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1/60

PELAPORAN KESELAM

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN :JANUARI 2016

KONDISI POTENSIAL CIDERA KEJADIAN NYARIS CIDERA KEJADIAN TIDAK Jumlah : 0 KPC Jumlah : 0 I !"#$ Jumlah : 0 IR" %"a : T"#a& a#a '$la'()a R" %"a : T"#a& a#a '$la'()a R" %"a : T"#a& a#a1 1 12 2 2* * *+ + +, , ,6 6 6- - -

/ / /10 10 1011 11 1112 12 121* 1* 1*1+ 1+ 1+1, 1, 1,16 16 161- 1- 1-1 1 1

P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()

................................................. ...................................................NIP. ......................................... NIP. ...........................................

8/19/2019 Tugs Terbaru Smt i Jci

2/60

TAN PASIEN

IDERA KEJADIAN TIDAK DIHARAPKAN KEJADIAN SENTINEL "#$ Jumlah : 0 I !"#$ Jumlah : 0 I !"#$

'$la'()a R" %"a : T"#a& a#a '$la'()a R" %"a : T"#a& a#a '$la'()a1 12 2* *+ +, ,6 6- -

/ /10 1011 1112 121* 1*1+ 1+1, 1,16 161- 1-1 1

M$ $ ahu"5Ka.............................................

...................................................NIP. .........................................

8/19/2019 Tugs Terbaru Smt i Jci

3/60

PELAPORAN KESELAM

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN : EBRUARI 2016

KONDISI POTENSIAL CIDERA KEJADIAN NYARIS CIDERA KEJADIAN TIDAK Jumlah : 0 KPC Jumlah : 0 I !"#$ Jumlah : 0 IR" %"a : T"#a& a#a '$la'()a R" %"a : T"#a& a#a '$la'()a R" %"a : T"#a& a#a1 1 12 2 2* * *+ + +, , ,6 6 6- - -

/ / /10 10 1011 11 1112 12 121* 1* 1*1+ 1+ 1+1, 1, 1,16 16 161- 1- 1-1 1 1

P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()

................................................. ...................................................NIP. ......................................... NIP. ...........................................

8/19/2019 Tugs Terbaru Smt i Jci

4/60

8/19/2019 Tugs Terbaru Smt i Jci

5/60

PELAPORAN KESELAM

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN :MARET 2016

KONDISI POTENSIAL CIDERA KEJADIAN NYARIS CIDERA KEJADIAN TIDAK Jumlah : 0 KPC Jumlah : 0 I !"#$ Jumlah : 0 IR" %"a : T"#a& a#a '$la'()a R" %"a : T"#a& a#a '$la'()a R" %"a : T"#a& a#a1 1 12 2 2* * *+ + +, , ,6 6 6- - -

/ / /10 10 1011 11 1112 12 121* 1* 1*1+ 1+ 1+1, 1, 1,16 16 161- 1- 1-1 1 1

P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()

................................................. ...................................................NIP. ......................................... NIP. ...........................................

8/19/2019 Tugs Terbaru Smt i Jci

6/60

TAN PASIEN

IDERA KEJADIAN TIDAK DIHARAPKAN KEJADIAN SENTINEL "#$ Jumlah : 0 I !"#$ Jumlah : 0 I !"#$

'$la'()a R" %"a : T"#a& a#a '$la'()a R" %"a : T"#a& a#a '$la'()a1 12 2* *+ +, ,6 6- -

/ /10 1011 1112 121* 1*1+ 1+1, 1,16 161- 1-1 1

M$ $ ahu"5Ka.............................................

...................................................NIP. .........................................

