FORMULIR SURVEILANS HARIAN INFEKSI RUMAH SAKIT

RUMAH SAKIT UMUM SEMARA RATIH

BULAN/TAHUN: AGUSTUS 2017

RUANGAN : RAWAT INAP
SURVEYOR :
DIVISI/DEPARTMEN :
TINDAKAN INFEKSI RUMAH SAKIT TIRAH HASIL
TGL S NAMA/RM U JK DX.MEDIS AB
UC IVL CVL ETT/VENTI VAP HAP ISK IAD BARING KULTUR
Nyoman
1/8/17-
1/8/17 37 Amba 75 L PPOK
5/8/17
(170955)

1/8/17 36 Made Tinggi 50 L Arthalgia 1/8/17-

( 172858 ) shoulder 4/8/17

2/8/17 36,7 Suka Atmaja 30 L Febris 2/8/17-

( 172329 ) 4/8/17

2/8/17 36 Wayan 42 L HT 2/8/17-

Suarya 4/8/17
( 172862)
2/8/17 36,7 Kadek 34 P G2p1A0 2/8/17- 2/8/17-
Indrayani 4/8/17 4/8/17
(172862)
3/8/17 38,3 I Made 3 L Febris 3/8/17-
Bagus Dwi 4/8/17
Purnawan
(170753)
3/8/17 36,4 Made Seken 65 L HT 3/8/17-
(172870) 5/8/17
4/8/17 36 Ni Wayan 77 P Pneumonia 4/8/17-
Lisig 7/8/17
(170973)
4/8/17 37,6 Made Tangi 55 L Febris 4/8/17-
(172876)
4/8/17 37,6 Made Jeger 55 L HT 4/8/17-
(172881) 6/8/17
4/8/17 36,4 Ketut Astuti 18 P Vertigo 4/8/17-
Mahadewi 6/8/17
(172882)
5/8/17 36,5 Ni Komang 17 P GEA 5/8/17-
 Dewi U 7/8/17
(171698)
5/8/17 36,7 I Wayan 60 L PPOK 5/8/17-
Benti 8/8/17
(171749)
6/8/17 36 I Ketut 74 L PPOK 6/8/17-
Kabik 7/8/17
(172893)
7/8/17 38,6 Putu Angga 9 L Kejang 7/8/17-
(172896) Konvulsi 8/8/17
7/8/17 36,2 Kadek Dwi 15 L Abdominal 7/8/17-
Maita N Pain 9/8/17
(170970)
7/8/17 36 Made Sura 65 L Luka Infeksi 7/8/17-
(172898 ) 10/8/17
7/8/17 36,6 I Ketut 65 L Colic 7/8/17-
Kemprung Abdomen 10/8/17
(172899 )
8/8/17 36,4 I Nyoman 75 L PPOK 8/8/17-
Amba 11/8/17
(170955)
9/8/17 36,8 Ni Made 65 P UTI 9/8/17-
Seken 11/8/17
(172870 )
9/8/17 36 I Made Rena 60 L DM 9/8/17-
(172915) 11/8/17
10/8/17 36,6 Made Sriasih 35 P Vertigo 10/8/17-
(172927) 12/8/17
10/8/17 36,6 Putu Ardika 2 L GEA 10/8/17-
Satria 11/8/17
( )
11/8/17 36,2 Ni Ketut 55 P Gastritis 11/8/17-
Mara 13/8/17
( 172932 )
11/8/17 36,2 Wayan Sire 75 L UTI, BPH 11-817- 11/8/17-
(172908) 14/8/17 14/8/17
12/8/17 36,6 I Wayan 9 L Susp apendik 3/8/17-
Budiasa
(172949)
14/8/17 36 Nyoman 50 L Colic 14/8/17-
Sumerta Abdomen
(172947)
14/7/17 36 Nyoman Niti 40 P Post Insect 14/8/17-
Rai Santi Bite 21/8/17
 (172959)
15/8/17 36 Nyoman 36 L Dispepsia 15/8/17-
Sara 16/8/17
(172964)
16/8/17 36,4 Riska 15 P Thypoid 16/8/17-
Kurniawan Abdominal 17/8/17
(172970)
17/8/17 36 Ni Wayan 37 P Infiltrat 17/8/17-
Suriani 20/8/17
(170668)
17/8/17 36,2 Ayu Putu 28 P G2P1A0 17/8/17-
Oka Riantini 20/8/17
(170944)
17/8/17 36 Made Unda 21 P Episiotomi 17/8/17-
Wati Infeksi Infiltrat 20/8/17
(172980)
18/8/17 36,4 Ni Nyoman 62 P GE 18/8/17-
Sarmini 20/8/17
(172992)
18/8/17 36,8 Nyoman 65 L PPOK 18/8/17-
Pugir 21/8/17
(172989)
18/8/17 37,2 I Made L Dispepsia 18/8/17-
