FORMKONTROLSUHURUANGAN

(STANDAR:15°-30°C)TAHUN2022
BULAN :
NAMARUANGAN :RUANG OBAT INSTALASI FARMASI KCP

NO TGL JAM SUHU JAM SUHU KET NAMA/PARAFPETUGAS

1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
 CATATANSUHULEMARIPENDINGINSTANDAR(2°-8°C)
TAHUN2022

BULAN :
NAMARUANGAN :LEMARI PENDINGIN KCP

NO TGL JAM SUHU JAM SUHU KET NAMA/PARAFPETUGAS

1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
 RUMAH SAKIT JIWA TAMPAN PROVINSI
RIAUCATATANPEMAKAIAN OBATDAN ALKES
EMERGENCY
DIUNIT/RUANGAN: (CODEBLUE)

PETUGASRUANGAN=PENGELUARAN/PEMAKAIAN PETUGASFARMASI=CEKSISASEDIAAN
TGL&JAM NO NOSEGELKUNCI NAMA&PARAF NOSEGELKUNCIDISP JUMLAHAKHIR KETERANGAN NAMA&PARAF
NAMA OBAT JUMLAH MASUK
DISP.YANGDIRUSAK PETUGAS LAMA BARU NO BATCH ED PETUGAS
 LAMPIRANISIEMERGENCYKIT

NONAMA
I.
AIRWAYMANAGEMENTSUPPORT: IV.OTHERS
1. 1SetguedelAirway(7size) 1.1pcAneroidSphygmomanometer
2. 1setEndrotrachealtube(7size) 2.1pcStethoscopeDuplex
3. 1pcLaringoscopeHandle 3.1eaThermometer
4. 1setLaringoscopBladesize.1,2,3 4.5pcsinfusionset
5. 1tubeXylocaineJelly2% 5.5pcsintreravenusCathethersize24
6. 1pcstylet 6.5pcsintreravenusCathethersize22
7. 1pcAdultMagillForceps 7.5pcsintreravenusCathethersize20
8. 1rollMicropore 8.2eaKainSegitiga(Mitela)
9. 2BoxkasaSterile16x16cm
II.
VENTILATIONSUPPORT: 10.1eaKapas50gr
1. 1pcCPRMask 11.2eaPembalutCepatsize1
2. 1pcTongSpaselStanlessSteel 12.1eaPembalutCepatsize2
3. 1pcAmbuBagAdult&child 13.1eaPembalutCepatsize3
4. pcManualSuction(hand) 14.3rollElastisPerban7,5.10,15cm
15.10eaPlesterCepat
III.
HELTINGSET 16.1rollPlesterGulungf
1. 1pcNeedleHolder"MayorHegar"14cmSS 17.1packPerbanGulung5cm
2. 1pcOperatingScissorSTRE14cmSS 18.1packPerbanGulung10cm
3. 1pcOperatingScissorCVD14cmSS 19.2eaSofratulle
4. 1pcDressing Forcep(pincetanatomi)14cmSS 20.1pankCottonBud
5. 1pcsTissueForsep(pincetChirugis)14cmSS 21.10eaAlcoholSwab
6. 2pcsArteryKlemPeanStr14cmSS 22.1BotolBetadine60ml
7. 2pcsArteryKlemPeanCVD14cmSS 23.1eaPinsetanatomi
8. 1pcScalpelHeandleNo.3SS 24.1eaPenlight
9. 1pcScalpelBladeNo.10/11SS 25.10eaSarungTangan
10. 1packsutureNeedle 26.5eaMasker
11. 1packCutgutPlain150cm 27.2pcIceCommpres
12. 1pcInstrumentTray 28.1botolGlugosa,RI
29. 1pcTournyquet
30. 1botolAlkohol
31. 5pcSiring5ml
32. 1pcReflexHammer
33. 1pcSoofCase

YangMenerima Pekanbaru, , 2016

yang
memberikanKa,Inst
alasiFarmasi

Betti Kristina ,S
Farm,AptNip:1979040402006042007
LAMPIRANISITROLIEMERGENCY

NONAMA
I. TOPSHELF/IVPOLE/SIDEOFTROLLEY
1. 1xdisposableambubagwithfacemaskattacked
2. 1xpaediatricfacemask(frusewithlaringesctomy/tracheostomy
3. 1xoxygencylinder
4. 1x24/28%oxygenmaskandset
5. xsuctionunit(sideoftrolly)
6. 1xsharpersbox