8/19/2019 Tugs Terbaru Smt i Jci

7/60

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN :JANUARI 2016

N( Nama Pa!"$ Ta al Lah") Nama L$ &a' DPJP

1 PUTRI RAHMA7ATI /2/,1* 2- Ja ua)" 200/

2 DE7I SUSILA7ATI /06/16 1+ A')"l 1/-/

* ARPAN BIN AHMAD /01/+2 1, Ju " 1/6/

+ JOR8I CAMPOS /2-621 2- Ju " 1//-

, /1 - 02 Ja ua)" 1/6/

6 /2 +* 01 Ja ua)" 1/,-

- LEKAT BIN ALI UNAN8 /*1011 16 Ja ua)" 1/+1

*0 6+ 01 A')"l 1/-2

/ YOSA AT INDARYADI /*1+26 20 A')"l 1/--

10 DEDE ARISANDI /1/,+1 0/ A u! u! 1//6

11 126/1 20 M$" 1/,

12 PUTRI CINTA MAYURA /2-2*- 2- D$!$m9$) 2002

1* - 0+,- 0- Ma)$ 1/,/

1+ /1 666 10 OCT ,/

1, M.HELMRAN /12,/2 *0 N(;$m9$) 1/-0

16 SRI MELANI --00 0 1, M$" 1//,

1- BAMBAN8 IRA7AN /*1+,, 0, O& (9$) 1/-6

1 YANTO BIN OE7 CUEK /16216 0, Ma)$ 1/61

1/ RIPAN BIN DARMO /0,6 6 2+ M$" 1/6,

N(. R$&amM$#"&

#). Y(a L$;"a Ma #"5S'.T.H.T.K.L

#). Y(a L$;"a Ma #"5S'.T.H.T.K.L#). D$ < Sa )"aU ama5 S'.T.H.T.K.L#). Yul" D()"! M$m

SUS7ATI BINTIM.DIAH

#). D$ < Sa )"aU ama5 S'.T.H.T.K.L

NURHASANAH BINTINAN8YU

#). D$ < Sa )"aU ama5 S'.T.H.T.K.L#). D$ < Sa )"aU ama5 S'.T.H.T.K.L#). Yul" D()"! M$m

