Lamp for Mtb

8/15/2019 Lamp for Mtb

1/23

TGL.REGISTRASI

No.REGLAB

NAMALENGKAP

JENISKELAMIN(L/P)

UMUR ALAMAT LENGKAPNAMA UNITPELAYANANKESEHATAN

TGL.MULAIBEROBAT

PADUANYG

DIBERIKAN

KLASIFIKASI

PENYAKIT(PARU/EKSTRAPARU)

TIPEPASIEN HASILPEMERIKSAAN DAHAK TANGGAL BERHENTI BEROBATDAN HASILPENGOBATANTANGGALIDENTIFIKASI KASUSDANPENGOBOBATAN KO INFEKSI TB/ HIV

Baru(B)

Kam u!(K)

P"#$a!a#(P)

Ga%a&(G)

Kro#"'(Kr)

D()au&*(r (D)

La"#+&a"#(L)

S( (&um P(#%o a*a#A,!"r u&a#,(-A,!"r u&a#,(A,!"r u&a# ,(Bu&a# , 0 a*auA,!"r P(#%o .2. m ! . P # . . " #" # . & . ) & r. P" # ! " # 4 r , # T HI T HI

Mu&a"" "R %

La

Ha'"& R %

LaHa'"&R %

La

Ha'"&R %

LaHa'"&R %

LaHa'"&R %

La

Ha'"&


2/23

PENGENDALIAN TB NASIONAL

KARTU PENGOBATAN PASIEN TBNama Pa'" # 5 . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .No.* &6/H65 . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . Ta!u# 5 . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .

A&ama* & #%,a6 5 .................................... ....................................... ............................ No. R %"'* r TB.7 UPK 5 ..................................................Nama PMO 5 ...................................................No.* &6/H65 ................................. No. R %"'* rTB.7 Ka /Ko*a 5 .................................................

A&ama* & #%,a6 PMO 5 .................................... ....................................... ............................ Nama UPK 5 ....................................................Jenis kelamin : L P Umur

:*!# Paru B!G : J &a' T"$a, a$a M ra%u,a#

Ri"a#a $en%&'a an se'elumn#a : B &u m 6 r# a!/ P r# a! $"o a*" & &! $a r" 2 u &a#Kura#% $ar" 2 u&a#

!a a an : (u#*u, !a'"& 6 m r",'aa# &a"#8 m"'aa 5 o*o *ora,'8 "o6'"8 ,u&*ur8 ',or"#% TB a#a,8 $&&

Pemeriksaan k&n ak seruma( :

N&. Nama L)P Umur Tan%%al Pemeriksaan *asil2. ..................................... ........... ........... ................................. ............

-. ..................................... ........... ........... ................................. ............. ..................................... ........... ........... ................................. ............. ..................................... ........... ........... ................................. ............

0. ..................................... ........... ........... ................................. ............

J #"' OAT 5 Kom "6a, KDT (FD:)

TA*AP INTEN SI+ :

Ka* %or" 2 Ka* %or" - Ka* %or" a#a, S"'"6a#

KDT (FD:) 5 *a & */!ar" S*r 6*om"'"# 5 m%/!r ,- Tulisla( 1 / / a au Ne% sesuai 2en%an (asil $emeriksa

Bu&a# 2 - 0 3 1 ; < 27 22 2- 2 2 20 23 21 2; 2< -7 -2 -- - - -0 -3 -1 -; -< 7 2 K * ra#%a

B r"&a! *a#$a 4",a 6a'" # $a*a#% m #%am "& o a* a*au 6 #%o a*a# $" a=a! 6 #%a=a'a# 6 *u%a', ' !a*a#. B r"&a! *a#$a 3%aris lurus men#am'un%4 4",a o a* $" a=a 6u&a#% $a# $"* &a# ' #$"r" $"ruma!.

KLASI+IKASI P

Paru E,'*raLo,a......

KLASI+IKASI PEN5AKIT

I#"'"a*" 6a'" # A#%%o*a ma'9RS/BP /Pu',KTS/PDPLa"#+&a"#8 ' u*,a#..........................

