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<title>Quiz 1</title>
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<th colspan=3 bgcolor=white width ="890"><img src="D:\SEMESTER 2\WEB DESEN\Quiz 1\q.png" />FORMULIR DETEKSI DINI/LAPORAN KEJADIAN HASIL (Healthcart Associated Infections)</th>
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<th colspan=3 bgcolor=white>DI RS.ST.ELISABETH SEMARANG</th>
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<td>Ruang</td>
<td>:...................................</td>
<td colspan=3 align="left" width="160"> Tgl.Masuk/jam :........../....</td>
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<td>Cara dirawat</td>
<td>:Emergency/Elektif</td>
<td colspan=3 align="left" width="160"> No.Rekam medik :..............</td>
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<th colspan=3 align="left">I. IDENTITAS PASIEN</th>
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<td>1. Nama Pasien</td>
<td>:........................................</td><br /><br />
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<td>2. Umur</td>
<td>: th/ bln/ hr</td>
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<td>3. Jenis kelamin</td>
<td>:L/P</td>
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<td>4. Alamat</td>
<td>:.......................................</td>
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<th colspan=3 align="left">II. DIAGNOSA WAKTU MASUK</th>
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<td>.....................................................</td>
<td>.....................................................</td>
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<th colspan=3 align="left">III. PINDAH KE RUANGAN</th>
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<td>1. .............................</td>
<td>Tgl. .......................................</td>
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<td>2. .............................</td>
<td>Tgl. .......................................</td>
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<th colspan=3 align="left">IV. FAKTOR RESIKO SELAMA DIRAWAT</th>
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<th rowspan=2 width="50" >NO</th>
<th rowspan=2 width="122">Jenis tindakan /alkes</th>
<th rowspan=2 width="150">Lokasi</th>
<th colspan=2 width="150">Tanggal pemasangan</th>
<th colspan=0 width="50">total harga</th>
<th colspan=0 width="50">Tanggal infeksi</th>
<th colspan=0 width="50">catatan</th>
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<th>Mulai</th>
<th>S/D</th>
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<td>1</td>
<td>intra vena keteter</td>
<td align="center"rowspan=5 width="150">-</td>
<td align="center"rowspan=5 width="150">-</td>
<td align="center"rowspan=5 width="150">-</td>
<td align="center"rowspan=5 width="150">-</td>
<td align="center"rowspan=5 width="150">-</td>
<td align="center"rowspan=5 width="150">-</td>
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<td><input type="checkbox" name="" size="10"/>Vena Sentral<br /></td>
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<td></td>
<td><input type="checkbox" name="" size="10"/>Vena Periver<br /></td>
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<td></td>
<td><input type="checkbox" name="" size="10"/>Arteri<br /></td>
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<td></td>
<td><input type="checkbox" name="" size="10"/>Umbikal<br /></td>
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<td>2</td>
<td><input type="checkbox" name="" size="10"/>Urine Kateter<br /></td>
<td align="center"rowspan=2 width="150">-</td>
<td align="center"rowspan=2 width="150">-</td>
<td align="center"rowspan=2 width="150">-</td>
<td align="center"rowspan=2 width="150">-</td>
<td align="center"rowspan=2 width="150">-</td>
<td align="center"rowspan=2 width="150">-</td>
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<td></td>
<td><input type="checkbox" name="" size="10"/>Suprabubik Kateter<br /></td>
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<td>3</td>
<td>Ventilasi Mekanik</td>
<td align="center"rowspan=3 width="150">-</td>
<td align="center"rowspan=3 width="150">-</td>
<td align="center"rowspan=3 width="150">-</td>
<td align="center"rowspan=3 width="150">-</td>
<td align="center"rowspan=3 width="150">-</td>
<td align="center"rowspan=3 width="150">-</td>
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<td></td>
<td><input type="checkbox" name="" size="10"/>Tuba Endotrakeal<br /></td>
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<td></td>
<td><input type="checkbox" name="" size="10"/>Trakeostomi<br /></td>
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<td>4</td>
<td>Lain-lain.......</td>
<td align="center"rowspan=2 width="150">-</td>
<td align="center"rowspan=2 width="150">-</td>
<td align="center"rowspan=2 width="150">-</td>
<td align="center"rowspan=2 width="150">-</td>
<td align="center"rowspan=2 width="150">-</td>
<td align="center"rowspan=2 width="150">-</td>
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<td></td>
<td>Drain/IABP/CVVH</td></tr>
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<th colspan="3" align="left">Faktor penyakit</th>
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<th colspan=3 align="left" width="300"> Hasil laboratorium :</th>
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<td>HBS Ag</td>
<td>: Positif/Negatif/Tidak diperiksa</td>
<td colspan=3 align="left" width="160"> Leukocit<td>:....................</td></td>
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<td>Anti HCV</td>
<td>: Positif/Negatif/Tidak diperiksa</td>
<td colspan=3 align="left" width="160"> LED<td>:....................</td></td>
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<td>Anti HIV</td>
<td>: Positif/Negatif/Tidak diperiksa</td>
<td colspan=3 align="left" width="160"> GDS<td>:....................</td></td>
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<td>Lain-lain</td>
<td>: ................................</td>
<td colspan=3 align="left" width="160"> HB<td>:....................</td></td>
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<td></td>
<td></td>
<td colspan=3 align="left" width="160"> Albumin<td>:....................</td></td>
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<th colspan=3 align="left" width="300"> Hasil Radiologi : ...................................................................................................................................</th>
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<th colspan=3 align="left">V. TINDAKAN/OPERASI</th>
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<td>1.Macam tindakan</td>
<td> :............................................................................</td>
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<td>(di kamar operasi mana dikerjakan</td>
<td> KOI/II/III/IV/V lainya......)</td>
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<td>2. diaknosa</td>
<td> : ..............................................................................</td>
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<td>3. Tgl Operasi</td>
<td>1 :.............Lama Operasi............ Jam, ..............Mnt</td>
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<td>2 :.............Lama Operasi............ Jam, ..............Mnt</td>
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<td>4. Jenis operasi (A)</td>
<td>:<input type="checkbox" size="10"/>Bersih<input type="checkbox" size="10"/>Bersih Tercemar<input type="checkbox" size="10"/>Tercemar<input type="checkbox" size="10"/>Kotor<br /><br /><br /><br /></td>
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<th colspan=3 align="left">II. DIAGNOSA WAKTU MASUK</th>
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<td>.....................................................</td>
<td>.....................................................</td>
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<th colspan=3 align="left">III. PINDAH KE RUANGAN</th>
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<td>1. .............................</td>
<td>Tgl. .......................................</td>
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<td>2. .............................</td>
<td>Tgl. .......................................</td>
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<th colspan=3 align="left">IV. FAKTOR RESIKO SELAMA DIRAWAT</th>
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