PENANGGULANGAN TB NASIONAL TB MDR
FORMULIR RUJUKAN SUSPEK TB MDR UPK yang meruju : ……………………………………………………… ……………………………………………………………. ……. Ke Keur ura! a!an an…… ………… …… Ke"am e"ama# a#an an…… ………… ………… ………… ………… ……… … Tangga Tangga ruju'an : ……………………………………………………………. ……………………………………………………………. N&m& N&m&rr ruju ruju'a 'an n : …… ………… ………… ………… ………… ………… ………… ………… ………… ………… ………… ………. ….
Ka$% Ka$%K Ka… a……… ………… ………… ……… …
(#!. D&'#er P&) P&) DOTS Pu* ………………………………………………… ………………………………………………… Dengan !&rma#+ Ber*ama )n) 'am) !a,a-'an -a*)en : Nama
: ………………………………………………………………….
U*)a
: ……………… #a! Jen)* 'eam)n :
Aama#
: …………………………………………………………………. RT……% T……% R… Keur eura! a!an an:: …… ………… ………… ………… ………… ……
L
%
P
Ke".: e".: …… ………… ………… ………… ………… ……
Ka%Ka$u-a#e: ………………………………………………………………. N&m&r Te-% Te-%/ / : …………………… ………………………………… ……………………… …………………… …………………. ………. ,engan ,engan 'r)#er)a 'r)#er)a *u*-e' *u*-e' : 0$er) 0$er) #an,a 1 -a,a 'r)#er)a 'r)#er)a yang ,)-))!2 ,)-))!2 Ka*u* Kr&n)'%Gaga Peng&$a#an Ka#eg&r) 3 T),a' K&n4er*) K&n4er*) -a,a Peng&$a#an Peng&$a#an Ka#eg&r) Ka#eg&r) 3
T),a' T),a' '&n4e '&n4er*) r*) *e#ea *e#ea! ! *)*) *)*)-an -an -, Peng&$ eng&$a#a a#an n Ka#. Ka#. 5 Ka*u* Kam$u! Kam$u! 0Ka#eg&r) 5 a#au a#au Ka#eg&r) 32
Pa*)e a*)en n TB -er -erna! na! ,)&$a )&$a##) O OA AT TB MDR
Peng&$ ng&$a# a#an an *e# *e#ea! a! aa aa))
Gaga Peng&$a#an Ka#eg&r) 5
K&n#a' era# ,engan -a*)en TB MDR Pa*)en K& In6e'*) TB 7 /I8
RIA(AT PENGOBATAN TB NO KAPAN
UPK
TERAPI YANG DIBERIKAN
ASIL PENGOBATA
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BUKU BANTU RUJUKAN SUSPEK MDR TB UPK SATELIT UPTD PUSKESMAS JALAKSANA UMUR NO
NAMA
ALAMAT LENGKAP L
P
NO TELPON
KRITERIA SUSPEK (TULIS NOMOR)
TANGGAL MERUJUK
UPK TUJUAN RUJUKAN
BALASAN RUJUKAN
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@
Pasien Ko n#eksi TB ' *+
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PENANGGULANGAN TB NASIONAL Nama Pasien (1)
: ______________________
Alamat en!kap en!kap (")
: ____________________________ __________________________________________ ______________
Telp.
______________
Nama PM () Alamat en!kap en!kap PM (+)
: ____________________________ __________________________________________ ______________
,enis kelamin (-)
:
L
Paut /3 (4)
:
,elas
P
Telp.
______________
tahun
$mu () :
Ti5ak a5a
__________________
Nama RS Rujukan MDR (9) :
N#. Re!.MDR $P% (11) : ____________
: ______________________
atatan (6)
TB.01MDR
KARTU PENGOBATAN PASIEN TB-MDR
Tan!!al Re!istasi (1)
Klasifikasi Pasien (17 A
%elas (1+) :
/
au
2 a au
# as : ____ ______ ____ ____ ____ __
(!n"!k #asil $e%e&iksaan lain' %isalna Bi)$si' Sk)&in* TB Anak' +ll
Ti$e Pasien (1/
Di&!,!k )le# (1 Pasien sen5ii
ae
Pe%e&iksaan k)n"ak se&!%a# (1
L2P
U%!&
1. ___________________
____
_____
__________________
_____
".
___________________
____
_____
__________________
_____
.
___________________
____
_____
__________________
_____
+.
___________________
____
_____
__________________
_____
-. ___________________
Na%a
Tan**al Pe%e&iksaan
____
_____
__________________
_____
Tan**al %!lai T8
Re,i%en OAT
3asil
3asil
/ a u
____________
ain7ain
am u
$P% Satelit " ____________
De8aulte
DPS :__________________
3a!al % 1
ain7lain Se&utkan ______________________
3a!al % "
Pe&"e%!an Ti% A#li Klinis (40 Tan**al
Ri5aa" Pen*)6a"an TB Se6el!%na (1 N)
: _______
____________ ____________
Mea!ukan
______________________________________________________________ ___________________________________________________________ ___ ___________________________________________________________ ____________________________ __________________________________ ___
N).
Tahun (10)
N#.Re!.MDR %a& (1") :
: ____________ P#*insi :
T!,!an
Ke$!"!san
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Nama Pasien Re!iste MDR $P%
n a l u /
N#. a&
/TA
" %ultu
/TA
%ultu
T!l
N#. a&
<
R
=
S
%m m 82 t# s PAS PAS
Da8ta Sin!katan &at < R = S
: >s#niasi5 : Ri8ampi?in : Pia@inami5 : tham&ut#l : Stept#misin
T!l #t#
* aluasi Pas?a Pen!#&atan 1" 16 "+
1
/ 1 " + 4 6 9 10 11 1" 1 1+ 11 14 16 19 "0 "1 "" " "+
: :
%m : %anam;?in m : ape#m;?in 82 : e*#8l#2a?in
t# : thi#nami5e S : Sikl#sein PAS : P7Amin#sali?;li? A?i5
%#5e
%#5e
0 : N#mal 1 : %a* itas " : >n8iltat : N#5ul + : Milie - : im8a5en#pati : n5#&#n?hial
/aseline 4 : i&#sis 1+ : %#ns#li5asi 6 : i&#th#a2 1- : Massa 9 : /ula 10 : 8usi Pleua 11 : Pneum#th#a2 1" : /#n?hie?tasis 1 : Atelektasis #ll#B $p
"1 : Mem&aik "" : Mem&uuk tam&ahkan k#5e &aseline " : Sta&il
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Nama Pasien Re!iste MDR $P%
: :
PADUAN OAT TB MDR :ANG DIBERIKAN (") (Tan!!al mulai pen!#&atan ejimen peu&ahan 5#sis pen!hentian AT) RejimenE Tan!!al
Be&a" 6a+an
< 00m!
R 00m!
= -00m!
+00m!
S 13
%m 13
m 13
82 "-0m!
t# "-0m!
s "-0m!
PAS +3
/ -0m!
......
.......
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Nama Pasien Re!iste MDR $P%
: :
II. TA3AP LAN
/ulan N#* Des ,an e& Ma
1
"
+
-
4
6
9
10
11
1"
1
1+
1-
1
14
16
19
"0
"1
""
"
"+
"-
"
"4
"6
"9 0 1
//
,ml D#sis