TIPE PASIEN

Baru KamP"#$a!a# Ga%aP #%o a*a# La"#' * & a! $ au &* S

......

Bu&a# ,

*ASIL PE6ERIKSAAN DA*AK

La ora*or"um P m a>aTa#%%a& No. R %. La BTA

7 (a=a&)-

0/31/;

AP


3/23

Berilah tandapada kotak yang sesuai jenis paduan obat yang diberikan.

TA*AP LANJUTAN

Ka* %or" 2 Ka* %or" - Ka* %or" a#a,

- KDT (FD:) 5 *a & */!ar" E*!am u*!o& 5 *a & */!r

Bu&a# 2 - 0 3 1 ; < 27 22 2- 2 2 20 23 21 2; 2< -7 -2 -- - - -0 -3 -1 -; -< 7 2 Jum&a!

B r"&a! *a#$a 4",a 6a'" # $a*a#% m #%am "& o a* a*au 6 #%o a*a# $" a=a! 6 #%a=a'a# 6 *u%a' , ' !a*a#.B r"&a! *a#$a3%aris lurus $u us7$u us sesuai (ari minum &'a 4 4",a o a* $" a=a 6u&a#% $a# $"* &a# ' #$"r" $"ruma!.

!ATATAN :

*ASIL AK*IR PENGOBATAN :(tulis tanggal dalam kotak yang sesuai)

SE6BU* LENGKAP DE+AULT

GAGAL PINDA* 6ENINGGAL

R"=a9a* * ' HIV 5 Ya T"$a,

T%& * ' HIV * ra,!"r 5 / / Ha'"&? 5 R

La#anan K&nselin% 2an Tes SukarelaT%&.

$"a#4ur,a#T%& Pr T 'Ko#' &"#%T m6a* T ' T%& T ' Ha'"& T '


4/23

? Ha'"& * ' $"*u&"' $ #%a# ,o$ 5R @ R a,*" (Po'"*" ) NR @ No# R a,*" (N %a*" )I

La#anan PDP 8Pera"a an/ Dukun%an 9 Pen%&'a an

T%& Ru4u,a# PDP T%& Mu&a" PPK


5/23

Nama Lengkap:Alamat Lengkap:

Jenis Kelamin : L P Umur : tahun

Nama UPK :Telp.

No. eg. TB. UPK :

No. eg. Kab!Kota :Pro"insi :

KLASIFIKASI PENYAKIT

PENGENDALIAN TB NASIONAL TB.0

KARTU IDENTITAS PASIEN TB


6/23

Tan%%al Per an ian

M #%am "& O a*8 Ko#'u&*a'" Do,* r8 P r",'a U&a#% Da!a,

Tan%%alTa(a$

Pen%&'a anJumla( OAT #an%

Di'erikanTan%%al (arus

Kem'ali


7/23

REKAPITULASI +OR6ULIR TB.1 KABUPATEN)KOTAAnalisis *asil !r&ss !(e;k Daiam Tri"ulan ..... Ta(un ...........

Ka'u$a en)K& a: ............................................................................................

Jumla( Seluru( La'. Pemeriksa Per ama: ...................................................

No. Nama La . P m r",'a P r*ama(PRM/PPM/$&&)

Jum&a!' $"aa#9a#% $"+

>ro'' >! >,

Po'"*" Pa&'u( )

N %a*" Pa&'u( )

Error Ra*( )

Kua&"*a'S $"aa#

J & ,( )

Kua&"*a'P =ar#aa#

J & ,( )

2 - 0 3 1 ;

2-

0

3

1

;

<

27


8/23

REKAPITULASI +OR6ULIR TB.1 PROPINSI

Analisis *asil !r&ss !(e;k Dalam Tri"ulan ..... Ta(un ...........

Pr&$insi ............................................................

