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Formulir CSSD
Formulir CSSD
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13 views25 pagesThe document is an inventory list of linens and surgical instruments from the Central Sterile Supply Department (CSSD) of a hospital. It contains a table listing various types of linens like towels, gowns, and mayo covers. It also contains detailed lists and counts of the contents of multiple minor surgery, curettage, and dental extraction instrument sets. The lists include the name of each instrument and sterilization dates.
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FORMULIR CSSD
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Report this DocumentThe document is an inventory list of linens and surgical instruments from the Central Sterile Supply Department (CSSD) of a hospital. It contains a table listing various types of linens like towels, gowns, and mayo covers. It also contains detailed lists and counts of the contents of multiple minor surgery, curettage, and dental extraction instrument sets. The lists include the name of each instrument and sterilization dates.
Copyright:
© All Rights Reserved
Available Formats
Download as XLSX, PDF, TXT or read online from Scribd
Download as xlsx, pdf, or txt
0 ratings0% found this document useful (0 votes)
13 views25 pagesFormulir CSSD
Formulir CSSD
Uploaded by
RB RSUDCPThe document is an inventory list of linens and surgical instruments from the Central Sterile Supply Department (CSSD) of a hospital. It contains a table listing various types of linens like towels, gowns, and mayo covers. It also contains detailed lists and counts of the contents of multiple minor surgery, curettage, and dental extraction instrument sets. The lists include the name of each instrument and sterilization dates.
Copyright:
© All Rights Reserved
Available Formats
Download as XLSX, PDF, TXT or read online from Scribd
Download as xlsx, pdf, or txt
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DAFTAR INVENTARIS LINEN LEMARI PENYIMPANAN CSSD
BULAN:
No. Nama Barang 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 Duk Besar
2 Duk Bolong Besar
3 Duk Bolong Gigi
4 Duk Bolong Kecil
5 Duk Bolong Sedang
6 Duk Instrumen
7 Duk Kaki Anak
8 Duk Kaki Dewasa
9 Duk Sedang
10 Duk Tangan Anak
11 Handuk
12 Jas Dokter
13 Sarung Mayo
14 Sarung Perlak
Petugas CSSD Petugas CSSD Kepala Unit CSSD
(Yenni Sari) (Piqih Rizki) Jesse Rajabosi S
DAFTAR INVENTARIS SET/INSTRUMEN LEMARI PENYIMPANAN CSSD
BULAN:
No. Nama Barang 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 Set SC 1
2 Set SC 2
3 Set SC 3
4 Set SC 4
5 Set SC 5
6 Set Minor 1
7 Set Minor 2
8 Set THT / Tonsilektomi
9 Set Kuret 1
10 Set Kuret 2
11 Set Hernia
12 Set Histerektomi
13 Set HPP 1
14 Set HPP 2
15 Set Mata
16 Abdominal Retractor
Petugas CSSD Petugas CSSD Kepala Unit CSSD
(Yenni Sari) (Piqih Rizki) Jesse Rajabosi S
SET MINOR SET MINOR
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 3 1 GUNTING BENANG 3
2 KLEM BENGKOK 1 2 KLEM BENGKOK 1
3 KOHER BENGKOK 1 3 KOHER BENGKOK 1
4 KOHER LURUS 1 4 KOHER LURUS 1
5 NEEDLE HOLDER 1 5 NEEDLE HOLDER 1
6 PINSET ANATOMIS 2 6 PINSET ANATOMIS 2
7 PINSET SIRURGIS 1 7 PINSET SIRURGIS 1
8 SCALPEL HOLDER 1 8 SCALPEL HOLDER 1
9 SONDE 1 9 SONDE 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET MINOR SET MINOR
