Ceklis Tas Emergency 2019 Juli Ke Atas

CEKLIST EMERGENCY KIT / AMBULANCE
PERIODE BULAN : ........................2019

RUANGAN : AMBULANCE RS YARSI
SERIAL NUMBER :
TANGGAL
EXP DATE
STOK
NO NAMA BARANG 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
P S M P S M P S M P S M P S M P S M P S M P S M P S M P S M P S M P S M P S M P S M P S M P S M
Kantong depan & samping

1 Ultra sound Gel 1
2 Elektrode (Skintact cloth D50m) 6
3 Handscoon Ukuran M ( 1box) 1
4 Handscoon 6,5 1
5 Handscoon 7 1
6 Handscoon 7,5 1
7 Kassa 55,10 X 3,6 5
8 kassa 55, 6 X 3,6 1

9 Kassa lipat 5cm X 5cmx16 (satuan) 30
10 Kassa Steril 16X 16 cm Husada 2
11 Policrepe 7,5 X4,55 mm 1

12 Laringoscope pediatric 1 set 1
13 Laringoscope adult 1 set 1
14 Saturasi No . 023766 1
15 Gunting 1
16 Tensi + stetoscope 1
17 Senter Led 1
Didalam Tas ( Box kecil hijau)

1 Aminophylin Inj 240 mg/10 ml 1
2 Cordarone 150mg inj 2
3 Aspilet Tab 5
4 Atropin Inj 6
5 Calcium Gluconate 10% Inj 1
6 Clopidogrel Tab 5
7 Dexamethasone Inj 5 mg/2 ml 2
8 Dextrose 40% 25 ml 2
9 Stesolid inj 2
10 Stesolid 10 mg supp 1
12 Dipenhydramine Inj 2
13 Epinephrine Inj 4
14 Lasix 20 mg/2 ml Inj 2
15 Isosorbide Dinitrate Tab 5 mg 5

16 Lidocain Inj 5
17 MgSO4 20% 25 ml 2
EXP DATE
TANGGAL
STOK
NO NAMA BARANG 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
18 Ventolin Nebules 3
19 Miloz 15 mg 1
20 Pulmicort 0,5 5
21 Ondansentron 4mg 1
22 Asam mefenamat tablet 10
23 Keterolac 2
24 Paracetamol tablet 10
25 Betadine10gr 1
Emergency Kit (dalam)

1 Perfusor / Extion tube 1
2 3 Way Stopcock With E T 1
3 Alkohol Swab 10
4 Blood Set 1
5 Infus Set (Intrafix) 2
6
IV Cannula G18 Polyflex 2
7 IV Cannula G20 Polyflex 2
11 IV chateter surflo 14 1
13 Spuit 10 ml Terumo/kimsmed 3
14 Spuit 1cc terumo 1
15 Spuit 20 ml Terumo 1
18 Spuit 50 ml Catheter tip Terumo 1
19 Spuit 50 ml Perfusor Bbraun 1
20 Micropore / Plester Paper tape 1
21 Suction Connector 1
22 Stick ice cream 10
23 Tegaderem 1623 3M 2
24 Transofix B Braun 4090500 2
25 underpad 60x 90 cm 1
Emergency Kit
1 ETT King-king Cuffed No. 4 1
2 ETT King-king Cuffed No. 4,5 1
4 ETT King-king cuffed No. 5,5 1
5 ETT King-king cuffed No. 6 1
EXP DATE
TANGGAL
STOK
NO NAMA BARANG 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

