BEDAH SET-OK- BEDAH SET-OK- BEDAH SET-OK- BEDAH SET-OK- BEDAH SET-OK-

Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 HAK B/S 1.2 1 HAK B/S 1.2 1 HAK B/S 1.2 1 HAK B/S 1.2 1 HAK B/S 1.2
2 Langen back 2 2 Langen back 2 2 Langen back 2 2 Langen back 2 2 Langen back 2
3 Cock section 1 3 Cock section 1 3 Cock section 1 3 Cock section 1 3 Cock section 1
4 Penster klem 2 4 Penster klem 2 4 Penster klem 2 4 Penster klem 2 4 Penster klem 2
5 Needle holder 3 5 Needle holder 3 5 Needle holder 3 5 Needle holder 3 5 Needle holder 3
6 Pinset serugi B/K 2 6 Pinset serugi B/K 2 6 Pinset serugi B/K 2 6 Pinset serugi B/K 2 6 Pinset serugi B/K 2
7 Pinset anatomis B/K 2 7 Pinset anatomis B/K 2 7 Pinset anatomis B/K 2 7 Pinset anatomis B/K 2 7 Pinset anatomis B/K 2
8 Pinset diatermi 1 8 Pinset diatermi 1 8 Pinset diatermi 1 8 Pinset diatermi 1 8 Pinset diatermi 1
9 Gunting jaringan 1 9 Gunting jaringan 1 9 Gunting jaringan 1 9 Gunting jaringan 1 9 Gunting jaringan 1
10 Gunting benang 1 10 Gunting benang 1 10 Gunting benang 1 10 Gunting benang 1 10 Gunting benang 1
11 Kocher 2 11 Kocher 2 11 Kocher 2 11 Kocher 2 11 Kocher 2
12 Alise klem 2 12 Alise klem 2 12 Alise klem 2 12 Alise klem 2 12 Alise klem 2
13 Bab cock 1 13 Bab cock 1 13 Bab cock 1 13 Bab cock 1 13 Bab cock 1
14 Pean bengkok sedang 10 14 Pean bengkok sedang 10 14 Pean bengkok sedang 10 14 Pean bengkok sedang 10 14 Pean bengkok sedang 10
15 Pean bengkok kecil 5 15 Pean bengkok kecil 5 15 Pean bengkok kecil 5 15 Pean bengkok kecil 5 15 Pean bengkok kecil 5
16 Pean lurus sedang 2 16 Pean lurus sedang 2 16 Pean lurus sedang 2 16 Pean lurus sedang 2 16 Pean lurus sedang 2
17 Scapel no.3/4 2.1 17 Scapel no.3/4 2.1 17 Scapel no.3/4 2.1 17 Scapel no.3/4 2.1 17 Scapel no.3/4 2.1
18 Duk klem 4 18 Duk klem 4 18 Duk klem 4 18 Duk klem 4 18 Duk klem 4
19 Curete 1 19 Curete 1 19 Curete 1 19 Curete 1 19 Curete 1
20 Sonde 1 20 Sonde 1 20 Sonde 1 20 Sonde 1 20 Sonde 1
 LAPARATOMY SET-OK- LAPARATOMY SET-OK- LAPARATOMY SET-OK- LAPARATOMY SET-OK- LAPARATOMY SET-OK-

