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F/006/008/R/00

KOMITE MEDIK
RSUP FATMAWATI

____________________________________________________________________

2ND PARTY AUDIT


Tanggal :………………………………….

I. Identitas Kasus

Diagnosa Kasus :
Nama :
Umur :
Jenis Kelamin :
No RM :

II. Pembahasan Diagnosis

Uraian Masalah SPO/PPK/SPM/Clinical


Pathway

III. Penatalaksanaan

Uraian Masalah SPO/PPK/SPM/


Clinical Pathway

IV. Kesimpulan :
................................................................................................................................................
................................................................................................................................................
V. Saran-saran :
................................................................................................................................................
................................................................................................................................................

Mengetahui Jakarta,................................
Komite Medik RSUP Fatmawati Sub Komite Etik dan Mutu Profesi
Ketua, Ketua,

Dr. Dody Firmanda, SpA, MA .........................................................


NIP : 195902201987021001

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