PEMERINTAH

RUMAH SAKIT U
Jln. Raya Babat - Jombang N
Email: ppirsu

FORMULIR SU
Bulan : Oktober
RUANGAN : VIP Graha Medika

No Tanggal No RM Nama Pasien Umur Sex

 No Tanggal No RM Nama Pasien Umur Sex

1 2021-10-01 004571 Ny. SAENAH 71 P

2 2021-10-01 186202 Tn. AANG IKHBAL PRIAMBODO 27 L
3 2021-10-01 186188 Ny. OKTAFIATININGSIH 40 P
1 2021-10-02 186188 Ny. OKTAFIATININGSIH 40 P
2 2021-10-02 186202 Tn. AANG IKHBAL PRIAMBODO 27 L
1 2021-10-03 169250 Sdr. PANJI DEWA YUDHA 21 L
1 2021-10-04 169250 Sdr. PANJI DEWA YUDHA 21 L
2 2021-10-04 181919 Tn. SUNARI 57 L
1 2021-10-05 169250 Sdr. PANJI DEWA YUDHA 21 L
1 2021-10-06 186300 Tn. WARIS 51 L
1 2021-10-07 186320 Tn. ANDRIANTO 31 L
2 2021-10-07 186300 Tn. WARIS 51 L
1 2021-10-08 186300 Tn. WARIS 51 L
2 2021-10-08 186320 Tn. ANDRIANTO 31 L
3 2021-10-08 145198 Ny. SARILAH 47 P
1 2021-10-09 186300 Tn. WARIS 51 L
2 2021-10-09 141327 Ny. YULI TRI DIYANTI 27 P
1 2021-10-10 141303 Ny. TUMISIH 61 P
2 2021-10-10 115160 Tn. CHOIRUL 70 L
3 2021-10-10 186347 Ny. SIYEM 53 P
1 2021-10-11 186347 Ny. SIYEM 53 P
2 2021-10-11 101738 Ny. SISWATI 60 P
3 2021-10-11 115160 Tn. CHOIRUL 70 L
4 2021-10-11 162098 Tn. DADANG 49 L
5 2021-10-11 141303 Ny. TUMISIH 61 P
1 2021-10-12 186385 Tn. UJUD 63 L
2 2021-10-12 186382 Tn. SAIR 69 L
3 2021-10-12 155675 Sdr. INDRA SHAHDAN DARIANTO 16 L
4 2021-10-12 018109 Ny. KHOIROTUN NISA' 27 P
5 2021-10-12 181926 Ny. INDRA DENIS MARGARITA, S.PD 37 P
6 2021-10-12 115160 Tn. CHOIRUL 70 L
7 2021-10-12 186347 Ny. SIYEM 53 P
8 2021-10-12 162098 Tn. DADANG 49 L
9 2021-10-12 186365 Ny. SRI PUJI NINGRUM 21 P
10 2021-10-12 145635 Tn. JOKO SUSANTO 41 L
11 2021-10-12 186383 Tn. MULYANI 62 L
12 2021-10-12 101738 Ny. SISWATI 60 P
1 2021-10-13 115160 Tn. CHOIRUL 70 L
2 2021-10-13 115160 Tn. CHOIRUL 70 L
3 2021-10-13 141514 Ny. TATIK 55 P
4 2021-10-13 162098 Tn. DADANG 49 L
5 2021-10-13 145635 Tn. JOKO SUSANTO 41 L
6 2021-10-13 186383 Tn. MULYANI 62 L
7 2021-10-13 186382 Tn. SAIR 69 L
8 2021-10-13 155675 Sdr. INDRA SHAHDAN DARIANTO 16 L
9 2021-10-13 018109 Ny. KHOIROTUN NISA' 27 P
10 2021-10-13 181926 Ny. INDRA DENIS MARGARITA, S.PD 37 P
11 2021-10-13 186417 Nn. UMDAH NAFISAH 18 P
12 2021-10-13 186347 Ny. SIYEM 53 P
13 2021-10-13 136890 Ny. HANIS NUR SAADAH 27 P
