FORMULIR "HOSPITAL RECORD REVIEW"

KASUS AFP DAN PD3I LAINNYA (MOHON CEK KELENGKAPAN DATA MELALUI STATUS PASIEN)

Nama Rumah Sakit

Kab./Prov

Tanggal HRR :

Periode HRR

Tanggal
Tanggal Tanggal
pengumpula
Unit di Rumah KODE No Register Umur (th, Tanggal Tanggal dilaporkan ke pengumpula
No. Diagnosa Nama Kasus Nama orang tua Alamat n spesimen KET
Sakit 1CD-10 Pasien bulan) lumpuh/sakit masuk RS DINAS n spesimen
- 2 (untuk
KESEHATAN -1
AFP)

1
2
3

10

11

12

13

14

15

16

17

18
19

20

21

22

23

24

25

26

27

28

29

30

31
 JUMLAH KASUS TAHUN
2022 (JIKA KASUS BELUM
DILAPORKAN KE DINAS
KESEHATAN MAKA
DIAGNOSIS of Diseases with Accute Flaccid Paralysis MOHON STATUS KASUS
NO. ICD 10 (AFP) → ANAK USIA <15 TAHUN DISIAPKAN)
1 G. 54 Nerve root and plexus disorder
2 G. 56 Mononeuropathies of upper limb
3 G. 57 Mononeuropathies of lower limb
G. 61 Inflamatory Polyneuropathy
4 G. 61.0 Guillain - Barre Syndrome
5 G. 61.8 Other Inflamatory Polyneuropathy
G. 62 Other Polyneuropathies
6 G. 62.0 Drug - induce Polyneuropathy
7 G. 62.1 Alcoholic Polyneuropathy
8 G. 62.2 Polyneuropathy due to other toxic agents
9 G. 62.8 Radiation - induce Polyneuropathy
10 G. 62.9 Polyneuropathy, unspecified
G. 63 Polyneuropathy in diseases clssified
11 G. 63.0 Polyneuropathy in infectious and parasitic diseases
Diptheria
Lyme disease
Mumps
Posterpetic
G. 70 - 73 Diseases of Myoneural junction annd muscle
12 G. 70.0 Myasthenia gravis
13 G. 70.1 Toxic Myoneural disorders
G. 71 Primary disorders of muscle
14 G. 71.0 Muscular dystrophy
(Autosomal ressive, Becker, Duchenne)
G. 72 Other Myopathies
15 G. 72.0 Drug - induce Myopathy
16 G. 72.1 Alcoholic Myopathy
17 G. 72.3 Periodic Paralysis
Hyperkalaemic
Hypokalaemic
Myotonic
Normokalaemic
18 G. 72.4 Inflamatory Myopathy
19 G. 72.8 Other Specipied Myopathies
20 G. 72.9 Myopathy,
b
G. 73 Disorders of Myoneural junction and muscle in diseases classified
21 G. 73.4 Myopathy in infectious and parasitic diseases classified
22 G. 73.5 Myopathy in endocrine diseases
Hyperparathyroidism
Hypoparathyroidism
(Thyrotoxic Myopathy)
23 G. 73.6 Myopathy in Metabolic diseases
Glycogen storage diseases
Lipid storage disorders
24 G. 73.7 Myopathy on other diseases classified
 Rheumatoid arthritis
Scleroderma
Sicca syndrome
Systemic Lupus Erythematosus
G. 81 Hemiplegia
25 G. 81.0 Flaccid Hemiplegia
G. 82 Paraplegia and Tetraplegia
26 G. 82.0 Flaccid Paraplegia
27 G. 82.3 Flaccid Tetraplegia
G. 83 Other Paralytic Syndrome
28 G. 83.0 Diplegia of Upper Limbs
29 G. 83.1 Monoplegia of Lower Limb
30 G. 83.2 Monoplegia of Upper Limb
OTHERS
31 Myelitis Transversa
32 Neuritis Traumatic
33 Myelopathy
34 A.80 Acute Poliomyelitis
 A80.0  Acute paralytic poliomyelitis, vaccine-associated
 A80.1  Acute paralytic poliomyelitis, wild virus, imported
 A80.2  Acute paralytic poliomyelitis, wild virus, indigenous
 A80.3  Acute paralytic poliomyelitis, other and unspecified
A80.30  Acute paralytic poliomyelitis, unspecified
A80.39  Other acute paralytic poliomyelitis
 A80.4  Acute nonparalytic poliomyelitis
 A80.9  Acute poliomyelitis, unspecified
 JU MLAH KASUS TAH UN
2022 (JIK A KASUS BELU M
DILAPORKAN KE DINAS
K ESEHA TAN MA KA
MOHON ST ATUS K ASUS
NO. ICD 10 DIAGNOSIS of Diphtheria → SEMUA UMUR DISIAPKAN)
A36 Diphtheria
A36.0 Pharyngeal diphtheria
Diphtheritic membranous angina
Tonsillar diphtheria
A36.1 Nasopharyngeal diphtheria
A36.2 Laryngeal diphtheria
Diphtheritic laryngotracheitis
A36.3 Cutaneous diphtheria
A36.8 Other diphtheria
Diphtheritic:
H13.1 conjunctivitis†
I41.0 myocarditis†
G63.0 polyneuritis†
A36.9 Diphtheria, unspecified

