B. RINCIAN KEJADIAN
1. Tanggal dan waktu kejadian
: ............................................................................................................................
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2. Insiden : ....................................................................................................
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3. Kronologi kejadian : ....................................................................................................
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4. Jenis kejadian :
a. Kejadian Nyaris Cedera ( KNC )
b. Kejadian Tidak Diharapkan ( KTD )
5. Orang pertama yangmelaporkan insiden
a. Karyawan : Dokter/ Perawat/Petugas lainnya
b. Pasien
c. Keluarga/Pendamping Pasien
d. Pengunjung
e. Lain-lain...................................................................................................
(sebutkan)
6. Insiden terjadi pada.:
a. Pasien
b. Lain-lain ...................................................................................................
(sebutkan)
7. Insiden menyangkut :
a. Pasien Rawat Jalan
b. Pasien Rawat Inap
c. Pasien UGD
d. Lain lain....................................................................................................(sebutkan)
8. Tempat Insiden :
Lokasi
kejadian................................................................................................................
(tempat pasien berada )
9. Unit terkait yang menyebabkan
insiden : ........................................................................
......................................................................................................................( sebutkan )
10. Akibat Insiden terhadap pasien :
a. Kematian
b. Cederaberat
c. Cedera sedang
d. Cedera ringan
e. Tidak menyebabkan cedera
11. Tindakan yang dilakukan segera setelah kejadian, dan hasilnya :
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12. Tindakan dilakukan oleh :
a. Tim, terdiri
dari : .......................................................................................................
b. Dokter
c. Perawat
d. Petugas lainnya :........................................................................................................
13. Rencana yang akan dilakukan untuk mengcegah kejadian terulang kembali :
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Mengetahui,
Kepala Puskesmas Sambungmacan II