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KELOMPOK PANDUAN ELEMEN KETERANGAN

AKSES KE PELAYANAN &


KONTINUITAS PELAYANAN
Panduan Skrining Pasien
Policies identify which screening and diagnostic tests are standard before
admission.
Policy
Panduan TRIAGE

Panduan Identifikasi Pasien

Panduan Pendaftaran Pasien Rawat
Jalan & Rawat Inap
Written policies and procedures support the processes for admitting inpatients
and registering outpatients. Includes:
Outpatient registration
Admitting inpatients
Admitting emergency patients
Holding patients for observation
Policy and Procedure
Panduan Praktik Kedokteran

Panduan Penundaan Pelayanan Pasien
Written policies and/or procedures support consistent practice [on the process
for managing inpatients and outpatients when there is a delay in treatment].
Policy and Procedure
Panduan Informasi Pelayanan Pasien

Pedoman Pelayanan Unit Intensif

Panduan Pemulangan Pasien
Organization policy guides the process for patients being permitted to leave
the organization during the planned course of treatment on an approved
pass for a defined period of time
Policy and procedure define when the discharge summary must be
completed and in the record
Clinical records contain the completed summary list per organization policy
Policy


Policy and Procedure

Policy
Panduan Transfer (di dalam/ keluar RS)
Pasien
The organization has established entry and/or transfer criteria for its
intensive and specialized services or units, including research and other
programs to meet special patient needs.
Established criteria or policies determine the appropriateness of transfers
within the organization
The transfer of responsibility from individual to individual of the patients
care is described in organization policy
The records of transferred patients contain documentation or other notes as
required by the policy of the transferring organization
Criteria


Criteria or Policies

Policy

Policy and Procedure
Panduan Pelayanan Ambulance

KELOMPOK PANDUAN ELEMEN KETERANGAN

HAK PASIEN & KELUARGA
Panduan Kebutuhan Privasi dan
Perlindungan Harta

Panduan Perlindungan terhadap
Kekerasan Fisik

Panduan Penolakan Tindakan
(Resusitasi) dan Pengobatan
Policies and procedures support consistent practice [on resuscitative
practices].
Policy and Procedure
Panduan Menanggapi Keluhan
Policies and procedures support consistent practice [in the complaint process]. Policy and Procedure
Panduan Pelayanan Kerohanian Pasien

Panduan Perlindungan Hak Pasien dan
Keluarga
Policies and procedures guide and support patient and family rights in the
organization.
Policies and procedures are developed to support and to promote patient and
family participation in care processes.
Policies and procedures address the patients right to seek a second opinion
without fear of compromise to their care within or outside the organization.
Policy and Procedure
Panduan Tantang Bantuan Hidup Dasar
Policies and procedures support consistent practice [on resuscitative
practices].
Policy and Procedure
Panduan Persetujuan Tindakan
Kedokteran
The organization has a clearly defined informed consent process described in
policies and procedures.
The organization has listed those procedures and treatments that require
separate consent.
Policy and Procedure

Policy and Procedure
Panduan Informasi Pelayanan
Policies and procedures guide the information and decision process [for
research].
Policy and Procedure
Panduan Donor Organ
Policies and procedures guide the procurement and donation process. Policy and Procedure
Panduan Transplantasi
Policies and procedures guide the transplantation process. Policy and Procedure

