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File: checklist orientasi pasien baru.html
<html> <head> <meta http-equiv="Content-Type" content="text/html; charset=UTF-8"> <style type="text/css"> .txt { white-space:nowrap; } #f0 { font-family:sans-serif; font-weight:normal; font-style:normal; } #f1 { font-family:sans-serif; font-weight:bold; font-style:normal; } #f2 { font-family:sans-serif; font-weight:normal; font-style:normal; } @font-face { font-family: ff0; src: url("0.ttf"); } #f3 { font-family:ff0,monospace; font-weight:normal; font-style:normal; } @font-face { font-family: ff1; src: url("1.ttf"); } #f4 { font-family:ff1,sans-serif; font-weight:normal; font-style:normal; } @font-face { font-family: ff2; src: url("2.ttf"); } #f5 { font-family:ff2,sans-serif; font-weight:normal; font-style:normal; } #f6 { font-family:sans-serif; font-weight:normal; font-style:italic; } #f7 { font-family:monospace; font-weight:normal; font-style:normal; } </style> </head> <body> <img id="background" style="position:absolute; left:0px; top:0px;" width="595" height="841" src="page1.png"> <div class="txt" style="position:absolute; left:120px; top:23px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Rumah Sakit Umum Aulia</span></div> <div class="txt" style="position:absolute; left:120px; top:35px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Jl. Jeruk Raya No.15 Jagakarsa, Jakarta Selatan</span></div> <div class="txt" style="position:absolute; left:120px; top:48px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Kotak Pos : 12620 Telp : (021) 727 0208</span></div> <div class="txt" style="position:absolute; left:458px; top:28px;"><span id="f2" style="font-size:9px;vertical-align:baseline;color:rgba(0,0,0,1);">No Form : FR.RI.106-22</span></div> <div class="txt" style="position:absolute; left:460px; top:46px;"><span id="f2" style="font-size:9px;vertical-align:baseline;color:rgba(0,0,0,1);">No Rev : 00</span></div> <div class="txt" style="position:absolute; left:56px; top:87px;"><span id="f1" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">FORMULIR ORIENTASI PASIEN BARU</span></div> <div class="txt" style="position:absolute; left:376px; top:75px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">No.RM</span></div> <div class="txt" style="position:absolute; left:448px; top:75px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">: ……………………….</span></div> <div class="txt" style="position:absolute; left:376px; top:88px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Nama</span></div> <div class="txt" style="position:absolute; left:448px; top:88px;"><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">: ……………………….</span></div> <div class="txt" style="position:absolute; left:376px; top:101px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Jenis Kelamin </span><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">: ……………………….</span></div> <div class="txt" style="position:absolute; left:376px; top:113px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tanggal Lahir </span><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">: ……………………….</span></div> <div class="txt" style="position:absolute; left:33px; top:139px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Diberikan kepada : </span><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Pasien</span></div> <div class="txt" style="position:absolute; left:194px; top:139px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Keluarga</span></div> <div class="txt" style="position:absolute; left:282px; top:139px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Lain </span><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">– </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">lain</span></div> <div class="txt" style="position:absolute; left:127px; top:152px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tidak dapat dilakukan (</span><span id="f6" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">jelaskan</span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">) ..........................................</span></div> <div class="txt" style="position:absolute; left:33px; top:177px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Petugas Ruangan :</span></div> <div class="txt" style="position:absolute; left:42px; top:191px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Perkenalan nama Perawat / Bidan</span></div> <div class="txt" style="position:absolute; left:42px; top:204px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Perkenalan nama Dokter Penanggung Jawab Pasien (DPJP)</span></div> <div class="txt" style="position:absolute; left:42px; top:218px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Perkenalan nama petugas ADM dan lainnya</span></div> <div class="txt" style="position:absolute; left:33px; top:243px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Fasilitas Fisik :</span></div> <div class="txt" style="position:absolute; left:42px; top:256px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Counter Perawat</span></div> <div class="txt" style="position:absolute; left:42px; top:270px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Arah Kiblat</span></div> <div class="txt" style="position:absolute; left:42px; top:283px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Bel Pasien/ cara memanggil Perawat</span></div> <div class="txt" style="position:absolute; left:42px; top:297px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Penggunaan TV</span></div> <div class="txt" style="position:absolute; left:328px; top:256px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Penggunaan AC</span></div> <div class="txt" style="position:absolute; left:329px; top:270px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Lokasi ruang perawatan dan tempat tidur</span></div> <div class="txt" style="position:absolute; left:328px; top:283px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Lokasi kamar mandi dan cara menggunakan toilet</span></div> <div class="txt" style="position:absolute; left:33px; top:322px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Kebijakan Tata Tertib :</span></div> <div class="txt" style="position:absolute; left:42px; top:336px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Aktifitas harian bangsal</span></div> <div class="txt" style="position:absolute; left:42px; top:349px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Kebersihan kamar mandi</span></div> <div class="txt" style="position:absolute; left:42px; top:362px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Pengunjung dan jam kunjungan</span></div> <div class="txt" style="position:absolute; left:42px; top:376px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Jam Pemberian makan</span></div> <div class="txt" style="position:absolute; left:42px; top:389px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Nomor ruangan</span></div> <div