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 3 1 GUNTING BENANG 3
2 KLEM BENGKOK 1 2 KLEM BENGKOK 1
3 KOHER BENGKOK 1 3 KOHER BENGKOK 1
4 KOHER LURUS 1 4 KOHER LURUS 1
5 NEEDLE HOLDER 1 5 NEEDLE HOLDER 1
6 PINSET ANATOMIS 2 6 PINSET ANATOMIS 2
7 PINSET SIRURGIS 1 7 PINSET SIRURGIS 1
8 SCALPEL HOLDER 1 8 SCALPEL HOLDER 1
9 SONDE 1 9 SONDE 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET MINOR SET MINOR
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 3 1 GUNTING BENANG 3
2 KLEM BENGKOK 1 2 KLEM BENGKOK 1
3 KOHER BENGKOK 1 3 KOHER BENGKOK 1
4 KOHER LURUS 1 4 KOHER LURUS 1
5 NEEDLE HOLDER 1 5 NEEDLE HOLDER 1
6 PINSET ANATOMIS 2 6 PINSET ANATOMIS 2
7 PINSET SIRURGIS 1 7 PINSET SIRURGIS 1
8 SCALPEL HOLDER 1 8 SCALPEL HOLDER 1
9 SONDE 1 9 SONDE 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET MINOR SET MINOR
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 3 1 GUNTING BENANG 3
2 KLEM BENGKOK 1 2 KLEM BENGKOK 1
3 KOHER BENGKOK 1 3 KOHER BENGKOK 1
4 KOHER LURUS 1 4 KOHER LURUS 1
5 NEEDLE HOLDER 1 5 NEEDLE HOLDER 1
6 PINSET ANATOMIS 2 6 PINSET ANATOMIS 2
7 PINSET SIRURGIS 1 7 PINSET SIRURGIS 1
8 SCALPEL HOLDER 1 8 SCALPEL HOLDER 1
9 SONDE 1 9 SONDE 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET KURET SET KURET
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 KOM KECIL 1 1 KOM KECIL 1
2 KORENTANG 1 2 KORENTANG 1
3 PASTER KLEM 1 3 PASTER KLEM 1
4 SENDOK KURET 5 4 SENDOK KURET 5
5 SONDE 1 5 SONDE 1
6 SPEKULUM C 5 6 SPEKULUM C 5
7 TENAKULUM 1 7 TENAKULUM 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET KURET SET KURET
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 KOM KECIL 1 1 KOM KECIL 1
2 KORENTANG 1 2 KORENTANG 1
3 PASTER KLEM 1 3 PASTER KLEM 1
4 SENDOK KURET 5 4 SENDOK KURET 5
5 SONDE 1 5 SONDE 1
6 SPEKULUM C 5 6 SPEKULUM C 5
7 TENAKULUM 1 7 TENAKULUM 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET KURET SET KURET
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 KOM KECIL 1 1 KOM KECIL 1
2 KORENTANG 1 2 KORENTANG 1
3 PASTER KLEM 1 3 PASTER KLEM 1
4 SENDOK KURET 5 4 SENDOK KURET 5
5 SONDE 1 5 SONDE 1
6 SPEKULUM C 5 6 SPEKULUM C 5
7 TENAKULUM 1 7 TENAKULUM 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET KURET SET KURET
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 KOM KECIL 1 1 KOM KECIL 1
2 KORENTANG 1 2 KORENTANG 1
3 PASTER KLEM 1 3 PASTER KLEM 1
4 SENDOK KURET 5 4 SENDOK KURET 5
5 SONDE 1 5 SONDE 1
6 SPEKULUM C 5 6 SPEKULUM C 5
7 TENAKULUM 1 7 TENAKULUM 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET KURET SET KURET
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 KOM KECIL 1 1 KOM KECIL 1
2 KORENTANG 1 2 KORENTANG 1
3 PASTER KLEM 1 3 PASTER KLEM 1
4 SENDOK KURET 5 4 SENDOK KURET 5
5 SONDE 1 5 SONDE 1
6 SPEKULUM C 5 6 SPEKULUM C 5
7 TENAKULUM 1 7 TENAKULUM 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET ODONTEKTOMI SET ODONTEKTOMI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 KLEM BENGKOK 1 3 KLEM BENGKOK 1
4 NEEDLE HOLDER 1 4 NEEDLE HOLDER 1
5 PINSET 1 5 PINSET 1
6 RASPATORIUM 1 6 RASPATORIUM 1
7 SCALPEL HOLDER 1 7 SCALPEL HOLDER 1
8 SENDOK KURET 1 8 SENDOK KURET 1
9 SUCTION 1 9 SUCTION 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET ODONTEKTOMI SET ODONTEKTOMI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 KLEM BENGKOK 1 3 KLEM BENGKOK 1
4 NEEDLE HOLDER 1 4 NEEDLE HOLDER 1
