KONFLIKATAUPERBEDAANPENDAPAT
NamaPasien/Keluarga
TanggalLahir
Tanggal/JamKomplain
Ruangan/Bagian
:
:
:
:
URAIANMASALAH
No
:
Masalah:Baru
Lama
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PenerimaKomplain
(..............................)
TINDAKANPENYELESAIANSAATKEJADIAN:
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YangMenyelesaikan
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EVALUASI/TINDAKLANJUT:
Tidakperlutindaklanjut
PerlutindaklanjutdenganCorrectiveActionRequest
Evaluasioleh
(...................................)
MH/1289/10/200803