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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$)"4&a ()
................................................. ...................................................NIP. ......................................... NIP. ...........................................
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TAN PASIEN
IDERA KEJADIAN TIDAK DIHARAPKAN KEJADIAN SENTINEL "#$ 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. .........................................
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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$)"4&a ()
................................................. ...................................................NIP. ......................................... NIP. ...........................................
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8/19/2019 Tugs Terbaru Smt i Jci
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PELAPORAN KESELAM
UNIT KERJA :DEPARTEMEN T.H.T.K.L RSUP DR. MOH. HOESINBULAN :MARET 2016
KONDISI POTENSIAL CIDERA KEJADIAN NYARIS CIDERA KEJADIAN TIDAK Jumlah : 0 KPC Jumlah : 0 I !"#$ 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$)"4&a ()
................................................. ...................................................NIP. ......................................... NIP. ...........................................
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TAN PASIEN
IDERA KEJADIAN TIDAK DIHARAPKAN KEJADIAN SENTINEL "#$ 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. .........................................
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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
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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$m
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++ BUJAN8 BIN SALAH /*2- 6 0- A')"l 1/62
+, RIANSYAH PUTRA /***- 1* Jul" 1/ *
+6 DELLA A??AHRA /**+0* 2+ Ma)$ 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 "$5S'.T.H.T.K.L =K>
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P$ um'ul Da a 1
.................................................NIP. .........................................
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11/60
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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
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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
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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
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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
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M$ $ ahu"5..........................................
............................................ ........................................
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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$m
8/19/2019 Tugs Terbaru Smt i Jci
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P$ um'ul Da a 1
.................................................NIP. .........................................
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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
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8/19/2019 Tugs Terbaru Smt i Jci
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KET PJP T"#a& 3"!" $2* 2+ 2, 26 2- 2 2/ *0 *1
8/19/2019 Tugs Terbaru Smt i Jci
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M$ $ ahu"5...................
.......................................
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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
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P$ um'ul Da a 1
.................................................
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NIP. .........................................
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+ , 6 - / 10 11
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P$ um'ul Da a 2 3$)"4&a ()
...................................................
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NIP. ...........................................
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WORKSHEETPELAKSANAAN VISITE OLEH DPJP
Ta al P$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/
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Ka.............
.................
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& 3"!" $20 21 22 2* 2+ 2, 26 2-
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M$ $ ahu"5................................
..................................
8/19/2019 Tugs Terbaru Smt i Jci
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KET2 2/ *0 *1
8/19/2019 Tugs Terbaru Smt i Jci
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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(& $)
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P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()
................................................. ...................................................NIP. ......................................... NIP. ...........................................
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K$Nama N( RM Ta al La
P$la&!a aa I#$ "4&a!" Pa!"$=9$)" a #a YA 5 TIDAK >
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M$ $ ahu"5Ka.............................................
...................................................NIP. .........................................
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P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()
................................................. ...................................................NIP. ......................................... NIP. ...........................................
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M$ $ ahu"5Ka.............................................
...................................................NIP. .........................................
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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(& $)
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P$ um'ul Da a 1 P$ um'ul Da a 2 3$)"4&a ()
................................................. ...................................................NIP. ......................................... NIP. ...........................................
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K$Nama N( RM Ta al La
P$la&!a aa I#$ "4&a!" Pa!"$=9$)" a #a YA 5 TIDAK >
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M$ $ ahu"5Ka.............................................
...................................................NIP. .........................................
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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
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HEALTH ORGANIZA
!$ $lah &( !$ $lah &( a& #$ a#$ a 'al" &u a 'a!"$
M$ $ ahu"5Ka.............................................
...................................................NIP. .........................................
5 TIDAK 5 a au
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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
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HEALTH ORGANIZA
!$ $lah &( !$ $lah &( a& #$ a#$ a 'al" &u a 'a!"$
M$ $ ahu"5Ka.............................................
...................................................NIP. .........................................
5 TIDAK 5 a au
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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
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HEALTH ORGANIZA
!$ $lah &( !$ $lah &( a& #$ a#$ a 'al" &u a 'a!"$
M$ $ ahu"5Ka.............................................
...................................................NIP
5 TIDAK 5 a au