5 PINSET 1 5 PINSET 1
6 RASPATORIUM 1 6 RASPATORIUM 1
7 SCALPEL HOLDER 1 7 SCALPEL HOLDER 1
8 SENDOK KURET 1 8 SENDOK KURET 1
9 SUCTION 1 9 SUCTION 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET ODONTEKTOMI SET ODONTEKTOMI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 KLEM BENGKOK 1 3 KLEM BENGKOK 1
4 NEEDLE HOLDER 1 4 NEEDLE HOLDER 1
5 PINSET 1 5 PINSET 1
6 RASPATORIUM 1 6 RASPATORIUM 1
7 SCALPEL HOLDER 1 7 SCALPEL HOLDER 1
8 SENDOK KURET 1 8 SENDOK KURET 1
9 SUCTION 1 9 SUCTION 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET ODONTEKTOMI SET ODONTEKTOMI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 KLEM BENGKOK 1 3 KLEM BENGKOK 1
4 NEEDLE HOLDER 1 4 NEEDLE HOLDER 1
5 PINSET 1 5 PINSET 1
6 RASPATORIUM 1 6 RASPATORIUM 1
7 SCALPEL HOLDER 1 7 SCALPEL HOLDER 1
8 SENDOK KURET 1 8 SENDOK KURET 1
9 SUCTION 1 9 SUCTION 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GIGI SET GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 EKSKAVATOR 1 1 EKSKAVATOR 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
4 PLASTIS 1 4 PLASTIS 1
5 SONDE 1 5 SONDE 1
6 TRAY 1 6 TRAY 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GIGI SET GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 EKSKAVATOR 1 1 EKSKAVATOR 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
4 PLASTIS 1 4 PLASTIS 1
5 SONDE 1 5 SONDE 1
6 TRAY 1 6 TRAY 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GIGI SET GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 EKSKAVATOR 1 1 EKSKAVATOR 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
4 PLASTIS 1 4 PLASTIS 1
5 SONDE 1 5 SONDE 1
6 TRAY 1 6 TRAY 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GIGI SET GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 EKSKAVATOR 1 1 EKSKAVATOR 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
4 PLASTIS 1 4 PLASTIS 1
5 SONDE 1 5 SONDE 1
6 TRAY 1 6 TRAY 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GIGI SET GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 EKSKAVATOR 1 1 EKSKAVATOR 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
4 PLASTIS 1 4 PLASTIS 1
5 SONDE 1 5 SONDE 1
6 TRAY 1 6 TRAY 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET AFF HECTING GIGI SET AFF HECTING GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET AFF HECTING GIGI SET AFF HECTING GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET AFF HECTING GIGI SET AFF HECTING GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET AFF HECTING GIGI SET AFF HECTING GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET AFF HECTING GIGI SET AFF HECTING GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET AFF HECTING GIGI SET AFF HECTING GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET AFF HECTING GIGI SET AFF HECTING GIGI
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 KACA MULUT 1 2 KACA MULUT 1
3 PINSET BAYONET 1 3 PINSET BAYONET 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET HECTING SET HECTING
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 NEEDLE HOLDER 1 2 NEEDLE HOLDER 1
3 PINSET ANATOMIS 1 3 PINSET ANATOMIS 1
4 PINSET SIRURGIS 1 4 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET HECTING SET HECTING
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 NEEDLE HOLDER 1 2 NEEDLE HOLDER 1
3 PINSET ANATOMIS 1 3 PINSET ANATOMIS 1
