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FORMULIR SURVEILANS HARIAN INFEKSI RUMAH SAKIT

RUMAH SAKIT : ISLAM SITI RAHMAH PADANG


FORMULIR SURVEILANS HARIAN INFEKSI RUMAH SAKIT
RUANGAN : ARAFAH , BULAN : OKTOBER 2018
SURVEYOR : DEWI KARTIKA SARI , S. Kep

TINDAKAN INFEKSI RUMAH SAKIT TIRAH


TGL NAMA UMUR Dx Medis PLEBITIS
UC CVL IVL ETT VAP HAP ISK IAD BARING
10/1/2018 NY. ROSMANIDAR 76 TH HHD FC CLASS II + BP √

TN. ZUFRAN 38 TH DHF √


TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √ √
NY. WALIZAR 50 TH POST OP LUMBOTOMY √
NY. RITA. M 48 TH CKR GCS 15 √
TN. M. AHLAN 21 TH VERTIGO + INTAKE SULIT √
6 1 6

10/2/2018 NY. ROSMANIDAR 76 TH HHD FC CLASS II + BP √


TN. ZUFRAN 38 TH DHF √
TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √ √
NY. WALIZAR 50 TH POST OP LUMBOTOMY √
4 1 4

10/3/2018 TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √ √


TN. FAKHAR ZAKY 18 TH SEPSIS EC? √
NY. WALIZAR 50 TH POST OP LUMBOTOMY √
NY. WINDA KURNIA PUTRI 26 TH POST SC √ √
4 2 4

10/4/2018 TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √ √


TN. FAKHAR ZAKY 18 TH SEPSIS EC? √
NY. WINDA KURNIA PUTRI 26 TH POST SC √
3 1 3
10/5/2018 TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √ √
TN. FAKHAR ZAKY 18 TH SEPSIS EC? √
NY. WINDA KURNIA PUTRI 26 TH POST SC √
3 1 3

10/6/2018 TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √ √


TN. FAKHAR ZAKY 18 TH SEPSIS EC? √
NY. WINDA KURNIA PUTRI 26 TH POST SC √
BY. NY. FITRIA NOLA 1 HR BBL
NN. NOVA YUNETTI 25 TH COLIC ABDOMEN √
NY. DEWI .O 53 TH BATU URETER (S), BATU GINJAL (S) MULTIPLE
NY. SILVIA 52 TH CENDA EQURIA SYNDROM
NY. FITRIA NOLA 31 TH POST PARTUM
8 1 4

10/7/2018 TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √ √


TN. FAKHAR ZAKY 18 TH SEPSIS EC? √
NN. NOVA YUNETTI 25 TH COLIC ABDOMEN √
NY. ALFINOZA 20 TH HIPERTERMI
NY. DEWI .O 53 TH BATU URETER (S), BATU GINJAL (S) MULTIPLE
NY. WINDA KURNIA PUTRI 26 TH POST SC √
NY. WENI 28 TH ABORTUS IMMINEM
7 1 4

10/8/2018 TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √ √


TN. FAKHAR ZAKY 18 TH SEPSIS EC? √
NN. NOVA YUNETTI 25 TH COLIC ABDOMEN √
TN. YUSERDI 68 TH BRADICARDI √
NY. VEMI ASWAR 29 TH # METAKARPAL √
5 1 5

10/9/2018 TN. YUSERDI 68 TH BRADICARDI √


TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √ √
HJ. UPIK KETEK 85 TH HEMIPARESE (D) + STROKE ISKEMIK √
NY. VEMI ASWAR 29 TH POST ORIF √
NN. RATU DARA 16 TH POST GASTROSCOPY
5 1 4

10/10/2018 TN. YUSERDI 68 TH BRADICARDI √


TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √
HJ. UPIK KETEK 85 TH HEMIPARESE (D) + STROKE ISKEMIK √
TN. NGADIRUN 60 TH PPOK + TB PARU DALAM PENGOBATAN √
TN. RISHI BAITAR 41 TH STROKE ISKEMIK √
5 5