1 2021-10-14 186347 Ny. SIYEM 53 P
2 2021-10-14 145635 Tn. JOKO SUSANTO 41 L
3 2021-10-14 186383 Tn. MULYANI 62 L
4 2021-10-14 186382 Tn. SAIR 69 L
5 2021-10-14 155675 Sdr. INDRA SHAHDAN DARIANTO 16 L
6 2021-10-14 018109 Ny. KHOIROTUN NISA' 27 P
7 2021-10-14 181926 Ny. INDRA DENIS MARGARITA, S.PD 37 P
8 2021-10-14 186417 Nn. UMDAH NAFISAH 18 P
9 2021-10-14 141514 Ny. TATIK 55 P
10 2021-10-14 141514 Ny. TATIK 55 P
11 2021-10-14 137087 Ny. HANIS NUR SAADAH 27 P
1 2021-10-15 155675 Sdr. INDRA SHAHDAN DARIANTO 16 L
2 2021-10-15 186347 Ny. SIYEM 53 P
3 2021-10-15 181926 Ny. INDRA DENIS MARGARITA, S.PD 37 P
4 2021-10-15 186417 Nn. UMDAH NAFISAH 18 P
5 2021-10-15 170618 Tn. SUJANTO 66 L
6 2021-10-15 186484 Ny. SUWANTININGSIH 32 P
7 2021-10-15 141514 Ny. TATIK 55 P
8 2021-10-15 186382 Tn. SAIR 69 L
1 2021-10-16 186382 Tn. SAIR 69 L
2 2021-10-16 186382 Tn. SAIR 69 L
3 2021-10-16 155675 Sdr. INDRA SHAHDAN DARIANTO 16 L
4 2021-10-16 155675 Sdr. INDRA SHAHDAN DARIANTO 16 L
5 2021-10-16 186508 Tn. ABD. ROHMAN 62 L
6 2021-10-16 186417 Nn. UMDAH NAFISAH 18 P
7 2021-10-16 141514 Ny. TATIK 55 P
8 2021-10-16 170618 Tn. SUJANTO 66 L
9 2021-10-16 186484 Ny. SUWANTININGSIH 32 P
10 2021-10-16 152018 Ny. NURUSH SHOFA 23 P
1 2021-10-17 186382 Tn. SAIR 69 L
2 2021-10-17 155675 Sdr. INDRA SHAHDAN DARIANTO 16 L
3 2021-10-17 186417 Nn. UMDAH NAFISAH 18 P
4 2021-10-17 170618 Tn. SUJANTO 66 L
5 2021-10-17 186426 Ny. FITRIANA LESTARI 25 P
6 2021-10-17 186484 Ny. SUWANTININGSIH 32 P
7 2021-10-17 152018 Ny. NURUSH SHOFA 23 P
8 2021-10-17 186508 Tn. ABD. ROHMAN 62 L
1 2021-10-18 186382 Tn. SAIR 69 L
2 2021-10-18 186417 Nn. UMDAH NAFISAH 18 P
3 2021-10-18 186484 Ny. SUWANTININGSIH 32 P
4 2021-10-18 152018 Ny. NURUSH SHOFA 23 P
5 2021-10-18 186426 Ny. FITRIANA LESTARI 25 P
6 2021-10-18 186007 Tn. EKO PRIJO RAHARDJO 60 L
7 2021-10-18 119354 An. M ARIF 10 L
8 2021-10-18 134726 An. ADITYA RAKA HERMANSYAH 8 L
9 2021-10-18 015708 Tn. M. CHOIRUL HUDA 53 L
10 2021-10-18 186508 Tn. ABD. ROHMAN 62 L
1 2021-10-19 186508 Tn. ABD. ROHMAN 62 L
2 2021-10-19 186426 Ny. FITRIANA LESTARI 25 P
3 2021-10-19 186007 Tn. EKO PRIJO RAHARDJO 60 L
4 2021-10-19 119354 An. M ARIF 10 L
5 2021-10-19 134726 An. ADITYA RAKA HERMANSYAH 8 L
