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  • TB 12

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    Novi Aristanti
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    This document is a form for sending TB test samples from a primary testing lab (Puskesmas Sungai Mariam) to another lab for cross checking. It includes fields for the sample ID number, patient name, test results from the primary lab including date and sputum quality, and fields to later fill in the cross check lab's test results for comparison. There are 115 sample entries included on the form to be sent for cross checking.

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    tb 12

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    This document is a form for sending TB test samples from a primary testing lab (Puskesmas Sungai Mariam) to another lab for cross checking. It includes fields for the sample ID number, patient name, test results from the primary lab including date and sputum quality, and fields to later fill in the cross check lab's test results for comparison. There are 115 sample entries included on the form to be sent for cross checking.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    11 views4 pages

    TB 12

    Uploaded by

    Novi Aristanti
    This document is a form for sending TB test samples from a primary testing lab (Puskesmas Sungai Mariam) to another lab for cross checking. It includes fields for the sample ID number, patient name, test results from the primary lab including date and sputum quality, and fields to later fill in the cross check lab's test results for comparison. There are 115 sample entries included on the form to be sent for cross checking.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 4

    PROGRAM TB NASIONAL TB 12

    FORMULIR PENGIRIMAN SEDIAAN UNTUK CROSS CHECK

    Nama Pemeriksa pertama : Puskesmas Sungai Mariam


    Nama Petugas Lab Pemeriksa Pertama : Isma Muryat
    Tanggal Sediaan diambil :

    Hasil
    Hasil Pemeriksaan
    No No No Kualitas Kualitas
    Pemeriksaan Lab Yang
    Uru Reg Identtas Nama penderita Sediaan Pewarnaan
    Lab Pertama Melakukan
    t Lab Sediaan
    Cross Check
    Tgl Hasil Tgl Hasil B J B J
    A B C D E F G H I J K L

    1 036 03/10/006 Saniah 3/7/17 Neg


    2 031 03/10/008 Nawisa 17/7/17 Neg
    3 032 03/10/004 Muslihudin 17/7/17 Neg
    4 033 03/10/019 Tiurlina Simarmata 22/7/17 2/100
    5 033 03/10/019 Tiurlina Simarmata 22/7/17 1+
    6 034 03/10/020 H.Muhammad 25/7/17 Neg
    7 035 03/10/021 Sariyat 26/7/17 2+
    8 035 03/10/021 Sariyat 26/7/17 2+
    9 036 03/10/013 Hasmiat 29/7/17 Neg
    10 037 03/10/014 Said Harli 31/7/17 1+
    11 028 03/10/010 Hatfah 7/8/17 Neg
    12 039 03/10/032 Mardiyant 8/8/17 Neg
    13 040 03/10/022 Harmawat 11/8/17 Neg
    14 040 03/10/022 Harmawat 11/8/17 Neg
    15 041 03/10/023 Fajar Wahyuni 11/8/17 1+
    16 042 03/10/024 Baha 16/8/17 2+
    17 042 03/10/024 Baha 16/8/17 2+
    18 043 03/10/025 Rasmi 18/8/17 1+
    19 044 03/10/006 Saniah 26/8/17 Neg
    20 045 03/10/026 Rochim 26/8/17 Neg
    21 045 03/10/026 Rochim 26/8/17 Neg
    22 046 03/10/008 Nawisa 29/8/17 Neg
    23 047 03/10/027 Basso Musakir 29/8/17 Neg
    24 048 03/10/028 Ambo Upe 31/8/17 Neg
    25 048 03/10/028 Ambo Upe 31/8/17 Neg
    26 049 03/10/013 Hasmiat 4/9/17 Neg
    27 050 03/10/014 Said Harli 5/9/17 6/100
    28 051 03/10/029 Mukni 11/9/17 Neg
    29 052 03/10/010 Hatfah 15/9/17 Neg
    30 053 03/10/004 Muslihudin 15/9/17 Neg
    31 054 03/10/031 Jamaludin 15/9/17 Neg
    32 055 03/10/030 Ambransyah 22/9/17 2+
    33 055 03/10/030 Ambransyah 22/9/17 1+
    34 056 03/10/019 Tiurlina Simarmata 23/9/17 Neg
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    Hasil
    Hasil Pemeriksaan
    No No No Kualitas Kualitas
    Pemeriksaan Lab Yang
    Uru Reg Identtas Nama penderita Sediaan Pewarnaan
    Lab Pertama Melakukan
    t Lab Sediaan
    Cross Check
    Tgl Hasil Tgl Hasil B J B J
    A B C D E F G H I J K L

    46
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    Hasil
    Hasil Pemeriksaan
    No No No Kualitas Kualitas
    Pemeriksaan Lab Yang
    Uru Reg Identtas Nama penderita Sediaan Pewarnaan
    Lab Pertama Melakukan
    t Lab Sediaan
    Cross Check
    Tgl Hasil Tgl Hasil B J B J
    A B C D E F G H I J K L

    100
    101
    102
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    115

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