FORMULIR SURVEILANS HARIAN IN

RUMAH SAKIT NAHDLATUL ULAM

Formulir B
Bulan /Tahun : Oct-23
Ruangan : Interna
No Besaran / Variabel 1 2 3 4 5 6 7 8 9 10 11 12
1 JumlahPasienMemakai Alat Infus 11 10 10 8 6 7 10 9 11 8 8 11
2 JumlahPasienMemakai Alat Kateter Urine 0 1 1 1 1 1 0 0 1 1 1 0
3 JumlahPasien Yang di Rawat/ MRS 11 10 10 8 6 7 10 9 11 8 8 11
4 Kasus ILO
5 KasusPlebitis 0 0 0 0 0 0 0 0 0 0 0 0
6 KasusCa UTI
7 JumlahPasienOperasi
8 Jumlah pasien terpasang Ventilator
9 Jumlah Pasien Terpasang CVC
RVEILANS HARIAN INFEKSI
KIT NAHDLATUL ULAMA

13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jumlah
9 4 11 10 7 11 8 2 10 6 11 6 6 9 2 7 6 14 7 255
1 2 2 2 2 3 3 2 3 2 3 4 6 4 3 2 3 3 2 60
9 4 11 10 7 11 8 2 10 6 11 6 6 9 2 7 6 14 7 255
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
 FORMULIR SURVEILANCE HAIS HARIAN