8/19/2019 Tugs Terbaru Smt i Jci

8/60

20 M.ALI HANA IAH /2+/*+ 20 A u! u! 1/ ,

21 62106 0+ $9)ua)" 1/,+

22 /11+0, 11 A')"l 1/-0

2* ADLI MUSOLIHIN +2+* 2+ A u! u! 1/ +

2+ RUSTAM E ENDI /2,*0+ 10 $9)ua)" 1/66

2, ARNALDI RENTAS /20/++ 2* M$" 1/-+

26 SUHARDIMAN HARUN /,-2+ 1 Ju " 1/6,

2- AHDIYAT MIDAR /226 6 1+ O& (9$) 1/-0

2 ASIA BINTI SAPRI ,2,,2 01 Jul" 1/,1

2/ ,2-61 02 O& (9$) 1/ -

*0 M. HIDAYAT /*2*-6 02 $9)ua)" 1/

*1 INES ALINDA /*2,-0 0, M$" 2012

*2 SINTOK BINTI AMAT /1//+6 21 Jul" 1/+-

** RUSMINI BINTI MADIA /*262* 06 S$' $m9$) 1/,,

*+ SALMIATI HARUN /1* /6 26 Jul" 1/,-

*, YENITA ?. ARI IN /0 6*- 0- N(;$m9$) 1/ -

*6 ADI 8USMANTO -+* 2 16 A u! u! 1/ /

*- /116-+2 12 A u! u! 1/-1

* TRIA RAHAYU /21+-/ 2, S$' $m9$) 1//+

*/ NARDI BIN ROSADI /-0*6 0* Ma)$ 1/6/

+0 -6,// 01 Jul" 1/6*

+1 M. SOLIHIN 0060/ 10 O& (9$) 1/ 6

+2 TAMPUN BIN YAKUB /*2// 1, Jul" 1/6*

+* M. 7ARIS BOY /2/21, 1- M$" 1//,

#). Yul" D()"! M$m

8/19/2019 Tugs Terbaru Smt i Jci

9/60

++ BUJAN8 BIN SALAH /*2- 6 0- A')"l 1/62

+, RIANSYAH PUTRA /***- 1* Jul" 1/ *

+6 DELLA A??AHRA /**+0* 2+ Ma)$ 201*

+- /*1 2 26 N(;$m9$) 1/ +

+ LAMA BINTI CIKMI /*1, / 0- O& (9$) 1/,,

+/ /1 - 02 Ja ua)" 1/6/

,0 RUSTAM ASRI +-1**6 2, M$" 1/ 0

,1 ISMAIL AHMI ,1*,02 1, Ju " 1/ 0

,2 AID? IRNANDO /2200 0* M$" 200

,* HERMAN SUKADI /0+ 6- 1* M$" 1/-*

,+ SERLY OKTARINA /**++, 26 O& (9$) 200+

,, M. DIAH PRATEJA /**+-, 0+ A u! u! 1///

,6 /2++61 0* Ma)$ 1/6

,- JOHERI BIN YOPAN /2+0+ 2, Jul" 1/ *

, /16006 0, A')"l 1/,6

,/ RUKMINI BINTI M.AKIP + / 01 Jul" 1/60

60 /2,+-1 0/ S$' $m9$) 1/,+

61 PUTRI CINTA MAYURA /2-2*- 2- D$!$m9$) 2002

62 LIANA MAR@UANI -++,*+ 2+ Ja ua)" 1/61

6* /220 0 0, A u! u! 1/60

6+ DEDE ARISANDI /1/,+1 0/ A u! u! 1//6

6, A. ROMANSYAH /*+/// 1, Ju " 1/ ,

#). L"!a A')" Ya "5S'.T.H.T.K.L#). L"!a A')" Ya "5S'.T.H.T.K.L#). A#$l"$ 5S'.T.H.T.K.L

SANTI BINTISAMSUDIN

#). A#$l"$ 5S'.T.H.T.K.L#). L"!a A')" Ya "5S'.T.H.T.K.L

N8ATIYEM BINTI7AKMAN

#). D$ < Sa )"aU ama5 S'.T.H.T.K.L#). A#$l"$ 5S'.T.H.T.K.L#). Yul" D()"! M$m#). D$ < Sa )"aU ama5 S'.T.H.T.K.L

SAKDIAH BINTIMUHAMAD

#). D$ < Sa )"aU ama5 S'.T.H.T.K.L#). D$ < Sa )"aU ama5 S'.T.H.T.K.L#). A9la 8ha "$5S'.T.H.T.K.L =K>

8/19/2019 Tugs Terbaru Smt i Jci

10/60

P$ um'ul Da a 1

.................................................NIP. .........................................

8/19/2019 Tugs Terbaru Smt i Jci

11/60

8/19/2019 Tugs Terbaru Smt i Jci

12/60

MRS 1 1 1 1 1 P

MRS 1 P

MRS 1 P

MRS 1 1 P

MRS 1 P

MRS 1 P

MRS 1 1 P

MRS 1 1 1 P

MRS 1 1 1 1 P

MRS 1 1 1 P

MRS 1 P

MRS 1 P

MRS 1 1 1

MRS 1 1 1

MRS 1 1

MRS 1 1

MRS 1 P

MRS 1 1

MRS 1 1

MRS 1 1 1

MRS 1 1 P

MRS 1 1 1

MRS 1 1 1

MRS

8/19/2019 Tugs Terbaru Smt i Jci

13/60

8/19/2019 Tugs Terbaru Smt i Jci

14/60

8/19/2019 Tugs Terbaru Smt i Jci

15/60

KET P 3"!" $5 0 DPJP T"#a& 3"!" $

20 21 22 2* 2+ 2, 26 2- 2 2/ *0 *1

1 P

1 1 P

8/19/2019 Tugs Terbaru Smt i Jci

16/60

1 1 P

1 1 1 1 1 1 P

1 P

1 P

P

1 1 1 1 1 P

1 1 P

1 P

1 P

1 P

8/19/2019 Tugs Terbaru Smt i Jci

17/60

MRS 1 1 1 P

MRS 1 1 1 1 1 P

MRS 1 1 1 1 P

MRS 1 1 1 P

MRS 1 1 1 P

MRS 1 1 1 1 P

MRS 1 P

MRS 1 P

MRS 1 P

MRS P

MRS 1 1 P

MRS 1 P

MRS 1 P

MRS 1 1 1 P

MRS 1 1 1 P

MRS 1 1 P

MRS 1 P

MRS 1 P

MRS 1 P

MRS 1

MRS

8/19/2019 Tugs Terbaru Smt i Jci

18/60

M$ $ ahu"5..........................................