II. TOPDRAWER
1. Endotrachealtubesize8,0x2size8,0x2
2. Nasopharingealairwayssize6,1xsize7
3. Size2guedeairwaysx1,size3guedelairways
4. 2xlaringoskophandle,2xmacinthos3blades(starndar)2xmacinthos4blades(longblade)
5. 2xspacelaryngoscopbaterris,1xspacelaringoscopebulp
6. 1size1-gellaryngealmaskairways(LMA)replacementstock
7. 1xmagilforceps
8. 1x10mlsyringe
9. 1xpairofscssors,1xtubeofk-yjelly,2xx-matchbottle
10. 1xrollof2,5cmmicroporreortranspore

III. SECONDRAWER
1. 3X20MLSYRINGES,6X10MLSYRINGES,6X2MLSYRINGES

YangMenerima Pekanbaru, , 2016

yang
memberikanKa,Inst
alasiFarmasi

Betti Kristina ,S
Farm,AptNip:1979040402006042
007
 DAFTARNAMAOBATDALAMEMERGENCYKIT

NO NAMA EXPDATE
1. 2AmpulEphineprinInj1mg/ml Aug-17
2. 2AmpulAtropinSulfat0,25mg/ml Mar-19
3. 2AmpulDexamethasonInj Jan-19
4. 10TabletAspilet80mg
5. 10TabletISDN5mg Mar-18
6. 2AmpulDiphenhidraminInj Aug-18
7. 2AmpulLidocainInj 40mg/2ml Jul-17
8. 2AmpulDiazepam10mg/2ml Apr-20
9. 2AmpulDopamin40mg/ml Nov-16
10. 2AmpulRanitidinInj Dec-16
11. 1SupStesolidRectal Mar-18
12. 2AmpulFurosemidInj Feb-17

DAFTARNAMAOBATDALAMEMERGENCYKIT

NO NAMA EXPDATE
1. 2AmpulEphineprinInj1mg/ml Aug-17
2. 2AmpulAtropinSulfat0,25mg/ml Mar-19
3. 2AmpulDexamethasonInj Jan-19
4. 10TabletAspilet80mg
5. 10TabletISDN5mg Mar-18
6. 2AmpulDiphenhidraminInj Aug-18
7. 2AmpulLidocainInj 40mg/2ml Jul-17
8. 2AmpulDiazepam10mg/2ml Apr-20
9. 2AmpulDopamin40mg/ml Nov-16
10. 2AmpulRanitidinInj Dec-16
11. 1SupStesolidRectal Mar-18
12. 2AmpulFurosemidInj Feb-17
 DAFTARNAMAOBATDALAMEMERGENCYKIT

NO NAMA
1. 2AmpulEphineprinInj1mg/ml
2. 2AmpulAtropinSulfat0,25mg/ml
3. 2AmpulDexamethasonInj

4. 10TabletAspilet80mg

5. 10TabletISDN5mg

6. 2AmpulDiphenhidraminInj

7. 2AmpulLidocainInj40mg/2ml

8. 2AmpulDiazepam10mg/2ml

9. 2AmpulDopamin40mg/ml

10. 2AmpulRanitidinInj

11. 1SupStesolidRectal

12. 2AmpulFurosemidInj
 DAFTARNAMAOBATOKTAPOTIKRAWATJALAN

NO NAMAOBAT SATUAN STOK EXP

1 ALPRAZOLAM1MG TABLET
2 ALPRAZOLAM0,5MG TABLET
3 ALPRAZOLAM0,25MG TABLET
4 CLOBAZAM10MG TABLET
5 LORAZEPAM2MG TABLET
6 CARBAMAZEPIN200MG TABLET
7 DIAZEPAM2MG TABLET
8 DIAZEPAM5MG TABLET
9 PROHIFER TABLET
10 PRONEURON TABLET
11 DIAZEPAMINJ AMP
12 CODEIN10MG TABLET

PenanggungjawabInstalasiFarmasi Pekanbaru 26 Oktober

2017yangmembon

Betti KristinaS.Farm,Apt Herlina

NIP:197904042006042007 NIP:196706231991032002
 PERMINTAANOBATOKTUNTUKAPOTIKR
AWATJALAN

NO NAMAOBAT SATUAN JUMLAH KETERANGAN

1 DIAZEPAM5MG TABLET 3,000 BN,160391
2 LORAZEPAM TABLET 3,000 BN.171674
3 CLOBAZAM TABLET 2,000 BN.4660261
4 DIAZEPAM5MG TABLET 2000 bn.160391
5 PROHIFER TABLET 300 BN,160293

PenanggungjawabInstalasiFarmasi Pekanbaru30Sptember2017
yangmembon

BettiKristinaS.Farm,Apt Herlina
NIP:197904042006042007 NIP:196706231991032002
 DAFTARNAMAOBAT-OBATTERTENTU

