Formulir Surveilans Harian Infeksi Rumah Sakit.docx
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FORMULIR SURVEILANS HARIAN INFEKSI RUMAH SAKIT BULAN/TAHUN RUANGAN SURVEILANS TGL
NO
NK
NAMA/MR
: Oktober 2018 : : U
JK
Dx Medis UC
TINDAKAN CVL IVL
ETT/ VENTI
INFEKSI RUMAH SAKIT VAP HAP ISK IAD
TIRAH BARING
PLEBETIS
HASIL KULTUR
02/11/2018
JUMLAH
Keterangan Dx Medis
: Diagnosa Medis : Usia : Jenis Kelamin : Urine Catheter : Intra Vena Line/Vena Perifer
ETT HAP VAP IAD NK
: Endotracheal Tube : Hospital Associated Pneumonia : Ventilator Associated Pneumonia : Infeksi Aliran Darah : Nomor Kamar
Dibuat Oleh
(…………………) IPCN
AB
NO
NK
NAMA/MR
: Oktober 2018 : : U
JK
Dx Medis UC
TINDAKAN CVL IVL
ETT/ VENTI
INFEKSI RUMAH SAKIT VAP HAP ISK IAD
TIRAH BARING
PLEBETIS
HASIL KULTUR
02/11/2018
JUMLAH
Keterangan Dx Medis
: Diagnosa Medis : Usia : Jenis Kelamin : Urine Catheter : Intra Vena Line/Vena Perifer
ETT HAP VAP IAD NK
: Endotracheal Tube : Hospital Associated Pneumonia : Ventilator Associated Pneumonia : Infeksi Aliran Darah : Nomor Kamar
Dibuat Oleh
(…………………) IPCN
AB
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