Download - CHECKLIST IGD & AMBULANCE.xlsx
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CHECKLIST FASILITAS INS
BULAN :
NO NAMA FASILITAS FARMALKES IGD SATUAN JUM
Tempat Penyimpanan Aat IGD1 Lemari Instrumen EA
2 Lemari obat Injeksi EA
3 Lemari obat Oral EA
4 Lemari Cairan Infus EA
5 Lemari Alkes EA
6 Lemari Pendingin EA
!rol" Emergen#" EA
Aat !e"#!te$an
1 !ensi $eter %&"gno EA
2 !ensi $eter Air 'aksa $obile EA
3 !ensi $eter Air 'aksa EA
4 %tetos#o& Anak EA
5 %tetos#o&e EA
6 !ermometer a(ila EA
!ermometer telinga EA
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) %enter EA
* Otos#o&e EA
1+ %urgi#al $inor %et EA
11 ,auter %unnat EA
12 $esin %u#tion EA
13 -ag .al/e $ask 0easa EA
14 -ag .al/e $ask Anak EA
15 ebulier Anak EA
16 ebulier 0easa EA
1 $esin E, EA
1) 0efibrilator Cardio EA
1* Pulse O("meter EA
2+ ula 0ara Cek EA
21 armer EA
22 %et Irigasi Lambung EA
23 Laringoss#o&e %et 0easa 7 Anak EA
24 !abung Oksigen EA
25 !abung Oksigen Portable EA
26 !iang Infus EA
2 Pis&ot EA
2) 8rinal EA
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2* -askom %tainles EA
3+ ater arm 9a#k EA
31 %terilisator EA
32
33
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Im#%ii&ati#n Set
1 e#k Collar %ie %: $: L EA
2 %&alk EA
3 L%- ; Long %&ine -oard < EA
4 %#oo& %tre#er EA
5 ,endri#k e(tri#ation de/i#e ;,E0< EA
6 %tre#er EA
)
O%at In'e!(i Eme$)en*y
1 E&ine&rine A$P
2 Atro&ine A$P
3 Cordarone A$P
4 Lasi( A$P
5 0o&amin A$P
6 0obutamin A$P
Cedo#ard A$P
) Amino&"lin A$P
* $e"lon = -i#nat >LA%?
1+ ,CL >LA%?
11 @"lo#ain A$P
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12 Cortide( A$P
13 !etagam A$P
14
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O%at O$a Eme$)en*y
1 Cedo#ard 5 mg !A-
2 Ca&to&ril 12:5 mg !A-
3 Amlodi&in 5 mg !A-
4 !romboAs&ilet !A-
5 Cardio As&irin !A-
6 Pla/i( !A-
Cai$an In+,(
1 'inger La#tat 5++ ## >LA%?
2 Otsu % +:* 5++ ## >LA%?
3 Otsu % +:* 1++ ## >LA%?
4 Otsu % +:* 25 ## >LA%?
5 0e(trose 5 5++ ## >LA%?
6 0e(trose 5 1++ ## >LA%?
0e(trose 4+ 25 ## >LA%?
) 0e(trose 1+ 5++ ## >LA%?
* Asering 5++ ## >LA%?
1+ ,aen 3 - 5++ ## >LA%?
Pe$en)!apan In+,(
1 Infus %et $akro EA
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2 Infus %et $ikro EA
3 Infus %et -lood EA
4 I. Cat 14 EA
5 I. Cat 1) EA
6 I. Cat 2+ EA
I. Cat 22 EA
) I. Cat 24 EA
* I. Cat 26 EA
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Aat Ke(e-atan Ha%i( Pa!ai
1 %u#tion Cateter EA
2 ! EA
3 >ole" Cateter EA
4 8rine -ag EA
5 Oroåeal !ube EA
6 asoåeal !ube EA
orotra#eal tube = E!! EA
) #annule nasal adult EA
* #annule nasal #ild EA
1+ %im&le $ask Adult EA
11 %im&le $ask Cild EA
12 on 'ebreting $ask Adult EA
13 on 'ebreting $ask Cild EA
14 $asker ebulier Adult EA
15 $asker ebulier Cild EA
16 %"ringe 1 ##: 3 ##: 5 ##: 1+ ##: 2+ ##: 5+ ## EA
1 -enang Bait ; %ilk: 0ermalon: Plain < EA
1) EA
Aat Pein",n) Di$i
1 !utu& ,e&ala EA
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2 ,a#a mata EA
3 $asker -iasa EA
4 $asker *5 EA
5 aun EA
6 Celemek EA
lo/e %teril EA
) lo/e 0is&osible EA
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Jumlah batas minimal di IGD
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ASI GAWAT DARURAT
TANGGALKET
. / 0 1 2 3 4 5 6 .7 .. ./ .0 .1 .2 .3 .4 .5 .6 /7 /. // /0 /1 /2 /3 /4 /5 /6 07 0.
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PE!8A%
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CHECKLIST PERALATAN AMB
BULAN: AMBUL
NO NAMA FASILITAS FARMALKES AMBULANCE JUMLA
Ta%,n) O8y)en 9 Pe$aatan
1 !abung O("gen 1 EA
2 Cannule asal 1 EA
3 %im&le $ask 1 EA
4 on 'ebreating $ask 1 EA
O%at #%at Eme$)en*y
1 E&ine&rin 2+ A$
2 Atro&in 2+ A$
Int$a;ena Set
1 Cairan Infus 'L 2 EA
2 I. Cat oD 2+: 22: 24 2 EA
3 I. Line -lood %et 2 EA
4 I. Line -iasa 2 EA
S,*ti#n Set
1 $esin %u#tion 1 EA
2 Cateter %u#tion 1 EA
0efibrillator 1 EA
Pulse O(imetr" 1 EA
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$inor %et Instrumen %urgi#al 1 %E!
Intubasi %et 1 %E!
,antong $a"at 1 EA
Pe$an)!at mm#%ii&ati#n
1 %tre#er $anufa#ture 1 EA
2 Long %&ine -oard 1 EA
3 %#oo& %tre#er 1 EA
4 ?ead Immobilitation 1 EA
Aat Pein",n) Di$i
1 $asker 0is&osible 1 ,O!A
2 lo/e dis&osible sie $ 1 ,O!A
3 aun 2 EA
4 Celemek 2 EA
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ANCE INSTALASI GAWAT DARURAT
E :
TANGGAL
. / 0 1 2 3 4 5 6 .7 .. ./ .0 .1 .2 .3 .4 .5 .6 /7 /. // /0 /1 /2 /3 /4 /5 /6 07 0.
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KETERANGAN
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PETUGAS
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BULA
NO
1
2
3
4
1
2
4
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CHECKLIST PERAL
:
FARMALKES UGD
O%at O$a
!abung O("gen
Cannule asal
%im&le $ask
on 'ebreating $ask
E&ine&rin
Atro&in
Celemek
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MBULANCE INSTALASI GAWAT DARURA
JUMLAHTANGGAL
. / 0 1 2 3 4 5 6 .7 .. ./ .0 .1 .2 .3 .4 .5 .6 /7 /. //
1 EA
1 EA
1 EA
1 EA
2+ A$P
2+ A$P
2 EA
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KETERANGAN
/0 /1 /2 /3 /4 /5 /6 07 0.
PETUGAS