JUDUL
RUANG/ UNIT/ BAGIAN Interna
BULAN / TAHUN Oct-23

ALIRAN DARAH PERIFER PERKEMIHAN

Tanggal
NO No.RM TERPASANG TERPASANG
MRS PHLEBITIS ISK
INFUS KATETER
1 07.24.65 01/10/2023 01/10/2023
2 16.53.06 01/10/2023 01/10/2023
3 17.18.72 01/10/2023 01/10/2023
4 17.18.73 01/10/2023 01/10/2023
5 09.38.01 01/10/2023 01/10/2023
6 13.15.37 01/10/2023 01/10/2023
7 17.18.85 01/10/2023 01/10/2023
8 17.18.90 01/10/2023 01/10/2023
9 17.18.87 01/10/2023 01/10/2023
10 17.18.91 01/10/2023 01/10/2023
11 17.18.92 01/10/2023 01/10/2023
12 17.18.94 02/10/2023 02/10/2023
13 17.18.86 02/10/2023 02/10/2023 10/2/2023
14 17.18.88 02/10/2023 02/10/2023
15 17.18.43 02/10/2023 02/10/2023
16 16.68.64 02/10/2023 02/10/2023
17 17.19.08 02/10/2023 02/10/2023
18 17.19.31 02/10/2023 02/10/2023
19 17.18.71 02/10/2023 02/10/2023
20 13.70.53 02/10/2023 02/10/2023
21 17.19.66 02/10/2023 02/10/2023
22 17.19.67 03/10/2023 03/10/2023
23 17.19.69 03/10/2023 03/10/2023
24 04.58.26 03/10/2023 03/10/2023
25 17.19.73 03/10/2023 03/10/2023
26 15.30.40 03/10/2023 03/10/2023
27 17.19.85 03/10/2023 03/10/2023
28 14.15.73 03/10/2023 03/10/2023
29 10.57.62 03/10/2023 03/10/2023
30 11.63.12 03/10/2023 03/10/2023
31 15.92.14 03/10/2023 03/10/2023
32 12.85.26 04/10/2023 04/10/2023
33 04.14.13 04/10/2023 04/10/2023
34 16.48.34 04/10/2023 04/10/2023
35 16.29.29 04/10/2023 04/10/2023
36 05.22.47 04/10/2023 04/10/2023
37 17.20.33 04/10/2023 04/10/2023
38 17.20.46 04/10/2023 04/10/2023
39 12.12.86 04/10/2023 04/10/2023
40 17.20.01 05/10/2023 05/10/2023
41 05.50.78 05/10/2023 05/10/2023 10/5/2023
42 16.65.80 05/10/2023 05/10/2023
43 16.36.60 05/10/2023 05/10/2023
44 17.20.84 05/10/2023 05/10/2023
45 17.20.85 05/10/2023 05/10/2023
46 12.87.57 06/10/2023 06/10/2023
47 17.21.17 06/10/2023 06/10/2023
48 17.21.34 06/10/2023 06/10/2023
49 02.18.24 06/10/2023 06/10/2023
50 11.71.31 06/10/2023 06/10/2023
51 05.28.90 06/10/2023 06/10/2023
52 17.21.39 06/10/2023 06/10/2023
53 17.21.44 07/10/2023 07/10/2023
54 17.21.45 07/10/2023 07/10/2023
55 17.21.48 07/10/2023 07/10/2023
56 17.21.58 07/10/2023 07/10/2023
57 17.21.70 07/10/2023 07/10/2023
58 17.21.74 07/10/2023 07/10/2023
59 04.45.57 07/10/2023 07/10/2023
60 09.37.39 07/10/2023 07/10/2023
61 15.90.90 07/10/2023 07/10/2023
62 09.87.93 07/10/2023 07/10/2023
63 17.21.78 08/10/2023 08/10/2023
64 17.21.81 08/10/2023 08/10/2023
65 12.60.30 08/10/2023 08/10/2023
66 05.59.88 08/10/2023 08/10/2023
67 15.52.16 08/10/2023 08/10/2023
68 13.00.55 08/10/2023 08/10/2023
69 16.47.79 08/10/2023 08/10/2023
70 02.39.31 08/10/2023 08/10/2023
71 17.22.01 08/10/2023 08/10/2023
72 17.22.05 09/10/2023 09/10/2023
73 17.22.07 09/10/2023 09/10/2023
74 09.38.54 09/10/2023 09/10/2023
75 17.22.28 09/10/2023 09/10/2023
76 16.98.14 09/10/2023 09/10/2023
77 16.85.05 09/10/2023 09/10/2023
 78 06.85.90 09/10/2023 09/10/2023 10/9/2023
79 17.22.42 09/10/2023 09/10/2023
80 05.21.31 09/10/2023 09/10/2023
81 09.37.39 09/10/2023 09/10/2023
82 17.22.59 09/10/2023 09/10/2023
83 17.22.64 10/10/2023 10/10/2023
84 10.01.32 10/10/2023 10/10/2023
85 17.22.62 10/10/2023 10/10/2023
86 13.53.92 10/10/2023 10/10/2023
87 17.22.89 10/10/2023 10/10/2023