No. Ka u6a* #/Ko*aJum&a! S &uru!La . P r*ama(PRM/PPM/$&&)

La . P r*ama9a#% ",u*

>ro'' >! >,

La . P r*ama9a#% Error Ra*& "! , >"& a*au

'ama $ #%a# 0

Error Ra*Ra#%

Jm& Jm&

2 - 0 3 1 ;

2-

0

3

1

;

<

27


9/23

D" ua* ra#%,a6 - 5

LEMBAR 2 5 $""'" ,o&om 2 '/$ 8 $","r"m ,( &a ru4u,a# :: 6(r*amaLEMBAR - 5 $""'" ,o&om 2 '/$ 0 8 $"*"#%%a& $" D"#,(' Ka /Ko*a

+OR6ULIR UJI SILANG PE6ERIKSAAN 6IKROSKOPIS BTANa ma L a . P m r", 'a P r* ama 5 . .. .... .. ..... ... ... ... .. .. .... .. ..... ... ... ... .... .... .. .. Na ma L a 9a #% m &a ,u ,a # u 4" ' "& a# % 5 .. ..... .... .. .... ... .... .. .... ....N am a P * u% a' L a . P m r ", 'a P r* am a 5 . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Ta# %% a& ' $ "a a# u 4" '" &a #% $" * r" ma 5 . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .Ta#%%a& ' $"aa# $"am "& 5 ........................................................... Ta#%%a& !a'"& u4" ' "&a#% $","r"m 5 ..................................

NoNo

I$ #*"*a'S $"aa#

NamaPa'" #

Ha'"&P m r",'aa#La .P r*ama

Ha'"&P m r",'aa#La .Ru4u,a# K&a'" ",a'"P #"&a"a#

Kua&"*a' S $"aa#

S6 '"m # P =ar#aa# K r'"!a# K * a&a# U,ura# (>m)

Ba", J & , Ba",

J & , Ba", J & ,

Ba",

J & ,Ba",

(- )

J &

M ra ! Pu >a * B r'" ! Ko*o r T a& T"6"' B 'ar (C - )T%& Ha'"& T%& Ha'"&

2 - / 0 3 1 ; < 27 22 2- 2 2/ 20 23 21 2; 2< -7

2-

/03

1

$'*To*a& ($a&am A 'o&u*)

To*a& ($a&am P r' #)

Kom(#*ar 5..............................................................................................................................................................................................................

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

R(,om(#$a'" 5..............................................................................................................................................................................................................

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

Ya#% m &a,u,a# u4" '"&a#% 5Ta#$a Ta#%a#

( ........................................... )NIP 5Ja a*a# 5


10/23

#$,&T# TB KABUPAT#N ! K%TA Kab!KotaNo. Kode Kab!Kota : Tahun :

PROGRAM TB NASIONAL TB.03

+OR6ULIR PE6ERIKSAAN UJI SILANG DENGAN *ASIL KETIDAK!O!OKAN(DISCORDANC

NO SEDIAAN

*ASIL PE6BA!AAN

KUALITASSPESI6EN

PEo>o, a#*ara &a $"a%#o'*", &a :: I• Ko&om - 5 Ha'"& 6 m a>aa# $ar" La $"a%#o'*",• Ko&om 5 Ha'"& 6 m a>aa# $ar" &a :: I• Ko&om 2 + $""'" o& ! a'or TB Ka /Ko*a

• Ko&om +27 $""'" o& ! La ru4u,a# :: II r$a'ar,a# !a'"& 6 m r",'aa# $" &a#9a

Ta#$a *a#

(...............


11/23

+OR6ULIR REKAPITULASI UJI SILANG KABUPATEN)KOTAKa u6a* # 5 ...................................................................................

a'or Ka u6a* # 5 ......................................................................P r"o$ >ro'' >! >, 5 Tr"=u&a# 5.................... Ta!u# 5 ..........................Su6 r "'or La ora*or"um5....................................................................

N&. NA6A UNITPELA5ANANKESE*ATAN

JU6LA* SLIDE 5ANG DIPERIKSA

PER TRIro'' >! >,

. ........... Fa'9a#, ' $ #%a# , 'a&a!a# 'ar/K 'a&a!a# , >"&/ *a#6a , 'a&a!a#.R ,om #$a'" 5 ...........................................................................................................................................

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

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

Ya#%

(........


