RUMAH
SAKIT
RIZANI
JL. Raya Surabaya – Situbondo KM. 135 Desa Sumberrejo Kecamatan Paiton – Kabupaten Probolingo Telpon (0335) 773444 Faximile (0335) 774556 Email :
[email protected]
FORMULIR LAPORAN PAPARAN BENDA TAJAM DN SUBSTANSI TUBUH BAGIAN A (diisi oleh petugas/ staff yang terpapar) Tgl. Laporan : ................................. Jam : .... : .... WIB Unit/ instalasi: .............................................................. Koordinator : ............................................................... IDENTITAS TERPAPAR Nama : ............................................................... Alamat : ............................................................... Memakai APD : APD yang dipakai :
□ Ya
□ Tidak
□ HandScone □ Apron □ Masker □ Google/ Kacamata/ Pelindung Wajah □ Lainnya : ..................................................................
Tgl. Laporan : ................................. Jam : .... : .... WIB Tempat Kejadian : ........................................................ Bagian Tubuh Yang Terpapar (sebut dengan jelas) : ...................................................................................... Jelaskan Kronologi Kejadian : ...................................................................................... ...................................................................................... ...................................................................................... ...................................................................................... ...................................................................................... ...................................................................................... ...................................................................................... ...................................................................................... Staff Terpapar
Imunisasi Hepatitis B :
□ Ya (Lengkap) □ Ya (Tidak Lengkap) □ Tidak Pertolongan Pertama :
□ Dilakukan
□ Tidak Dilakukan
(................................................)
BAGIAN B (diisi oleh IPCN/ Supervisor) Tgl. Periksa : .................................. Jam : .... : .... WIB Diperiksa oleh : ............................................................ Kondisi Luka (besarnya luka/dalamnya luka) : ...................................................................................... ...................................................................................... ...................................................................................... Materi dan Jumlah Paparan :
□ Darah : ........................... cc □ Serum/ plasma : ........................... cc □ Lainnya, sebutkan : ................................................. Resiko Paparan :
□ Resiko Paparan Rendah □ Resiko Paparan Tinggi
Jenis Paparan :
□ Jarum Suntik □ Pisau Bedah □ Gigitan □ Lainnya, sebutkan : ................................................. Hasil Pemeriksaan Laboratorium : HBSAg : ..................................................................... Anti HIV : ..................................................................... Anti HCV : .................................................................... Status Infeksius :
SUMBER (PASIEN) Tempel stiker ID disini
PENATALAKSANAAN ...................................................................................... ...................................................................................... ...................................................................................... FOLLOW UP 3 Bulan Hasil HBSAg : ..............................................................
□ Hepatitis B □ HIV □ Hepatitis C □ Tidak diketahui (+) ...................... □ Tidak diketahui (-) .......................
...................................................................................... ...................................................................................... ...................................................................................... HIV : .................. Rujuk ke RS : ................................... 6 Bulan Hasil HBSAg : ..............................................................
SARAN : ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ Paiton, ................................................. IPCN
Virnia Nourma Sutrisno, S.Kep.,Ners