Tgl Sterilisasi : ............................. Tgl Sterilisasi : ............................. Tgl Sterilisasi : ............................. Tgl Sterilisasi : ............................. Tgl Sterilisasi : .............................
Tgl ED : ................................... Tgl ED : ................................... Tgl ED : ................................... Tgl ED : ................................... Tgl ED : ...................................
Jam : ........................................... Jam : ........................................... Jam : ........................................... Jam : ........................................... Jam : ...........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 HAK B/S 1.1 1 HAK B/S 1.1 1 HAK B/S 1.1 1 HAK B/S 1.1 1 HAK B/S 1.1
2 Langen back 2 2 Langen back 2 2 Langen back 2 2 Langen back 2 2 Langen back 2
3 Cock section 1 3 Cock section 1 3 Cock section 1 3 Cock section 1 3 Cock section 1
4 Penster klem 4 4 Penster klem 4 4 Penster klem 4 4 Penster klem 4 4 Penster klem 4
5 Needle holder 3 5 Needle holder 3 5 Needle holder 3 5 Needle holder 3 5 Needle holder 3
6 Pinset serugi 2 6 Pinset serugi 2 6 Pinset serugi 2 6 Pinset serugi 2 6 Pinset serugi 2
7 Pinset anatomis 2 7 Pinset anatomis 2 7 Pinset anatomis 2 7 Pinset anatomis 2 7 Pinset anatomis 2
8 Pinset diatermi 1 8 Pinset diatermi 1 8 Pinset diatermi 1 8 Pinset diatermi 1 8 Pinset diatermi 1
9 Gunting jaringan 1 9 Gunting jaringan 1 9 Gunting jaringan 1 9 Gunting jaringan 1 9 Gunting jaringan 1
10 Gunting benang 1 10 Gunting benang 1 10 Gunting benang 1 10 Gunting benang 1 10 Gunting benang 1
11 Kocher 2 11 Kocher 2 11 Kocher 2 11 Kocher 2 11 Kocher 2
12 Alise klem 3 12 Alise klem 3 12 Alise klem 3 12 Alise klem 3 12 Alise klem 3
13 Pean bengkok besar 4 13 Pean bengkok besar 4 13 Pean bengkok besar 4 13 Pean bengkok besar 4 13 Pean bengkok besar 4
14 Pean bengkok sedang 5 14 Pean bengkok sedang 5 14 Pean bengkok sedang 5 14 Pean bengkok sedang 5 14 Pean bengkok sedang 5
15 Pean bengkok kecil 5 15 Pean bengkok kecil 5 15 Pean bengkok kecil 5 15 Pean bengkok kecil 5 15 Pean bengkok kecil 5
16 Klem cuci 1 16 Klem cuci 1 16 Klem cuci 1 16 Klem cuci 1 16 Klem cuci 1
17 Scapel no.3/4 2.1 17 Scapel no.3/4 2.1 17 Scapel no.3/4 2.1 17 Scapel no.3/4 2.1 17 Scapel no.3/4 2.1
18 Duk klem 4 18 Duk klem 4 18 Duk klem 4 18 Duk klem 4 18 Duk klem 4
19 Klem usus lurus 2 19 Klem usus lurus 2 19 Klem usus lurus 2 19 Klem usus lurus 2 19 Klem usus lurus 2
20 Spatel besar 1 20 Spatel besar 1 20 Spatel besar 1 20 Spatel besar 1 20 Spatel besar 1
 SECCAR SET-OK- SECCAR SET-OK- SECCAR SET-OK- SECCAR SET-OK- SECCAR SET-OK-
Tgl sterilisasi............................ Tgl sterilisasi............................ Tgl sterilisasi............................ Tgl sterilisasi............................ Tgl sterilisasi............................
Tgl ED..................................... Tgl ED..................................... Tgl ED..................................... Tgl ED..................................... Tgl ED.....................................
Jam :......................................... Jam :......................................... Jam :......................................... Jam :......................................... Jam :.........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 HAK besar 1 1 HAK besar 1 1 HAK besar 1 1 HAK besar 1 1 HAK besar 1
2 Spatel besar 1 2 Spatel besar 1 2 Spatel besar 1 2 Spatel besar 1 2 Spatel besar 1
3 Penster klem 4 3 Penster klem 4 3 Penster klem 4 3 Penster klem 4 3 Penster klem 4
4 Needle holder 2 4 Needle holder 2 4 Needle holder 2 4 Needle holder 2 4 Needle holder 2
5 Pinset serugi B/K 1.1 5 Pinset serugi B/K 1.1 5 Pinset serugi B/K 1.1 5 Pinset serugi B/K 1.1 5 Pinset serugi B/K 1.1
6 Pinset anatomis B/K 1.1 6 Pinset anatomis B/K 1.1 6 Pinset anatomis B/K 1.1 6 Pinset anatomis B/K 1.1 6 Pinset anatomis B/K 1.1
7 Gunting tali pusat 1 7 Gunting tali pusat 1 7 Gunting tali pusat 1 7 Gunting tali pusat 1 7 Gunting tali pusat 1
8 Gunting jaringan 1 8 Gunting jaringan 1 8 Gunting jaringan 1 8 Gunting jaringan 1 8 Gunting jaringan 1
9 Gunting benang 1 9 Gunting benang 1 9 Gunting benang 1 9 Gunting benang 1 9 Gunting benang 1
10 Pean lurus besar 2 10 Pean lurus besar 2 10 Pean lurus besar 2 10 Pean lurus besar 2 10 Pean lurus besar 2
11 Pean bengkok besar 2 11 Pean bengkok besar 2 11 Pean bengkok besar 2 11 Pean bengkok besar 2 11 Pean bengkok besar 2
12 Pean bengkok sedang 4 12 Pean bengkok sedang 4 12 Pean bengkok sedang 4 12 Pean bengkok sedang 4 12 Pean bengkok sedang 4
13 Miom BOR 13 Miom BOR 13 Miom BOR 13 Miom BOR 13 Miom BOR
14 Kocher L/B 14 Kocher L/B 14 Kocher L/B 14 Kocher L/B 14 Kocher L/B
15 Klem cuci 15 Klem cuci 15 Klem cuci 15 Klem cuci 15 Klem cuci
16 Scapel no.4 1 16 Scapel no.4 1 16 Scapel no.4 1 16 Scapel no.4 1 16 Scapel no.4 1
17 Duk klem 4 17 Duk klem 4 17 Duk klem 4 17 Duk klem 4 17 Duk klem 4
 HISTREKTOMY SET-OK- HISTREKTOMY SET-OK- HISTREKTOMY SET-OK- HISTREKTOMY SET-OK- HISTREKTOMY SET-OK-
Tgl sterilisasi............................. Tgl sterilisasi............................. Tgl sterilisasi............................. Tgl sterilisasi............................. Tgl sterilisasi.............................
Tgl ED....................................... Tgl ED....................................... Tgl ED....................................... Tgl ED....................................... Tgl ED.......................................
Jam : ......................................... Jam : ......................................... Jam : ......................................... Jam : ......................................... Jam : .........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 HAK besar 1 1 HAK besar 1 1 HAK besar 1 1 HAK besar 1 1 HAK besar 1
2 Spatel besar 1 2 Spatel besar 1 2 Spatel besar 1 2 Spatel besar 1 2 Spatel besar 1
3 Miom BOR 1 3 Miom BOR 1 3 Miom BOR 1 3 Miom BOR 1 3 Miom BOR 1
4 Penster klem 5 4 Penster klem 5 4 Penster klem 5 4 Penster klem 5 4 Penster klem 5
5 Needle holder 2 5 Needle holder 2 5 Needle holder 2 5 Needle holder 2 5 Needle holder 2
6 Pinset serugi B/K 2 6 Pinset serugi B/K 2 6 Pinset serugi B/K 2 6 Pinset serugi B/K 2 6 Pinset serugi B/K 2
7 Pinset anatomis B/K 2 7 Pinset anatomis B/K 2 7 Pinset anatomis B/K 2 7 Pinset anatomis B/K 2 7 Pinset anatomis B/K 2
8 Gunting tali pusat 1 8 Gunting tali pusat 1 8 Gunting tali pusat 1 8 Gunting tali pusat 1 8 Gunting tali pusat 1
9 Gunting jaringan 1 9 Gunting jaringan 1 9 Gunting jaringan 1 9 Gunting jaringan 1 9 Gunting jaringan 1
10 Gunting benang 1 10 Gunting benang 1 10 Gunting benang 1 10 Gunting benang 1 10 Gunting benang 1
11 Pean lurus besar 2 11 Pean lurus besar 2 11 Pean lurus besar 2 11 Pean lurus besar 2 11 Pean lurus besar 2
12 Pean bengkok besar 2 12 Pean bengkok besar 2 12 Pean bengkok besar 2 12 Pean bengkok besar 2 12 Pean bengkok besar 2
13 Pean bengkok sedang 4 13 Pean bengkok sedang 4 13 Pean bengkok sedang 4 13 Pean bengkok sedang 4 13 Pean bengkok sedang 4
14 Kocher lurus besar 2 14 Kocher lurus besar 2 14 Kocher lurus besar 2 14 Kocher lurus besar 2 14 Kocher lurus besar 2
15 Kocher bengkok besar 2 15 Kocher bengkok besar 2 15 Kocher bengkok besar 2 15 Kocher bengkok besar 2 15 Kocher bengkok besar 2
16 Scapel no.4 1 16 Scapel no.4 1 16 Scapel no.4 1 16 Scapel no.4 1 16 Scapel no.4 1
17 Duk klem 4 17 Duk klem 4 17 Duk klem 4 17 Duk klem 4 17 Duk klem 4
 APPENDIK/HERNIA APPENDIK/HERNIA APPENDIK/HERNIA APPENDIK/HERNIA APPENDIK/HERNIA
Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1
2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1
3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1
4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1
5 Pean Bengkok Sedang 5 5 Pean Bengkok Sedang 5 5 Pean Bengkok Sedang 5 5 Pean Bengkok Sedang 5 5 Pean Bengkok Sedang 5
6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5
7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2
8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2
9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1
10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1
11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4
12 Langen Back 2 12 Langen Back 2 12 Langen Back 2 12 Langen Back 2 12 Langen Back 2
13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1