KELOMPOK PANDUAN ELEMEN KETERANGAN

ASESMEN PASIEN
Panduan Asesmen Pasien :
a. Asesmen Medis
b. Asesmen Keperawatan
c. Asesmen Nutrisi
d. Asesmen Nyeri
Organization policy and procedure define the assessment information to be
obtained for inpatients.
Organization policy and procedure define the assessment information to be
obtained for outpatients.
Organization policy identifies the information to be documented for the
assessments.
The minimum content of assessments performed in inpatient settings is
defined in policies.
The minimum content of assessments performed in outpatient settings is
defined in policies.
All inpatients and outpatients have an initial assessment(s) that includes a
health history and physical examination consistent with the requirements
defined in hospital policy.
Policies and procedures support consistent practice in all areas [related to
identifying patient medical and nursing needs].
The initial medical assessment is conducted within the first 24 hours of
admission as an inpatient or earlier as indicated by the patients condition or
hospital policy.
The initial nursing assessment is conducted within the fist 24 hours of
admission as an inpatient or earlier as indicated by the patients condition or
hospital policy.
The organization defines criteria, in writing, that identify when additional,
specialized, or more in-depth special-needs assessments are performed.
Patients are reassessed at intervals based on their condition and when there
has been a significant change in their condition, plan of care, and individual
needs or according to organization policies and procedures.
For nonacute patients, the organization policy defines the circumstances in
which, and the types of patients or patient populations for which, a
physicians assessment may be less than daily and identifies the minimum
reassessment interval for these patients.
Those qualified to conduct patient assessments and reassessments have
their responsibilities defined in writing.
Policy and Procedure

Policy and Procedure

Policy and Procedure

Policy and Procedure

Policy and Procedure

Policy and Procedure


Policy and Procedure

Policy and Procedure


Policy and Procedure


Criteria

Policy and Procedure


Policy and Procedure



Policy and Procedure


KELOMPOK PANDUAN ELEMEN KETERANGAN


Panduan Pengelolaan Bahan dan limbah
Berbahaya
Written policies and procedures address the handling and disposal of infectious
and hazardous materials.
Policy and Procedure


Pedoman Pelayanan Laboratorium There is a laboratory equipment management program and it is
implemented.
The laboratory has and follows written guidelines for evaluation of all
reagents to provide for accuracy and precision of results.
Procedures guide the ordering of tests.
Procedures guide the collection and identification of specimens.
Procedures guide the transport, storage, and preservation of specimens.
Procedures guide the receipt and tracking of specimens.
There is a quality control program for the clinical laboratory.
Program

Guideline

Procedure
Procedure
Procedure
Procedure
Program

Pedoman Pelayanan Radiologi A radiation safety program is in place that addresses potential safety risks
and hazards encountered within or outside the department.
Written policies and procedures address compliance with applicable
standards, laws, and regulations.
Written policies and procedures address handling and disposal of
infectious and hazardous materials.
There is a radiology and diagnostic imaging equipment management
program, and it is implemented.
There is a quality control program for the radiology and diagnostic imaging
services, and it is implemented.
Program

Policy and Procedure

Policy and Procedure

Program

Program


PELAYANAN PASIEN
Panduan Pasien Risiko Jatuh
The use of restraint is guided by appropriate policies and procedures. Policy and Procedure
Panduan Manajemen Nyeri
Patients in pain receive care according to pain management guidelines. Guideline
Pedoman Pelayanan Laboratorium

Pedoman Pelayanan Radiologi

Pedoman Pelayanan Transfusi Darah
The handling, use, and administration of blood and blood products are guided
by appropriate policies and procedures.
Policy and Procedure
Pedoman Pelayanan Gizi RS

Panduan pelayanan pasien tahap
terminal


KELOMPOK PANDUAN ELEMEN KETERANGAN

PELAYANAN PASIEN
Panduan Pelayanan Pasien Risiko Tinggi
The care of comatose patients is guided by appropriate policies and
procedures.
The care of patients who are on life support is guided by policies and
procedures.
The care of patients with communicable diseases is guided by appropriate
policies and procedures.
The care of immune-suppressed patients is guided by appropriate policies
and procedures.
The care of patients on dialysis is guided by appropriate policies and
procedures.
The care of frail, dependent elderly patients is guided by appropriate
policies and procedures.
The care of young, dependent children is guided by appropriate policies
and procedures.
Patient populations at risk for abuse are identified, and their care is guided
by appropriate policies and procedures.
The care of patients receiving chemotherapy or other high-risk medications
is guided by appropriate policies and procedures.
Policy and Procedure

