Form Suveilans Infeksi Nosokomial
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7/24/2019 Form Suveilans Infeksi Nosokomial
1/2
RUMAH SAKIT
MARGA HUSADA WONOGIRIJl. Letjend. S. Parman No. 04 Wonogiri
Telp. 0273-321394, 321!! "a#. 0273-321!!
$mail % marga&'(ada)gmail.*om
FORMULIR SURVEILANS INFEKSI NOSOKOMIAL
Ruangan :Tgl masuk/Jam :......../.............Departemen :.Cara dirawat : Emergency/ elektif
No.Rekam edik:
a. Identitas Pasien
!. Nama "asien :......................................
#. $mur : t%/ &ln/ %r
'. Jenis (elamin : )/ "
*. +lamat :
II. DIAGNOSA WAKTU MASUK : ......................................................................
III. Pindah ke Ruanan!.tgl
#.........................................................tgl................................
VI. Fakt!" "esik! se#a$a di"a%at
No Jenis Tindakan / +lkes )okasiTanggal "emasangan Total
,ari
Tanggal
-nfeksiCatatan
ulai s/d
! -ntra ena kateter
ena 0entral
ena "erifer
+rteri
$m&ilikal
# $rine kateter
0uprapu&ik kateter
' entilasi ekanik
Tu&a endotrakeal
Trakeostomi
* )ain1lain ..................
Drain/ -+2"/ C,
Fakt!" Pen&akit Hasi# #a'!"at!"iu$(
,20 +g : "ositif / Negatif / Tidak diperiksa
+nti ,C : "ositif / Negatif / Tidak diperiksa
+nti ,- : "ositif / Negatif / Tidak diperiksa
)ain1lain : ......................................................
)eukocyt: .
)ED : .
3D0 :..
Hasi# "adi!#!i :..
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7/24/2019 Form Suveilans Infeksi Nosokomial
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V. TINDAKAN ) OPERASI ................................................................................................
!.D-+3N40+ ......................................................................................................
.......................................................................................................
#. Tanggal operasi !:.................................... )ama 4perasi..................5am6...............mnt
#:.................................... )ama 4perasi..................5am6...............mnt
' Jenis 4perasi : 2ersi% 2ersi% tercemar Tercemar (otor
*. Tindakan 4perasi : Cito Elektif
7. +0+8score : ! # ' * 7
VI. KOMPLIKASI) INFEKSI NOSOKOMIAL
!. -)4 ada / tidak ada %ari ke...........................
,asil kultur : ...........................................................................................................................
#. -0( ada / tidak ada %ari ke...........................
,asil kultur : ...........................................................................................................................
'. "neumonia ada / tidak ada %ari ke...........................
,asil kultur : ...........................................................................................................................
*. -+D" ada / tidak ada %ari ke........................... ,asil kultur : ...........................................................................................................................
7. )ain1lain 9 "le&itis/ diku&itus.................. ada / tidak ada %ari ke...........................
,asil kultur : ...........................................................................................................................
VII. Pe$akaian Anti$ik"!'a P"!*i#aksis ) +en!'atan
!..................................................dosis ......................mulai tgl....................s/d.....................
#..................................................dosis mulai tgl....................s/d.....................
'..................................................dosis ..mulai tgl....................s/d.....................
*..................................................dosis ..mulai tgl....................s/d.....................
;aktu pem&erian : "reoperasi/ selama / sesuda% operasi
VIII. Tgl. "asien keluar R0 / eninggal : ...............................................................................
"inda% ke R0 : ...............................................................................
Diagnosa +k%ir : ...............................................................................
"erawat penanggung 5awa&/ pengisi formulir (a. Ruangan
............................................................ ..............................Nama 5elas Nama 5elas
Catatan :
!.