10/11/2018 TN. YUSERDI 68 TH BRADICARDI √

TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √

HJ. UPIK KETEK 85 TH HEMIPARESE (D) + STROKE ISKEMIK √


TN. NGADIRUN 60 TH PPOK + TB PARU DALAM PENGOBATAN √
TN. RISHI BAITAR 41 TH STROKE ISKEMIK √
NY. DEWI SARTIKA 48 TH UAP dd/NSTEMI + HT √
NY. CITRA 25 TH POST SC √ √
NN. DINING 15 TH APPENDICITIS ACUTE √
8 1 8

10/12/2018 TN. YUSERDI 68 TH BRADICARDI √ √


TN. KUYAN 48 TH POST OP EXTENDED + TB PARU √
HJ. UPIK KETEK 85 TH HEMIPARESE (D) + STROKE ISKEMIK √
AN. SALMAN 11 TH ASMA BRONCHIAL √
TN. RISHI BAITAR 41 TH STROKE ISKEMIK √
NY. DEWI SARTIKA 48 TH UAP dd/NSTEMI + HT √
NY. CITRA 25 TH POST SC √
NN. DINING 15 TH APPENDICITIS ACUTE √
NY. MARTINI 46 TH POST LAPARATOMY + KISTA OVARIUM √ √
9 1 9

10/13/2018 TN. YUSERDI 68 TH BRADICARDI √


HJ. UPIK KETEK 85 TH HEMIPARESE (D) + STROKE ISKEMIK √
TN. MARIUS 72 TH DEHIDRASI SEDANG + HT URGENCY √
NY. CITRA 25 TH POST SC √
NY. MARTINI 46 TH POST LAPARATOMY + KISTA OVARIUM √
5 5

10/14/2018 HJ. UPIK KETEK 85 TH HEMIPARESE (D) + STROKE ISKEMIK √


TN. MARIUS 72 TH DEHIDRASI SEDANG + HT URGENCY √
NY. CITRA 25 TH POST SC √
NY. MARTINI 46 TH POST LAPARATOMY + KISTA OVARIUM √
NY. DARMAWATI 41 TH CA MAMAE PRO EXIXI
5 4

10/15/2018 NY. MARTINI 46 TH POST LAPARATOMY + KISTA OVARIUM √ √


NY. DARMAWATI 41 TH POST OPEN BIOPSI √
TN. MARIUS 72 TH GEA DEHIDRASI SEDANG + HT URGENCY √
3 3

10/16/2018 TN. MARIUS 72 TH GEA DEHIDRASI SEDANG + HT URGENCY √


NY. VICY MELISA 27 TH DHF GRADE II √
AN.M.RAKHA 4 TH TFA + VOMITUS √
NY. MARTINI 46 TH POST LAPARATOMY + KISTA OVARIUM √
NY. MARTHA 42 TH CA
5 4

10/17/2018 TN. MARIUS 72 TH GEA DEHIDRASI SEDANG + HT URGENCY √


NY. VICY MELISA 27 TH DHF GRADE II √
AN. M.RAKHA 4 TH TFA + VOMITUS √
NY. MASDARNI.K 68 TH HIPOGLIKEMIA+ HT + STROKE ISKEMIK √
NY. MARTHA 42 TH POST WIDE EXIXI √
TN. AFIFULLAH 52 TH POST EKSISI √
6 6

10/18/2018 NY. MASDARNI.K 68 TH HIPOGLIKEMIA+ HT + STROKE ISKEMIK √


NY. MAIYARNA 54 TH MELENA EC/ GASTRITIS EROSIF √
NY. DESI ASMARNI 38 TH STATUS EPILEPTIKUS TERKONTROL √
NY. MARLINA 32 TH HT RENOVASKULER √
BY. NY. DEWI 1 HR BBL
NY. MARTHA 42 TH POST WIDE EXIXI √
NY. YESSY MARLINA 40 TH BATU URETER DEXTRA
NY. DEWI YETRI 29 TH POST SC √
8 6

