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CATA CATATAN TAN KUNJUNGAN K UNJUNGAN HARIAN KLIEN VCT Nama Waktu Alasan Kunjungan Kunjungan
Nama
: : :
Waktu
Alasan Kunjungan VCT
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KODE : Tipe Klien :
L = Laki-laki P = Perempuan Latarbelakang Kunjungan: I = Informasi VCT = Konseling !an testing ukarela VCTL = Konseling Tin!ak Lanjut
'rsip Klien
Ko!e Klie n
L
P
PL = Pasangan laki-laki PP = Pasangan perempuan K P" L#
= Konseling = Penanganan "e!is = La$anan jarum suntik steril Lainn$a = %tolong !isebutkan&
I" = Pemeriksaan I"
TIPE KLIEN
Refrat Radiologi Kelompok 1
ALASAN UNTUK BERKUNJUNG
PL
PP
I
K( T
P"
VCTL I"
L#
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FORMULIR VCT
RA
)omor *egistrasi
'lamat ++++++++++++++++Kota,Kab : 1. Laki-laki 2. Perempuan eksualitas: mur Ta.un Pen!i!ikan Terak.ir +++++++++++ #umla. anak kan!ung +++++++ orang tatus Perka/inan 1. "enika. 2. 0elum,Ti!ak "enika. 3.Cerai Pekerjaan 1. Ti!ak 0ekerja 2.0ekerja1 #enis Pekerjaan : tatus ke.amilan: 12 Trimester I 22 II 32 III 42 Ti!ak .amil 92 Ti!ak ta.u mur anak terke3il +++++++++++++++++ta.un Kelompok *isiko : 1.P1 4 52 langsung 62 Ti!ak Langsung 7 Laman$a 2222222222 0ln,T.n 2.8aria 3.Penasun1 Laman$a 2222222222 0ln,T.n 4.9a$ .Pelanggan P !.Pasien T0 ".Pasangan *isti #.80P 9. Lainn$a 2 %bole. !iisi lebi. !ari satu& Ta$%%al Ko$&'l($% P)' T'& HIV Stat,& Pa&('$ Ala&a$ T'&t($% HIV M'$%'ta,( A-a$a T'& a)( P')$a t'& HIV &''l,5$a
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Unlock access2.with a free trial. gratis 3. ntuk bekerja 1. Ingin ta.ufullsaja "umpung gejala tertentu . 'kan menika. !."erasa berisiko "2 ruj Download With perio!& Free Trial9. -(),,/ -a)( LSM 10. #.Tes ulang %/in!o/ : 2222222222222222222222222222 1.0rosur 2. koran 3.TV 4. Dokter .Teman Sign up to vote on this title Outrea3. ".Poster #.La$ Konselor 9. Lainn$a useful Useful Not 1. a1 (5a$a 2222222222222222222222 Ka6a$ 7 22222222222222222 .r,0ln, Ha&(l 1. )egatip 2. Positip 9. ti!ak ta.u 2. Ti!ak
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Ha&(l T'& R1
1. )on *eaktif
2. *eaktif
)ama *eagen
Ha&(l T'& R2
1. )on *eaktif
2. *eaktif
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1. "obile VCT Klinik atelit
2. Klinik tama
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FORMULIR PERSETUJUAN TES HIV
a$a $ang bernama !iba/a ini tela. menerima informasi !an konseling $a men$angkut .al-.al sebagai berikut: a2 Informasi !asar ;IV !an 'ID b2 Kegunaan !ari tes ;IV 32 Keuntungan !an tantangan $ang sa$a perole. setela. tes ;IV !2 Pen3ega.an ;IV !an peningkatan kualitas .i!up !engan ;IV
a$a se3ara sukarela men$etujui untuk menjalani pemeriksaan testing ;IV !engan
ketentuan ba./a .asil tes akan tetap ra.asia !an terbuka .an$a kepa!a sa$a2 a$a men$etujui
untuk
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kemu!
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a$a !engan ini men$etujui tes ;IV2 Download With Free Trial
Tan!a Tangan,Cap #empol
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Fo)5,l() R,,//a$ P')5($taa$ P'5')(/&aa$ A$t( HIV
Tanggal
:
Ko!e2 Klien
:
u!a. menan!atangani persetujuan pemeriksaan :
< a < Ti!ak
Klien memiliki risiko tertular ;IV :
< a < Ti!ak
Klien menunjukan gejala 'ID :
< a < Ti!ak
You're Reading a Preview "en$etujui pemeriksaan !ara.1
Unlock full access with a free trial.