6 2021-10-19 186484 Ny. SUWANTININGSIH 32 P
7 2021-10-19 186382 Tn. SAIR 69 L
8 2021-10-19 015708 Tn. M. CHOIRUL HUDA 53 L
1 2021-10-20 186508 Tn. ABD. ROHMAN 62 L
2 2021-10-20 186508 Tn. ABD. ROHMAN 62 L
3 2021-10-20 186426 Ny. FITRIANA LESTARI 25 P
4 2021-10-20 015708 Tn. M. CHOIRUL HUDA 53 L
1 2021-10-21 186508 Tn. ABD. ROHMAN 62 L
2 2021-10-21 186597 An. MUHAMMAD HAZIQ IMAM ZUBAID L
3 2021-10-21 180826 An. VILLA KASELA YULIANTO 10 L
1 2021-10-22 180826 An. VILLA KASELA YULIANTO 10 L
2 2021-10-22 174595 Tn. KARJAN 69 L
3 2021-10-22 186597 An. MUHAMMAD HAZIQ IMAM ZUBAID L
1 2021-10-23 174595 Tn. KARJAN 69 L
2 2021-10-23 173827 Tn. NUR HADI 25 L
1 2021-10-24 174595 Tn. KARJAN 69 L
2 2021-10-24 173827 Tn. NUR HADI 25 L
3 2021-10-24 109491 Tn. KEMARI 64 L
1 2021-10-25 109491 Tn. KEMARI 64 L
2 2021-10-25 173827 Tn. NUR HADI 25 L
1 2021-10-26 109491 Tn. KEMARI 64 L
2 2021-10-26 186691 An. HANIN HANANIS 1 L
1 2021-10-27 186691 An. HANIN HANANIS 1 L
2 2021-10-27 108049 Ny. WINARNI 56 P
3 2021-10-27 127687 Tn. SUPARNO 58 L
4 2021-10-27 186745 Tn. MARSID 62 L
5 2021-10-27 109491 Tn. KEMARI 64 L
1 2021-10-28 108049 Ny. WINARNI 56 P
2 2021-10-28 186745 Tn. MARSID 62 L
3 2021-10-28 186569 Tn. NITI 67 L
4 2021-10-28 185761 Ny. SATIMI 51 P
5 2021-10-28 109491 Tn. KEMARI 64 L
6 2021-10-28 127687 Tn. SUPARNO 58 L
1 2021-10-29 186745 Tn. MARSID 62 L
2 2021-10-29 186569 Tn. NITI 67 L
3 2021-10-29 185761 Ny. SATIMI 51 P
4 2021-10-29 186783 Ny. NUR ILLA AGUSTINA 30 P
5 2021-10-29 127687 Tn. SUPARNO 58 L
6 2021-10-29 186780 Ny. SRINI 89 P
7 2021-10-29 108049 Ny. WINARNI 56 P
1 2021-10-30 108049 Ny. WINARNI 56 P
2 2021-10-30 186780 Ny. SRINI 89 P
3 2021-10-30 186745 Tn. MARSID 62 L
4 2021-10-30 111750 Tn. SUWADJI 62 L
5 2021-10-30 127687 Tn. SUPARNO 58 L
6 2021-10-30 185761 Ny. SATIMI 51 P
1 2021-10-31 186820 Ny. GEMRU 69 P
2 2021-10-31 111750 Tn. SUWADJI 62 L
3 2021-10-31 185761 Ny. SATIMI 51 P
4 2021-10-31 179909 An. FEBRINA VARIA SHEZA PUTRI 1 P
5 2021-10-31 186825 Tn. KASTUR 73 L
6 2021-10-31 127687 Tn. SUPARNO 58 L
7 2021-10-31 186780 Ny. SRINI 89 P
 PEMERINTAH KABUPATEN LAMONGAN
RUMAH SAKIT UMUM DAERAH NGIMBANG
Jln. Raya Babat - Jombang No. 277 Sendangrejo, Kecamatan ngimbang
Email: ppirsudngimbang@gmail.com

