FORMULIR SURVEILANS HARIAN INFEKSI RUMAH SAKIT

RUMAH SAKIT UMUM SEMARA RATIH

BULAN/TAHUN: JUNI 2017

RUANGAN : RAWAT INAP
SURVEYOR :
DIVISI/DEPARTMEN :
INFEKSI RUMAH
TINDAKAN TIRAH HASIL
TGL S NAMA/RM U JK DX.MEDIS SAKIT AB
BARING KULTUR
UC IVL CVL ETT/VENTI VAP HAP ISK IAD
Ika Regina
1/6/17-
1/6/17 37,8 Putri 6 P Febris
3/6/17
(172245)

1/6/17 37,7 Ketut Adi 43 L Febris 1/6/17-

( ) 3/6/17

1/6/17 36,4 Warniasih 30 P Post partum 1/6/17-

( ) 6/6/17

1/6/17 36,3 Ni Komang 7 P Tonsilitis akut, 1/6/17-

Sri Rinitis, Moderate, 4/6/17
Handayani Dehidration
( 171272)
1/6/17 36,2 Wayan 80 L HT epitaksis 1/6/17-
Tompel 3/6/17
(172248)
1/6/17 36,3 Ni Made 35 P Tonsilitis 1/6/17-
Swandewi 3/6/17
2/6/17 36,4 Ni Kadek 31 P Post partum 2/6/17-
Ariantini 3/6/17
(171154)
2/6/17 37 I Wayan 57 L HT + Dispepsia 2/6/17-
Surata 5/6/17
(172271)
3/6/17 36,3 Kadek Bayu 3 L Vomiting 3/6/17-
Cahya 6/6/17
(172277)
3/6/17 36 Budi L Apendiktomi 4/6/17- 3/6/17-
Setiawan 6/6/17 6/6/17
(172274)
3/6/17 36 Ni Nyoman 50 P Gastritis 3/6/17-
 Candra 6/6/17
3/6/17 36.2 Ni Kadek 27 P Post Partum 3/6/17- 3/6/17-
Sumertini 4/6/17 4/6/17
3/6/17 36,5 Ida Bagus 19 L Dispepsia + ISK 3/6/17-
Rama 6/6/17
(172280)
4/6/17 37,6 Restu 14 L DHF +Dispepsia 3/6/17-
Karunia 4/6/17
4/6/17 36,2 Wayan 61 L CVA Trombosis, 4/6/17-
Nyandil DM Grade II, HT 9/6/17
(172273)
4/6/17 36 Komang 24 L Post Partum 4/6/17-
Budiarta 6/6/17
4/6/17 36 Wayan Arga 62 L Konstipasi 4/6/17-
(172282) 7/6/17
5/6/17 36,3 Ni Wayan 72 P Pneumonia 5/6/17-
Ribin 9/6/17
(171714)
5/6/17 36,3 Komang 28 P G1P1A0 5/6/17-
Mastriani 6/6/17
(171317)
5/6/17 36,4 Kadek Aira 1,5 P Bronchitis 5/6/17-
Pratiwi 11/6/17
(171974)
6/6/17 36,2 Made Retog 78 L DM Tipe 2 6/6/17-
(172306) 10/6/17
6/6/17 36,3 Ni Nyoman 40 P Atrial Fibrilation 6/6/17-
Rinun 8/6/17
(172309)
7/6/17 36 Made 80 L HF, HT,Pneumonia 7/6/17-
Sedeng 7/6/17
(172312)
7/6/17 36,5 Made Subur 30 L Tumor paru sinistra 7/6/17-
(160266) 14/6/17
7/6/17 36,4 Ni Wayan 35 P Dispepsia 7/6/17-
Wirati 8/6/17
7/6/17 36,6 Made Bagus 2,6 L GE 7/6/17-
Dwi P 13/6/17
(170753)
8/6/17 36,8 Wayan 80 L HT 8/6/17-
Rareg 11/6/17
(170598)
8/6/17 36 Ketut Ladri 59 P Acute ALL 8/6/17-
(172088) 12/6/17
8/6/17 36 Agung 3 L Broncopneumonia 8/6/17-
Rahayu 10/6/17
(172323)
8/6/17 36,4 Wayan 60 L Anemia Grafis 8/6/17-
Sueta 13/6/17
9/6/17 36,3 Nanda 18 L Asma Bronchiale 9/6/17-
Cahaya 11/6/17
9/6/17 36 Ni Wayan 31 P Syndrome 9/6/17-
Anjani Neuropatik 11/6/17
10/6/17 36 Wayan 60 L Abses Mamae 10/6/17-
Mukun Dextra 13/6/17
(172338)
11/6/17 36 I Ketut 42 L Perianal Astula 11/6/17-
Ginarta Abses 13/6/17
(172347)
11/6/17 36,8 Ni Ketut 50 P Combustio Grade 11/6/17- 11/6/17-
Suri II-III 36 % 16/6/17 16/6/17
(172350)
11/6/17 36,5 Ni Wayan 74 P CVA, Hypertiroid, 11/6/17-
Ridis Pneuminia 13/6/17
11/6/17 37,4 Made 31 P DHF 11/6/17-