10/19/2018 NY. MASDARNI.K 68 TH HIPOGLIKEMIA+ HT + STROKE ISKEMIK √


NY. MAIYARNA 54 TH MELENA EC/ GASTRITIS EROSIF √
NY. DESI ASMARNI 38 TH STATUS EPILEPTIKUS TERKONTROL √
BY. NY. DEWI 1 HR BBL
NY. NOVA. A 35 TH DHF GRADE II √
NY. AULIZA 65 TH VERTIGO DALAM SERANGAN + OBS. FEBRIS √
NY. YESSY MARLINA 40 TH POST URS + DJ STAND
NY. DEWI YETRI 29 TH POST SC √
8 6

10/20/2018 NY. MASDARNI.K 68 TH HIPOGLIKEMIA+ HT + STROKE ISKEMIK √


NY. MAIYARNA 54 TH MELENA EC/ GASTRITIS EROSIF √
NY. DESI ASMARNI 38 TH STATUS EPILEPTIKUS TERKONTROL √
NY. NOVA. A 35 TH DHF GRADE II √
NY. AULIZA 65 TH VERTIGO DALAM SERANGAN + OBS. FEBRIS √
TN. ALDI 41TH TYPUS ABDOMINALIS √
6 6

10/21/2018 NY. MASDARNI.K 68 TH HIPOGLIKEMIA+ HT + STROKE ISKEMIK √


NY. MAIYARNA 54 TH MELENA EC/ GASTRITIS EROSIF √
NY. DESI ASMARNI 38 TH STATUS EPILEPTIKUS TERKONTROL √
NY. NOVA. A 35 TH DHF GRADE II √
NY. AULIZA 65 TH VERTIGO DALAM SERANGAN + OBS. FEBRIS √
TN. ALDI 41TH TYPUS ABDOMINALIS √
6 6
10/22/2018 TN. DENI PRIMA 45 TH TUMOR PAROTIS √
NY. AULIZA 65 TH VERTIGO DALAM SERANGAN + OBS. FEBRIS √
TN. ALDI 41TH TYPUS ABDOMINALIS √
NY. DESI ASMARNI 38 TH STATUS EPILEPTIKUS TERKONTROL √
NY. MASDARNI.K 68 TH HIPOGLIKEMIA+ HT + STROKE ISKEMIK √
NY. YELNA OSMITA 53 TH STROKE + HT √
TN. MASDI HERMAN 64 TH UAP dd/ NSTEMI √
7 7

23/20/2018 TN. DENI PRIMA 45 TH TUMOR PAROTIS √


TN. ALDI 41TH TYPUS ABDOMINALIS √
NY. MASDARNI.K 68 TH HIPOGLIKEMIA+ HT + STROKE ISKEMIK √
NY. YELNA OSMITA 53 TH STROKE + HT √
TN. MASDI HERMAN 64 TH UAP dd/ NSTEMI √
NY. JASMI 69 TH RECURENT STROKE ISKEMIK + HT + RIW. DM √
6 6

10/24/2018 TN. ALDI 41TH TYPUS ABDOMINALIS √


TN. MASDI HERMAN 64 TH UAP dd/ NSTEMI √
NY. MASDARNI.K 68 TH HIPOGLIKEMIA+ HT + STROKE ISKEMIK √
NY. JASMI 69 TH RECURENT STROKE ISKEMIK + HT + RIW. DM √
TN. BAHRIAL. BK 61 TH HT HEART FAILURA √
TN. DENI PRIMA 45 TH TUMOR PAROTIS √
TN. MUKHLIS 39 TH VL REGIO CRURIS √
7 7

10/25/2018 TN. MASDI HERMAN 64 TH UAP dd/ NSTEMI √


TN. BAHRIAL. BK 61 TH HT HEART FAILURA √
NY. JASMI 69 TH RECURENT STROKE ISKEMIK + HT + RIW. DM √
TN. DENI PRIMA 45 TH TUMOR PAROTIS √
TN. MUKHLIS 39 TH VL REGIO CRURIS √
NY. LOVERA SYOFYAN 50TH BATU URETER SINISTRA
6 5
10/26/2018 TN. BAHRIAL. BK 61 TH HT HEART FAILURA √
NY. JASMI 69 TH RECURENT STROKE ISKEMIK + HT + RIW. DM √
TN. MAHESA 32 TH DYSPEPSIA √
NN. FICINIA. A 31 TH SVT √
TN. MUKHLIS 39 TH VL REGIO CRURIS √
5 5

