CEK LIST DOKUMEN

PENCEGAHAN DAN PENGENDALIAN INFEKSI

CHEKLIST OF PREVENTION AND INFECTION CONTROL

PPI 1

PPI 2

PPI 3

PPI 4

PPI 5

DOCUMEN T
Decree of IPCN & IPCLN
Job description
The schedule/Work program of
IPCN
SK Komite/Panitia/Tim PPI
Committe Decre / PPI team
Job description
Notulen rapat
Minutes of the meeting
Bukti dokumentasi lainnya,
misalnya surat menyurat
Evidence of documentation
ex: correspondence
Program of PPI
Adanya SIRS untuk program PPI
( bisa secara manual atau
elektronik)
SIRS for PPI (manually or
electronic)
SK penetapan IPCLN dan uraian
tugasnya
Anggaran PPI APD, diklat,
desinfektan
Decree of determination of
IPCLN and job
description.Budget of PPI.
Personel protective equipment.
Program PPI komprehensif (untuk
pasien, pengunjung dan staf) yg
antara lain meliputi
Comphrehensive program of PPI
(for patient,visitor,staff) that
include:
Melaksanakan Surveilans PPI 6
Do surveillance----- PPI 6
Melakukan Investigasi outbreak
PPI 6
Investigate the
outbreak--------PPI 6
Membuat Infection Control Risk
Assessment (ICRA) PPI 6 EP 4,
PPI 7, PPI 7.1 sd PPI 7.5
Make Infection Control Risk
Assessment

Y/N

REKOMENDATION

 Monitoring Sterilization in
hospital PPI 7.1
Monitoring laundry dan linen
management PPI 7.1
Monitoring expired equipment
&single-use become re-use
Monitoring Pembuangan sampah
infectious & cairan tubuh
Monitoring Disposal of
infectious waste &and body
fluids
Monitoring Penanganan
pembuangan darah dan
komponen darah

Monitoring blood handling

and disposal of blood
components
Monitoring Area kamar mayat
dan post mortem

Monitoring mortuary area

and post-mortem
Monitoring Pembuangan benda
tajam dan jarum

Monitoring disposal of
sharps and needles
Pencatatan dan pelaporan
tertusuk jarum

Recording and reporting of

needle stick
Monitoring penggunaan ruang
Isolasi

Monitoring the use of

space Insulation
Monitoring kepatuhan Hand
hygiene

Hand hygiene compliance

monitoring

PPI 5.1
PPI 6

Sasaran Program PPI

The target of PPI
Pedoman dan petunjuk teknis
surveilance RS
Guidelines
and
clinical

instruction of surveillance
Profil/kamus data/indikator PPI
Profile/ dictionary/ PPI
indicator
Laporan Komite/panitia PPI
Report of the committee
Data surveilance, hasil analisis
dan rekomendasi
Suveillance data, analysis, and
recomendation
Tindak lanjut hasil analisis dan
rekomendasi
Follow up from the result of
analysis and recomendation
Hasil asesmen risiko infeksi pada
setiap unit kerja pelayanan (ICRA)
Assessment result of ICRA
Kebijakan tentang penggunaan
antibiotik yg rasional
Policy of the rational used of
antibiotic
Kebijakan pelaksanaan surveilans
Policy Implementation of
surveillance
Kebijakan & SPO penanganan KLB
Policy & SPO management of
outbreak
Kebijakan
&
SPO
upaya
pencegahan infeksi ILO, IADP, ISK,
Pneumoni
Policy & SPO the prevention of
infection,
Surgical
wound,
Pheriperal
arteri
Infection,
Urinary
track
Infection,
Pneumoni
PPI 7

Bukti telah dilakukan assessemen

risiko (ICRA) pada pemberian
terapi cairan

Evidence has been done

assessemen risk (ICRA) in
fluid therapy
Strategi penurunan risiko
The strategy of reducing risk
Identifikasi
dan
strategi
penurunan risiko untuk PPI 7.1,
7.2, 7.3, 7.4, 7.5
Identification and the strategy

reducing
risk
for
PPI
7.1,7.2,7.3,7.4,7.5
SPO praktik menyuntik yg aman
SPO Giving injection safely
SPO praktik untuk lumbal punksi
SPO lumbal punction practice

PPI 7.1

PPI
7.1.
1

Pedoman dan SPO pelayananan

Sterillisasi central & diluar CSSD
Guidelines and SPO Central
sterilization service and outside
CSSD
Pedoman dan SPO pelayananan
Linen dan Laundry
Guidelines &SPO linen and
laundry
Hasil monitoring dan evaluasi,
pembersihan dan sterilisasi
Monitoring and evaluation
result, cleanning & Sterilization
Kebijakan dan SPO tentang
pengawasan peralatan
kadaluwarsa
Policy &SPO of monitoring the
expired equipment
Kebijakan dan SPO tentang
pemakaian ulang (re-use)
peralatan dan material
Policy &SPO use of equipment
re-use &material
Document monitoring dan
evaluation
Document of examination of germ
Kebijakan dan prosedur
pengelolaan sampah infeksius dan
cairan tubuh
Policy & procedure of infectious
waste &and body fluids

