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Checklist Persiapan Operasional Emergency Departmen

CHECKLIST
NO. ITEM DESKRIPSI
TERSEDIA
1 RMO √
2 Nurse √
3 Ambulans Driver √
4 SDM ISS
5 Security
6 Kasir / Registrasi
7 Billing/wardclerk
8 Kursi Barstoll √
9 Wheelchair √
10 Pat Slide √
11 Computer √
12 Printer √
13 Printer Sticker √
14 Timer Amano √
15 Bed Mobile √
16 Draw Sheet √
17 Bed Sheet
18 Pillow + Pillow Case + Protector √
Registrasi dan Triage
19 Bantex box file biru √
20 Rekam Medis Kosong √
21 Form Pendaftaran Pasien Baru √
22 Form Registrasi Dept. ED √
23 Form Klaim Rawat Jalan √
24 Perforator
25 Staples
26 Papan Alas Ujian √
27 Tempat Sampah plastik kecil √
28 Lampu penerangan √
29 Telpon dan sambungan LAN
30 Kursi Barstoll √
31 Kursi Coklat √
32 Computer √
33 Telpon dan headset √
34 Timbangan dewasa √
35 Timbangan bayi √
36 Tabung Aerocom √
37 Aerocom √
38 APAR (Tabung pemadam) √
39 Tempat Sampah plastik kecil √
40 Jam dinding √
41 Sphygmomanometer Mobile √
42 Nurse Station Penlight √
43 Thermometer digital ear √
44 Torniquet √
45 Reflex Hammer √
46 Stetoskop dewasa √
47 Stetoskop pediatrik √
48 Stetoskop infant √
49 Oksigen 1000L + Flowmeter √

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50 Jolly Box no.300 √
51 Glucotest √
52 Doppler √
53 Pulse Oxymeter mobile √
54 Telpon √
55 Bed Pasien √
56 Draw Sheet √
57 Bed Sheet √
58 Pillow + Pillow Case + Protector √
59 Blanket √
60 Oksigen Flowmeter √
Isolation Room
61 Sphygmomanometer Wall √
62 Trolley tindakan √
63 Tempat Sampah plastik kecil √
64 Monitor Mobile √
65 Pressure Changer / magna helix
66 Kabel Call Nurse √
67 Bed Pasien √
68 Draw Sheet √
69 Bed Sheet √
70 Pillow + Pillow Case + Protector √
71 Blanket √
72 Sphygmomanometer Wall √
73 Overbed Table √
74 Lampu Tindakan (Ceiling Lamp) √
75 Trolley tindakan √
Procedure Room
76 Jolly Box √
77 Headlamp √
78 Penlight √
79 Monitor Mobile √
80 Tempat Sampah plastik kecil √
81 X-ray Viewer 3 film √
82 Hecting / Kit Box for Instrument
83 Oksigen Flowmeter √
84 Kabel Call Nurse √
85 Bed Pasien √
86 Draw Sheet √
87 Bed Sheet √
88 Pillow + Pillow Case + Protector √
89 Blanket √
90 Monitor + Bracket wall √
91 Overbed Table √
92 Monitor Mobile √
93 X-ray Viewer 3 film √
94 Tempat Sampah plastik kecil √
95 Stetoskop dewasa √
96 Emergency Trolley + Oksigen 500L √
97 Laryngoscope adult + child √
98 Laryngoscope infant √
99 Trolley tindakan √
Resuscitation Room
100 Defibrilator √
101 Ampu Bag Dewasa √
102 Ampu Bag Pediatric √