12/23

+OR6ULIR REKAPITULASI UJI SILANG PROPINSI

TABEL I

Pro6"#'" 5 ........................................................ P r"o$ >ro'' >! >, 5 Tr"=u&a# 5....... Ta!u# 5 ..............Su6 r "'or La ora*or"um 5 ........................................................ a'or Pro6"#'" 5 ...................................................


13/23

N& NA6AKAB)KOTA

JL* SLIDE 5G DIPERIK7SA PER TRI"& (KK)

.NPT 5 N %a*" Pa&'u T"#%%"K 'a&a!a# 'ar (KB).PPT 5 Po'"*" Pa&'u T"#%%" K 'a&a!a# 'ar (KB)

Ya#% m &a6or,a#

(...........................


14/23

:ONTOH FORMULIR

DATA SITUASI KETENAGAAN PROGRA6 PENGENDALIAN TBKa u6a* #/Ko*a 5 S m '* r 5Pro "#'" 5 Ta!u# 5

Ka* %or" '*a 6ro%ram TB

S"*ua'" Po'"'" K * #a%aa# S"*ua'" P &a*"!a# (Kom6 * #'") P r #>a#aa# P #% m a#

Jum&a!

6o'"'" '*a 9a#% a$a

Jum&a!6o'"'" '*a (,o&.-) 9a#%

* r"'"

Jum&a! '*a (,o&. )9a#%

$"&a*"!

Dar" ,o&.9a#%

*"$a, &a%"$a&am

Jum&a! '*a (,o&.-) 9a#%

$"&a*"! $a&am' m '* r * ra,!"r

Jum&a! 6o'"'"9a#% a,a#

$", ma#%,a#

K u*u!a#'*a

(,o&.-+ 1)

Po'"'" '*9a#% a$""'" *a

"#"

2 - . / 0 3 1 ; <

TINGKAT +AS5ANKESDo,* r P *u%a' TB (6 ra=a*/$&&)P *u%a' La ora*or"umP *u%a' Pu', 'ma' P m a#*uKa* %or" &a"# (' u*,a#)2.-.TINGKAT KABUPATEN)KOTAKoor$"#a*or TBSu6 r "'or TBP *u%a' Gu$a#% Farma'"Ka* %or" &a"# (' u*,a#)2.-.TINGKAT PRO INSIKoor$"#a*or TBSu6 r "'or TBSu6 r "'or La ora*or"umKoor$"#a*or P &a*"!a#Fa'"&"*a*or P &a*"!a#Ka* %or" &a"# (' u*,a#)2.-.

K * ra#%a# 5+ Fa'9a#, ' * rma'u, Pu', 'ma'8 RS8 ,&"#", &a"#.+ P *u%a' Ka /Ko*a m #%"'" ,umu"a*" *"#%,a* Fa'9a#, ' $a# '"*ua'" , * #a%aa# '6 '" ", $" Ka /Ko*a. P *u%a' Pro "#'" m #%

*"#%,a* Ka /Ko*a $a# '"*ua'" , * #a%aa# '6 '" ", Pro "#'"+ Jum&a! , u*u!a# 6o'"'" '*a $"' 'ua",a# $ #%a# '*a#$ar 9a#% a$a 6a$a u,u 6 $oma#.

+ Jum&a! 6o'"'" 9a#% a,a# $", m a#%,a# $"' 'ua",a# $ #%a# r #>a#a 6 #% m a#%a# 6 &" a*a# Fa'9a#, ' $a# '*a#$ar , *


15/23

:ONTOH FORMULIR

Ka u6a* #/Ko*a 5DATA SITUASI PUBLI! PRI ATE 6IH 8PP6- DALA6 PELA5ANAN TB

ProG"#'" 5 Ta!u# 5 ..

