Form Monitoring Kepatuhan HH [PDF]

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PEMERINTAH KABUPATEN BANGKA TENGAH DINAS KESEHATAN



RUMAH SAKIT UMUM DAERAH KomplekPerkantoranPemerintah Daerah Kabupaten Bangka Tengah Jl. By Pass KobaTelp/Fax (0718) 7362046 KodePos 33181 MONITORING KEPATUHAN HAND HYGENE



OBSERVER



UNIT/INST



TGL OBSERVASI



RUANG



PROFESI KODE WAKTU Jam Opp Indication 1.  bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



s/d HH action  HR HW  missed  gloves



2.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



3.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



4.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



5.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



6.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



7.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr  bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



8.



9.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves  HR HW  missed  gloves  HR HW  missed  gloves



PROFESI KODE WAKTU Jam Opp Indication 1.  bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



s/d HH action  HR HW  missed  gloves



2.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



3.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



4.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



5.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



6.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



7.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr  bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



8.



9.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves  HR HW  missed  gloves  HR HW  missed  gloves



PROFESI KODE WAKTU Jam Opp Indication 1.  bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



s/d HH action  HR HW  missed  gloves



2.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



3.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



4.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



5.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



6.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



7.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr  bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



8.



9.



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves  HR HW  missed  gloves  HR HW  missed  gloves



Petugas,



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Petunjuk Teknis Pengisian FORM Observasi Observer



Diisi nama jelas yang melakukan observasi



Tanggal observasi



Diisi tanggal observasi dilakukan, tanggal – bulan – tahun



Unit / instalasi



Diisi unit/instalasi saat observasi dilakukan



Ruang / lantai



Diisi ruang/lantai saat observasi dilakukan



Profesi



Diisi menurut klasifikasi berikut : 1. Perawat / Bidan



1.1. Perawat 1.2. Bidan 1.3. Mahasiswa Kebidanan / keperawatan



2. Dokter



2.1. 2.2. 2.3. 2.4.



Dokter umum Dokter spesialis Dokter konsultan Dokter Intership



4.1. 4.2. 4.3. 4.4.



Terapis (fisioterapis) Teknisi (radiologis, analis, dll) Lainya (ahli gizi, pekerja social, dan profesi lain yang terlibat di pelayan pasien) Siswa



3. Pekarya 4. Petugas lain



Kode



Diisi oleh petugas entry data



Waktu Observasi



Diisi waktu memulai dilakukan observasi di ruang terpilih, sampai dengan waktu selesai melakukan observasi, contoh : mulai jam 09.30 s/d jam 10.30



Opp



Opportunity : kesempatan subjek yang diobservasi melakukan HH



Indication



Indikasi yang membutuhkan HH Bef.pat Bef.asept Aft.pat Aft.b.f Aft.p.surr



HH Action



: sebelum kontak dengan pasien : sebelum melakukan tindakan aseptic : setelah kontak dengan pasien : setelah terkena cairan tubuh pasien ; setelah kontak dengan lingkungan sekitar pasien



Respon terhadap indikasi yang membutuhkan HH, dapat berupa aksi positif dengan melakukan handrub atau handwash, atau aksi negative dengan meninggalkan handrub atau handwash HR : beri tanda bila petugas melakukan handrub dengan menggunakan disinfektan handrub berbahan dasar alcohol HW : beri tanda bila petugas melakukan hand wash dengan menggunakan air dan sabun Missed :beri tanda bila petugas tidak melakukan HR atau HW Gloves : beri tanda petugas bila menggunakan sarung tangan namun tidak melakukan HR atau HW



RUMAH SAKIT UMUM DAERAH KABUPATEN BANGKA TENGAH



OBSERVASI : HAND HYGENE COMPLIANCE OBSERVER TGL OBSERVASI PROFESI UNIT / RUANGAN WAKTU Opp



Mulai jam :



s/d



Indication



HH action



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



Opp 2.



Indication



HH action



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



Opp 3.



Indication



HH action



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



Indication



HH action



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



Indication



HH action



 bef.pat  bef.asept  aft.pat  aft.b.f  aft.p.surr



 HR HW  missed  gloves



1.



Opp 4.



Opp 5.



1. Kuku panjang (>0.5 mm)



 ya



 Tdk



2. Kuku memakai kuteks



 ya



 Tdk



3. Kuku Artificial / paslu



 ya



 Tdk



4. Memakai cincin



 ya



 Tdk



5. Memakai jam tangan



 ya



 Tdk



6. Memakai gelang



 ya



 Tdk



7. Mengeringkan dengan handuk pakai bersama



 ya



 Tdk



8. Buang sampah ke tempat sampah infeksius



 ya



 Tdk