APPENDIK/HERNIA APPENDIK/HERNIA APPENDIK/HERNIA APPENDIK/HERNIA APPENDIK/HERNIA

Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1
2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1
3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1
4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1
5 Pean Bengkok Sedang 5 5 Pean Bengkok Sedang 5 5 Pean Bengkok Sedang 5 5 Pean Bengkok Sedang 5 5 Pean Bengkok Sedang 5
6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5
7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2
8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2
9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1
10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1
11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4
12 Langen Back 2 12 Langen Back 2 12 Langen Back 2 12 Langen Back 2 12 Langen Back 2
13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1
 HERNIA SET HERNIA SET HERNIA SET HERNIA SET HERNIA SET
Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1
2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1
3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1
4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1
5 Pean Bengkok Sedang 10 5 Pean Bengkok Sedang 10 5 Pean Bengkok Sedang 10 5 Pean Bengkok Sedang 10 5 Pean Bengkok Sedang 10
6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5
7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2
8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2
9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1
10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1
11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4
12 Langen Back 2 12 Langen Back 2 12 Langen Back 2 12 Langen Back 2 12 Langen Back 2
13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1

HERNIA SET HERNIA SET HERNIA SET HERNIA SET HERNIA SET
Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1 1 Pinset Anatomi B/K 1.1
2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1 2 Pinset Serugi B/K 1.1
3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1 3 Gunting Jaringan 1
4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1 4 Gunting Benang 1
5 Pean Bengkok Sedang 10 5 Pean Bengkok Sedang 10 5 Pean Bengkok Sedang 10 5 Pean Bengkok Sedang 10 5 Pean Bengkok Sedang 10
6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5 6 Pean Bengkok Kecil 5
7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2
8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2
9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1 9 Kocher Lurus 1
10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1 10 Kocher Bengkok 1
11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4 11 Duk Kleam 4
12 Langen Back 2 12 Langen Back 2 12 Langen Back 2 12 Langen Back 2 12 Langen Back 2
13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1 13 Scapel No.3 1
 PARTUS SET-VK- PARTUS SET-VK- PARTUS SET-VK- PARTUS SET-VK- PARTUS SET-VK-
Tgl sterilisasi : .........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : .........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ........................................ Jam : ........................................Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Gunting epis 1 1 Gunting epis 1 1 Gunting epis 1 1 Gunting epis 1 1 Gunting epis 1
2 Gunting talipusat 1 2 Gunting talipusat 1 2 Gunting talipusat 1 2 Gunting talipusat 1 2 Gunting talipusat 1
3 ½ Kocher 1 3 ½ Kocher 1 3 ½ Kocher 1 3 ½ Kocher 1 3 ½ Kocher 1
4 Arteri Klem 2 4 Arteri Klem 2 4 Arteri Klem 2 4 Arteri Klem 2 4 Arteri Klem 2
5 Duk 1 5 Duk 1 5 Duk 1 5 Duk 1 5 Duk 1

PARTUS SET-VK- PARTUS SET-VK- PARTUS SET-VK- PARTUS SET-VK- PARTUS SET-VK-
Tgl sterilisasi : .........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : .........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ........................................ Jam : ........................................Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Gunting epis 1 1 Gunting epis 1 1 Gunting epis 1 1 Gunting epis 1 1 Gunting epis 1
2 Gunting talipusat 1 2 Gunting talipusat 1 2 Gunting talipusat 1 2 Gunting talipusat 1 2 Gunting talipusat 1
3 ½ Kocher 1 3 ½ Kocher 1 3 ½ Kocher 1 3 ½ Kocher 1 3 ½ Kocher 1
4 Arteri Klem 2 4 Arteri Klem 2 4 Arteri Klem 2 4 Arteri Klem 2 4 Arteri Klem 2
5 Duk 1 5 Duk 1 5 Duk 1 5 Duk 1 5 Duk 1

PARTUS SET-VK- PARTUS SET-VK- PARTUS SET-VK- PARTUS SET-VK- PARTUS SET-VK-
Tgl sterilisasi : .........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : .........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ........................................ Jam : ........................................Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Gunting epis 1 1 Gunting epis 1 1 Gunting epis 1 1 Gunting epis 1 1 Gunting epis 1
2 Gunting talipusat 1 2 Gunting talipusat 1 2 Gunting talipusat 1 2 Gunting talipusat 1 2 Gunting talipusat 1
3 ½ Kocher 1 3 ½ Kocher 1 3 ½ Kocher 1 3 ½ Kocher 1 3 ½ Kocher 1
4 Arteri Klem 2 4 Arteri Klem 2 4 Arteri Klem 2 4 Arteri Klem 2 4 Arteri Klem 2
5 Duk 1 5 Duk 1 5 Duk 1 5 Duk 1 5 Duk 1
 HEACTHING SET-VK- HEACTHING SET-VK- HEACTHING SET-VK- HEACTHING SET-VK- HEACTHING SET-VK-
Tgl sterilisasi : .........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : .........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ........................................ Jam : ........................................Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset 2 1 Pinset 2 1 Pinset 2 1 Pinset 2 1 Pinset 2
2 Gunting runcing 1 2 Gunting runcing 1 2 Gunting runcing 1 2 Gunting runcing 1 2 Gunting runcing 1
3 Needle Holder 1 3 Needle Holder 1 3 Needle Holder 1 3 Needle Holder 1 3 Needle Holder 1
4 Kasa Steril 2 4 Kasa Steril 2 4 Kasa Steril 2 4 Kasa Steril 2 4 Kasa Steril 2