JU MLAH KASUS TAH UN

2022 (JIK A KASUS BELU M
DILAPORKAN KE DINAS
K ESEHA TAN MA KA
MOHON ST ATUS K ASUS
D IAGNOSIS of Tet anus Neonat orum (T N) → ANAK USIA
NO. ICD 10 < 28 HA RI DISIAPKAN)
A33 Tetanus Neonatorum
 JUMLAH KASUS
TAHUN 2022 (JIKA
KASUS BELUM
DILAPORKAN KE
DINAS KESEHATAN
MAKA MOHON
STATUS KASUS
NO. ICD 10 DD/ UNTUK SUSPEK CAMPAK DISIAPKAN)
VIRUS
B05 Measles/Morbilli
B05.0 Measles complicated by encephalitis
B05.01 Measles complicated by meningitis
B05.02 Measles complicated by pneumonia
B05.3 Measles complicated by otitis media
H67.1 Otitis Media
B05.4 Measles with intestinal complications
B05.8 Measles with other complications
H19.2 Measles keratitis and keratoconjunctivi
B05.9 Measles without complication

B06 Rubella
B06.0 Rubella with neurological complications
G05.1 Encephalitis
G02.0 Meningitis
G05.1 Meningoencephalitis
B06.8 Rubella with other complicatio
M01.4 Arthritis
J17.1 Pneumonia
B06.9 Rubella without complication

B08.2 Roseola (HHV-6)

B27.90 Epstein-Barr virus

B34.0 Adenovirus

B34.3 Fifth disease (parvovirus)

B16 Hepatitis B virus (popular acrodermatitis)

B20 HIV
 A90 Dengue virus

BAKTERI
J15.7 Mycoplasma pneumoniae

A38 Group A Streptococcus (Scarlett fever)

B96. 89 Arcanobacterium hemolyticus

A51.4 Secondary syphillis

A27 Leptospirosis

B96.5 Pseudomonas

A39 Meningococcal infection (early)

A02.9 Salmonella

A69.2 Lyme disease

A32 Listeria monocytogenes

RICKETTSIA
A77.0 Early Rocky Mountain spotted fever

A75.2 Typhus

A77.4 Ehrlichiosis

LAINNYA
M30.3 Kawasaki Disease

B38 Coccidioides immitis

 JUMLAH KASUS TAHUN
2021 (JIKA KASUS BELUM
DILAPORKAN KE DINAS
KESEHATAN MAKA
MOHON STATUS KASUS
NO. ICD 10 DIAGNOSIS of Tetanus Neonatorum (TN) DISIAPKAN)
A33 Tetanus Neonatorum