88 17.22.96 10/10/2023 10/10/2023
89 17.23.00 10/10/2023 10/10/2023
90 16.74.04 10/10/2023 10/10/2023
91 17.23.14 11/10/2023 11/10/2023
92 05.05.00 11/10/2023 11/10/2023
93 17.23.34 11/10/2023 11/10/2023
94 17.23.41 11/10/2023 11/10/2023
95 11.93.70 11/10/2023 11/10/2023
96 17.23.39 11/10/2023 11/10/2023
97 17.23.43 11/10/2023 11/10/2023
98 08.25.31 11/10/2023 11/10/2023
99 02.51.45 12/10/2023 12/10/2023
100 02.86.87 12/10/2023 12/10/2023
101 09.94.78 12/10/2023 12/10/2023
102 17.23.65 12/10/2023 12/10/2023
103 10.47.28 12/10/2023 12/10/2023
104 17.23.70 12/10/2023 12/10/2023
105 17.23.78 12/10/2023 12/10/2023
106 08.84.93 12/10/2023 12/10/2023
107 17.23.85 12/10/2023 12/10/2023
108 17.23.76 12/10/2023 12/10/2023
109 17.23.84 12/10/2023 12/10/2023
110 17.23.88 13/10/2023 13/10/2023
111 02.31.96 13/10/2023 13/10/2023
112 14.83.05 13/10/2023 13/10/2023
113 17.21.50 13/10/2023 13/10/2023 10/13/2023
114 13.96.05 13/10/2023 13/10/2023
115 09.64.68 13/10/2023 13/10/2023
116 17.24.19 13/10/2023 13/10/2023
117 09.44.08 13/10/2023 13/10/2023
118 10.99.60 13/10/2023 13/10/2023
119 09.75.97 14/10/2023 14/10/2023
120 17.24.37 14/10/2023 14/10/2023
121 17.24.34 14/10/2023 14/10/2023
122 05.19.29 14/10/2023 14/10/2023 10/14/2023
123 17.24.48 15/10/2023 15/10/2023 10/15/2023
124 03.27.68 15/10/2023 15/10/2023
125 17.24.50 15/10/2023 15/10/2023
126 14.52.72 15/10/2023 15/10/2023
127 17.24.54 15/10/2023 15/10/2023
128 09.29.78 15/10/2023 15/10/2023
129 17.24.58 15/10/2023 15/10/2023
130 17.24.61 15/10/2023 15/10/2023
131 17.24.63 15/10/2023 15/10/2023
132 17.24.62 15/10/2023 15/10/2023
133 17.24.67 15/10/2023 15/10/2023
134 17.21.67 16/10/2023 16/10/2023
135 12.01.95 16/10/2023 16/10/2023
136 17.24.91 16/10/2023 16/10/2023
137 17.24.97 16/10/2023 16/10/2023
138 15.96.81 16/10/2023 16/10/2023
139 11.06.54 16/10/2023 16/10/2023 10/16/2023
140 17.25.14 16/10/2023 16/10/2023
141 17.25.17 16/10/2023 16/10/2023
142 00.39.01 16/10/2023 16/10/2023
143 07.10.64 16/10/2023 16/10/2023
144 17.25.29 17/10/2023 17/10/2023
145 17.25.52 17/10/2023 17/10/2023
146 17.25.61 17/10/2023 17/10/2023
147 17.25.79 17/10/2023 17/10/2023
148 17.25.72 17/10/2023 17/10/2023
149 07.25.75 17/10/2023 17/10/2023
150 12.38.06 17/10/2023 17/10/2023
151 07.86.86 18/10/2023 18/10/2023
152 17.25.91 18/10/2023 18/10/2023
153 17.25.90 18/10/2023 18/10/2023
154 17.26.02 18/10/2023 18/10/2023
155 17.25.62 18/10/2023 18/10/2023 10/18/2023
156 17.26.19 18/10/2023 18/10/2023
157 17.26.18 18/10/2023 18/10/2023
158 08.82.65 18/10/2023 18/10/2023
159 09.32.25 18/10/2023 18/10/2023
160 15.13.48 18/10/2023 18/10/2023
161 14.11.31 18/10/2023 18/10/2023
162 17.23.53 19/10/2023 19/10/2023
163 17.26.70 19/10/2023 19/10/2023
164 17.26.73 19/10/2023 19/10/2023 10/19/2023
165 17.26.71 19/10/2023 19/10/2023
166 17.26.75 19/10/2023 19/10/2023
167 10.61.80 19/10/2023 19/10/2023
168 16.11.82 19/10/2023 19/10/2023
169 17.26.85 19/10/2023 19/10/2023
170 17.05.79 20/10/2023 20/10/2023
171 17.07.35 20/10/2023 20/10/2023
172 16.58.70 21/10/2023 21/10/2023
173 17.27.31 21/10/2023 21/10/2023
174 17.27.35 21/10/2023 21/10/2023
175 17.27.40 21/10/2023 21/10/2023