Policy and Procedure

Policy and Procedur

Policy and Procedure

Policy and Procedure

Policy and Procedure

Policy and Procedure

Policy and Procedure

Policy and Procedure
Panduan Pelayanan Kedokteran dan
keperawatan
Policies and procedures guide uniform care and reflect relevant laws and
regulations.
Orders are written when required and follow organization policy.
Policy and Procedure

Policy
Panduan Pelayanan Kasus Emergensi
The care of emergency patients is guided by appropriate policies and
procedures.
Policy and Procedure
Panduan Pelayanan Resusitasi
The uniform use of resuscitation services throughout the organization is guided
by appropriate policies and procedures.
Policy and Procedure

KELOMPOK PANDUAN ELEMEN KETERANGAN

PELAYANAN ANESTESI &
BEDAH
Pedoman Pelayanan Kamar Operasi

Panduan Pelayanan anestesi
Policy and procedure address the minimum frequency and type of
monitoring during anesthesia and are uniform for similar patients receiving
similar anesthesia wherever anesthesia is provided.
Physiological status is monitored according to policy and procedure during
anesthesia administration.
Patients are monitored according to policy during the postanesthesia
recovery period.
Policy


Policy and Procedure

Policy
Panduan Pelayanan Bedah

Panduan Pembuatan Laporan Operasi

Panduan Sedasi
Appropriate policies and procedures, addressing at least elements a) through f)
found in the intent statement, guide the care of patients undergoing moderate
and deep sedation.
There is a pre-sedation assessment performed that is consistent with
organization policy to evaluate risk andappropriateness of the sedation for the
patient.
Estab lished criteria are developed and documented for the recovery and
discharge from sedation.
Policy and Procedure


Policy



Criteria



KELOMPOK PANDUAN ELEMEN KETERANGAN


MANAJEMEN
PENGGUNAAN OBAT



Pedoman Pelayanan Farmasi
There is a plan or policy or other document that identifies how medication
use is organized and managed throughout the organization.
There is a list of medications stocked in the organization or readily available
from outside sources.
Organization policy defines how medications brought in by the patient are
identified and stored.
Organization policy defines how appropriate nutrition products are stored.
Organization policy defines how radioactive, investigational, and similar
medications are stored.
Organization policy defines how sample medications are stored and
controlled.
Policies and procedures address any use of medications known to be
expired or outdated.
Policies and procedures address the destruction of medications known to
be expired or outdated.
Policies and procedures guide the safe prescribing, ordering, and
transcribing of medications in the organization.
Policies and procedures address actions related to illegible prescriptions
and orders.
The organization has a policy that identifies those adverse effects that are
to be recorded in the patients record and those that must be reported to
the organization.
A medication error and near miss are defined through a collaborative
process.
Plan or Policy

List

Policy


Policy
Policy

Policy

Policy and Procedure

Policy and Procedure


Policy and Procedure

Policy and Procedure

Policy



Document




PENDIDIKAN PASIEN &
KELUARGA
Pedoman Pelayanan PKRS

Bahan Materi Edukasi

Formulir Pemberian Edukasi

Panduan Komunikasi Yang Efektif

Panduan Rekam Medis

KELOMPOK PANDUAN ELEMEN KETERANGAN


PENINGKATAN MUTU &
KESELAMATAN PASIEN
Panduan Upaya Peningkatan Mutu
Pelayanan RS
The organizations leadership participates in developing the plan for the
quality improvement and patient safety program.
On an annual basis, clinical leaders determine at least five priority areas on
which to focus the use of guidelines, clinical pathways, and/or clinical
protocols.
The organization has an internal data validation process that includes a)
through f) in the intent statement.
Plan/Program

Priority Areas


Process

Panduan Keselamatan Pasien
The hospital leaders have established a definition of a sentinel event that at
least includes a) through d) found in the intent statement.
The organization establishes a definition of a near miss.
The organizations leaders adopt a risk management framework to include
a) through f) in the intent.
Policy Definition

Policy Definition
Framework


PENCEGAHAN &
PENGENDALIAN INFEKSI
Pedoman pelayanan PPI
The program is guided by appropriate policies and procedures [to reduce risks
of health careassociated infections].

