FORMULIR "HOSPITAL RECORD REVIEW"

KASUS AFP DAN PD3I LAINNYA (MOHON CEK KELENGKAPAN DATA MELALUI S
Nama Rumah Sakit
Kab./Prov
Tanggal HRR :
Periode HRR

Unit di No Tanggal
KODE Nama Umur (th, Nama
No. Rumah Diagnosa Register Alamat lumpuh/sa
1CD-10 Kasus bulan) orang tua
Sakit Pasien kit

1
2
3
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
VIEW"
DATA MELALUI STATUS PASIEN)

Tanggal
Tanggal Tanggal
pengumpu
dilaporkan pengumpu
Tanggal lan
ke DINAS lan KET
masuk RS spesimen
KESEHAT spesimen
- 2 (untuk
AN -1
AFP)
 JUMLAH KASUS TAHUN 2022
JUMLAH JUMLAH
(JIKA KASUS BELUM
KASUS KASUS
DILAPORKAN KE DINAS
TAHUN TAHUN
DIAGNOSIS of Diseases with Accute Flaccid Paralysis (AFP) → KESEHATAN MAKA MOHON
2017 2018
NO. ICD 10 ANAK USIA <15 TAHUN STATUS KASUS 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 - 73Diseases 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, ub
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