PPI 7.2

PPI 7.3

Kebijakan dan prosedur

pengelolaan darah dan komponen
darah
Policy & procedure of blood &
blood products management
Kebijakan dan prosedur pelayanan
kamar jenazah
Policy &procedur of mortuary
area service
Kebijakan dan prosedur
pengelolaan limbah RS khususnya
untuk benda tajam dan jarum
Policy &procedure of waste
management esspecially sharp

disposal and nedlie

Kebijakan dan prosedur n
persiapan makanan, pemasakan
dan penyajian dan pengambilan
sample makanan secara rutin

PPI 7.4

Policies and procedures n

food preparation, cooking
and presentation of food and
regular sampling
Kebijakan dan prosedur
engontrolan peralatan periksa
kuman

Policies and procedures germ

control equipment check
ICRA Kontruksi bangunan
Building Constuction of ICRA
Kebijakan ICRA kontruksi
bangunan
Policy Building constraction
Penetapan pemantauan kualitas
udara
PPI 7.5

Determination of air quality

monitoring
Hasil pelaksanaan pemantauan
kualitas udara.akibat dampak
renovasi.

The results of the

implementation of quality air
because of the impact of
renovation.
PPI 8

Kebijakan prosedur kewaspadaan

isolasi yg antara lain meliputi :

Policy of isolation
precautions procedures
which include the following:
Kebersihan tangan
Hand hygiene
Penggunaan APD
Use of Self Protective
equipment
Peralatan perawatan pasien
Patient tools
Pengendalian lingkungan,
termasuk ambulance setelah
mengantar pasien/jenazah
infectious

Environment contoll,

including ambulance after

dropping off a patient /
corpse infectious
Pemrosesan peralatan pasien dan
penatalaksanaan linen

Processing patients
equipment and management
of linens
Kesehatan karyawan/perlindungan
petugas kesehatan

employee health / health

protection officer
Penempatan pasien.
Placement of the patient
Hygiene respirasi/etika batuk

Respiratory hygiene /
cough etiquette
Praktik menyuntik yang aman

Safe injecting practices

Isolasi dengan dugaan emerging
disease

Isolation with allegations

emerging disease

PPI 9

Bukti edukasi staf

Evidence of staff education
Area yang menggunakan APD
Area that used Self protecting
tools
Prosedur pemakaian APD
Procedure
protective tools

of

using

self

Area yang harus cuci tangan,

disinfeksi tangan atau disinfeksi
permukaan

Areas that should wash their

hands, disinfect hands or
disinfect surfaces
Prosedur
disinfeksi

cuci

tangan

dan

Procedure of hand hygiene and

desinfection
Hasil pemantauan cuci
Hand hygiene compliance

tangan

PMKP Program
PPI program

PPI 10

Kebijakan dan prosedur

monitoring/pengawasan dari
Komite/Panitia/Tim PMKP
Policy and procedure
,monitoring
Minutes of the meeting of PMKP
dan PPI
Data pemantauan angka infeksi

Data monitoring infection rates

PPI
10.1

indikator angka infeksi

Indicator of infection rate
Notulen rapat pembahasan
The record of the meeting

Laporan Komite/panitia PPI

see PPI 6 EP 2 dan 3 dan
PMKP 3.1, PMKP 4.
Committee report

PPI
10.2

PPI
10.3

Hasil monitoring dan evaluasi

pelaksanaan kegiatan PPI

The results of the monitoring and

evaluation of implementation of
the PPI

Hasil analisis epidemiologi

Analysis of epidemiology
Lihat Kamus indikator PPI (PPI
6) dan hasil analisis data
surveilance (PPI 6, PMKP 3.1,
PMKP 4)
Look at dictionary PPI indicator
Follow up based on result of
analysis
see analysa data and follow up
PPI 6, PMKP 3.1, PMKP 4

Bukti data RS lain

Evidence of data other

hospitals
PPI
10.4

Bukti data acuan

Evidence reference data

Analysis result
see PMKP.4.2, EP 2 dan
MKI.20.2, EP 3)

 Bukti
komunikasi,
dalam forum rapat

misalnya

Evidence of communication, for

example in a meeting forum
PPI
10.5

Dokumen laporan Komite/panitia

PPI kepada manajemen RS
lihat PMKP 1.4 (publikasi
data)

Documents
Committee
report / PPI to the hospital
management committee
see pmkp 1.4 (publication
data)

Dokumen laporan kepada Kemkes

atau Dinas Kesehatan -> RL 6
PPI
10.6

Documents or reports to the MoH

Public Health Service -> RL 6
Bukti tindak lanjut atas laporan

Evidence
reports

of

follow

up

on

Program kerja PPI/Program diklat

tentang PPI

PPIs work program /training

program on PPI

PP1 11

Program pendidikan pasien dan

keluarga

Patient and family

education programs

Bukti implementasi
dan edukasi

pelatihan

Evidence of implementation
of training and education