The organization assesses these risks [of the infection prevention and
reduction program] at least annually, and the assessment is documented.
The organization has identified those processes associated with infection risk.
The organization identifies which risks require policies and/or procedures, staff
education, practice changes, and other
activities to support risk reduction.
There is a policy and procedure consistent with national laws and regulations
and professional standards in place that identifies the process for managing
expired supplies.
When single-use devices and materials are reused, the policy includes items a)
through e) in the intent statement.
The disposal of sharps and needles is consistent with infection prevention and
control polices of the organization.
The organization develops an infection prevention and control program that
includes all staff and other professionals and patients and families.
Policy and Procedure


Risk Assessment


Processes
Policy and Procedure


Policy and Procedure


Policy

Policy

Program

KELOMPOK PANDUAN ELEMEN KETERANGAN

PENCEGAHAN &
PENGENDALIAN INFEKSI
Panduan Sterilisasi

Panduan Manajemen Linen & Laundry

Panduan Kamar Isolasi
Patients with known or suspected contagious diseases are isolated in
accordance with organization policy and recommended guidelines.
Policies and procedures address the separation of patients with
communicable diseases from patients and staff who are at greater risk due
to immunosuppression or other reasons.
Policies and procedures address how to manage patients with airborne
infections for short periods of time when negative pressure rooms are not
available.
Policy

Policy and Procedure


Policy and Procedure
Panduan APD

Panduan hand hygiene
The organization has adopted hand-hygiene guidelines from an authoritative
source.
Guideline


KUALIFIKASI & PENDIDIKAN
STAF
Panduan Standar Fasilitas

Pedoman manajemen SDM :
a. Panduan Penilaian Kinerja Profesional
b. Panduan Penerimaan Staf
c. Panduan Persyaratan Jabatan
d. Panduan Uraian Jabatan
e. Panduan Ketenagaan
There is a written plan for staffing the organization.
There is a process described in policy for the review of each medical staff
members credential file at uniform intervals at least once every three
years.
The organization uses a standardized process that is documented in official
organization policy for granting privileges to each medical staff member to
provide services on initial appointment and on reappointment.
The ongoing professional practice evaluation and annual review of each
medical staff member are accomplished by a uniform process that is
defined by organization policy.
The organization has a standardized procedure to gather the credentials of
each nursing staff member.
The organization has a standardized procedure to gather the credentials of
each health professional staff member.
Plans
Policy


Policy


Policy


Procedure

Procedure
Panduan Pemberian Vaksinasi dan
Imunisasi bagi staf
There is a policy on the provision of staff vaccinations and immunizations. Policy

Panduan evaluasi, konseling, dan tindak
lanjut terhadap staf yang terpapar
penyakit infeksius
There is a policy on the evaluation, counseling, and follow-up of staff exposed
to infectious diseases that is coordinated with the infection prevention and
control program.
Policy
KELOMPOK PANDUAN ELEMEN KETERANGAN

MANAJEMEN FASILITAS &
KESELAMATAN
Pedoman pelayanan K3
There are written plans that address the risk areas a) though f) in the intent
statement.
a) Safety and security (Also see FMS.4 ME 1 through ME 4)
b) Hazardous materials (Also see FMS.5 ME 2 through ME 7)
c) Emergencies (Also see FMS.6, ME 1)
d) Fire Safety (Also see FMS.7.1 ME 1 through ME 5)
e) Medical equipment (Also see FMS.8 MEs 1 through ME 3 and FMS.8.1 ME 1
and ME 2)
f ) Utility systems (Also see FMS.9.1, ME 3)
Plans
Panduan K3 Konstruksi
The organization has a documented, current, accurate inspection of its
physical facilities.
The organization has a plan to reduce evident risks based on the inspection.
Document

