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FORMAT OBSERVASI

HAND HYGIENE
(KEBERSIHAN TANGAN)
Unit/Instalasi : Tanggal :
Ruang/Lantai : Waktu (mulai-selesai) : ( : / : )
Observer : Lama Observasi (menit) :
Periode Observasi :
Kes Indikasi Tind. Kes Indikasi Tind. Kes
Kd:
Indikasi Tind.
Kd: Kd:
HH HH HH
 sbl ktk psn  HW  sbl ktk psn  HW  sbl ktk psn  HW
 sbl aspk  HR  sbl aspk  HR  sbl aspk  HR
1  sth ktk crntb  THH 1  sth ktk crntb  THH 1  sth ktk crntb  THH
 sth ktk psn  sth ktk psn  sth ktk psn
 sth ktk ling  sth ktk ling  sth ktk ling
 sbl ktk psn  HW  sbl ktk psn  HW  sbl ktk psn  HW
 sbl aspk  HR  sbl aspk  HR  sbl aspk  HR
2  sth ktk crntb  THH 2  sth ktk crntb  THH 2  sth ktk crntb  THH
 sth ktk psn  sth ktk psn  sth ktk psn
 sth ktk ling  sth ktk ling  sth ktk ling
 sbl ktk psn  HW  sbl ktk psn  HW  sbl ktk psn  HW
 sbl aspk  HR  sbl aspk  HR  sbl aspk  HR
3  sth ktk crntb  THH 3  sth ktk crntb  THH 3  sth ktk crntb  THH
 sth ktk psn  sth ktk psn  sth ktk psn
 sth ktk ling  sth ktk ling  sth ktk ling
 sbl ktk psn  HW  sbl ktk psn  HW  sbl ktk psn  HW
 sbl aspk  HR  sbl aspk  HR  sbl aspk  HR
4  sth ktk crntb  THH 4  sth ktk crntb  THH 4  sth ktk crntb  THH
 sth ktk psn  sth ktk psn  sth ktk psn
 sth ktk ling  sth ktk ling  sth ktk ling
 sbl ktk psn  HW  sbl ktk psn  HW  sbl ktk psn  HW
 sbl aspk  HR  sbl aspk  HR  sbl aspk  HR
5  sth ktk crntb  THH 5  sth ktk crntb  THH 5  sth ktk crntb  THH
 sth ktk psn  sth ktk psn  sth ktk psn
 sth ktk ling  sth ktk ling  sth ktk ling
 sbl ktk psn  HW  sbl ktk psn  HW  sbl ktk psn  HW
 sbl aspk  HR  sbl aspk  HR  sbl aspk  HR
6  sth ktk crntb  THH 6  sth ktk crntb  THH 6  sth ktk crntb  THH
 sth ktk psn  sth ktk psn  sth ktk psn
 sth ktk ling  sth ktk ling  sth ktk ling
 sbl ktk psn  HW  sbl ktk psn  HW  sbl ktk psn  HW
 sbl aspk  HR  sbl aspk  HR  sbl aspk  HR
 sth ktk crntb  THH 7  sth ktk crntb  THH  sth ktk crntb  THH
7 7
 sth ktk psn  sth ktk psn  sth ktk psn
 sth ktk ling  sth ktk ling  sth ktk ling

KETERANGAN :

 : diisi dengan √ sesuai indikasi momen


sbl ktk psn : sebelum kontak dengan pasien
sbl aspk : sebelum melakukan tindakan aseptik
sth ktk crntb : setelah kontak dengan cairan tubuh pasien
sth ktk psn : setelah kontak dengan pasien
sth ktk ling : setelah kontak dengan lingkungan pasien
HW : Hand Wash
HR : Hand Rub
THH : Tidak Hand Hygiene