HEACTHING SET-VK- HEACTHING SET-VK- HEACTHING SET-VK- HEACTHING SET-VK- HEACTHING SET-VK-
Tgl sterilisasi : .........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : .........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ........................................ Jam : ........................................Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset 2 1 Pinset 2 1 Pinset 2 1 Pinset 2 1 Pinset 2
2 Gunting runcing 1 2 Gunting runcing 1 2 Gunting runcing 1 2 Gunting runcing 1 2 Gunting runcing 1
3 Needle Holder 1 3 Needle Holder 1 3 Needle Holder 1 3 Needle Holder 1 3 Needle Holder 1
4 Kasa Steril 2 4 Kasa Steril 2 4 Kasa Steril 2 4 Kasa Steril 2 4 Kasa Steril 2

HEACTHING SET-VK- HEACTHING SET-VK- HEACTHING SET-VK- HEACTHING SET-VK- HEACTHING SET-VK-
Tgl sterilisasi : .........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : .........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ........................................ Jam : ........................................Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset 2 1 Pinset 2 1 Pinset 2 1 Pinset 2 1 Pinset 2
2 Gunting runcing 1 2 Gunting runcing 1 2 Gunting runcing 1 2 Gunting runcing 1 2 Gunting runcing 1
3 Needle Holder 1 3 Needle Holder 1 3 Needle Holder 1 3 Needle Holder 1 3 Needle Holder 1
4 Kasa Steril 2 4 Kasa Steril 2 4 Kasa Steril 2 4 Kasa Steril 2 4 Kasa Steril 2
 CURRATE SET-VK- CURRATE SET-VK- CURRATE SET-VK- CURRATE SET-VK- CURRATE SET-VK- CURRATE SET-VK-
Tgl sterilisasi : .........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : .................................Tgl ED : .................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ......................................Jam : ......................................Jam : ........................................ Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Sonde 1 1 Sonde 1 1 Sonde 1 1 Sonde 1 1 Sonde 1 1 Sonde 1
2 Stenakulum 1 2 Stenakulum 1 2 Stenakulum 1 2 Stenakulum 1 2 Stenakulum 1 2 Stenakulum 1
3 Peanster klem 1 3 Peanster klem 1 3 Peanster klem 1 3 Peanster klem 1 3 Peanster klem 1 3 Peanster klem 1
4 Sendok Curate 3 4 Sendok Curate 3 4 Sendok Curate 3 4 Sendok Curate 3 4 Sendok Curate 3 4 Sendok Curate 3
5 SIM 2 5 SIM 2 5 SIM 2 5 SIM 2 5 SIM 2 5 SIM 2
6 Kom 1 6 Kom 1 6 Kom 1 6 Kom 1 6 Kom 1 6 Kom 1
7 Doek 2 7 Doek 2 7 Doek 2 7 Doek 2 7 Doek 2 7 Doek 2
8 Kassa 3 8 Kassa 3 8 Kassa 3 8 Kassa 3 8 Kassa 3 8 Kassa 3

CURRATE SET-VK- CURRATE SET-VK- CURRATE SET-VK- CURRATE SET-VK- CURRATE SET-VK- CURRATE SET-VK-
Tgl sterilisasi : .........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : .................................Tgl ED : .................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ......................................Jam : ......................................Jam : ........................................ Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Sonde 1 1 Sonde 1 1 Sonde 1 1 Sonde 1 1 Sonde 1 1 Sonde 1
2 Stenakulum 1 2 Stenakulum 1 2 Stenakulum 1 2 Stenakulum 1 2 Stenakulum 1 2 Stenakulum 1
3 Peanster klem 1 3 Peanster klem 1 3 Peanster klem 1 3 Peanster klem 1 3 Peanster klem 1 3 Peanster klem 1
4 Sendok Curate 3 4 Sendok Curate 3 4 Sendok Curate 3 4 Sendok Curate 3 4 Sendok Curate 3 4 Sendok Curate 3
5 SIM 2 5 SIM 2 5 SIM 2 5 SIM 2 5 SIM 2 5 SIM 2
6 Kom 1 6 Kom 1 6 Kom 1 6 Kom 1 6 Kom 1 6 Kom 1
7 Doek 2 7 Doek 2 7 Doek 2 7 Doek 2 7 Doek 2 7 Doek 2
8 Kassa 3 8 Kassa 3 8 Kassa 3 8 Kassa 3 8 Kassa 3 8 Kassa 3
 LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK-
Tgl sterilisasi : .........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : .................................Tgl ED : .................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ......................................Jam : ......................................Jam : ........................................ Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1
2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1
3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2
4 Gunting 1 4 Gunting 1 4 Gunting 1 4 Gunting 1 4 Gunting 1 4 Gunting 1
5 Kom 1 5 Kom 1 5 Kom 1 5 Kom 1 5 Kom 1 5 Kom 1
6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2

LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK-

Tgl sterilisasi : .........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : .................................Tgl ED : .................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ......................................Jam : ......................................Jam : ........................................ Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1
2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1
3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2
4 Gunting 1 4 Gunting 1 4 Gunting 1 4 Gunting 1 4 Gunting 1 4 Gunting 1
5 Kom 1 5 Kom 1 5 Kom 1 5 Kom 1 5 Kom 1 5 Kom 1
6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2

LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK- LAMINARIA SET-VK-
Tgl sterilisasi : .........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : .................................Tgl ED : .................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ......................................Jam : ......................................Jam : ........................................ Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1 1 Peanster klem 1
2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1 2 Tenakulum 1
3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2 3 Cocor Bebek 2
4 Gunting 1 4 Gunting 1 4 Gunting 1 4 Gunting 1 4 Gunting 1 4 Gunting 1
 5 Kom 1 5 Kom 1 5 Kom 1 5 Kom 1 5 Kom 1 5 Kom 1
6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2 6 Tampon Rol 2

VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK-

Tgl sterilisasi : .........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : .................................Tgl ED : .................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ......................................Jam : ......................................Jam : ........................................ Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1
2 Pinset 2 2 Pinset 2 2 Pinset 2 2 Pinset 2 2 Pinset 2 2 Pinset 2
3 Gunting 1 3 Gunting 1 3 Gunting 1 3 Gunting 1 3 Gunting 1 3 Gunting 1
4 Spatel 2 4 Spatel 2 4 Spatel 2 4 Spatel 2 4 Spatel 2 4 Spatel 2
5 Doek 2 5 Doek 2 5 Doek 2 5 Doek 2 5 Doek 2 5 Doek 2
6 Kassa 3 6 Kassa 3 6 Kassa 3 6 Kassa 3 6 Kassa 3 6 Kassa 3

VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK-

Tgl sterilisasi : .........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : .................................Tgl ED : .................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ......................................Jam : ......................................Jam : ........................................ Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1
2 Pinset 2 2 Pinset 2 2 Pinset 2 2 Pinset 2 2 Pinset 2 2 Pinset 2
3 Gunting 1 3 Gunting 1 3 Gunting 1 3 Gunting 1 3 Gunting 1 3 Gunting 1
4 Spatel 2 4 Spatel 2 4 Spatel 2 4 Spatel 2 4 Spatel 2 4 Spatel 2
5 Doek 2 5 Doek 2 5 Doek 2 5 Doek 2 5 Doek 2 5 Doek 2
6 Kassa 3 6 Kassa 3 6 Kassa 3 6 Kassa 3 6 Kassa 3 6 Kassa 3

VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK- VAGINARAPI-VK-

Tgl sterilisasi : .........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : .................................Tgl ED : .................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ....................................... Jam : ......................................Jam : ......................................Jam : ........................................ Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : ........................Petugas CSSD : ........................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1 1 Needle Holder 1
2 Pinset 2 2 Pinset 2 2 Pinset 2 2 Pinset 2 2 Pinset 2 2 Pinset 2
3 Gunting 1 3 Gunting 1 3 Gunting 1 3 Gunting 1 3 Gunting 1 3 Gunting 1
4 Spatel 2 4 Spatel 2 4 Spatel 2 4 Spatel 2 4 Spatel 2 4 Spatel 2
5 Doek 2 5 Doek 2 5 Doek 2 5 Doek 2 5 Doek 2 5 Doek 2
6 Kassa 3 6 Kassa 3 6 Kassa 3 6 Kassa 3 6 Kassa 3 6 Kassa 3
 MINOR SET-IGD- MINOR SET-IGD- MINOR SET-IGD- MINOR SET-IGD- MINOR SET-IGD-
Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Scapel No.3 1 1 Scapel No.3 1 1 Scapel No.3 1 1 Scapel No.3 1 1 Scapel No.3 1
2 Pinset anatomis 1 2 Pinset anatomis 1 2 Pinset anatomis 1 2 Pinset anatomis 1 2 Pinset anatomis 1
3 Pinset Serugis 1 3 Pinset Serugis 1 3 Pinset Serugis 1 3 Pinset Serugis 1 3 Pinset Serugis 1
4 Pean bengkok kecil 3 4 Pean bengkok kecil 3 4 Pean bengkok kecil 3 4 Pean bengkok kecil 3 4 Pean bengkok kecil 3
5 Pean bengkok sedang 2 5 Pean bengkok sedang 2 5 Pean bengkok sedang 2 5 Pean bengkok sedang 2 5 Pean bengkok sedang 2
6 Pean Lurus 3 6 Pean lurus 3 6 Pean lurus 3 6 Pean lurus 3 6 Pean lurus 3
7 Kocher 1 7 Kocher 1 7 Kocher 1 7 Kocher 1 7 Kocher 1
8 Needle Holder 1 8 Needle Holder 1 8 Needle Holder 1 8 Needle Holder 1 8 Needle Holder 1
9 Gunting Jaringan 1 9 Gunting Jaringan 1 9 Gunting Jaringan 1 9 Gunting Jaringan 1 9 Gunting Jaringan 1
10 Gunting Benang 1 10 Gunting Benang 1 10 Gunting Benang 1 10 Gunting Benang 1 10 Gunting Benang 1
11 Duk lobang kecil 1 11 Duk lobang kecil 1 11 Duk lobang kecil 1 11 Duk lobang kecil 1 11 Duk lobang kecil 1
12 Kasa 20 12 Kasa 20 12 Kasa 20 12 Kasa 20 12 Kasa 20
13 Com kecil 1 13 Com kecil 1 13 Com kecil 1 13 Com kecil 1 13 Com kecil 1

MINOR SET-IGD- MINOR SET-IGD- MINOR SET-IGD- MINOR SET-IGD- MINOR SET-IGD-
Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Scapel No.3 1 1 Scapel No.3 1 1 Scapel No.3 1 1 Scapel No.3 1 1 Scapel No.3 1
2 Pinset anatomis 1 2 Pinset anatomis 1 2 Pinset anatomis 1 2 Pinset anatomis 1 2 Pinset anatomis 1
3 Pinset Serugis 1 3 Pinset Serugis 1 3 Pinset Serugis 1 3 Pinset Serugis 1 3 Pinset Serugis 1
4 Pean bengkok kecil 3 4 Pean bengkok kecil 3 4 Pean bengkok kecil 3 4 Pean bengkok kecil 3 4 Pean bengkok kecil 3
5 Pean bengkok sedang 2 5 Pean bengkok sedang 2 5 Pean bengkok sedang 2 5 Pean bengkok sedang 2 5 Pean bengkok sedang 2
6 Pean Lurus 3 6 Pean Lurus 3 6 Pean Lurus 3 6 Pean Lurus 3 6 Pean Lurus 3
7 Kocher 1 7 Kocher 1 7 Kocher 1 7 Kocher 1 7 Kocher 1
8 Needle Holder 1 8 Needle Holder 1 8 Needle Holder 1 8 Needle Holder 1 8 Needle Holder 1
9 Gunting Jaringan 1 9 Gunting Jaringan 1 9 Gunting Jaringan 1 9 Gunting Jaringan 1 9 Gunting Jaringan 1
10 Gunting Benang 1 10 Gunting Benang 1 10 Gunting Benang 1 10 Gunting Benang 1 10 Gunting Benang 1
11 Duk lobang kecil 1 11 Duk lobang kecil 1 11 Duk lobang kecil 1 11 Duk lobang kecil 1 11 Duk lobang kecil 1
12 Kasa 20 12 Kasa 20 12 Kasa 20 12 Kasa 20 12 Kasa 20
 13 Com kecil 1 13 Com kecil 1 13 Com kecil 1 13 Com kecil 1 13 Com kecil 1

