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FORMULIRPENYELESAIANKOMPLAIN,KELUHAN,

KONFLIKATAUPERBEDAANPENDAPAT

NamaPasien/Keluarga
TanggalLahir
Tanggal/JamKomplain
Ruangan/Bagian

:
:
:
:

URAIANMASALAH

No
:
Masalah:Baru
Lama

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PenerimaKomplain
(..............................)
TINDAKANPENYELESAIANSAATKEJADIAN:
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YangMenyelesaikan
(...............................)
EVALUASI/TINDAKLANJUT:
Tidakperlutindaklanjut
PerlutindaklanjutdenganCorrectiveActionRequest
Evaluasioleh

(...................................)
MH/1289/10/200803

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