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[12] Kit Troly Emergency Maternal - Formulir Assessment Layanan Esensial di Puskesmas
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!!! Pengantar Assessment !!!
!! Petunjuk Pengisian !!
1. Lengkapi data-data isian sesuai dengan hasil Assessment yang ada pada lembar kertas yang telah anda dapatkan.
2. Pastikan juga anda mengupload proses gambar/foto pelaksanaan assessment yang telah dilakukan.
3. Anda dapat mengosongkan beberapa kolom jika memang tidak ada informasi yang didapatkan dengan memberikan tanda "0" pada isian form.
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Kabupaten/Kota Fasyankes
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Tanggal Pengumpulan Data
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Foto Pelaksanaan
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Identitas Fasyankes Kota Mataram
Nama Enumerator
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Nama Puskesmas 
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Nama Responden [1]
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Jabatan Responden [2]
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Kontak Person (Telp/WA) Responden [1]
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Nama Responden [2]
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Jabatan Responden [2]
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Kontak Person (Telp/WA) Responden [2]
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Identitas Fasyankes Lombok Barat
Nama Enumerator
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Nama Puskesmas 
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Nama Responden [1]
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Jabatan Responden [1]
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Nama Responden [2]
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Jabatan Responden [2]
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Kontak Person (Telp/WA) Responden [2]
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Identitas Fasyankes Lombok Timur
Nama Enumerator
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Nama Puskesmas 
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Nama Responden [1]
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Jabatan Responden [1]
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Kontak Person (Telp/WA) Responden [1]
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Nama Responden [2]
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Jabatan Responden [2]
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12. Kit Troly Emergency Maternal
[1] Ambubag

(Jumlah: minimal 1)
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[2] Sungkup Oksigen Dewasa

(Jumlah: minimal 1)
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[3] Selang Oksigen, Kanula Oksigen

(Jumlah: minimal 1)
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[4] Kateter penghisap ukuran 18

(Jumlah: minimal 1)
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[5] Torniquet

(Jumlah: minimal 1)
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[6] Folley Catheter no 14

(Jumlah: minimal 1)
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[7] Kantong Urin

(Jumlah: minimal 1)
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[8] Palu Reflek

(Jumlah: minimal 1)
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[9] Plester

(Jumlah: minimal 1)
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[10] Povidone Iodine 10%

(Jumlah: minimal 1)
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[11] Alkohol Swab

(Jumlah: minimal 1)
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[12] Kasa Steril

(Jumlah: minimal 1)
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[13] Abocath ukuran 16

(Jumlah: minimal 2)
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[14] Abocath ukuran 18

(Jumlah: minimal 2)
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[15] Abocath ukuran 20

(Jumlah: minimal 1)
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[16] Infus Set

(Jumlah: minimal 2)
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[17] Blood infus set

(Jumlah: minimal 2)
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[18] Cairan Infus RL

(Jumlah: minimal 2)
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[19] Akuabides

(Jumlah: minimal 1)
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[20] Spuit 1 cc

(Jumlah: minimal 2)
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[21] Spuit 2,5 cc

(Jumlah: minimal 2)
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[22] Spuit 3 cc

(Jumlah: minimal 2)
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[23] Spuit 5 cc

(Jumlah: minimal 2)
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[24] Spuit 10 cc

(Jumlah: minimal 2)
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[25] Spuit 20 cc

(Jumlah: minimal 2)
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[26] Adrenaline Injeksi

(Jumlah: minimal 1)
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[27] Atropine Sulfat Injeksi

(Jumlah: minimal 1)
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[28] Dipenhidrydamine injeksi

(Jumlah: minimal 1)
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[29] Lidokain injeksi

(Jumlah: minimal 1)
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[30] Deksametason injeksi

(Jumlah: minimal 1)
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[31] Ergometrin Injeksi

(Jumlah: minimal 1)
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[32] Nifedipine tablet

(Jumlah: minimal 1)
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[33] MgSO4 40% 

(Jumlah: minimal 1)
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[34] Kalsium Glukonas

(Jumlah: minimal 1)
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[35] Oksitosin Injeksi

(Jumlah: minimal 6)
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[36] Diazepam injeksi

(Jumlah: minimal 1)
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[37] Troli emergensi

(Jumlah: minimal 1)
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