PARTUS SET -IGD- PARTUS SET -IGD- PARTUS SET -IGD- PARTUS SET -IGD- PARTUS SET -IGD-
Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset anatomis 1 1 Pinset anatomis 1 1 Pinset anatomis 1 1 Pinset anatomis 1 1 Pinset anatomis 1
2 Pinset Serugis 1 2 Pinset Serugis 1 2 Pinset Serugis 1 2 Pinset Serugis 1 2 Pinset Serugis 1
3 Pean Lurus 2 3 Pean Lurus 2 3 Pean Lurus 2 3 Pean Lurus 2 3 Pean Lurus 2
4 Kocher 1 4 Kocher 1 4 Kocher 1 4 Kocher 1 4 Kocher 1
5 1/2 Kocher 1 5 1/2 Kocher 1 5 1/2 Kocher 1 5 1/2 Kocher 1 5 1/2 Kocher 1
6 Kateter metal 1 6 Kateter metal 1 6 Kateter metal 1 6 Kateter metal 1 6 Kateter metal 1
7 Needle Holder 1 7 Needle Holder 1 7 Needle Holder 1 7 Needle Holder 1 7 Needle Holder 1
8 Gunting Jaringan 1 8 Gunting Jaringan 1 8 Gunting Jaringan 1 8 Gunting Jaringan 1 8 Gunting Jaringan 1
9 Gunting Benang 1 9 Gunting Benang 1 9 Gunting Benang 1 9 Gunting Benang 1 9 Gunting Benang 1
10 Gunting Episiotomi 1 10 Gunting Episiotomi 1 10 Gunting Episiotomi 1 10 Gunting Episiotomi 1 10 Gunting Episiotomi 1
11 Duk lobang 1 11 Duk lobang 1 11 Duk lobang 1 11 Duk lobang 1 11 Duk lobang 1

PARTUS SET -IGD- PARTUS SET -IGD- PARTUS SET -IGD- PARTUS SET -IGD- PARTUS SET -IGD-

Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset anatomis 1 1 Pinset anatomis 1 1 Pinset anatomis 1 1 Pinset anatomis 1 1 Pinset anatomis 1
2 Pinset Serugis 1 2 Pinset Serugis 1 2 Pinset Serugis 1 2 Pinset Serugis 1 2 Pinset Serugis 1
3 Pean Lurus 2 3 Pean Lurus 2 3 Pean Lurus 2 3 Pean Lurus 2 3 Pean Lurus 2
4 Kocher 1 4 Kocher 1 4 Kocher 1 4 Kocher 1 4 Kocher 1
5 1/2 Kocher 1 5 1/2 Kocher 1 5 1/2 Kocher 1 5 1/2 Kocher 1 5 1/2 Kocher 1
6 Kateter metal 1 6 Kateter metal 1 6 Kateter metal 1 6 Kateter metal 1 6 Kateter metal 1
7 Needle Holder 1 7 Needle Holder 1 7 Needle Holder 1 7 Needle Holder 1 7 Needle Holder 1
8 Gunting Jaringan 1 8 Gunting Jaringan 1 8 Gunting Jaringan 1 8 Gunting Jaringan 1 8 Gunting Jaringan 1
9 Gunting Benang 1 9 Gunting Benang 1 9 Gunting Benang 1 9 Gunting Benang 1 9 Gunting Benang 1
10 Gunting Episiotomi 1 10 Gunting Episiotomi 1 10 Gunting Episiotomi 1 10 Gunting Episiotomi 1 10 Gunting Episiotomi 1
11 Duk lobang 1 11 Duk lobang 1 11 Duk lobang 1 11 Duk lobang 1 11 Duk lobang 1
 GV SET-IGD- GV SET-IGD- GV SET-IGD- GV SET-IGD- GV SET-IGD-
Tgl sterilisasi : .............................Tgl sterilisasi : .............................Tgl sterilisasi : .............................Tgl sterilisasi : .............................Tgl sterilisasi : ..............................
Tgl ED : .......................................Tgl ED : ...................................... Tgl ED : .......................................Tgl ED : ...................................... Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pean lurus 1 1 Pean lurus 1 1 Pean lurus 1 1 Pean lurus 1 1 Pean lurus 1
2 Pean bengkok kecil 2 2 Pean bengkok kecil 2 2 Pean bengkok kecil 2 2 Pean bengkok kecil 2 2 Pean bengkok kecil 2
3 Pinset anatomi 1 3 Pinset anatomi 1 3 Pinset anatomi 1 3 Pinset anatomi 1 3 Pinset anatomi 1
4 Pinset serugi 1 4 Pinset serugi 1 4 Pinset serugi 1 4 Pinset serugi 1 4 Pinset serugi 1
5 Gunting Benang 1 5 Gunting Benang 1 5 Gunting Benang 1 5 Gunting Benang 1 5 Gunting Benang 1
6 Gunting jaringan 1 6 Gunting jaringan 1 6 Gunting jaringan 1 6 Gunting jaringan 1 6 Gunting jaringan 1
7 Com kecil 1 7 Com kecil 1 7 Com kecil 1 7 Com kecil 1 7 Com kecil 1

