HSAAS DOCUMENT | HOSPITAL SULTAN ABDUL AZIZ SHAH (HSAAS) UNIVERSITI PUTRA MALAYSIA
» HSAAS DOCUMENT

HSAAS INTERNAL DOCUMENT

HSAAS DOCUMENT - DEPARTMENT OF MEDICAL
1
Borang Persetujuan Penerimaan Rawatan Risiko
2
Spirometry Test Form
3
Echocardiography Request Form
4
Holter Registration Form
5
Exercise Stress Test Form
6
Osptretinoin Treatment Consent Form
7
Patch Test Consent Form
8
Patch Test Form
9
Phototherapy Consent Form
10
Photography Consent Form
11
Phototherapy Form
12
Dermatology Life Quality Index (DLQI) Worksheet
13
Eczema Area And Severity Index (EASI) Worksheet
14
Psoriasis Area And Severity Index (PASI) Worksheet
15
Cytarabine (ARA-C) for Acute Leucostasis in Older Patient
16
Cytarabine (ARA-C) for Acute Myeloid Leukemia in Older Patient

HSAAS DOCUMENT - DEPARTMENT OF OTORHINOLARYNGOLOFY, HEAD AND NECK SURGERY (ENT)
17
Audiogram Form
18
Universal Neonatal Hearing Screening Form
19
Skin Prick Test Form
20
Pediatric Case History Form

HSAAS DOCUMENT - OFTALMOLOGI DEPARTMENT
21
Retinopathy of Prematuring (ROP) Screening & Clerking
22
Retinopathy of Prematuring (ROP) Follow Up Case
23
OT Procedure Form
24
Procedure Minor OT Checklist
25
Optometry Clinical Notes
26
Ophtalmology Clinical Notes
27
Ophtalmology Clinical Notes (Procedure)
28
Borang Preskripsi Kanta
29
Borang Persetujuan Bayaran Kanta
30
Referral Letter

HSAAS DOCUMENT - PEDIATRIC DEPARTMENT
31
Discharge declaration form
32
Abstinence chart
33
Exchange transfussion record
34
Nasal Septum assessment
35
NICU Feeding Diary
36
NICU Investigation chart
37
NICU Kardex
38
Nursing Assessment on Admission for Neonate
39
PICC Monitoring
40
Temperature Monitoring for Neonatal Cooling Therapy
41
Weight Gain and Coh Chart
42
Senarai Semak Discaj NICU
43
Senarai Semak Orientasi NICU
44
NICU Observation Chart

HSAAS DOCUMENT - DEPARTMENT OF REHABILITATION MEDICINE
45
Borang Rujukan Servis Fisioterapi (Pesakit Luar)
46
Borang Rujukan Servis Fisioterapi (Pesakit Dalam)
47
Prosthetic & Orthotic Outpatient Referral Form
48
Speech Therapy Referral Form
49
Rehabilitation Medicine (Clinical) Referral Form
50
Occupational Therapy Referral Form

HSAAS DOCUMENT - OBSTETRIC AND GYNAECOLOGY DEPARTMENT
51
Borang Akuan Menolak Rawatan
52
Borang Keizinan Prosedur Abdominal Hysterectomy with Salphingo-Oopherectomy with Consevation of Ovaries
53
Borang Keizinan Prosedur Amniocentesis
54
Borang Keizinan Prosedur Amnioreduction
55
Borang Keizinan Prosedur Caesarean Section
56
Borang Keizinan Prosedur Chorionic Villus Sampling
57
Borang Keizinan Prosedur Evakuasi Hasil Kandungan Keguguran
58
Borang Keizinan Prosedur Diagnostik Histeroskopi dan Currettage
59
Borang Keizinan Prosedur Induksi Bersalin
60
Borang Keizinan Prosedur Laparoskopi
61
Borang Keizinan Prosedur Pemandulan
62
Borang Keizinan Prosedur Pengguguran Kandungan
63
Borang Keizinan Prosedur Vaginal Hysterectomy
64
Borang Keizinan Prosedur Perancangan Kelahiran melaui Vagina selepas Pembedahan Caesarean (VBAC)
65
Borang Notifikasi Kematian Lahirmati (Stillbirth)
66
Labour Summary Form
67
Newborn Discharge Form
68
Stillbirth & Intrauterine Death (IUD) Form
69
Swab & Count Instrument Form_vaginal delivery
70
Newborn Checklist
71
7 Point Glucose Monitoring Chart
72
Bishop Score Chart
73
Fetal Kick Chart
74
Partograph