4 PINSET SIRURGIS 1 4 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET HECTING SET HECTING
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 NEEDLE HOLDER 1 2 NEEDLE HOLDER 1
3 PINSET ANATOMIS 1 3 PINSET ANATOMIS 1
4 PINSET SIRURGIS 1 4 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET HECTING SET HECTING
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 NEEDLE HOLDER 1 2 NEEDLE HOLDER 1
3 PINSET ANATOMIS 1 3 PINSET ANATOMIS 1
4 PINSET SIRURGIS 1 4 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET HECTING SET HECTING
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 NEEDLE HOLDER 1 2 NEEDLE HOLDER 1
3 PINSET ANATOMIS 1 3 PINSET ANATOMIS 1
4 PINSET SIRURGIS 1 4 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET HECTING SET HECTING
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 NEEDLE HOLDER 1 2 NEEDLE HOLDER 1
3 PINSET ANATOMIS 1 3 PINSET ANATOMIS 1
4 PINSET SIRURGIS 1 4 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET PARTUS SET PARTUS
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 1/2 KOHER 1 1 1/2 KOHER 1
2 KLEM LURUS 2 2 KLEM LURUS 2
3 GUNTING TALI PUSAT 1 3 GUNTING TALI PUSAT 1
4 GUNTING EPISIOTOMIS 1 4 GUNTING EPISIOTOMIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET PARTUS SET PARTUS
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 1/2 KOHER 1 1 1/2 KOHER 1
2 KLEM LURUS 2 2 KLEM LURUS 2
3 GUNTING TALI PUSAT 1 3 GUNTING TALI PUSAT 1
4 GUNTING EPISIOTOMIS 1 4 GUNTING EPISIOTOMIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET PARTUS SET PARTUS
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 1/2 KOHER 1 1 1/2 KOHER 1
2 KLEM LURUS 2 2 KLEM LURUS 2
3 GUNTING TALI PUSAT 1 3 GUNTING TALI PUSAT 1
4 GUNTING EPISIOTOMIS 1 4 GUNTING EPISIOTOMIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET PARTUS SET PARTUS
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 1/2 KOHER 1 1 1/2 KOHER 1
2 KLEM LURUS 2 2 KLEM LURUS 2
3 GUNTING TALI PUSAT 1 3 GUNTING TALI PUSAT 1
4 GUNTING EPISIOTOMIS 1 4 GUNTING EPISIOTOMIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET PARTUS SET PARTUS
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 1/2 KOHER 1 1 1/2 KOHER 1
2 KLEM LURUS 2 2 KLEM LURUS 2
3 GUNTING TALI PUSAT 1 3 GUNTING TALI PUSAT 1
4 GUNTING EPISIOTOMIS 1 4 GUNTING EPISIOTOMIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET PARTUS SET PARTUS
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 1/2 KOHER 1 1 1/2 KOHER 1
2 KLEM LURUS 2 2 KLEM LURUS 2
3 GUNTING TALI PUSAT 1 3 GUNTING TALI PUSAT 1
4 GUNTING EPISIOTOMIS 1 4 GUNTING EPISIOTOMIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET PARTUS BESAR SET PARTUS BESAR
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 1/2 KOHER 1 1 1/2 KOHER 1
2 GUNTING BENANG 1 2 GUNTING BENANG 1
3 GUNTING EPISIOTOMIS 1 3 GUNTING EPISIOTOMIS 1
4 GUNTING TALI PUSAT 1 4 GUNTING TALI PUSAT 1
5 KLEM LURUS 2 5 KLEM LURUS 2
6 NEEDLE HOLDER 1 6 NEEDLE HOLDER 1
7 PINSET ANATOMIS 1 7 PINSET ANATOMIS 1
8 PINSET SIRURGIS 1 8 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET PARTUS BESAR SET PARTUS BESAR
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 1/2 KOHER 1 1 1/2 KOHER 1
2 GUNTING BENANG 1 2 GUNTING BENANG 1
3 GUNTING EPISIOTOMIS 1 3 GUNTING EPISIOTOMIS 1
4 GUNTING TALI PUSAT 1 4 GUNTING TALI PUSAT 1
5 KLEM LURUS 2 5 KLEM LURUS 2
6 NEEDLE HOLDER 1 6 NEEDLE HOLDER 1
7 PINSET ANATOMIS 1 7 PINSET ANATOMIS 1