Kartika 21/8/17
(172991)
19/8/17 36 Ni Made 4 P GE 19/8/17-
Swandewi 21/8/17
(172244)
19/8/17 36,2 Nur Vitria 40 P Colic Renalis 19/8/17-
(170905) 20/8/17
19/8/17 36 Sinaryasa 50 L Stroke 19/8/17-
(172993) Hemiplagi 21/8/17
19/8/17 36,4 Ni Putu 17 P Vertigo 19/8/17-
Riska Ayu 21/8/17
(172998)
20/8/17 36 Made 64 L Colic 20/8/17-
Tambun Abdomen 22/8/17
( 173001)
21/8/17 36 Luh Renasih 42 P Acute 21/8/17-
(173013) Phylonefritis 24/8/17
21/8/17 37,8 Nyoman 21 P Febris 21/8/17-
Yuliana 24/8/17
Dewi
(173023)
22/8/17 36,6 I Ketut 56 L Varises 22/8/17-
Prangika 23/8/17
(173025)
22/8/17 37,9 Rendi putra 3 L Febris 22/8/17-
Pratama 23/8/17
(173021)
23/8/17 36 Ni Made 50 P Vertigo 23/8/17-
Mini 24/8/17
(173027)
23/8/17 36,2 Ni Nyoman 45 P GE 23/8/17-
Purniati 26/8/17
(173031)
24/8/17 37,6 Ni Ketut 55 P Hipoglikemi 24/8/17-
Kembur 25/8/17
(172581)
24/8/17 37 I wayan 50 L PPOK 24/8/17-
Benti 27/8/17
(171749)
24/8/17 36,2 Ni Wayan 85 P Dispepsia 24/8/17-
Ridis 30/8/17
(172224)
25/8/17 36 Ni Luh 24 P Post SC 25/8/17-
Prasiani 27/8/17
( )
25/8/17 36,2 Ni wayan 35 P P2A0 25/8/17-
seniati 27/8/17
(170847)
25/8/17 36 Sri Radha 18 P Febris 25/8/17-
Nare Swari 27/8/17
(173040)
25/8/17 36,5 Nyoman 40 P Menometroragi 25/8/17-
Kondre
( 173042 )
25/8/17 37,2 Nyoman 31 L Intoksikasi 25/8/17-
Merta 27/8/17
Widana
(173048)
26/8/17 36 Wayan 43 L Obstipasi 26/8/17-
Ramia 29/8/17
(173056)
28/8/17 36 Ni Wayan 85 P Bronchitis 28/8/17-
Nadi 31/8/17
(173075)
28/8/17 36,7 Rita P Post SC 28/8/17-
 Andriyani 31/8/17
(172569)
28/8/17 36.5 Ni Kadek Sri 15 P P1A0 28/8/17-
Anggraini 39/8/17
(172933)
29/8/17 37,8 I Wayan 50 L Vertigo 29/8/17-
Winantra
(173069)
30/8/17 36,5 Putu Adi 3 L Traumatic 30/8/17-
Setiawan Amputasi 2/9/17
(173104) digiti I Pedis
dextra
36,6 Ida Ayu 66 P Decom Cordis 30/8/17-
30/8/17 Nyoman sari
(172624)
36,7 Sudi 35 P Bronchitis 30/8/17-
30/8/17 Pramayanti 1/9/17
(173105)
30/8/17 36 Kadek 19 L Post syncope 30/8/17-
Kastani 31/8/17
(173091)
30/8/17 36,3 Muliastini 29 P Chepalgia 30/8/17-
(173100) 31/8/17
31/8/17 37,7 Ni Kadek 8 P GE 31/8/17-
Giani 4/9/17
Permata D
(171923)
31/8/17 36 Ni Made 27 P G2P1A0 31/8/17-
Sutrisna 1/9/17
( )
31/8/17 36,5 I Made 37 L Apendiksitis 31/8/17-
Kamiarta 5/9/17
( )
31/8/17 36,9 Wayan 9 L Illeus 31/8/17- 69
Budiasa 3/9/17
(172548)
KETERANGAN
Dx MEDIS : Diagnosa Medis U : Usia
S : Suhu JK : Jenis Kelamin
UC : Urine Kateter HAP : Hospital Aquired Pnemonia
IVL : Intra Vena Line/ Vena Perifer VAP : Ventilator Associated
ETT : Endotrakheal Tube IAD : Infeksi Aliran Darah
 FORMULIR SURVEILANS HARIAN INFEKSI RUMAH SAKIT
RUMAH SAKIT UMUM SEMARA RATIH