HSAAS DOCUMENT - DEPARTMENT OF PSYCHIATRY
75
Psychiatry Clerking Sheet
76
Patient Interview Form
77
Patient Information Checklist Form
78
Patient Consent Form (Teleconsultation)
79
Borang Laporan Guru Sekolah
80
Borang Keizinan Telekonsultansi
81
Borang Keizinan Mengeluar dan Bertukar Maklumat
82
Borang Arahan Pemerhatian Rapi
83
Borang Arahan Kekangan
84
Behaviour Chart
85
ECT Documentation Form
86
Inpatient Clozapine Initiation
87
Pre and Post ECT Intervention

HSAAS DOCUMENT - DEPARTMENT OF RADIOLOGY
88
Copy of Radiological Examination Image/Report and Image Service Form Digitization
89
Borang Keizinan Menjalankan Prosedur Radiologi Yang Memerlukan Pemberian Kontras Media
90
Radiology Post Angiogram Orders and Hand-Off
91
Slip Persediaan Pesakit Pemeriksaan Bone MIneral Densitometry (BMD)
92
Slip Persediaan Pesakit Pemeriksaan Tomografi Berkomputer (CT Scan)
93
Hysterosalpingogram (HSG) Examination Preparation Slip
94
Mammography Examination Slip
95
Slip Persediaan Pesakit Pemeriksaan Magnetic Resonance Imaging (MRI)
96
Slip Pemeriksaan Ultasound (US)
97
Radiology Pre-Procedure Checklist
98
Radiological Examination Request Form
99
Breast Imaging Request Form
100
Special Consent of Patient With Implant For MRI Procedure
101
Slip Persediaan Pesakit Pemeriksaan Barium
102
Arahan Kerja Penetapan Temujanji Pemeriksaan Radiologi
103
Arahan Kerja Pengendalian Pemeriksaan Radiologi
104
Work Instruction for Contrast Media Extravasation Management
105
Work Instruction for Contrast Media Adverse Reaction Management
106
Magnetic Resonance (MR) Procedure Screening Form

DOKUMEN HSAAS - JABATAN FARMASI
107
Guideline for Manufacturing and Repacking
108
Guideline for Medication Therapy Adherence Clinic
109
Work Instruction for Outpatient Pharmacy
110
Borang Laporan Tumpahan Ubat Sitotoksik
111
Borang Pemulangan Bancuhan Ubat Sitotoksik dari Wad/Unit
112
Medication History Assessment Form (CP1)
113
Clinical Pharmacy Report Form (CP3)
114
Referral of Counselling (CP4)
115
Borang keizinan untuk menjalani rawatan dengan ubat diluar indikasi (off-label)
116
Borang Permohonan Ujian/ Sampel Analisa Ubatan Tradisional/ Supplemen
117
Drug Enquiry Form
118
Borang Aduan Kecuaian yang melibatkan kehilangan/ pecah/ pembaziran dadah berbahaya (DDA) di Wad/ Klinik/ Unit
119
Borang kecuaian ubat terkawal bukan dadah berbahaya
120
Floorstock Amendment Request Form
121
Pharmacy Counselling Form
122
Return Medication Form (Inpatient)
123
Borang Aduan Produk (Stor Perubatan)
124
Floor Stock Amendment Request Form
125
Borang Permohonan Stok (Stor Perubatan)
126
Medication Return Form (Medical Store)
127
Consent Form: Medication Therapy Adherence Clinic (MTAC)
128
Borang Pendaftaran Loker Farmasi Pharmabox
129
Borang Permohonan Pembekalan Ubat Kuota
130
Borang Permohonan Ubat Kuota
131
Therapeutic Drug Monitoring (TDM) Request Form
132
Parenteral Nutrition Order Form (Adult)
133
Sterile Eye Drops Order Form
134
Rekod Suhu Bilik
135
Template surat pembekalan ubat (Stor perubatan)
136
Guideline for Clinical Pharmacy

DOKUMEN HSAAS - UNIT PENGIMEJAN NUKLEAR
137
Nuclear Imaging Request Form
138
Mycordial Perfusion Scan Form

HSAAS DOCUMENT - DEPARTMENT OF DIETETICS
139
Enteral Product_Feeding Bag Ordering Form
140
Borang Aduan Perkhidmatan Makanan
141
Dietetics Referral Form
142
Borang Persetujuan Bayaran Diet_Mother Accompanied Child

HSAAS DOCUMENT - MEDICAL MICROBIOLOGY DEPARTMENT
143
Microbiology Laboratory Request Form
144
Borang Permohonan Bekas Spesimen
145
Premilinary Report Form
146
Garis Panduan Kemasukan Pelawat ke Jabatan Mikrobiologi Perubata
147
Borang Permohonan Pindaan Dokumen