8 PINSET SIRURGIS 1 8 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET PARTUS BESAR SET PARTUS BESAR
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 1/2 KOHER 1 1 1/2 KOHER 1
2 GUNTING BENANG 1 2 GUNTING BENANG 1
3 GUNTING EPISIOTOMIS 1 3 GUNTING EPISIOTOMIS 1
4 GUNTING TALI PUSAT 1 4 GUNTING TALI PUSAT 1
5 KLEM LURUS 2 5 KLEM LURUS 2
6 NEEDLE HOLDER 1 6 NEEDLE HOLDER 1
7 PINSET ANATOMIS 1 7 PINSET ANATOMIS 1
8 PINSET SIRURGIS 1 8 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET PARTUS BESAR SET PARTUS BESAR
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 1/2 KOHER 1 1 1/2 KOHER 1
2 GUNTING BENANG 1 2 GUNTING BENANG 1
3 GUNTING EPISIOTOMIS 1 3 GUNTING EPISIOTOMIS 1
4 GUNTING TALI PUSAT 1 4 GUNTING TALI PUSAT 1
5 KLEM LURUS 2 5 KLEM LURUS 2
6 NEEDLE HOLDER 1 6 NEEDLE HOLDER 1
7 PINSET ANATOMIS 1 7 PINSET ANATOMIS 1
8 PINSET SIRURGIS 1 8 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET THT SET THT
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 ALIGATOR 1 1 ALIGATOR 1
2 APLIKATOR 1 2 APLIKATOR 1
3 BENGKOK 1 3 BENGKOK 1
4 CORONG 1 4 CORONG 1
5 KOM 1 5 KOM 1
6 PENGAIT 1 6 PENGAIT 1
7 SUCTION 3 7 SUCTION 3
8 TRAY 1 8 TRAY 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET THT SET THT
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 ALIGATOR 1 1 ALIGATOR 1
2 APLIKATOR 1 2 APLIKATOR 1
3 BENGKOK 1 3 BENGKOK 1
4 CORONG 1 4 CORONG 1
5 KOM 1 5 KOM 1
6 PENGAIT 1 6 PENGAIT 1
7 SUCTION 3 7 SUCTION 3
8 TRAY 1 8 TRAY 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET THT SET THT
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 ALIGATOR 1 1 ALIGATOR 1
2 APLIKATOR 1 2 APLIKATOR 1
3 BENGKOK 1 3 BENGKOK 1
4 CORONG 1 4 CORONG 1
5 KOM 1 5 KOM 1
6 PENGAIT 1 6 PENGAIT 1
7 SUCTION 3 7 SUCTION 3
8 TRAY 1 8 TRAY 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET THT SET THT
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 ALIGATOR 1 1 ALIGATOR 1
2 APLIKATOR 1 2 APLIKATOR 1
3 BENGKOK 1 3 BENGKOK 1
4 CORONG 1 4 CORONG 1
5 KOM 1 5 KOM 1
6 PENGAIT 1 6 PENGAIT 1
7 SUCTION 3 7 SUCTION 3
8 TRAY 1 8 TRAY 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GV SET GV
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 PINSET ANATOMIS 1 2 PINSET ANATOMIS 1
3 PINSET SIRURGIS 1 3 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GV SET GV
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 PINSET ANATOMIS 1 2 PINSET ANATOMIS 1
3 PINSET SIRURGIS 1 3 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GV SET GV
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 PINSET ANATOMIS 1 2 PINSET ANATOMIS 1
3 PINSET SIRURGIS 1 3 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GV SET GV
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 PINSET ANATOMIS 1 2 PINSET ANATOMIS 1
3 PINSET SIRURGIS 1 3 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GV SET GV
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 PINSET ANATOMIS 1 2 PINSET ANATOMIS 1
3 PINSET SIRURGIS 1 3 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GV SET GV
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 PINSET ANATOMIS 1 2 PINSET ANATOMIS 1
3 PINSET SIRURGIS 1 3 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET GV SET GV
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 PINSET ANATOMIS 1 2 PINSET ANATOMIS 1
3 PINSET SIRURGIS 1 3 PINSET SIRURGIS 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET IUD SET IUD