FORMULIR SURVEILANS HARIAN INFEKSI

HARI PEMASANGAN ALAT JENIS OPERASI

Diagnosa Medis
 Diagnosa Medis
ETT IVL UC CVC B

Other and unspecified abdominal pain 1

Snake venom 1
Premature rupture of membranes, unspecified 1
Premature rupture of membranes, unspecified 1
Snake venom 1
Acute abdomen 1
Acute abdomen 1
Follow-up examination after surgery for other conditions 1 1
Acute abdomen 1
Typhoid fever 1
Other specified anaemias 1
Typhoid fever 1
Typhoid fever 1
Other specified anaemias 1
Hypertensive heart disease 1
Typhoid fever 1
Acute abdomen 1
Acute appendicitis 1
1
Acute abdomen 1
Acute abdomen 1
Calculus of kidney 1 1
1
Fever, unspecified 1
Acute appendicitis 1
Snake venom 1
Epilepsy, unspecified 1
Dengue haemorrhagic fever 1
Prolonged pregnancy 1
1
 1
Acute abdomen 1
Fever, unspecified 1
Maternal care for intrauterine death 1 1 1
Intracranial injury, unspecified 1
Tuberculosis of lung, confirmed by unspecified means 1
Calculus of kidney 1 1 1
1
1
Fracture of clavicle 1
Fever, unspecified 1
Intracranial injury, unspecified 1
Tuberculosis of lung, confirmed by unspecified means 1
Epilepsy, unspecified 1
Dengue haemorrhagic fever 1
Prolonged pregnancy 1
1
Fever with chills 1
Acute abdomen 1
Prolonged first stage (of labour) 1
Acute abdomen 1
Intracranial injury, unspecified 1
Tuberculosis of lung, confirmed by unspecified means 1
Epilepsy, unspecified 1
Dengue haemorrhagic fever 1
Prolonged pregnancy 1
1
Fever with chills 1
Fracture of clavicle 1 1 1
Fracture of clavicle 1 1 1
Prolonged first stage (of labour) 1
Dengue haemorrhagic fever 1
Acute abdomen 1
1
Fever with chills 1
Haematemesis 1
Vertigo of central origin 1
Fracture of clavicle 1 1 1
Epilepsy, unspecified 1
Epilepsy, unspecified 1
Epilepsy, unspecified 1
Dengue haemorrhagic fever 1
Dengue haemorrhagic fever 1
1
Fever with chills 1
Fracture of clavicle 1 1
Haematemesis 1
Vertigo of central origin 1
Maternal care for known or suspected disproportion 1 1
Epilepsy, unspecified 1
Dengue haemorrhagic fever 1
Fever with chills 1
Haematemesis 1
1
Vertigo of central origin 1
Maternal care for known or suspected disproportion 1
1
Epilepsy, unspecified 1
Fever with chills 1
Vertigo of central origin 1
Maternal care for known or suspected disproportion 1
1
1
Redundant prepuce, phimosis and paraphimosis 1 1
Redundant prepuce, phimosis and paraphimosis 1 1
Insulin-dependent diabetes mellitus 1
1
1
1
1
Redundant prepuce, phimosis and paraphimosis 1 1
Redundant prepuce, phimosis and paraphimosis 1 1
Vertigo of central origin 1
Epilepsy, unspecified 1
Insulin-dependent diabetes mellitus 1
1
1
1
Insulin-dependent diabetes mellitus 1
1 1
Connective and other soft tissue, unspecified 1 1
Fracture of lower end of radius 1 1
Fracture of lower end of radius 1
Anaemia, unspecified 1
Connective and other soft tissue, unspecified 1 1
Anaemia, unspecified 1
Acute appendicitis 1
Anaemia, unspecified 1
Acute appendicitis 1
Haematemesis 1
Haematemesis 1 1
Acute appendicitis 1 1
Haematemesis 1 1
Diarrhoea and gastroenteritis of presumed infectious origin 1
Diarrhoea and gastroenteritis of presumed infectious origin 1
Nausea and vomiting 1
Malignant neoplasm of bronchus and lung 1
Anaemia due to enzyme disorders 1
Haematemesis 1 1
Nausea and vomiting 1
Anaemia due to enzyme disorders 1
Unilateral or unspecified inguinal hernia, without obstruction organ 1
Non-insulin-dependent diabetes mellitus 1
Haematemesis 1 1
Malignant neoplasm of bronchus and lung 1 1
Anaemia due to enzyme disorders 1
Unilateral or unspecified inguinal hernia, without obstruction organ 1
Non-insulin-dependent diabetes mellitus 1
1
Malignant neoplasm of bronchus and lung 1 1
Other intracerebral haemorrhage 1 1
Nausea and vomiting 1
Nausea and vomiting 1
Other intracerebral haemorrhage 1 1
Anaemia due to enzyme disorders 1
Benign lipomatous neoplasm, unspecified 1 1
Malignant neoplasm of bronchus and lung 1 1
Non-insulin-dependent diabetes mellitus 1
Gastro-oesophageal reflux disease without oesophagitis 1
Benign lipomatous neoplasm, unspecified 1 1
Non-insulin-dependent diabetes mellitus 1
Febrile convulsions 1
Hypovolaemic shock 1
Malignant neoplasm of bronchus and lung 1
Other intracerebral haemorrhage 1 1
155 13 22
JENIS OPERASI INFEKSI RS ANTI BIOTIK
 BT
T
K
VAP

1
PLEB
ISK
IDO
IADP

AMPHICILIN

CEFOPARAZONE-SULBAKTAM

CEFOTAXIME

CEFTRIAXONE

CEFUROXIME 750 MG

CIPROFLOXACIN
1
1

1
1
1

1
1
8
ANTI BIOTIK
FLUKONAZOL

GENTAMISIN

KANAMISIN

KLORAMFENICOL

LEVOFLOXACIN

MEROPENEM

METRONIDAZOL

PENISILIN G MEIJI