HSAAS DOCUMENT - PATOLOGY DEPARTMENT
148
Borang Bayaran Perkhidmatan Penyelidikan
149
Borang Laporan Tindakan Susulan Program Kualiti Luaran (EQA Corrective Action)
150
Borang Pengambilan Ais Cube daripada Mesin Ice Maker
151
Borang Pengesahan Pembacaan Dokumen
152
Borang Pengesahan Penerimaan Dokumen
153
Borang Permohonan Inventori Makmal Sitologi
154
Borang Permohonan Inventori Makmal
155
Borang Permohonan Menjalankan Penyelidikan
156
Borang Permohonan Pinjaman Stok Jabatan Patalogi
157
Borang Semakan Keputusan EQA
158
Borang Semakan Mata CPD Latihan Staf Seliaan
159
Bone Marrow Aspiration Request Form
160
Borang Permohonan Peminjaman Slaid Hematopatologi atau Pengambilan Gambar
161
Full Blood Picture Request Form
162
Haematology Specialised Test Booking Form
163
HB Analysis Request Form
164
Request Form for DNA Analysis of Thalassaemia and Haemoglobinopathies
165
Application Form for Histopathology_Cytology Slide_Block or Image Acquisition
166
Borang Penolakan Spesimen
167
Histopathology Request Form
168
Request Form FNAC
169
Request Form Gynae
170
Request Form Non-Gynae
171
Collection of Blood and Blood Component Form
172
Record of Return Unused Blood Product Form
173
Request Form for Transfusion Reaction Investigation (Blood and Blood Components)
174
Worksheet for Investigation of Transfusion Reaction
175
Emergency Shower and Eyewash Test Record
176
GSH to GXM Conversion Slip
177
Slip Memo Bayaran Ujian
178
Pathology Request Form
179
Reporting Form for Transfusion Related Adverse Event
180
Blood Transfusion Request Form

DOKUMEN HSAAS - CENTRAL STERILE SERVICES UNIT (CSSU)
181
Borang Laporan Insiden atau Aduan Alatan Surgikal
182
Borang Penghantaran dan Penerimaan Peralatan Surgikal
183
Borang Permohonan Linen dan Soft Good
184
Borang Permohonan Peralatan Steril

HSAAS DOCUMENT - PUBLIC HEALTH UNIT
185
Borang Kebenaran Suntikan Hepatitis B Anggota Kesihatan
186
Borang Kebenaran Suntikan Hepatitis B Pelajar
187
Borang Kebenaran Suntikan Tifoid Anggota Kesihatan
188
Borang Kebenaran Uijan Saringan Darah Anti HBs Anggota Kesihatan
189
Borang Pemeriksaan Tempat Pembiakan Nyamuk
190
Mantoux Test Referral Form
191
Notification of Occupational Accident and Dangerous Occurrence Form
192
Notification of Occupational Noise Induced Hearing Loss Form
193
Notification of Occupational Lung Disease Form
194
Notification of Occupational Skin Disease Form
195
General Assessment Form OMC
196
Spirometry Test Form
197
Tuberculin Vial Request Form
198
Pemeriksaan Premis Makanan RTE
199
Borang Pemeriksaan Pusat Pengumpulan Sampah
200
Notis penyerahan import, eksport atau tranship mayat
201
Pemakluman kes kematian disyaki covid-19
202
Surat undertaking untuk menyerahkan mayat
203
Notis penyerahan mayat kematian penyakit berjangkit kepada PKD
204
Notification of Occupational Poisoning or Disease
205
Borang Persetujuan Blood Borne Disease
206
Fitness for Work Form

HSAAS DOCUMENT - CLINICAL RESEARCH UNIT
207
Arahan Kerja Pengurusan Perkhidmatan Klinik Konsultasi Penyelidikan
208
Borang Permohonan Menjalankan Penyelidikan Klinikal
209
Application to Conduct Research Project
210
Senarai Semak Permohonan Penyelidikan Klinikal
211
Garis Panduan Permohonan Menjalankan Penyelidikan Klinikal di HSAAS

DOKUMEN HSAAS - UNIT FIZIK PERUBATAN
212
Exposure Dose Rate for Handling Radioactive Patient Form
213
Exposure Rate Received by Personnel Form
214
Radioactive Patient Transfer Information Form

HSAAS DOCUMENT - COUNSELLING AND MEDICAL SOCIAL SERVICE UNIT
215
Borang Perubatan 1/09(T) Jabatan Perkhidmatan Awam Malaysia
216
Borang Rujukan Kaunseling
217
Borang Rujukan Bantuan Perubatan
218
Borang Pinjaman Peralatan Perubatan
219
Memo Permohonan Pesara Persekutuan