10 ETT King-king Uncuffed No. 2,5 1
11 ETT King-king Uncuffed No. 3 1
13 Laringoskop Adult 1
14 Laringoskop Pediatric 1
15 Mandrin/Intubation Stylet Uk. L 1
16 Mandrin/Intubation Stylet Uk. M 1
17 Mandrin/Intubation Stylet Uk. S 1
18 Masker Nebulizer Adult 1
19 Masker Nebulizer Pedriatric 1
20 Nasal Canul Adult 1
21 Nasal Canul Pedriatric 1
22 Nasopharingeal Uk. 6 1
23 Oropharengeal Uk. 0 1
30 Urine Bag 2 L 1
31 Xylocain Gel 1
32 Masker medium adult (Simple) 1
Emergency Kit
1 Folley Catheter Uk. 14 1
3 LMA Uk. 3 1
4 LMA Uk. 4 1
5 LMA Uk. 5 1
6 NGT Uk. 10 1
7 NGT Uk. 12 1
8 NGT Uk. 16 1
9 NGT Uk. 18 1
10 NGT Uk. 3,5 1
11 NGT UK. 5 1
EXP DATE
TANGGAL
STOK
NO NAMA BARANG 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
12 NRBM Adult 1
13 NRBM Pediatric 1
14 Selang Bag Mask / O2 Tubing 1
15 Suction catheter UK. 10 1
Emergency Kit
1 BVM Adult 1
2 BVM Neonatus 1
3 BVM Pediatric 1
4 Dextrose 10 % 500 ml 1
6 Nacl 0,9% 25 ml 2
7 Nacl 0,9% 100 ml 1
8 Nacl 0,9% 500 ml 1
9 RL 500 ml 1
10 WFi 25 2
Diperiksa oleh
(Nama Perawat)
Serial number
Jakarta, ...........................
Diperiksa Oleh, Mengetahui
(..............................) (.....................................) (....................................)
PJ Ambulance Ka. Bidang Keperawatan Ka. Instalasi Farmasi

PERIODE BULAN : ........................2019
RUANGAN : AMBULANCE RS YARSI
SERIAL NUMBER :
EXP DATE
TANGGAL
STOK
NO NAMA BARANG 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 Ultra sound Gel 1
2 Elektrode (Skintact cloth D50m) 6
3 Handscoon Ukuran M ( 1box) 1
4 Handscoon 6,5 1
5 Handscoon 7 1
6 Handscoon 7,5 1
7 Kassa 55,10 X 3,6 5
8 kassa 55, 6 X 3,6 1

9 Kassa lipat 5cm X 5cmx16 30
10 Kassa Steril 16X 16 cm Husada 2
11 Policrepe 7,5 X4,55 mm 1

12 Laringoscope pediatric 1 set 1
13 Laringoscope adult 1 set 1
14 Saturasi No . 023766 1
15 Gunting 1
16 Tensi + stetoscope 1
17 Senter Led 1
Didalam Tas ( Box kecil hijau)

1 Aminophyllin Inj 240 mg/10 ml 1
2 Cordarone 150mg inj 2
3 Aspilet Tab 5
4 Atropin Inj 6
5 Calcium Gluconate 10% Inj 1
6 Clopidogrel Tab 5
7 Dexamethasone Inj 5 mg/2 ml 2

9 Stesolid inj 2
12 Dipenhydramine Inj 2
13 Epinephrine Inj 4
14 Lasix 20 mg/2 ml Inj 2
15 Isosorbide Dinitrate Tab 5 mg 5
16 Lidocain Inj 5
EXP DATE TANGGAL

STOK
NO NAMA BARANG 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
17 MgSO4 20% 25 ml 2
18 Ventolin Nebules 3
19 Miloz 15 mg 1
20 Pulmicort 0,5 5
21 Ondansentron 4mg 1
22 Asam mefenamat tablet 10
23 Keterolac 2
24 Paracetamol tablet 10
25 Betadine10gr 1

1 Perfusor / Extion tube 1
2 3 Way Stopcock With E T 1
3 Alkohol Swab 10
4 Blood Set 1
5 Infus Set (Intrafix) 2
6
IV Cannula G18 Polyflex 2
14 Spuit 1cc terumo 1
15 Spuit 20 ml Terumo 1
18 Spuit 50 ml Catheter tip Terumo 1
19 Spuit 50 ml Perfusor Bbraun 1
20 Micropore / Plester Paper tape 1
21 Suction Connector 1
22 Stick ice cream 10
23 Tegaderem 1623 3M 2
24 Transofix B Braun 4090500 2
25 underpad 60x 90 cm 1
Emergency Kit
2 ETT King-king Cuffed No. 4,5 1
EXP DATE
TANGGAL
STOK
NO NAMA BARANG 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

