BKJ-BOR-PPK-11 Pind.

1/2018

BAHAGIAN KEJURURAWATAN
KEMENTERIAN KESIHATAN MALAYSIA
CUMULATIVE DATA COLLECTION FOR THROMBOPHLEBITIS
Ward :_______________________
Thrombo
Additive VIP Score Sign Name Chop

Palpable Venous
Site of IV Canulation

Pain Score at IV site

Unconscious patient
phlebitis

Slight Redness

(Adult) ( √ ) or (x)
Plain IV drip

IV Branula

Redness

Swelling

Pyrexia
Medication

cord
Blood TX
SN RN 0 1 2* 3* 4* 5* YES NO

(√) (√) (√) (√) (√)

JUMLAH
To be filled by Ward Sister U32/ KUP U32 Reviewed in March 2018
* Data of Unconscious/ Paeds & Neonates patients are recorded for study purpose only but excluded from HPIA DATA collection

Disediakan oleh: Disemak Oleh:

_____________________________ __________________________________
(Ketua Jururawat ward) ( Ketua Penyelia Jururawat Kawasan)
Tarikh : Tarikh: