pelaksanaan Jejaring Eksternal
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
8. Proses Investigasi Kontak
RS mengirim IK ke Puskesmas , petugas membantu follup agar IK cepat di slesaikan......
.............................................................................................................................................
.............................................................................................................................................
9. Pelaksanaan Program TBC-DM
a. MoU TB DM : sudah
b. Proses berjalan: sudah
c. Kendala:
Sejauh ini masih belum ada kendala dan , pasien TB dengan Dm belum ada di RS Kami
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
10. Pelaksanaan Program TBC-HIV
a. Jumlah pasien TB yang periksa HIV : Semua pasien TbC
b. Jumlah pasien HIV yang skrining TB: Semua pasien TBC
c. Kendala:
Kurangnya inform consent yang jelas kepada penderita , terkadang pasien masih sering
menolak di lakukan tes...................................................................................................
........................................................................................................................................
........................................................................................................................................
11. Laboratorium
a. Jumlah pemeriksaan TCM:
b. Follow Up Pengobatan Pasien: Dilakukan/ tidak dilakukan
Alasan tidak dilakukan:
........................................................................................................................................
........................................................................................................................................
c. Uji Silang: Dilakukan/ tidak dilakukan
Alasan tidak dilakukan:
........................................................................................................................................
........................................................................................................................................
d. Kendala lain:
........................................................................................................................................
........................................................................................................................................
12. Logistik
a. OAT:
b. OAT Anak:
c. TPT:
d. Pot sputum:
e. Catridge:
f. Tuberkulin:
13. Pencatatan dan Pelaporan
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
14. Hambatan dalam tatalaksana TBC
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
15. Usulan saran penyelesaian
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
16. Rencana Tindak Lanjut
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................

Malang,……………………………..

Petugas yang disupervisi Petugas Supervisi

…………………………… …………………………….

………………………………

……………………………….

……………………………….

Wasor TBC

…………………………….
 CATATAN SUPERVISI

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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