Form Surveilans PPIRS

KOMITE PENCEGAHAN DAN PENGENDALIAN INFEKSI RUMAH SAKIT ISLAM SITI RAHMAH PADANG PADANG

FORMULIR SURVEILANS INFEKSI NOSOKOMIAL

Ruang Ruangan an :……… :…………… ………… ………. …... .... Cara Cara dira dirawa watt : Emer Emerge gency ncy/E /Ele lekt ktif if

Tgl Tgl masu masuk/ k/Ja Jam m No.Re No.Reka kam m Medi Medik k

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DIAGNOSA WAKTU MASUK 

III.

Pindah ke Ran!an   1................................tgl.....................................   !................................tgl......................................

VI. Fakt"# #esik" se$a%a di#a&at

 No 1

Jenis Tindakan Tindakan

'okasi

Tanggal emasangan Mulai 'e,as

 Nama emasang

Total *ari

Tanggal +nfeksi

+ntra -ena Cateter C- "m$ilikal )rteri -ena erifer

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Cateter "rine

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-entilasi Mekanik Trakeostomie

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Hasi$ $a("#at"#i%) 'eukocyt: …………. 'E : ……………. 0 :……………..

V. TINDAKAN * OPERASI   ..............................................................................................

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............................................... .......................................................   ...................................................................................................... !. Tanggal o,erasi 1:.................................... 'ama 3,erasi..................4am5...............mnt !:.................................... 'ama 3,erasi..................4am5...............mnt % Jenis 3,erasi : 2ersi# 2ersi# tercemar Tercemar &otor   (. Tindakan 3,erasi : Cito Elektif   6. ))7score :1 ! % ( 6 VI. KOMPLIKASI* INFEKSI NOSOKOMIAL 1. +'3 ada / tidak ada #ari ke........................... *asil kultur : ............................................... ............................................................................

!. +& ada / tidak ada #ari ke........................... *asil kultur : ............................................... ............................................................................ %. neumonia ada / tidak ada #ari ke........................... *asil kultur : ............................................... ............................................................................ (. +) ada / tidak ada #ari ke........................... *asil kultur : ............................................... ............................................................................ 6. 'ainlain 8 le$itis/ diku$itus9...... ada / tidak ada #ari ke........................... *asil kultur : ............................................... ............................................................................ VII. Pe%akaian Anti%ik#"(a P#"+i$aksis * ,en!"(atan 1................................................. .dosis ......................mulai tgl....................s/d..................... !................................................. .dosis…………… mulai tgl....................s/d..................... %................................................. .dosis ……………..mulai tgl....................s/d..................... (................................................. .dosis ……………..mulai tgl....................s/d..................... aktu ,em$erian : reo,erasi/ selama / sesuda# o,erasi VIII. Tgl. asien keluar R / Meninggal : ................................................................ inda# ke R : ................................................................ iagnosa )k#ir : ................................................................

erawat ,enanggung 4awa$/ ,engisi formulir

&a. Ruangan

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 Nama 4elas

Nama 4elas

&eterangan : 1. !. %. (. 6. =. >. ?.

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