Form Surveilans

 

 

PERHIMPUNAN PENGENDALIAN INFEKSI INDONESIA PERHIMPUNAN   CABANG JAKARTA

  FORMULIR SURVEILANS INFEKSI RUMAH SAKIT

Ruangan :………………………………………. Depart artemen :……………………………………….  No.Rekam edik :…………………………………… I. Identi Identitas tas Pasien Pasien !. Nam Nama "asi "asien en #. $mur '. Jenis (elamin *. +lamat

Tgl masuk/Jam : ........... /............. Car araa di dira raw wat: Eme Emergency cy/E /Eel elek ekttif 

: .... ...... .... .... .... .... .... .... .... ........ ...... .... .... .... .... .... .... : t%/ &ln/ %r   : )/ )/ " : : ............................................ ................................................................... ........................... ....

II.

DIAGNOSA WAKTU MA MASUK 

III.

Pinda !e R"an#an   !.……………………………………tgl ...............…………   #.......................................... #.........................................................tgl...... ...............tgl............................. .......................... ...

VI. Fa!t$% %esi!$ se&a'a di%a(at

 No

Jenis tindakan / alkes

!

)okasi

Tanggal pe pemasangan ulai s/d

Total ,ari

Tanggal -nfeksi

-ntra ena kateter   ena 0entral ena "erifer  +rteri $m&ilikal

#

$rine kateter   0uprapu&ik kateter 

'

entilasi e ekanik   Tu&a endotrakeal Trakeostomi )ain1 ain1la lain in .... ...... .... .... .... .... .... .... .. Drain/ -+2"/ C,

*

Fa!t$% Pen)a!it ,20 +g • +nti ,C • • •

+nti ,- )ain1lain

Hasi& Radi$&$#i 

: "ositif / Negatif / Tidak diperiksa : "ositif / Negatif / Tidak diperiksa : "ositif / Negatif / Tidak diperiksa : ............................................. ...................................................... ......... : …………………………………..

Hasi& &a*$%at$%i"'+ )eukocyt: …………. )ED : …………….

3D0

:……………..

Catatan

 

V. TINDAKAN , OPERASI .................... ........................................... .............................................. .............................................. ............................ .....

!.D-+3N40+

' Jenis 4perasi *. Tindakan 4perasi

......................................................................................................   ...................................................................................................... !:........ !:............. .......... .......... .......... .......... ........ ... )ama 4perasi.... 4perasi......... .......... .........5 ....5am6.. am6...... ......... .........m ....mnt nt #:.................................... #:..................... ............... )ama 4perasi..................5am6...............mnt 4perasi..................5am6...............mnt : 2ersi% 2ersi% tercemar Tercemar (otor   : Cito Elektif  

7. +0+8score

:!

#. Ta Tangga nggall operasi operasi

#

'

*

7

VI. KOMPLIKASI, INFEKSI RUMAH SAKIT !. -D4 ada / tidak ada %ari ke........................... ke...........................   ,asil kultur : .............................................. ..................................................................... .............................................. .............................................. ............................... ........   #. -0( ada / tidak ada %ari ke...........................   ,asil kultur : .............................................. ..................................................................... .............................................. .............................................. ............................... ........   '. "neumonia ada / tidak ada %ari ke........................... ke...........................   ,asil kultur : .............................................. ..................................................................... .............................................. .............................................. ............................... ........   *. -+D" ada / tidak ada %ari ke...........................   ,asil kultur : .............................................. ..................................................................... .............................................. .............................................. ............................... ........

7. )ain1lain 9 "le&itis/ diku&itus.................. diku&itus.................. ada / tidak ada %ari ke........................... ke...........................   ,asil kultur : .............................................. ..................................................................... .............................................. .............................................. ............................... ........   VII. Pe Pe'a!aian Anti'i!%$*a P%$-i&a!sis , en#$*atan   !............................................ !..................................................dosis ......dosis ......................mulai ......................mulai tgl....................s/d..................... tgl....................s/d.....................   #............................................ #..................................................dosis…………… ......dosis…………… mulai tgl....................s/d..................... tgl....................s/d.....................   '............................................ '..................................................dosis ......dosis ……………..mulai tgl....................s/d..................... tgl....................s/d.....................   *............................................ *..................................................dosis ......dosis ……………..mulai tgl....................s/d..................... tgl....................s/d..................... ;aktu ktu pem& pem&er eria ian n : "r "ree 4pe 4pera rasi si// sel selam amaa / se sesu suda da% % 4per 4peras asii .................................................................. .................................... ............. VIII. Tgl. "asien keluar R0 / eninggal : ...........................................   

"inda% ke +k%ir R0 Diagnosa

:: .............................................. ................................................................... .......................................................... ................................... .......... .....................

"erawat penanggung 5awa&/ pengisi formulir

(a. Ruangan

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

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

 Nama 5elas

Nama 5elas

  Catatan + /. 0. 2.

F$%'"& F$%'"&i% i% ini ini *e%ad *e%ada a da& da&a' a' d$!"' d$!"'en en 'edi 'edi! ! as asien ien Diisi $&e e%a(a e%a(att )an# *e%tan##"n# *e%tan##"n# 1a(a* ada asien asien te% te%se*"t se*"t Die%i Die%i!sa !sa $& $&e e e% e%a(a a(att en# en#end enda&i a&i in-e! in-e!si si setia setia  a%i