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 ALIGATOR 1 1 ALIGATOR 1
2 GUNTING JARINGAN 1 2 GUNTING JARINGAN 1
3 PASTER KLEM 1 3 PASTER KLEM 1
4 SONDE 1 4 SONDE 1
5 SPEKULUM 1 5 SPEKULUM 1
6 TENAKULUM 1 6 TENAKULUM 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET IUD SET IUD
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 ALIGATOR 1 1 ALIGATOR 1
2 GUNTING JARINGAN 1 2 GUNTING JARINGAN 1
3 PASTER KLEM 1 3 PASTER KLEM 1
4 SONDE 1 4 SONDE 1
5 SPEKULUM 1 5 SPEKULUM 1
6 TENAKULUM 1 6 TENAKULUM 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET IUD SET IUD
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 ALIGATOR 1 1 ALIGATOR 1
2 GUNTING JARINGAN 1 2 GUNTING JARINGAN 1
3 PASTER KLEM 1 3 PASTER KLEM 1
4 SONDE 1 4 SONDE 1
5 SPEKULUM 1 5 SPEKULUM 1
6 TENAKULUM 1 6 TENAKULUM 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET IUD SET IUD
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 ALIGATOR 1 1 ALIGATOR 1
2 GUNTING JARINGAN 1 2 GUNTING JARINGAN 1
3 PASTER KLEM 1 3 PASTER KLEM 1
4 SONDE 1 4 SONDE 1
5 SPEKULUM 1 5 SPEKULUM 1
6 TENAKULUM 1 6 TENAKULUM 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET IUD SET IUD
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 ALIGATOR 1 1 ALIGATOR 1
2 GUNTING JARINGAN 1 2 GUNTING JARINGAN 1
3 PASTER KLEM 1 3 PASTER KLEM 1
4 SONDE 1 4 SONDE 1
5 SPEKULUM 1 5 SPEKULUM 1
6 TENAKULUM 1 6 TENAKULUM 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET MINOR UKO SET MINOR UKO
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 GUNTING JARINGAN 3 2 GUNTING JARINGAN 3
3 HAK 3 3 HAK 3
4 HAK GIGI 2 4 HAK GIGI 2
5 KLEM ALIS 1 5 KLEM ALIS 1
6 KLEM BENGKOK 4 6 KLEM BENGKOK 4
7 KLEM DUK 2 7 KLEM DUK 2
8 KLEM LURUS 3 8 KLEM LURUS 3
9 NEEDLE HOLDER 1 9 NEEDLE HOLDER 1
10 PINSET ANATOMIS 2 10 PINSET ANATOMIS 2
11 PINSET SIRURGIS 1 11 PINSET SIRURGIS 1
12 SCALPEL HOLDER 2 12 SCALPEL HOLDER 2
13 SENDOK KURET 1 13 SENDOK KURET 1
14 SONDE 1 14 SONDE 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET MINOR UKO SET MINOR UKO
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 GUNTING JARINGAN 3 2 GUNTING JARINGAN 3
3 HAK 3 3 HAK 3
4 HAK GIGI 2 4 HAK GIGI 2
5 KLEM ALIS 1 5 KLEM ALIS 1
6 KLEM BENGKOK 4 6 KLEM BENGKOK 4
7 KLEM DUK 2 7 KLEM DUK 2
8 KLEM LURUS 3 8 KLEM LURUS 3
9 NEEDLE HOLDER 1 9 NEEDLE HOLDER 1
10 PINSET ANATOMIS 2 10 PINSET ANATOMIS 2
11 PINSET SIRURGIS 1 11 PINSET SIRURGIS 1
12 SCALPEL HOLDER 2 12 SCALPEL HOLDER 2
13 SENDOK KURET 1 13 SENDOK KURET 1
14 SONDE 1 14 SONDE 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
SET MINOR UKO SET MINOR UKO
NO NAMA ALAT JUMLAH NO NAMA ALAT JUMLAH
1 GUNTING BENANG 1 1 GUNTING BENANG 1
2 GUNTING JARINGAN 3 2 GUNTING JARINGAN 3
3 HAK 3 3 HAK 3
4 HAK GIGI 2 4 HAK GIGI 2
5 KLEM ALIS 1 5 KLEM ALIS 1
6 KLEM BENGKOK 4 6 KLEM BENGKOK 4
7 KLEM DUK 2 7 KLEM DUK 2
8 KLEM LURUS 3 8 KLEM LURUS 3
9 NEEDLE HOLDER 1 9 NEEDLE HOLDER 1
10 PINSET ANATOMIS 2 10 PINSET ANATOMIS 2
11 PINSET SIRURGIS 1 11 PINSET SIRURGIS 1
12 SCALPEL HOLDER 2 12 SCALPEL HOLDER 2
13 SENDOK KURET 1 13 SENDOK KURET 1
14 SONDE 1 14 SONDE 1
TGL STERIL: TGL STERIL:
EXP DATE: EXP DATE:
FORMULIR SERAH PROSES STERILISASI SET/ALAT DAN LINEN
TANGGAL :
NAMA PETUGAS :
SHIFT :
NO. NAMA SET/ALAT/LINEN JUMLAH RUANGAN KETERANGAN
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