11 ETT King-king Uncuffed No. 3 1
13 Laringoskop Adult 1
14 Laringoskop Pediatric 1
15 Mandrin/Intubation Stylet Uk. L 1
16 Mandrin/Intubation Stylet Uk. M 1
17 Mandrin/Intubation Stylet Uk. S 1
18 Masker Nebulizer Adult 1
19 Masker Nebulizer Pedriatric 1
20 Nasal Canul Adult 1
21 Nasal Canul Pedriatric 1
22 Nasopharingeal Uk. 6 1
30 Urine Bag 2 L 1
31 Xylocain Gel 1
32
Masker medium conc adult (Simple) 1
Emergency Kit
3 LMA Uk. 3 1
4 LMA Uk. 4 1
5 LMA Uk. 5 1
6 NGT Uk. 10 1
7 NGT Uk. 12 1
8 NGT Uk. 16 1
9 NGT Uk. 18 1
10 NGT Uk. 3,5 1
EXP DATE
TANGGAL
STOK
NO NAMA BARANG 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
11 NGT UK. 5 1
12 NRBM Adult 1
13 NRBM Pediatric 1
14 Selang Bag Mask / O2 Tubing 1
Emergency Kit
1 BVM Adult 1
2 BVM Neonatus 0
3 BVM Pediatric 0
4 Dextrose 10 % 500 ml 1
6 Nacl 0,9% 25 ml 2
7 Nacl 0,9% 100 ml 1
8 Nacl 0,9% 500 ml 1
9 RL 500 ml 1
10 WFi 25 2
Diperiksa oleh
(Nama Perawat)
Serial number
Jakarta, ...........................
Diperiksa Oleh, Mengetahui
(..............................) (.....................................) (....................................)

PJ Ambulance Ka. Bidang Keperawatan Ka. Instalasi Farmasi
RUANGAN : AMBULANCE RS YARS
SERIAL NUMBER :
EXP DATE
STOK
NO NAMA BARANG 17 18
P S M P S

1 Ultra sound 1
Gel
Elektrode
2 6
(Skintact
cloth D50m)
Handscoon
3 1
Ukuran M
( 1box)
4 Handscoon 1
6,5
5 2
Handscoon 7
6 Handscoon 2
7,5
7 Kassa 55,10 7
X 3,6
8 kassa 55, 6 1
X 3,6
Kassa lipat
9 5cm X 30
5cmx16
(satuan)
Kassa Steril
10 2
16X 16 cm
Husada
11
Policrepe 7,5
X4,55 mm 1
Laringoscop
12 1
e pediatric 1
set
13 1
Laringoscop
e adult 1 set
14 Saturasi No . 1
023766
15 Gunting 1
16 Tensi + 1
stetoscope
17 Senter Led 1
Didalam Tas ( Box kecil hij