Plan
Panduan Pengelolaan Bahan & Limbah
Berbahaya
The organization identifies hazardous materials and waste and has a current
list of all such materials within the organization.
List
Panduan Penanggulangan Kebakaran,
Kewaspadaan Bencana & Evakuasi

Panduan Pembelian Alat Medis

Panduan Pemeliharaan Alat Medis
Inspection, testing, and maintenance of equipment and systems are
documented.
Documented Inspections

Panduan Larangan Merokok
The organization has developed a policy and/or procedure to eliminate or to
limit smoking.
Policy and Procedure
Panduan Penarikan Produk dan
Peralatan
Policy or procedure addresses any use of any product or equipment under
recall.
Policy

KELOMPOK PANDUAN ELEMEN KETERANGAN

MANAJEMEN KOMUNIKASI &
INFORMASI
Panduan Komunikasi Yang Efektif

Pedoman Pelayanan Rekam Medis
Policy establishes those health care practitioners who have access to the
patients record(s).
There is a written policy for addressing the privacy and confidentiality of
information that is based on and consistent with laws and regulations.
The policy defines the extent to which patients have access to their health
information and the process to gain access whenpermitted.
The organization has a written policy for addressing information security,
including data integrity, that is based on or consistent with law or
regulation.
The policy includes levels of security for each category of data and
information identified.
The organization has a policy on retaining patient clinical records and other
data and information.
There is a written policy or protocol that defines the requirements for
developing and maintaining policies and procedures including at least items
a) through h) in the intent, and it is implemented.
There is a written protocol that outlines how policies and procedures that
originated outside the organization will be controlled, and it is
implemented.
There is a written policy or protocol that defines retention of obsolete
policies and procedures for at least the time required by laws and
regulations, while ensuring that they will not be mistakenly used, and it is
implemented.
There is a written policy or protocol that outlines how all policies and
procedures in circulation will be identified and tracked, and it is
implemented.
Those authorized to make entries in the patient clinical record are
identified in organization policy.
The format and location of entries are determined by organization policy.
Those authorized to have access to the patient clinical record are identified
in organization policy.
There is a process to ensure that only authorized individuals have access to
the patient clinical record.
Policy

Policy

Policy

Policy

Policy

Policy

Policy

Protocol

Policy or Protocol



Policy or Protocol


Policy

Policy
Policy

Policy

KELOMPOK PANDUAN ELEMEN KETERANGAN


SASARAN KESELAMATAN
PASIEN
Panduan Identifikasi Pasien
Policies and procedures support consistent practice in all situations and
locations. (See ME 1 through ME 4 for policy inclusions.)
Policy and Procedure
Panduan Komunikasi Yang Efektif
Policies and procedures support consistent practice in verifying the accuracy of
verbal and telephone communications. (See ME 1 through ME 3 for policy
inclusions.)
Policy and Procedure
Panduan obat high alert, NORUM
Policies and/or procedures are developed to address the identification,
location, labeling, and storage of high-alert medications
Policy and Procedure
Surgical Safety Checklist
Policies and procedures are developed that will support uniform processes to
ensure the correct site, correct procedure, and correct patient, including
medical and dental procedures done in settings other than the operating
theatre.
Policy and Procedure
Panduan Hand Hygiene
Policies and/or procedures are developed that support continued reduction of
health careassociated infections.
Policy and Procedure
Panduan pencegahan pasien jatuh
Policies and/or procedures support continued reduction of risk of patient harm
resulting from falls in the organization.
Policy and Procedure


MDGs
Panduan penyelenggaraan PONEK 24
jam di RS

Pedoman pelaksanaan program RS
sayang ibu dan bayi

Panduan pelayanan kesehatan BBLR
dengan perawatan metode kanguru

Panduan rawat gabung ibu dan bayi

Panduan pelayanan orang dengan
HIV/AIDS (ODHA)

Panduan pelayanan TBC dengan strategi
DOTS