176 17.22.23 21/10/2023 21/10/2023
177 17.27.42 21/10/2023 21/10/2023
178 14.26.77 21/10/2023 21/10/2023
179 07.62.39 21/10/2023 21/10/2023
180 17.27.45 21/10/2023 21/10/2023
181 07.67.49 21/10/2023 21/10/2023 10/21/2023
182 09.13.82 22/10/2023 22/10/2023
183 15.98.70 22/10/2023 22/10/2023 10/22/2023
184 17.27.55 22/10/2023 22/10/2023
185 03.57.81 22/10/2023 22/10/2023
186 16.45.18 22/10/2023 22/10/2023
187 17.27.66 22/10/2023 22/10/2023
188 17.27.77 23/10/2023 23/10/2023
189 17.27.79 23/10/2023 23/10/2023
190 08.09.71 23/10/2023 23/10/2023
191 04.18.93 23/10/2023 23/10/2023 10/23/2023
192 12.67.30 23/10/2023 23/10/2023
193 17.27.92 23/10/2023 23/10/2023
194 16.92.19 23/10/2023 23/10/2023
195 15.66.10 23/10/2023 23/10/2023
196 10.14.36 23/10/2023 23/10/2023
197 17.28.08 23/10/2023 23/10/2023
198 17.28.15 23/10/2023 23/10/2023
199 17.28.44 2410/2023 24/10/2023
200 17.04.75 24/10/2023 24/10/2023 10/24/2023
201 17.28.47 24/10/2023 24/10/2023
202 17.28.55 24/10/2023 24/10/2023
203 03.00.33 24/10/2023 24/10/2023
204 17.28.69 24/10/2023 24/10/2023
205 17.02.29 25/10/2023 25/10/2023
206 17.28.97 25/10/2023 25/10/2023
207 17.28.99 25/10/2023 25/10/2023
208 11.71.29 25/10/2023 25/10/2023
209 17.28.23 25/10/2023 25/10/2023 10/25/2023
210 13.37.88 25/10/2023 25/10/2023 10/25/2023
211 07.34.03 26/10/2023 26/10/2023
212 03.94.78 26/10/2023 26/10/2023
213 15.41.24 26/10/2023 26/10/2023
214 07.46.29 26/10/2023 26/10/2023
215 04.86.37 26/10/2023 26/10/2023
216 17.29.26 26/10/2023 26/10/2023 10/26/2023
217 16.22.56 26/10/2023 26/10/2023
218 17.29.60 26/10/2023 26/10/2023
219 17.29.64 26/10/2023 26/10/2023
220 17.29.69 27/10/2023 27/10/2023
221 09.85.36 27/10/2023 27/10/2023
222 17.30.10 28/10/2023 28/10/2023 10/29/2023
223 04.73.21 28/10/2023 28/10/2023
224 13.85.38 28/10/2023 28/10/2023
225 17.30.27 28/10/2023 28/10/2023
226 01.77.41 28/10/2023 28/10/2023
227 17.30.32 28/10/2023 28/10/2023
228 06.64.09 28/10/2023 28/10/2023
229 17.30.36 29/10/2023 29/10/2023 29/10/2023
230 13.40.30 29/10/2023 29/10/2023
231 06.71.30 29/10/2023 29/10/2023
232 07.45.98 29/10/2023 29/10/2023
233 17.30.41 29/10/2023 29/10/2023
234 11.16.37 29/10/2023 29/10/2023
235 15.10.93 30/10/2023 30/10/2023
236 11.01.61 30/10/2023 30/10/2023
237 17.30.66 30/10/2023 30/10/2023
238 17.30.78 30/10/2023 30/10/2023
239 15.55.26 30/10/2023 30/10/2023
240 17.30.18 30/10/2023 30/10/2023 10/30/2023
241 17.30.79 30/10/2023 30/10/2023
242 13.34.98 30/10/2023 30/10/2023
243 15.76.33 30/10/2023 30/10/2023
244 17.00.86 30/10/2023 30/10/2023
245 17.30.95 30/10/2023 30/10/2023
246 17.30.93 30/10/2023 30/10/2023
247 17.30.97 30/10/2023 30/10/2023
248 17.31.00 30/10/2023 30/10/2023
249 17.31.10 31/10/2023 31/10/2023
250 17.31.07 31/10/2023 31/10/2023
251 17.31.17 31/10/2023 31/10/2023
252 17.31.27 31/10/2023 31/10/2023
253 12.26.57 31/10/2023 31/10/2023
254 17.31.46 31/10/2023 31/10/2023
255 17.31.55 31/10/2023 31/10/2023

Catatan : Berikan Angka 1 pada pilihan yang dianggap benar

Pengumpul Data / PIC

( )
VEILANCE HAIS HARIAN

VENTILATOR OPERASI ALIRAN DARAH PRIMER

TERPASANG DILAKUKAN TERPASANG
VAP ILO/ IDO CLABSI
VENTILATOR OPERASI CVC