NO NAMA KETERANGAN
STOK EXPDATE
1. AMITRIPTILIN25MG

2. CHLORPROMAZIN25MG

3. CHLORPROMAZIN100MG

4. HALOPERIDOL0,5MG

5. HALOPERIDOL1,5MG

6. HALOPERIDOL 5 MG

7. HEXYMER2 MG

8. HALDOLINJE KSI

9. LODOMERI NJEKSI

10. LODOMERDR OP
 PEMERINTAHPROVINSIRIAU
RUMAHSAKITJIWATAMPANPROVINSIRIAU
Jl.HRSoebrantasKm.12,5Pekanbaru

PEMANTAUANSUHUKULKAS
Bulan/Tahun :

TGL/ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
JAM 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14 8 14
9oC
8oC
7oC
6oC
5oC
4oC
3oC
2oC
1oC

Mengetahui, Pekanbaru,
Koord.PerbekalanFarmasi Spv.GudangFarmasi

AmaliaPut
iMaretta,S.Farm,AptNip.19840
3242009042003
 PEMERINTAHPROVINSIRIAU
RUMAHSAKITJIWATAMPANPROVINSIRIAU
Jl.HRSoebrantasKm.12,5Pekanbaru

MONITORINGSUHURUANG
Bulan /Tahun :
StandarSuhudanKelembapandiRuangan
No Ruangan Suhu Kelembapan
1 PublikArea 21oC-26oC 45%-60%
2 RuangObat:
-SuhuRuangan 15oC-25oC 35%-60%
-SuhuSejuk 9oC-15oC
-SuhuDingin 10oC-15oC
 PEMERINTAHPROVINSIRIAU
RUMAHSAKITJIWATAMPANPROVINSIRIAU
Jl.HRSoebrantasKm.12,5Pekanbaru

PEMANTAUANSUHUKULKAS
Bulan/Tahun :

TGL/ 1 2 3 5 5 6 7 8 9 10 11 12 13 15 15 16 17 18 19 20 21 22 23 25 25 26 27 28 29 30 31
JAM 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15
9oC
8oC
7oC
6oC
5oC
4oC
3oC
2oC
1oC

Mengetahui, Pekanbaru,
Koord.ApotekRawatInap/IGD Spv.ApotekRawatInap/IGD

Nip. Nip.
 PEMERINTAHPROVINSIRIAU
RUMAHSAKITJIWATAMPANPROVINSIRIAU
Jl.HRSoebrantasKm.12,5Pekanbaru

PEMANTAUANSUHURUANG
Bulan/Tahun :
TGL/ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
JAM 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15
35oC
34oC
33oC
32oC
31oC
30oC
29oC
28oC
27oC
26oC
25oC
24oC
23oC
22oC
21oC
20oC
19oC
18oC
17oC
16oC
15oC
14oC

Mengetahui, Pekanbaru,
Koord.ApotekRawatInap/IGD Spv.ApotekRawatInap/IGD

Nip. Nip.
 PEMERINTAHPROVINSIRIAU
RUMAHSAKITJIWATAMPANPROVINSIRIAU
Jl.HRSoebrantasKm.12,5Pekanbaru

PEMANTAUANSUHUKULKAS
Bulan/Tahun :

TGL/ 1 2 3 5 5 6 7 8 9 10 11 12 13 15 15 16 17 18 19 20 21 22 23 25 25 26 27 28 29 30 31
JAM 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15
9oC
8oC
7oC
6oC
5oC
4oC
3oC
2oC
1oC

Mengetahui, Pekanbaru,
Ka.InstalasiFarmasi Koord.ApotekRawatJalan

BettiKristina,S.Farm,AptNip.
197904042006042007
Nip.
 PEMERINTAHPROVINSIRIAU
RUMAHSAKITJIWATAMPANPROVINSIRIAU
Jl.HRSoebrantasKm.12,5Pekanbaru

PEMANTAUANSUHURUANG
Bulan/Tahun :
TGL/ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
JAM 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15 8 15
35oC
34oC
33oC
32oC
31oC
30oC
29oC
28oC
27oC
26oC
25oC
24oC
23oC
22oC
21oC
20oC
19oC
18oC
17oC
16oC
15oC
14oC

Mengetahui, Pekanbaru,
Ka.InstalasiFarmasi Koord.ApotekRawatInap/IGD

BettiKristina,S.Farm,AptNip.
197904042006042007
Nip.
StandarSuhudanKelembapandiRuangan

No Ruangan Suhu Kelembapan

1 PublikArea 21oC-26oC 45%-60%
2 RuangObat
-SuhuRuangan 15oC-25oC 35%-60%
-Suhu Sejuk 9oC-15oC
-SuhuDingin 10oC-15oC