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FORMULIR INFEKSI NOSOKOMIAL DECUBITUS TANGGAL JAM NAMA PASIEN NO. MR DIAGNOSA UTAMA DIAGNOSA SEKUNDER NAMA PERAWAT YANG MENEMUKAN GEJALA DECUBITUS HARI TIRAH BARING TANDA2 INFLAMASI(*) KETERANGAN(**)
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(*) ISI DENGAN LAMBANG + / (**) ISI DENGAN GEJALA INFLAMASI YANG TIMBUL : PEMBENGKAKAN (B) / RASA PANAS (P) / KEMERAHAN (M) / RASA SAKIT(S) / ULKUS (U) TTD KA RU / KA TIM