Format Surveilans Hais
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Transcript of Format Surveilans Hais
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• Surveilans HAIs merupakan salah satu bagian dari Program PPI
• Untuk melakukan surveilans HAIs diperlukan formulir dan tools pengumpulan data
• Rancangan formulir dan tools dapat disesuaikan dengan perencanaan surveilans
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Format Surveilans HAIs meliputi1. Data Medikal Rekord2. Data Demografik pasien3. Faktor Risiko Pasien4. Pemakaian peralatan perawatan pasien5. Pengunaan Antibiotika6. Pemeriksaan Penunjang7. Komplikasi Infeksi Untuk tindakan operasi
- Data petugas kamar bedah- Tipe operasi- Jenis operasi- Kategori Risk
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I.Data Medikal RekordRuangan :…………………Tgl masuk/Jam : ........... ………/...........Tanggal keluar :…………………..Departemen : ……………………Cara dirawat : □ Emergency □ EelektifNo.Rekam Medik :……………Diagnosa Masuk :……………..Diagnosa Keluar:…………………
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2. Data Demografik PasienNama Pasien : ......................................Tanggal lahir : ......................................Jenis Kelamin : □ L □ PAlamat :………………….
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3. Faktor Risiko pasien□ Umur□ Gizi□ Obesitas
□ Penyakit penyerta : □ Diabetes □ HIV □ HBV □ HCV
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Pemakaian Peralatan perawatan pasienIntra vena Kateter Tgl pasang Tgl lepas Total Hari□ Intravena kateter sentral ……….. …….. ……
□ Intravena kateter perifer ……….. ……… ……
□ Intra Arteri ……….. ……… ……□ Umblikal ……….. ……… ……
□ Urine Kateter Menetap …….. …….. ………
□ Suprapubik Kateter
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Ventilasi Mekanik Tgl pasang Tgl lepas Total□ Endotrakheal Tube ………… …………. …….
□ Trakheostomi ………… ……… ……□ Lain-lain ………… ………. ……
□ Drain/IADP/CVVH ……… ……… ……
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Penggunaan antibiotic Tgl pakai Tgl berhenti 1. ……………… …………. …………….2………………… …………. …………… 3………………… …………. ……………
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Pemeriksaan Penunjang
Radiologi :......................Laboratorium :......................Suhu Tubuh :......................
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Hasil Kultur specimen
Darah : …………………Urine : …………………
Sputum : ………………
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Komplikasi infeksi
□ IADP □ ISK □ VAP□ Pneumonia □ Plebitis □ Dekubitus
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• I.Data Medikal Rekord• Ruangan :…………………• Tgl masuk/Jam : ........... ………/...........• Tanggal keluar :…………………..• Departemen : ……………………• Cara dirawat : □ Emergency □ Eelektif• No.Rekam Medik :……………• Diagnosa Masuk :……………..• Diagnosa Keluar :…………………
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2. Data Demografik Pasien
Nama Pasien : ...............................Tanggal lahir : ...............................Jenis Kelamin : □ L □ PAlamat :………………….
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3. Faktor Risiko pasien
□ Umur□ Gizi□ Obesitas
□ Penyakit penyerta : □ Diabetes □ HIV □ HBV □ HCV
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Data petugas kamar bedahAhli bedah 1 :……… Ahli bedah 2 ............Ahli anasthesi:………………Scrub Nurse 1:………. Scrub Nurse 2 ...........
Jenis operasi : □ Apendik □ SC □ CABG □Hernia □ dll
Tipe operasi : □ terbuka □ tertutup
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Kategori Risk□ 0 □ 1 □ 2 □ 3
Klasifikasi luka□ Bersih □ Bersih terkontaminasi □ Terkontaminasi □ Kotor
Klasifikasi ASA□ 1 □ 2 □ 3 □ 4 □ 5
T.Time□ Kurang dari T .Time □ Lebih dari T Time
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Penggunaan antibiotic Tgl pakai Tgl berhenti 1. ……………. …………. ……………2……………… …………. …………… 3……………… …………. ……………
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Hasil Kultur specimen jaringan/luka..........................................................
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