GV SET-IGD- GV SET-IGD- GV SET-IGD- GV SET-IGD- GV SET-IGD-

Tgl sterilisasi : .............................Tgl sterilisasi : .............................Tgl sterilisasi : .............................Tgl sterilisasi : .............................Tgl sterilisasi : ..............................
Tgl ED : .......................................Tgl ED : ...................................... Tgl ED : .......................................Tgl ED : ...................................... Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pean lurus 1 1 Pean lurus 1 1 Pean lurus 1 1 Pean lurus 1 1 Pean lurus 1
2 Pean bengkok kecil 2 2 Pean bengkok kecil 2 2 Pean bengkok kecil 2 2 Pean bengkok kecil 2 2 Pean bengkok kecil 2
3 Pinset anatomi 1 3 Pinset anatomi 1 3 Pinset anatomi 1 3 Pinset anatomi 1 3 Pinset anatomi 1
4 Pinset serugi 1 4 Pinset serugi 1 4 Pinset serugi 1 4 Pinset serugi 1 4 Pinset serugi 1
5 Gunting Benang 1 5 Gunting Benang 1 5 Gunting Benang 1 5 Gunting Benang 1 5 Gunting Benang 1
6 Gunting jaringan 1 6 Gunting jaringan 1 6 Gunting jaringan 1 6 Gunting jaringan 1 6 Gunting jaringan 1
7 Com kecil 1 7 Com kecil 1 7 Com kecil 1 7 Com kecil 1 7 Com kecil 1
 SPINAL SET SPINAL SET SPINAL SET SPINAL SET SPINAL SET SPINAL SET
Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : ..................................Tgl ED : ..................................Tgl ED : ..................................Tgl ED : .................................Tgl ED : ........................................
Jam : ...................................... Jam : ...................................... Jam : .......................................Jam : .......................................Jam : ......................................Jam : ........................................
Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : .......................Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1
2 Com kecil 1 2 Com kecil 1 2 Com kecil 1 2 Com kecil 1 2 Com kecil 1 2 Com kecil 1
3 Kocher 1 3 Kocher 1 3 Kocher 1 3 Kocher 1 3 Kocher 1 3 Kocher 1
4 Kassa 5 4 Kassa 5 4 Kassa 5 4 Kassa 5 4 Kassa 5 4 Kassa 5

SPINAL SET SPINAL SET SPINAL SET SPINAL SET SPINAL SET SPINAL SET
Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : ..................................Tgl ED : ..................................Tgl ED : ..................................Tgl ED : .................................Tgl ED : ........................................
Jam : ...................................... Jam : ...................................... Jam : .......................................Jam : .......................................Jam : ......................................Jam : ........................................
Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : .......................Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1
2 Com kecil 1 2 Com kecil 1 2 Com kecil 1 2 Com kecil 1 2 Com kecil 1 2 Com kecil 1
3 Kocher 1 3 Kocher 1 3 Kocher 1 3 Kocher 1 3 Kocher 1 3 Kocher 1
4 Kassa 5 4 Kassa 5 4 Kassa 5 4 Kassa 5 4 Kassa 5 4 Kassa 5

SPINAL SET SPINAL SET SPINAL SET SPINAL SET SPINAL SET SPINAL SET
Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ........................Tgl sterilisasi : ..............................
Tgl ED : ..................................Tgl ED : ..................................Tgl ED : ..................................Tgl ED : ..................................Tgl ED : .................................Tgl ED : ........................................
Jam : ...................................... Jam : ...................................... Jam : .......................................Jam : .......................................Jam : ......................................Jam : ........................................
Petugas CSSD : ......................Petugas CSSD : ......................Petugas CSSD : .......................Petugas CSSD : .......................Petugas CSSD : ......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1 1 Doek kecil 1
2 Com kecil 1 2 Com kecil 1 2 Com kecil 1 2 Com kecil 1 2 Com kecil 1 2 Com kecil 1
3 Kocher 1 3 Kocher 1 3 Kocher 1 3 Kocher 1 3 Kocher 1 3 Kocher 1
4 Kassa 5 4 Kassa 5 4 Kassa 5 4 Kassa 5 4 Kassa 5 4 Kassa 5
 PAKET TROMOL 1

NO NAMA BARANG JUMLAH

1 DUK BESAR 2

2 DUK SEDANG 3

4 JAS OPERASI 3

5 PERLAK 2

6 SLAYER 2

7 KASSA 3

8 COM 2

9 SELANG SECTION 1
 MINOR SET MINOR SET MINOR SET MINOR SET MINOR SET MINOR SET
Tgl sterilisasi : .........................Tgl sterilisasi : .........................Tgl sterilisasi : ........................Tgl sterilisasi : ..........................Tgl sterilisasi : .........................Tgl sterilisasi : ..............................
Tgl ED : ...................................Tgl ED : ..................................Tgl ED : ..................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ........................................Jam : ....................................... Jam : .......................................Jam : ........................................Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : .......................Petugas CSSD : .......................Petugas CSSD : ........................Petugas CSSD : .......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Scapel No.3 1 Scapel No.3 1 Scapel No.3 1 Scapel No.3 1 Scapel No.3 1 Scapel No.3
2 Pinset anatomis 2 Pinset anatomis 2 Pinset anatomis 2 Pinset anatomis 2 Pinset anatomis 2 Pinset anatomis
3 Pinset Serugis 3 Pinset Serugis 3 Pinset Serugis 3 Pinset Serugis 3 Pinset Serugis 3 Pinset Serugis
4 Pean bengkok 4 Pean bengkok 4 Pean bengkok 4 Pean bengkok 4 Pean bengkok 4 Pean bengkok
5 Pean Lurus 5 Pean Lurus 5 Pean Lurus 5 Pean Lurus 5 Pean Lurus 5 Pean Lurus
6 Needle Holder 6 Needle Holder 6 Needle Holder 6 Needle Holder 6 Needle Holder 6 Needle Holder
7 Gunting Jaringan 7 Gunting Jaringan 7 Gunting Jaringan 7 Gunting Jaringan 7 Gunting Jaringan 7 Gunting Jaringan
8 Gunting Benang 8 Gunting Benang 8 Gunting Benang 8 Gunting Benang 8 Gunting Benang 8 Gunting Benang
9 9 9 9 9 9
10 10 10 10 10 10
11 11 11 11 11 11
12 12 12 12 12 12
13 13 13 13 13 13