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

8/19/2019 Tugs Terbaru Smt i Jci

19/60

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN : EBRUARI 2016

N( Nama Pa!"$ Ta al Lah") Nama L$ &a' DPJP1 2 *

/20,++ 2* M$" 1/-+

/0,6 6 2+ M$" 1/6,

N(. R$&amM$#"&

ARNALDI BINRENTAS

#). D$ < Sa )"aU ama5 S'.T.H.T.K.L

RIPAN BINDARMO

#). D$ < Sa )"aU ama5 S'.T.H.T.K.L

#). D$ < Sa )"aU ama5 S'.T.H.T.K.L

#). Yul" D()"! M$m

8/19/2019 Tugs Terbaru Smt i Jci

20/60

8/19/2019 Tugs Terbaru Smt i Jci

21/60

P$ um'ul Da a 1

.................................................NIP. .........................................

8/19/2019 Tugs Terbaru Smt i Jci

22/60

WORKSHEETPELAKSANAAN VISITE OLEH DPJP

Ta al P$la&!a aa 3"!" $ >B$)"&a a #a: MRS Pa!"$ ma!u&5 P Pa!"$ Pula 5 1 DPJP 3"!" $5 0

+ , 6 - / 10 11 12 1* 1+ 1, 16 1- 1 1/ 20 21 22

8/19/2019 Tugs Terbaru Smt i Jci

23/60

8/19/2019 Tugs Terbaru Smt i Jci

24/60

8/19/2019 Tugs Terbaru Smt i Jci

25/60

KET PJP T"#a& 3"!" $2* 2+ 2, 26 2- 2 2/ *0 *1

8/19/2019 Tugs Terbaru Smt i Jci

26/60

8/19/2019 Tugs Terbaru Smt i Jci

27/60

M$ $ ahu"5...................

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

8/19/2019 Tugs Terbaru Smt i Jci

28/60

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN :MARET 2016

N( ama Pa!"$1 2 *

N(.R$&amM$#"&

Ta alLah")

NamaL$ &a'

DPJP

8/19/2019 Tugs Terbaru Smt i Jci

29/60

P$ um'ul Da a 1

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

8/19/2019 Tugs Terbaru Smt i Jci

30/60

NIP. .........................................

8/19/2019 Tugs Terbaru Smt i Jci

31/60

+ , 6 - / 10 11

8/19/2019 Tugs Terbaru Smt i Jci

32/60

P$ um'ul Da a 2 3$)"4&a ()

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

8/19/2019 Tugs Terbaru Smt i Jci

33/60

NIP. ...........................................

8/19/2019 Tugs Terbaru Smt i Jci

34/60

WORKSHEETPELAKSANAAN VISITE OLEH DPJP

Ta al P$la&!a aa 3"!" $ >B$)"&a a #a: MRS Pa!"$ ma!u&5 P Pa!"$ Pula 5 1 DPJP 3"!" $5 0 DPJP T"#

12 1* 1+ 1, 16 1- 1 1/

8/19/2019 Tugs Terbaru Smt i Jci

35/60

Ka.............

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

8/19/2019 Tugs Terbaru Smt i Jci

36/60

8/19/2019 Tugs Terbaru Smt i Jci

37/60

& 3"!" $20 21 22 2* 2+ 2, 26 2-

8/19/2019 Tugs Terbaru Smt i Jci

38/60

M$ $ ahu"5................................

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

8/19/2019 Tugs Terbaru Smt i Jci

39/60

8/19/2019 Tugs Terbaru Smt i Jci

40/60

KET2 2/ *0 *1

8/19/2019 Tugs Terbaru Smt i Jci

41/60

8/19/2019 Tugs Terbaru Smt i Jci

42/60

8/19/2019 Tugs Terbaru Smt i Jci

43/60

WORKSHEETPELAKSANAAN IDENTIFIKASI PASIEN

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN :JANUARI 2016

N( ama Pa!"$ T" #a&a Ta alSu);$"

N(.R$&amM$#"!

Ta alLah")

RuaP$)a a a

NamaD(& $)

8/19/2019 Tugs Terbaru Smt i Jci

44/60

P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()

................................................. ...................................................NIP. ......................................... NIP. ...........................................