Arisita 13/6/17
12/6/17 36 Tri Wahyuni 20 P Apendik 13/6/17- 12/6/17-
18/6/17 18/6/17
13/6/17 36 Wayan 39 L Colic Abdomen 13/6/17-
Suwadi 18/6/17
(172384)
13/6/17 36 Ni Made 50 P Multipel Abses 13/6/17-
Ngi 21/6/17
14/6/17 36 Ni Wayan 27 P G2P1A0 14/6/17-
Damayanti 15/6/17
(171321)
15/6/17 36 Made 27 L 15/6/17-
Santiari 20/6/17
(172074)
16/6/17 36,5 Luh Biana 19 P CKR, Vulnus 16/6/17-
harisanti Apertum 17/6/17
16/6/17 37,8 Gede 50 L DHF 16/6/17-
Wijaya 19/6/17
(172403)
16/6/17 38 Ketut Riana 28 L Febris 16/6/17-
(172404) 19/6/17
18/6/17 36,4 Ketut Sudira 65 L CKR 18/6/17-
(172422) 20/6/17
18/6/17 36,3 Ni Wayan 73 P Febris 18/6/17-
Suwantari 23/6/17
18/6/17 36,4 Made Cuil L DM, Dispepsia 18/6/17-
(170903) 21/6/17
18/6/17 36 Putu 57 L Stroke 18/6/17-
Budiada 23/6/17
(172421)
18/6/17 36 Luh Yunita 16 PL 18/6/17-
L (171867) 20/6/17
18/6/17 37,8 I Made 46 L DHF 18/6/17-
Suarda 21/6/17
(171585)
19/6/17 36 Desak Putu 45 P Colic Abdomen 19/6/17-
(172430) 21/6/17
19/6/17 36 I Ketut 47 L Post Trauma 19/6/17-
Manik 22/6/17
(172431)
19/6/17 36 I Wayan 34 L Sincope 19/6/17-
Subawa 20/6/17
(172435)
19/6/17 37,3 Ni Made 80 P DM 19/6/17-
Gamongan 24/6/17
(172399)
20/6/17 36 Miasih 42 L Aritmia 19/6/17-
(172410) 21/6/17
20/6/17 36,6 I Putu 11bln L Bronchopneumonia 20/6/17-
Teguh 23/6/17
(171513)
20/6/17 36 Ni Wayan 69 P 20/6/17-
Astini 23/6/17
(172437)
21/6/17 36,4 Darmawan 42 L Colic Abdomen 21/6/17-
23/6/17
21/6/17 36,3 Rendi Arta 3.3 L Tonsilitis Akut 21/6/17-
24/6/17
22/6/17 36,5 Desak Putu 47 P Colic Abdomen 22/6/17-
artini 24/6/17
(172430)
36,6 Made Merig 55 L HT 22/6/17-
22/6/17 (172455) 24/6/17
36,7 Made 80 L Melena 23/6/17-
23/6/17 Sedeng 29/6/17
(172317)
23/6/17 36 I Made Lega 68 L AFRVR 23/6/17-
 (172193) 25/6/17
24/6/17 36,3 Ni Wayan 25 P Vertigo 24/6/17-
Ratni 26/6/17
(172985)
26/6/17 36 Ni Nyoman 18 P Gastritis 26/6/17-
Prastiti 29/6/17
26/6/17 36,6 Ni Ketut 35 P Dispepsia 26/6/17-
Nuratni 27/6/17
(172500)
26/6/17 36,5 Wayan Yogi 17 L Dispepsia 26/6/17-
Astuti 1/7/17
(172509)
27/6/17 36,4 Nyoman 85 L Illeus 27/6/17-
Dunia 29/6/17
(172510)
27/6/17 37 I Made Giri 40 L Febris 27/6/17-
(172526) 30/6/17
27/6/17 36 Komang 41 P Post SC 27/6/17-
Ayu 29/6/17
Setiawati
(170571)
28/6/17 37,8 Silvia 2,5 P Febris 28/6/17-
Maharani 1/7/17
(172533)
28/6/17 36 Nyoman 50 L Intoksikasi 28/6/17-
Yadnya Metanol Aki 29/6/17
29/6/17 36 Made Sandi 36 L GEA 29/6/17-
A (172541) 30/6/17
29/6/17 36 I Nyoman 72 L Bronchitis 29/6/17- 74
Rantem 3/7/17
(172543)
KETERANGAN
Dx MEDIS : Diagnosa Medis U : Usia
S : Suhu JK : Jenis Kelamin
UC : Urine Kateter HAP : Hospital Aquired Pnemonia
IVL : Intra Vena Line/ Vena Perifer VAP : Ventilator Associated
ETT : Endotrakheal Tube IAD : Infeksi Aliran Darah
 FORMULIR SURVEILANS HARIAN INFEKSI RUMAH SAKIT
RUMAH SAKIT UMUM SEMARA RATIH

