FORM A.

SENSUS HARIAN INDIKATOR SASARAN MUTU

UNIT :
JUDUL INDIKATOR AREA : Pencatatan dan Pelaporan Kasus Tuberculosis

BULAN :
TAHUN :
AREA MONITORING
: Unit Rawat Jalan
SUMBER DATA
: Survey Rekam Medis/ checklist
SAMPLE SIZE
:
Tangg Numerator Denumerator
al
1
2
3
4
5
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8
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10
11
12
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31
Jumla
h

Pangkalan
Bun, ............................................
Verifikator Indikator mutu utama/
Indikator mutu unit Penanggungjawab
Kepala bagian/Kasi/Karu/Kepala
instalasi-penanggungjawab unit

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 FORM B. LAPORAN BULANAN DARI UNIT KE KOMITE MUTU

Nama Unit :
Indikator Sasaran Mutu : Pencatatan dan Pelaporan Kasus Tubercolusis

Area : Unit Rawat Jalan

Numerator : Jumlah Pasien TB yang dicatat dan dilaporkan
Denumerator : Jumlah seluruh pasien tersangka tuberculosis yang
diperiksa
Formula : Numerator
----------------- x 100 % = ------------------------- x
100 %
Denumerator
Target : 100%
Hasil indikator mutu unit :
Kesimpulan : TERCAPAI / TIDAK TERCAPAI *)

Analisa unit : (Tercapai / tidak tercapai /, alasan *)

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Rekomendasi :

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Pangkalan Bun, ..............................................

Penanggungjawab Verifikator Komite mutu

Kepala bagian/Kasi/Karu/Kepala instalasi- (Ketua/Wakil Ketua/Sekretaris/*)
penanggungjawab unit/*)
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*) coret yang tidak perlu