Download With Free Trial +++++++++++++++++++++++
)ama Terang Dokter :
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Fo)5,l() P'$%a5(la$ Ha&(l P'5')(/&aa$ A$t( HIV M'lal,( Ko$&'l($% Pa&
Tanggal : Ko!e2 Klien
:
You're Reading a Preview Unlock full access with a free trial.
Download With FreeTan!a Trial Tangan:
Sign upDokter: to vote on this title )ama
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You're Reading a Preview
Catatan Unlock full access with a"e!is free trial.Klien
: --
LAPORAN TESWith HIVFree ANTI Download TrialBOI Sign up to vote onTanggal this title : ++,++,+
Ko!e Klien : ++++++++++++++++++++
LAPORAN LABORATORIUM Na5a T'&
Ha&(l
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+++++++++++++++++++++++++ Tan!a tangan $ang ber/enang Lokasi serta alamat !an nomor telepon .arus !isertakan !iba/a. ini2
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FORM RUJUKAN UNTUK SignKLIEN up to vote on this title
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Tanggal *ujukkan !ibuat
: 222222222222222 , 22222222222222222222222222 ,
*ujukkan !ibuat ole.
:
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52 Konseling Psikososial Lanjutan 62 Pemeriksaan kese.atan !asar untuk ;IV 2 0antuan untuk pera/atan !i sosial !i ruma. !an lingkungan @2 Kelompok !ukungan orang !engan ;IV A2 Konseling )'PB' 2 0antuan akomo!asi 2 Lainn$a1 sebutkan 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 Catatan k.usus :
Tan!a tangan petugas )ama: )o Telep.on:
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#umla. $ang !iterima untuk pela$anan ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Diterima ole. : ++++++++++++++++++++++++++++++
++++++++++++++++++++++ )ama taf VCT
++++++++++++++++++ Tan!a tangan
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FORM PELA:ANAN VCT
% 0erikan tan!a V pa!a lingkaran berikut& 52'paka. an!a men!apatkan pela$anan VCT se3ara bersa.abatF a
Ti!ak
62'paka. an!a men!apatkan informasi ;IV 'ID !an tes ;IV se3ara lengkapF a
Ti!ak
2'paka. proses pela$anan VCT sesuai !engan .arapan an!aF a
Ti!ak
@2 aran-saran $ang !apat an!a berikan:
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IZIN KLIEN UNTUK PERSETUJUAN MELEPAS INFORMASI KETERANGAN KLIEN Nama Klin Kt!angan untuk "i#u$ungi %jika klin stuju& :
IZIN PERSETUJUAN UNTUK MELEPAS INFORMASI
Sa'a (((((((((((((((((((((((((((((( mm$!ikan i)in k*a"a (((((((((((((((((((((((((( %nama klin& %nama "+kt!,K+nsl+ Untuk mn'"iakan in-+!masi "an m!ujuk sa'a *a"a *nanganan lanjutan. s$agai $!ikut : In-+!masi k+nsling lanjutan In-+!masi "ukungan *sik+s+sial k+n+mi +!ang/+!ang 'ang sa'a #u$ungi Lainn'a %s$utkan& Kt!angan: In-+!masi mn'"iakan untuk :
0000000000000000000000001 %nama sta-- angg+ta You're Reading a Preview "i 01111111111111111111111111110000000000000000000000000000000 %nama tm*at,instansi& Unlock full access with a free trial.
Sa'a mng!ti $a#2a "imana in-+!masi t!s$ut "is"iakan untuk tujuan "i!ujuk k*a"a +!ang lain. sa Download With Free Trial in-+!masi k*a"a k+nsl+! s mm$!ikan i)in k*a"a +!ganisasi t!s$ut untuk km$ali mn'"iakan mngnai #al !ujukan t!#a"a* "i!i sa'a1 Sa'a mng!ti $a#2a sa'a "a*at mm$atalkan 22nang u mm$!ikan in-+!masi atau kt!angan "i!i sa'a 'ang !a#asia ini ka*an saja inginkan1 T!tan"a : (((((((((((((((((((((((((((((( T!tan"a: ((((((((((((((((((((((((((((((((( %tan"a tangan klin&
Tanggal "itan"a tangani : ((,((,((
%tan"a tangan "+kt!,k+nsl+!& Sign up to vote on this title
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