BULAN/TAHUN:
RUANGAN :
SURVEYOR :
DIVISI/DEPARTMEN :
MACAM
DX. TINDAKAN INFEKSI RUMAH SAKIT TIRAH HASIL JENIS KUMAN
TGLSUJK DEKU AB ANTIBIOTOK hasil
MEDIS BARING KULTUR
UCIVLCVLETT/VOBOBTOK VAP HAPISKPLEBITISIADILSILDILO TAB 1 2 3 >3 darahswabsputumurine

KETERANGAN
Dx MEDIS : Diagnosa Medis U : Usia IVL: Intra Vena Line/ Vena Perifer CPL : Central Vena Line OK : Operasi Kotor
ILD : Infeksi Luka Dalam
S : Suhu JK : Jenis Kelamin ETT : Endotrakheal Tube OB : Operasi Bersih DEKU : Dekubitus
ILK : Infeksi Luka Kotor
UC : Urine Kateter HAP : Hospital Aquired Pnemonia VAP : Ventilator Associated OBT : Operasi Bersih Tercemar SS/IDO : Surgical
Side Infaction/Infeksi Darah Operasi ILS : Infeksi Luka Superficial
PLEB : Plebitis

FORMULIR LAPORAN HASIL SURVEILANS

INFEKSI RUMAH SAKIT & PEMAKAIAN ANTIBIOTIK
RUMAH SAKIT UMUM SEMARA RATIH

LAPORAN BULANAN : JUNI 2017

DEPARTEMNE : RAWAT INAP
DOKTER PENANGGUNG JAWAB :
VARIABEL
VENA
VENA PERIFER KATETER OPERASI TIRAH BARING ETT/ENTILATOR TIRAH BARING
SENTRAL
0/ 0/ 0/
SSI 0/ 0/ 0/
N IAD 00 N PLEBITIS 00 N ISK 00 N % N HAP 00 N VAP 00 N DEKUBITUS 00
ILS ILD ILO

12,5
1 4,4 %

LAPORAN PENGGUNAAN ANTIBIOTIKA dan/atau SUNTIKAN

MACAM A B YANG DIGUNAKAN PADA PASIEN BERESIKO INFEKSI RUMAH SAKIT

TANPA A B 1 MACAM 2 MACAM 3 MACAM JENIS ANTIBIOTIK/JUMLAH

Pre opp Cefotaxime 2gr,

Post opp cefotaxim 3x1 gr,

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