Aminophyllin
1 1
Inj 240
mg/10 ml
2 Cordarone 2
150mg inj
3 Aspilet Tab 5
4 Atropin Inj 6
Calcium
5 1
Gluconate
10% Inj
6 Clopidogrel 5
Tab
Dexamethas
7 2
one Inj 5
mg/2 ml
8 Dextrose 2
40% 25 ml
9 Stesolid inj 2
10 Stesolid 10 1
mg supp
11 Stesolid 5 1
mg supp
12 Dipenhydram 2
ine Inj
13 Epinephrine 4
Inj
14 Lasix 20 2
mg/2 ml Inj
Isosorbide
15 5
Dinitrate Tab
5 mg
16 Lidocain Inj 5
17 MgSO4 20% 2
25 ml
18 Ventolin 3
Nebules
19 Miloz 15 mg 1
20 5
Pulmicort 0,5
21 Ondansentro 1
n 4mg
Asam
22 10
mefenamat
tablet
23 Keterolac 2
24 Paracetamol 10
tablet
25 1
Betadine10gr
1 Perfusor / Extion tube
2 3 Way Stopcoc 1
3 Alkohol Swab 10
4 Blood Set 1
5 Infus Set (Intra 2
6
IV Cannula G1 2
7 IV Cannula G2 2
8 IV Cannula G2 2
9 IV Cannula G2 2
10 IV Cannula G2 2
11 iv chateter sur 1
12 iv chateter sur 1
13 Spuit 10 ml T 3
14 Spuit 20 ml T 1
15 Spuit 3 ml Te 3
16 Spuit 5 ml Te 3
17 Spuit 50 ml Ca 1
18 Spuit 50 ml P 1
19 Suction Conne 1
20 Stick ice crea 10
21 Tegaderem 16 2
22 Transofix B B 2
23 underpad 60x 1
Emergency Kit
1 ETT King-king 1
2 ETT King-king 1
3 ETT King-king 1
4 ETT King-king 1
5 ETT King-king 1
6 ETT King-king 1
7 ETT King-king 1
8 ETT King-king 1
9 ETT King-king 1
10 ETT King-king 0
11 ETT King-king 1
12 ETT King-king 1
13 Laringoskop A 1
14 Laringoskop Pe 1
15 Mandrin/Intuba 1
16 Mandrin/Intuba 1
17 Mandrin/Intuba 1
18 Masker Nebuli 1
19 Masker Nebuliz 1
20 Nasal Canul A 1
21 Nasal Canul Pe 1
22 Nasopharingea 1
23 Nasopharingea 0
24 Oropharengeal 1
25 Oropharengeal 1
26 Oropharengeal 1
27 Oropharengeal 1
28 Oropharengeal 1
29 Oropharengeal 1
30 Oropharengeal 1
31 Urine Bag 2 L 1
32 Xylocain Gel 1
Masker
medium
conc adult
33 (Simple) 1
Emergency Kit
1 Folley Cathete 1
2 Folley Cathete 1
3 LMA Uk. 3 1
4 LMA Uk. 4 1
5 LMA Uk. 5 1
6 NGT Uk. 10 1
7 NGT Uk. 12 1
8 NGT Uk. 16 1
9 NGT Uk. 18 1
10 NGT Uk. 3 0
11 NGT Uk. 3,5 1
12 NGT UK. 5 1
13 NRBM Adult 1
14 NRBM Pediatr 1
15 Selang Bag Ma 0
16 Suction cathet 2
17 Suction cathet 1
18 Suction cathet 1
19 Suction cathet 1
20 Suction cathet 1
Emergency Kit
1 BVM Adult 1
2 BVM Neonatu 0
3 BVM Pediatric 0
4 Dextrose 10 % 1
5 Dextrose 5% 1
6 Nacl 0,9% 25 2
7 Nacl 0,9% 100 1
8 Nacl 0,9% 500 1
9 RL 500 ml 1
10 WFi 25 2
Diperiksa
oleh
(Nama
Perawat)
Serial
number
Jakarta, ...........................
Diperiksa Oleh,
(..............................)
PJ Ruangan/Shift
18 19 20 21
M P S M P S M P S
PERIODE BULAN :
21 22 23 24
M P S M P S M P S
(.....................................)
Ka. Bidang Keperawatan
CY KIT / AMBULANCE
E BULAN :
24 25 26 27
M P S M P S M P S
Mengetahui
27 28 29 30
M P S M P S M P S
(....................................)
Ka. Instalasi Farmasi
TANGGAL
30 31 16
M P S M P S M P S
)
16 17 18 19
M P S M P S M P S
19 20 21 22
M P S M P S M P S
22 23 24 25
M P S M P S M P S
25 26 27 28
M P S M P S M P S
28 29 30 31
M P S M P S M P S
31

Ceklis Tas Emergency 2019 Juli Ke Atas

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Ceklis Tas Emergency 2019 Juli Ke Atas

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Available Formats

CEKLIST EMERGENCY KIT / AMBULANCE

PERIODE BULAN : ........................2019

Kantong depan & samping

2 Elektrode (Skintact cloth D50m) 6

3 Handscoon Ukuran M ( 1box) 1

7 Kassa 55,10 X 3,6 5

8 kassa 55, 6 X 3,6 1

11 Policrepe 7,5 X4,55 mm 1

13 Laringoscope adult 1 set 1

Didalam Tas ( Box kecil hijau)

2 Cordarone 150mg inj 2

5 Calcium Gluconate 10% Inj 1

7 Dexamethasone Inj 5 mg/2 ml 2

14 Lasix 20 mg/2 ml Inj 2

15 Isosorbide Dinitrate Tab 5 mg 5

22 Asam mefenamat tablet 10

Emergency Kit (dalam)

6 ETT King-king cuffed No. 6,5 1

CEKLIST EMERGENCY KIT / AMBULANCE

Kantong depan & samping

2 Elektrode (Skintact cloth D50m) 6

3 Handscoon Ukuran M ( 1box) 1

7 Kassa 55,10 X 3,6 5

8 kassa 55, 6 X 3,6 1

11 Policrepe 7,5 X4,55 mm 1

13 Laringoscope adult 1 set 1

Didalam Tas ( Box kecil hijau)

2 Cordarone 150mg inj 2

5 Calcium Gluconate 10% Inj 1

7 Dexamethasone Inj 5 mg/2 ml 2

14 Lasix 20 mg/2 ml Inj 2

15 Isosorbide Dinitrate Tab 5 mg 5

EXP DATE TANGGAL

22 Asam mefenamat tablet 10

Emergency Kit (dalam)

5 ETT King-king cuffed No. 6 1

(..............................) (.....................................) (....................................)

Kantong depan & samping

Didalam Tas ( Box kecil hij

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