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 Resuscitation Room

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103 Ampu Bag Infant √
104 Oksigen Flowmeter √
105 Suction regulator √
106 ECG + ECG Trolley √
107 Nebulizer √
108 Jam digital
109 Jolly Box √
110 Oxylog Ventilator Mobile + Oksigen √
111 Reflex Hammer √
112 Penlight √
113 Kabel Call Nurse √
114 Kursi hitam kecil √
115 Bed Pasien √
116 Draw Sheet √
117 Bed Sheet √
118 Pillow + Pillow Case + Protector √
119 Blanket √
120 Overbed Table √
121 Bed Gynec √
122 Sphygmomanometer Wall √
123 Sphygmomanometer Mobile √
124 Suction regulator √
125 Suction canister (blue small) √
126 Emergency Trolley + Oksigen 500L √
127 Laryngoscope adult + child √
128 Laryngoscope infant √
129 Observation Bay Defibrilator √
130 Ampu Bag Dewasa √
131 Ampu Bag Pediatric √
132 Ampu Bag Infant √
133 Oksigen Flowmeter √
134 Tempat Sampah plastik kecil √
135 Tempat sampah besi kecil √
136 X-ray Viewer 3 film √
137 Oksigen 1000L + Flowmeter √
138 Bracket – Alcohol gel
139 Bracket – Glove box & Mask
140 Bracket – Sharp Container (Large)
141 Whiteboard (Papan Tulis)
142 Kabel Call Nurse √
143 Kursi hitam kecil √
144 Jolly Box √
145 Refrigerator √
146 Clean Utility Team code blue rescue pack √
147 Bengkok plastik √
148 Trolley linen kecil √
149 Tempat sampah besar hijau √
150 Basin stand + Basin √
151 Dirty Utility Bedpan washer √
152 Bedpan + cover √
153 Bedpan rack + urinal
154 Manequin dewasa √
155 Manequin bayi √

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Storage
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156 Stepstool (tangga kecil) √
157 Gips Cutter + Vacuum Cleaner √
158 Long Spine Board √
159 Storage KED for spinal √
160 Splint Traction √
161 Diagnostic set (Ophtalmoscope+otoscope) √
162 Electric Shaver √
163 Stopwatch √
164 Oksigen 1000L + Flowmeter √
165 Sphygmomanometer Wall √
166 Stetoskop dewasa √
167 Computer √
168 Kursi Dokter √
GP Room
169 Kursi Coklat √
170 Jam dinding √
171 Tempat sampah besi kecil √
172 X-ray Viewer 2 film √
173 Sphygmomanometer Wall √
174 Computer √
175 Kursi Dokter √
176 Ruang Dokter Kursi Coklat √
177 Jam dinding √
178 Tempat sampah besi kecil √
179 X-ray Viewer 2 film √
180 SPNG Fcpserstr180mm √
181 scalpel handle #3 125mm √
182 tissue forceps str 1x2 145mm √
183 tissue forceps serr 145mm √
184 strabismus scissor cvd 115mm √
185 strabismus scissors str 115mm √
186 surgical scissors str 145mm √
Instrument
187 TC ndl hldr hvyserr145mm √
188 crile forceps cvd 140mm √
189 crile forceps str 140mm √
190 suture scissors str 120mm √
191 Stille-aesculaps plstr shearopn-jw260mm √
192 plaster spreader usa 230mm √
193 bergmann plaster scissors 230mm √
194 Catatan Medis Gawat Darurat √
195 Catatan Perkembangan Terintegrasi (Integreted Note) √
196 Permohonan Konsultasi √
197 Surat Pengantar Rawat √
198 Catatan Pemberian Informasi dan Edukasi Multidisiplin √
199 Catatan Serah Terima Pasien Antar Ruangan √
200 Catatan Observasi √
201 Catatan Pengobatan (IMR=inpasient medication record) √
202 Pemesanan Diet Pasien √
203 Catatan Medis Ambulans Pre Hospital Care √
204 Catatan Medis Ambulans Monitoring Pasien √
205 Persetujuan Tindakan Medik / Bedah √
206 Persetujuan Tindakan Anestesi √
207 Catatan Keperawatan Peri Operatif √
208 Surat Pernyataan Menolak Tindakan Medis √