MINOR SET MINOR SET MINOR SET MINOR SET MINOR SET MINOR SET
Tgl sterilisasi : .........................Tgl sterilisasi : .........................Tgl sterilisasi : ........................Tgl sterilisasi : ..........................Tgl sterilisasi : .........................Tgl sterilisasi : ..............................
Tgl ED : ...................................Tgl ED : ..................................Tgl ED : ..................................Tgl ED : ...................................Tgl ED : ...................................Tgl ED : ........................................
Jam : ........................................Jam : ....................................... Jam : .......................................Jam : ........................................Jam : ........................................Jam : ........................................
Petugas CSSD : .......................Petugas CSSD : .......................Petugas CSSD : .......................Petugas CSSD : ........................Petugas CSSD : .......................Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Scapel No.3 1 Scapel No.3 1 Scapel No.3 1 Scapel No.3 1 Scapel No.3 1 Scapel No.3
2 Pinset anatomis 2 Pinset anatomis 2 Pinset anatomis 2 Pinset anatomis 2 Pinset anatomis 2 Pinset anatomis
3 Pinset Serugis 3 Pinset Serugis 3 Pinset Serugis 3 Pinset Serugis 3 Pinset Serugis 3 Pinset Serugis
4 Pean bengkok 4 Pean bengkok 4 Pean bengkok 4 Pean bengkok 4 Pean bengkok 4 Pean bengkok
5 Pean Lurus 5 Pean Lurus 5 Pean Lurus 5 Pean Lurus 5 Pean Lurus 5 Pean Lurus
6 Needle Holder 6 Needle Holder 6 Needle Holder 6 Needle Holder 6 Needle Holder 6 Needle Holder
7 Gunting Jaringan 7 Gunting Jaringan 7 Gunting Jaringan 7 Gunting Jaringan 7 Gunting Jaringan 7 Gunting Jaringan
8 Gunting Benang 8 Gunting Benang 8 Gunting Benang 8 Gunting Benang 8 Gunting Benang 8 Gunting Benang
9 9 9 9 9 9
10 10 10 10 10 10
11 11 11 11 11 11
12 12 12 12 12 12
13 13 13 13 13 13
 HERNIA ANAK HERNIA ANAK HERNIA ANAK HERNIA ANAK HERNIA ANAK
Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset A/S 1.1 1 Pinset A/S 1.1 1 Pinset A/S 1.1 1 Pinset A/S 1.1 1 Pinset A/S 1.1
2 Currate 1 2 Currate 1 2 Currate 1 2 Currate 1 2 Currate 1
3 Gunting J/B 1.1 3 Gunting J/B 1.1 3 Gunting J/B 1.1 3 Gunting J/B 1.1 3 Gunting J/B 1.1
4 Pean Bengkok Sedang 2 4 Pean Bengkok Sedang 2 4 Pean Bengkok Sedang 2 4 Pean Bengkok Sedang 2 4 Pean Bengkok Sedang 2
5 Pean Bengkok Kecil 5 5 Pean Bengkok Kecil 5 5 Pean Bengkok Kecil 5 5 Pean Bengkok Kecil 5 5 Pean Bengkok Kecil 5
6 Pean lurus 5 6 Pean lurus 5 6 Pean lurus 5 6 Pean lurus 5 6 Pean lurus 5
7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2
8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2
9 Kocher 1 9 Kocher 1 9 Kocher 1 9 Kocher 1 9 Kocher 1
10 HAK kecil 1 10 HAK kecil 1 10 HAK kecil 1 10 HAK kecil 1 10 HAK kecil 1
11 HAK kecil panjang 1 11 HAK kecil panjang 1 11 HAK kecil panjang 1 11 HAK kecil panjang 1 11 HAK kecil panjang 1
12 Duk Kleam 4 12 Duk Kleam 4 12 Duk Kleam 4 12 Duk Kleam 4 12 Duk Kleam 4
13 Langen Back 2 13 Langen Back 2 13 Langen Back 2 13 Langen Back 2 13 Langen Back 2
14 Scapel No.3 1 14 Scapel No.3 1 14 Scapel No.3 1 14 Scapel No.3 1 14 Scapel No.3 1

HERNIA ANAK HERNIA ANAK HERNIA ANAK HERNIA ANAK HERNIA ANAK
Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : .............................. Tgl sterilisasi : ..............................
Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................ Tgl ED : ........................................
Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................ Jam : ........................................
Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : ......................... Petugas CSSD : .........................
NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML NO INSTRUMEN JML
1 Pinset A/S 1.1 1 Pinset A/S 1.1 1 Pinset A/S 1.1 1 Pinset A/S 1.1 1 Pinset A/S 1.1
2 Currate 1 2 Currate 1 2 Currate 1 2 Currate 1 2 Currate 1
3 Gunting J/B 1.1 3 Gunting J/B 1.1 3 Gunting J/B 1.1 3 Gunting J/B 1.1 3 Gunting J/B 1.1
4 Pean Bengkok Sedang 2 4 Pean Bengkok Sedang 2 4 Pean Bengkok Sedang 2 4 Pean Bengkok Sedang 2 4 Pean Bengkok Sedang 2
5 Pean Bengkok Kecil 5 5 Pean Bengkok Kecil 5 5 Pean Bengkok Kecil 5 5 Pean Bengkok Kecil 5 5 Pean Bengkok Kecil 5
6 Pean lurus 5 6 Pean lurus 5 6 Pean lurus 5 6 Pean lurus 5 6 Pean lurus 5
7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2 7 Needle holder 2
8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2 8 Elis Kleam 2
9 Kocher 1 9 Kocher 1 9 Kocher 1 9 Kocher 1 9 Kocher 1
10 HAK kecil 1 10 HAK kecil 1 10 HAK kecil 1 10 HAK kecil 1 10 HAK kecil 1
11 HAK kecil panjang 1 11 HAK kecil panjang 1 11 HAK kecil panjang 1 11 HAK kecil panjang 1 11 HAK kecil panjang 1
12 Duk Kleam 4 12 Duk Kleam 4 12 Duk Kleam 4 12 Duk Kleam 4 12 Duk Kleam 4
13 Langen Back 2 13 Langen Back 2 13 Langen Back 2 13 Langen Back 2 13 Langen Back 2
14 Scapel No.3 1 14 Scapel No.3 1 14 Scapel No.3 1 14 Scapel No.3 1 14 Scapel No.3 1