HSAAS DOCUMENT - NURSING MANAGEMENT UNIT
220
Application Form for Credentialing and Privileging (Nursing dan AMO)
221
Checklist for C&P (Nursing & AMO)
222
Garis Panduan Pengurusan Katil
223
Arahan Kerja Penyediaan Jadual Staf
224
Minit Mesyuarat Pagi
225
Ringkasan Laporan Atas Talian
226
Skin Integrity Assessment (Adopted Braden Scale)
227
Patient Fall Information
228
Humpty Dumpty Fall Assessment
229
Morse Fall Scale
230
Nursing Care Plan Format
231
General Nursing Kardex
232
General Nursing Assessment
233
Skin Assessment
234
4 Hourly Observation Chart for Phlebitis
235
Glucose Monitoring Chart
236
Intake & Output Chart
237
Observation Chart
238
Positioning Chart
239
Wound Record Chart
240
5 Bundle of Fall Interventions Task (5B-FIT) Checklist
241
Senarai Semak Discaj (Wad)
242
Senarai Semak Discaj (O&G)
243
Senarai Semak Orientasi Pesakit Wad
244
Arahan Kerja Pengurusan Perakuan Pengamalan APC

DOKUMEN HSAAS - UNIT SUMBER PENDIDIKAN KANSER DAN KLINIKAL (CCARE)
245
Referral Form CCARE

HSAAS DOCUMENT - UNIT OF INFECTION CONTROL
246
Air Sampling Form
247
Case Monitoring Form
248
Infection Control Round Form
249
Inter Healthcare Infection Prevention Transfer Form
250
Particulate Count Form
251
Wound Surveillance Form
252
Contact Precaution Checklist for Multi-Drug Resistance Organism (MDRO)
253
Ward/Clinic Audit Report Checklist
254
Work Instruction Terminal Cleaning
255
Work Instruction Terminal Cleaning OT
256
Senarai Semak Terminal Cleaning
257
Senarai Semak Terminal Cleaning OT

HSAAS DOCUMENT - HUMAN RESOURCE DIVISION
258
Borang Tuntutan Cuti Gantian (Kerja Lebih Masa)
259
Borang Permohonan Latihan Program Lanjutan (Pos Basik)
260
Laporan Pelaksanaan Latihan

HSAAS DOCUMENTS - FINANCE DEPARTMENT
261
Payment Form
262
Endorsement Foem Conducting Examinatiom/Research
263
Borang Tuntutan Bayaran Balik
264
Lampiran E-Borang Pengecualian Caj Penyakit Berjangkit
265
Deposit Adjustment Form

HSAAS DOCUMENTS - ACQUISITION AND FINANCE UNIT
266
Borang Pembatalan Iklan ePUPM
267
Borang Senarai Semak Penerimaan Perolehan

HSAAS DOCUMENT - MEDICAL RECORD UNIT
268
Borang Permohonan Penggunaan Rekod Perubatan Pesakit (Untuk Penyelidikan, Rujukan dsb)
269
Borang Permohonan & Pemulangan Rekod Perubatan Pesakit Masuk Wad
270
Borang Permohonan & Pemulangan Rekod Perubatan Pesakit Temujanji Klinik
271
Borang Permohonan Laporan Perubatan

HSAAS DOCUMENT - QUALITY AND RISK MANAGEMENT UNIT
272
Patient Safety Incident Reporting (IR) Form
273
Patient Safety Incident Reporting Form_MIRCA Format
274
Root Cause Analysis and Action Report_RCA2 Form
275
Application for Renewal of Clinical Privileges Form
276
Credentialing and Privileging Application Form
277
Checklist for Credentialing and Privileging
278
Incident Reporting Prescription Slip

BUSINESS DEVELOPMENT AND MARKETING UNIT
279
Borang Permohonan Sewaan Tapak Ruang Bangunan/Kiosk
280
Borang Permohonan Cenderamata
281
Borang Permohonan Menduduki Asrama Jururawat HSAAS (Pelajar)
282
Borang Permohonan Menduduki Asrama Jururawat HSAAS (Staf)
283
Surat Akuan Menduduki Asrama Jururawat
284
Slip Akuan Keluar Asrama
285
Slip Akuan Masuk Asrama

HSAAS DOCUMENT - SECURITY UNIT
286
Borang Akuan Penerimaan dan Penyerahan Kunci
287
Borang Permohonan Semakan Data Akses Keselamatan

HSAAS DOCUMENT - ISLAMIC AFFAIRS UNIT
288
Borang Khidmat Bimbingan Agama
289
Panduan Tatacara Pembacaan Doa dalam Majlis-Majlis Rasmi dan Separuh Rasmi Kerajaan di HSAAS
290
Borang Orientasi Pesakit (Program Hospital Mesra Ibadah)
HOSPITAL SULTAN ABDUL AZIZ SHAH (HSAAS) UNIVERSITI PUTRA MALAYSIA
Universiti Putra Malaysia
43400 UPM Serdang
Selangor Darul Ehsan
03 9769 5500
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