8/19/2019 Tugs Terbaru Smt i Jci

45/60

K$Nama N( RM Ta al La

P$la&!a aa I#$ "4&a!" Pa!"$=9$)" a #a YA 5 TIDAK >

8/19/2019 Tugs Terbaru Smt i Jci

46/60

M$ $ ahu"5Ka.............................................

...................................................NIP. .........................................

8/19/2019 Tugs Terbaru Smt i Jci

47/60

8/19/2019 Tugs Terbaru Smt i Jci

48/60

P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()

................................................. ...................................................NIP. ......................................... NIP. ...........................................

8/19/2019 Tugs Terbaru Smt i Jci

49/60

8/19/2019 Tugs Terbaru Smt i Jci

50/60

M$ $ ahu"5Ka.............................................

...................................................NIP. .........................................

8/19/2019 Tugs Terbaru Smt i Jci

51/60

WORKSHEETPELAKSANAAN IDENTIFIKASI PASIEN

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN :MARET 2016

N( ama Pa!"$ T" #a&a Ta alSu);$"

N(.R$&amM$#"!

Ta alLah")

RuaP$)a a a

NamaD(& $)

8/19/2019 Tugs Terbaru Smt i Jci

52/60

P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()

................................................. ...................................................NIP. ......................................... NIP. ...........................................

8/19/2019 Tugs Terbaru Smt i Jci

53/60

K$Nama N( RM Ta al La

P$la&!a aa I#$ "4&a!" Pa!"$=9$)" a #a YA 5 TIDAK >

8/19/2019 Tugs Terbaru Smt i Jci

54/60

M$ $ ahu"5Ka.............................................

...................................................NIP. .........................................

8/19/2019 Tugs Terbaru Smt i Jci

55/60

WORKSHEETUHAN PETUGAS MELAKUKAN CUCI TANGAN BERDASARKAN ANJURAN WORLD

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN :JANUARI 2016

N(. ma P$ u $la&!a aa%u%" a a 9$)#a!a)

Ya T"#a&!$9$lum & !$9$lum " !$ $lah 9$#$ a 'aa!$' "& #$ a %a

P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()

................................................. ...................................................NIP. ......................................... NIP. ...........................................

a #"la&!a a&a =9$)" a #a Y

8/19/2019 Tugs Terbaru Smt i Jci

56/60

HEALTH ORGANIZA

!$ $lah &( !$ $lah &( a& #$ a#$ a 'al" &u a 'a!"$

M$ $ ahu"5Ka.............................................

...................................................NIP. .........................................

5 TIDAK 5 a au

8/19/2019 Tugs Terbaru Smt i Jci

57/60

WORKSHEETUHAN PETUGAS MELAKUKAN CUCI TANGAN BERDASARKAN ANJURAN WORLD

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN : EBRUARI 2016

N(. ma P$ u $la&!a aa%u%" a a 9$)#a!a)

Ya T"#a&!$9$lum & !$9$lum " !$ $lah 9$#$ a 'aa!$' "& #$ a %a

P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()

................................................. ...................................................NIP. ......................................... NIP. ...........................................

a #"la&!a a&a =9$)" a #a Y

8/19/2019 Tugs Terbaru Smt i Jci

58/60

HEALTH ORGANIZA

!$ $lah &( !$ $lah &( a& #$ a#$ a 'al" &u a 'a!"$

M$ $ ahu"5Ka.............................................

...................................................NIP. .........................................

5 TIDAK 5 a au

8/19/2019 Tugs Terbaru Smt i Jci

59/60

WORKSHEETUHAN PETUGAS MELAKUKAN CUCI TANGAN BERDASARKAN ANJURAN WORLD

UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN :MARET 2016

N(. ma P$ u $la&!a aa%u%" a a 9$)#a!a)

Ya T"#a&!$9$lum & !$9$lum " !$ $lah 9$#$ a 'aa!$' "& #$ a %a

P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()

................................................. ...................................................NIP. ......................................... NIP. ...........................................

a #"la&!a a&a =9$)" a #a Y

8/19/2019 Tugs Terbaru Smt i Jci

60/60

HEALTH ORGANIZA

!$ $lah &( !$ $lah &( a& #$ a#$ a 'al" &u a 'a!"$

M$ $ ahu"5Ka.............................................

...................................................NIP

5 TIDAK 5 a au