10/27/2018 TN. ARIZAL PUTRA 20 TH COLIC ABD ec/ SUSP ADHESI APP √
NY. JASMI 69 TH RECURENT STROKE ISKEMIK + HT + RIW. DM √
TN. MAHESA 32 TH DYSPEPSIA √
NN. FICINIA. A 31 TH SVT √
TN. HAK UDIN 64 TH UAP + NSTEMI √
NY. DESMAWATI 54 TH VERTIGO BERAT √
TN. ZALFUNIS 74 TH HT URGENCY √
7 7

10/28/2018 NY. JASMI 69 TH RECURENT STROKE ISKEMIK + HT + RIW. DM √


NY. DESMAWATI 54 TH VERTIGO BERAT √
TN. HAK UDIN 64 TH UAP + NSTEMI √
NY. GUSTI 65 TH HT URGENCY
TN. ARIZAL PUTRA 20 TH COLIC ABD ec/ SUSP ADHESI APP √
TN. SAMRAL 82 TH ILEUS OBSTRUKSI √
6 5

10/29/2018 TN. ARIZAL PUTRA 20 TH COLIC ABD ec/ SUSP ADHESI APP √
TN. SAMRAL 82 TH ILEUS OBSTRUKSI √
NY. GUSNI 43 TH POST LAPP CHOLE √
NY. DARMAWATI 41 TH POST CURATAGE
TN. HAK UDIN 64 TH UAP + NSTEMI √
NY. JASMI 69 TH RECURENT STROKE ISKEMIK + HT + RIW. DM √
AN. M. RAKHA 4 TH VOMITUS + INTAKE SULIT √
7 6
HASIL KULTUR AB

INFIBIOTIK

CEFTRIAXONE
CEFIZOX
CEFADROXIL

INFIBIOTIK

CEFTRIAXONE
CEFIZOX

CEFTRIAXONE

CEFIZOX
CEFTRIAXONE

CEFTRIAXONE

CEFTRIAXONE
CEFTRIAXONE

CEFTRIAXONE

CEFTRIAXONE

CEFTRIAXONE

CEFTRIAXONE

LEVOFLOXACIN
CEFTRIAXONE

CEFTRIAXONE

CEFOTAXIME

CEFTRIAXONE
CEFOTAXIME

CEFTRIAXONE

FORICEF

CEFTRIAXONE

FORICEF

ECOTRIXON

CEFTRIAXONE

ECOTRIXON
ECOTRIXON
CEFXON

ECOTRIXON
CEFXON

CEFXON
AMOXICILIN

CEFXON

CEFOTAXIME
CEFOTAXIME

CEFTRIAXONE

CEFOTAXIME
LEVOFLOXACIN
CEFTRIAXONE

CEFOTAXIME
CEFTRIAXONE

CEFOTAXIME
CEFTRIAXONE
CEFTRIAXONE
CEFOTAXIME
CEFTRIAXONE

CEFTRIAXONE
CEFTRIAXONE

CEFTRIAXONE

CEFTRIAXONE

CEFTRIAXONE

CEFTRIAXONE
CEFTRIAXONE

CEFTRIAXONE

CEFTRIAXONE
FORMULIR SURVEILANS BULANAN INFEKSI RUMAH SAKIT
RUMAH SAKIT : ……………………………………………………………

BULAN/TAHUN :
RUANGAN :
SURVEYOR :
DEPARTEMEN :

TINDAKAN INFEKSI RUMAH SAKIT TIRAH


TGL JUMLAH PASIEN PLE
UC IVL ETT VAP HAP ISK IAD BARING

KETERANGAN
Dx Medis : Diagnosa Medis ETT : Endotracheal Tube
U : Usia HAP : Hospital Associated Pneumonia
JK : Jenis Kelamin VAP : Ventilator Associated Pneumonia
UC : Urine Catheter IAD : Infeksi Aliran Darah
IVL : Intra Vena Line/Vena Perifer
RUMAH SAKIT
……………………

HASIL KULTUR AB