Bl&k 1 : +as#ankes #an% erli'a 2alam s ra e%i DOTS Penan%%ulan%an TB

Jenis +as#ankesJumla(seluru(

+as#ankes

+as#ankes #an% mela#aniDOTS +as#ankes 2en%an la'&ra &rium TB

+

Tar% * 4um&a!Fa'9a#, '9a#% a,a#$"&" a*,a#

Jum&a!Fa'9a#, '

9a#% * r&" a*

Tar% * 4um&a! La9a#% a,a#$"&" a*,a#

Jum&a! La9a#% * r&" a*

S &a"# (3) &a9a#% * r&" a*

' a%a"ru4u,a# A

S &a"# (3)&a 9a#%

r&" a*$a&am ,u&*ur8

Fa'9$

V, 66a

2 - 0 3 1 ;

Pu', 'ma'RS 6 m r"#*a!RS '=a'*aBPRS ,!u'u' ParuDo,* r Pra,* , S=a'*aK&"#", &a"#.............

Bl&k : K&n ri'usi 2alam 2ia%n&sis 2an $en%&'a an &le( masin%7masin% +as#ankes

Jenis +as#ankes Jumla( $asien TB 'aru BTA $&s #an% 2i2ia%n&sisPen%&'a an 2en%an s ra e%i

DOTSD"$"a%#o'"'o& !

D"ru4u,(6"#$a!)

*a*a&a,'a#a6a'" # o& !

Pu', 'ma'RS 6 m r"#*a!RS '=a'*aBPRS ,!u'u' ParuDo,* r Pra,* , S=a'*aK&"#", &a"#.............

K * ra#%a# 5+ P *u%a' Pro "#'" m #%"'" ,umu&a*" *"#%,a* Ka /Ko*a


16/23

REKAPITULASI SITUASI PUBLI! PRIGATE 6IH 8PP6- Pro "#'" Ta!u

NO Jenis +as#ankes T& al DOTS LABRu:ukan AKul ur U:i Resis ensi!T AR2 RS P(m(r"#*a!- RS P(m(r"#*a!. RS TNI/ POLRI/ RS BUMN0 RS S=a'*a3 RS K!u'u'

1 BBKPM/BKPM/BP; K&"#", S=a'*a


17/23

:ONTOH FORMULIR

Ka'u$a en)K& a :Pr&Jinsi :

DATA SITUASI UPK DALA6 PELA5ANAN

TB

Ta(un :

+as#ankes #an% erli'a 2alam s ra e%i DOTS Penan%%ulan%an TB 8#an% mela$&rkan $enemuan 2an $en%&'a an kasus TB-

Jenis +as#ankesNama

+as#ankes

DOTS LABORATORIU6 PELA5ANAN *I Jml DPS

Sesuai S an2ar

Pem. 6ikr *a$usan 2a(ak !&ss ;(e;k !en er Kul ur U i Resis ensi !T AR

1 ? @ = 10 11Puskesmas

Su' & al

RS P m r"#*a!

Su' & al

RS TNI/ POLRI

Su' & al

RS BUMN


18/23

PENANGGULANGAN TB NASIONAL

TB.0=

+OR6ULIR RUJUKAN ) PINDA* PASIEN TB

Nama I#'*a#'" 6 #%"r"m 5

T &6.

Nama I#'*a#'" 9a#%

$"*u4u 5 T &6.

Nama Pa'" #

5

J #"' K &am"# 5 L P

Umur *!#

A&ama* & #%,a6 5

No. R %. TB.

Ka / Ko*a


19/23

Ro#*% #

Po')P"#$a!a#

Jumla( 2&sis 8&'a - #an% su2a( 2i erima:

Ta!a6 I#* #'" 5 $o'"' Ta!a6 La#4u*a# 5 $o'"

Pemeriksaan ulan% 2a(ak erak(ir :

Ta#%%a& 5 Ha'"& 5

...............................8T%&. ..........................

(

)


20/23


21/23

PENGENDALIAN TB NASIONAL TB.10

+OR6ULIR *ASIL AK*IR PENGOBATAN PASIEN TB PINDA*AN

Nama Pa'" # 58sesuai 2en%an TB.0=-

J #"' K &am"# 5 L P Umur *!#

A&ama* & #%,a6 5

8sesuai2en%an TB.0=-

No. R %. TB. Ka / Ko*a a'a& 6a'" # 5

Ta#%%a& mu&a" ro a* $" * m6a* a'a& 5

8sesuai 2en%an TB.0=-

8sesuai 2en%an TB.0=-

Jenis $a2uan OAT: *asil Ak(ir Pen%&'a an :

Ka* %or"+2 S m u!