class="txt" style="position:absolute; left:42px; top:403px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Hak dan kewajiban pasien</span></div> <div class="txt" style="position:absolute; left:33px; top:428px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Manajemen Keselamatan :</span></div> <div class="txt" style="position:absolute; left:42px; top:442px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Kebersihan tangan / hand hygiene</span></div> <div class="txt" style="position:absolute; left:42px; top:455px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Pencegahan jatuh</span></div> <div class="txt" style="position:absolute; left:42px; top:468px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Penggunaan gelang identitas</span></div> <div class="txt" style="position:absolute; left:322px; top:442px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Lokasi pintu keluar bila terjadi kebakaran</span></div> <div class="txt" style="position:absolute; left:324px; top:455px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Bahaya Api </span><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">– </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">dilarang merokok di lingkungan RS</span></div> <div class="txt" style="position:absolute; left:323px; top:468px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Bila akan meninggalkan ruangan sesuai aturan RS</span></div> <div class="txt" style="position:absolute; left:33px; top:494px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Barang </span><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">– </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">barang berharga/ Protase :</span></div> <div class="txt" style="position:absolute; left:51px; top:507px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">a. Gigi palsu</span></div> <div class="txt" style="position:absolute; left:220px; top:507px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tidak</span></div> <div class="txt" style="position:absolute; left:326px; top:507px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Ya</span></div> <div class="txt" style="position:absolute; left:221px; top:521px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Atas</span></div> <div class="txt" style="position:absolute; left:325px; top:521px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Bawah, disimpan oleh .......................................</span></div> <div class="txt" style="position:absolute; left:51px; top:534px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">b. Alat bantu dengar</span></div> <div class="txt" style="position:absolute; left:220px; top:534px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tidak</span></div> <div class="txt" style="position:absolute; left:326px; top:534px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Ya</span></div> <div class="txt" style="position:absolute; left:221px; top:548px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Kanan</span></div> <div class="txt" style="position:absolute; left:328px; top:548px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Kiri , disimpan oleh ............................................</span></div> <div class="txt" style="position:absolute; left:51px; top:561px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">c. Barang berharga</span></div> <div class="txt" style="position:absolute; left:220px; top:561px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Tidak Ada</span></div> <div class="txt" style="position:absolute; left:328px; top:561px;"><span id="f4" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Ada</span></div> <div class="txt" style="position:absolute; left:69px; top:574px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Disimpan oleh pasien / keluarga (sebutkan) .............................................................................................</span></div> <div class="txt" style="position:absolute; left:51px; top:586px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">d. Lain </span><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">– </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">lain ...................................................................................................................................................</span></div> <div class="txt" style="position:absolute; left:69px; top:599px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Dikembalikan kepada pasien / keluarga ....................................................................................................</span></div> <div class="txt" style="position:absolute; left:33px; top:624px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Pernyataan :</span></div> <div class="txt" style="position:absolute; left:33px; top:637px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Bahwa saya (pasien/keluarga) setuju untuk menyimpan barang </span><span id="f5" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">– </span><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">barang berharga atau uang selama dirawat, saya tidak</span></div> <div class="txt" style="position:absolute; left:33px; top:650px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">akan meminta pertanggungjawaban rumah sakit jika terjadi kerusakan atau kehilangan .</span></div> <div class="txt" style="position:absolute; left:278px; top:675px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Jakarta, ....................................................... Jam ..........................</span></div> <div class="txt" style="position:absolute; left:33px; top:700px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Yang Memberikan Orientasi</span></div> <div class="txt" style="position:absolute; left:228px; top:700px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Yang Menyatakan/ Menerima Orientasi</span></div> <div class="txt" style="position:absolute; left:469px; top:700px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Saksi</span></div> <div class="txt" style="position:absolute; left:33px; top:751px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">( ..........................................)</span></div> <div class="txt" style="position:absolute; left:61px; top:764px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Nama Jelas & TTD</span></div> <div class="txt" style="position:absolute; left:255px; top:751px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">( .......................................... )</span></div> <div class="txt" style="position:absolute; left:268px; top:764px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Nama Jelas & TTD</span></div> <div class="txt" style="position:absolute; left:439px; top:751px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">( ............................... )</span></div> <div class="txt" style="position:absolute; left:445px; top:764px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">Nama Jelas & TTD</span></div> </body> </html>