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Formulir
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209 Surat Pernyataan Tidak Tindakan Resusitasi √
210 Persetujuan Pemberian Produk Darah √
211 Catatan Observasi Khusus √
212 Penatalaksaaan Nyeri Dada √
Formulir
213 Pengkajian Nyeri Komprehensif √
214 Pengkajian Luka / Luka Tekan √
215 Formulir pemeriksaan Radiologi Konvensional √
216 Formulir Pemeriksaan CT Scan √
217 Formulir Pemeriksaan USG √
218 Formulir Pemeriksaan MRI
219 Pemeriksaan Patologi Klinik Laboratorium Klinik Terpadu √
220 Pemeriksaan Mikrobiologi Laboratorium Klinik terpadu √
221 Pemeriksaan Patologi Anatomi Laboratorium Klinik Terpadu √
222 Pemeriksaan Patologi Klinik CITO √
223 Rujukan Eksternal √
224 Data Medis Pasien Rujukan √
225 Surat Keterangan Pasien DOA √
226 Surat Keterangan Pasien DOH √
227 Surat Keterangan Pasien DOE
228 Formulir Rujukan Kedokteran Forensik √
229 Surat Serah Terima Jenazah √
230 Permintaan Surat Keterangan Kematian √
231 Formulir Prosedur / Tindakan √
232 Blanket √
233 Draw Sheet √
234 Baby Towel small √
235 Baby Towel big √
236 Patient Gown S √
237 Patient Gown M √
238 Patient Gown L √
239 Linen Patient Gown XL √
240 Pillow Case √
241 Pillow Protector √
242 Pillow √
243 Bath Mat √
244 Bed Sheet
245 OT Towel 75x75 with hole
246 OT Towel 90x90 with hole
247 Laryngoscope adult + child √
248 Sphygmomanometer Wall √
249 Stetoskop Adult √
250 Stetoskop pediatrik √
251 Pulse Oxymeter mobile √
252 Thermometer digital ear √
253 Penlight √
254 Glucotest √
255 Torniquet √
256 Urinal √
Ambulance Hiace
257 Payung √
258 Draw Sheet √
259 Bedpan √
260 Diagnostic set (Ophtalmoscope+otoscope) √
261 Oksigen Flowmeter √

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 Ambulance Hiace

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262 Ampubag adult + child √
263 Portable Ventilator √
264 Defibrilator √
265 Splint adult set 6 sizes + Pump
266 Suction Machine (mobile) √
267 Laryngoscope infant √
268 Sphygmomanometer Wall √
269 Stetoskop Adult √
270 Stetoskop pediatrik √
271 Pulse Oxymeter mobile √
272 Thermometer digital ear √
273 Penlight √
274 Ambulance Luxio Glucotest √
275 Torniquet √
276 Urinal √
277 Payung √
278 Draw Sheet √
279 Bedpan √
280 Diagnostic set (Ophtalmoscope+otoscope) √
281 Oksigen Flowmeter √
282
283
284
285
286
287
288
289
290
291
292

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ergency Department

CHECKLIST
JUMLAH KET.
TIDAK TERSEDIA
5 Summary Persiapan Operasional :
9 1. RMO : 0%
3 2. Nurse : 80%
√ 1 3. Alat : 95%
√ 1 4. Alur : 90%
√ 1
√ 1
2
2
1
1
1
1
1
1
1
√
1
1
-
-
-
-
√ 1
√ 1
3 2 coklat
1
1
√ 1
2
2
2
1
1
1
5
1
1
1
1
1
2
2
2
2
2
2
1
1

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2
1
1
1
1
1
1
1
1
1
1
1
1
2
1
√ 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
√ 1
1
2
2
2
2
2
2
1
2
1
1
2
2
1
1
1
1
1
1
1

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1
2
1
1
1
√ 1 buat PR
1
1
1
1
2
2
6
6
6
6
6
6
1
7
2
2
3
1
1
1
1
1
1
1
7
4
1
1
1
√ 3
√ 5 proses pengadaan
√ 1
√ 1
7
2
1
1
2
5
1
1
1
1
1
√ 1
1
1

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1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
6
6
6
6
3
3
3
6
3
3
3
1
1
1

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18 (22)
18 (22) 11(ED),4(OT),2(Amb)
6
6
5
5
3
3
18
15
9
5
√ 22
√ 12
√ 12
2
1
1
1
1
1
1
1
2
1
1
1
1
1
1

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1
1 Disimpan di ED
1 Disimpan di ED
√ -
2 Disimpan di ED
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1

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siapan Operasional :

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