BULAN/TAHUN:
RUANGAN :
SURVEYOR :
DIVISI/DEPARTMEN :
MACAM
DX. TINDAKAN INFEKSI RUMAH SAKIT TIRAH HASIL JENIS KUMAN
TGLSUJK DEKU AB ANTIBIOTOK hasil
MEDIS BARING KULTUR
UCIVLCVLETT/VOBOBTOK VAP HAPISKPLEBITISIADILSILDILO TAB 1 2 3 >3 darahswabsputumurine
KETERANGAN
Dx MEDIS : Diagnosa Medis U : Usia IVL: Intra Vena Line/ Vena Perifer CPL : Central Vena Line OK : Operasi Kotor
ILD : Infeksi Luka Dalam
S : Suhu JK : Jenis Kelamin ETT : Endotrakheal Tube OB : Operasi Bersih DEKU : Dekubitus
ILK : Infeksi Luka Kotor
UC : Urine Kateter HAP : Hospital Aquired Pnemonia VAP : Ventilator Associated OBT : Operasi Bersih Tercemar SS/IDO : Surgical
Side Infaction/Infeksi Darah Operasi ILS : Infeksi Luka Superficial
PLEB : Plebitis

FORMULIR LAPORAN HASIL SURVEILANS

INFEKSI RUMAH SAKIT & PEMAKAIAN ANTIBIOTIK
RUMAH SAKIT UMUM SEMARA RATIH

LAPORAN BULANAN : JUNI 2017

DEPARTEMNE : RAWAT INAP
DOKTER PENANGGUNG JAWAB :
VARIABEL
VENA
VENA PERIFER KATETER OPERASI TIRAH BARING ETT/ENTILATOR TIRAH BARING
SENTRAL
0/ 0/ 0/
SSI 0/ 0/ 0/
N IAD 00 N PLEBITIS 00 N ISK 00 N % N HAP 00 N VAP 00 N DEKUBITUS 00
ILS ILD ILO

12,5
1 4,4 %

LAPORAN PENGGUNAAN ANTIBIOTIKA dan/atau SUNTIKAN

MACAM A B YANG DIGUNAKAN PADA PASIEN BERESIKO INFEKSI RUMAH SAKIT

TANPA A B 1 MACAM 2 MACAM 3 MACAM JENIS ANTIBIOTIK/JUMLAH
 Pre opp Cefotaxime 2gr,
Post opp cefotaxim 3x1 gr,

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