Rekam Pemberian Antimikrob1

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LEMBAR PENGUMPUL DATA (LPD) SURVEILANS PENGGUNAAN ANTIBIOTIK TIM PPRA RS.MATA UNDAAN SURABAYA

PETUNJUK PENGISIAN : 1. LPD diisi lengkap segera setelah operasi selesai/ setelah advis terapi AB oleh tim Dokter 2. LPD disimpan dalam Rekam Medik pasien Nama : Umur : No RM : Diagnosis

MRS/KRS : Ruangan :

Prosedur Operasi

1. 2. 1. 2.

Jenis Operasi Tanggal Operasi Nama AB

Dosis (mg)

Bersih

Bersih Terkontaminasi Terkontaminasi Lama Operasi :

Tipe Terapi

Kotor

Tgl. Jam Pr

Tgl. Jam Pr

Tgl. Jam Pr

Tgl. Jam Pr

Tgl. Jam Pr

Lama Hari Pemakaian

Tgl. Jam Pr

Tgl. Jam Pr

Tgl. Jam Pr

Tgl. Jam Pr

Tgl. Jam

Lama Hari Pemakaian

Profilaksis Empiris Definitif Cara Pemberian (iv drip/iv bolus/im/po)

Nama AB

Dosis (mg)

Tipe Terapi Profilaksis Empiris Definitif Cara Pemberian (iv drip/iv bolus/im/po)

Informasi Lain/Indikasi :

Dokter DPJP

..........................................

Ket. Lembar 1 : untuk RM Lembar 2 : untuk Tim PPRA

Perawat

..............................................

Pr

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