Ka* %or"+- P #%o a*a# L #%,a6Ka* %or" A#a, D au&*

La"#+&a"#8 ' u*,a# Ga%a& P"#$a!M #"#%%a&


22/23

PROGRA6 TB NASIONAL

REGISTER LABORATORIU6Nama Fa'9a#, ' M",ro',o6"' 5 ..............................................................Ka u6a* #/ Ko*a 5 ..............................................................Nama Fa'9a#, ' 5 2. .......................................................... 5 . ..........................................................

-. .......................................................... . ..........................................................Bu&a# Ta

No. R %La

Nomor I$ #*"*a'S $"aa#

Ta#%%a&S $"aa#$"* r"ma

Ta#%%a&P m r",'aa#

NamaL #%,a6Pa'" #

Umur A&ama*L #%,a6

NamaFa'9a#, '

A&a'a# P m r",'aa# Ha'"& P m r",'aa#TaTaU#*u,

D"a%#o'"'U#*u, T"#$a,

La#4u*S P S

L P(2) (-) ( ) ( ) (0) (3) (1) (;) (


23/23

PENGENDALIAN T

LAPORAN PENGE6BANGAN KETENAGAAN 8STA+- PROGRA6 PENGENDALIAN TBKa u6a* #/Ko*a 5 S m '* r 5Pro "#'" 5 Ta!u# 5

Ka* %or" '*a 6ro%ram TB

S"*ua'" Po'"'" K * #a%aa# S"*ua'" P &a*"!a# (Kom6 * #'") P r #>a#aa# P #% m a#%

Jum&a!6o'"'"'*a 9a#%

a$a

Jum&a!6o'"'" '*a (,o&.-) 9a#%

* r"'"

Jum&a! '*a (,o&. )9a#%

$"&a*"!

Dar" ,o&.9a#%

*"$a, &a%"$a&am

Jum&a! '*a

(,o&.-) 9a#%$"&a*"! $a&am' m '* r * ra,!"r

Jum&a! 6o'"'"9a#% a,a#

$", ma#%,a#

K u*u!a#'*a (,o&.-+ 1)

Po'"'" '*a9a#% a,a#$""'" *a!u

"#"

2 - . / 0 3 1 ; <

TINGKAT +AS5ANKESDo,* r P *u%a' TB (6 ra=a*/$&&)P *u%a' La ora*or"umP *u%a' Pu', 'ma' P m a#*uKa* %or" &a"# (' u*,a#)2.-.TINGKAT KABUPATEN)KOTAKoor$"#a*or TBSu6 r "'or TBP *u%a' Gu$a#% Farma'"

Ka* %or" &a"# (' u*,a#)2.-.TINGKAT PRO INSIKoor$"#a*or TBSu6 r "'or TBSu6 r "'or La ora*or"umKoor$"#a*or P &a*"!a#Fa'"&"*a*or P &a*"!a#Ka* %or" &a"# (' u*,a#)2.-.

K * ra#%a# 5+ Fa'9a#, ' * rma'u, Pu', 'ma'8 RS8 ,&"#", &a"#.

+ P *u%a' Ka /Ko*a m #%"'" ,umu"a*" *"#%,a* Fa'9a#, ' $a# '"*ua'" , * #a%aa# '6 '" ", $" Ka /Ko*a. P *u%a' Pro "#'" m #Fa'9a#, '8 ,umu"a*" *"#%,a* Ka /Ko*a $a# '"*ua'" , * #a%aa# '6 '" ", Pro "#'"

+ Jum&a! , u*u!a# 6o'"'" '*a $"' 'ua",a# $ #%a# '*a#$ar 9a#% a$a 6a$a u,u 6 $oma#.+ Jum&a! 6o'"'" 9a#% a,a# $", m a#%,a# $"' 'ua",a# $ #%a# r #>a#a 6 #% m a#%a# 6 &" a*a# Fa'9a#, ' $a# '*a#$ar , * #a%aa# 6a$a u,u 6 $oma#.

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