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PEMERINTAH KABUPATEN SRAGEN

DINAS KESEHATAN KABUPATEN SRAGEN


UPTD PUSKESMAS SAMBUNG MACAN II
Jalan Raya Timur km 15 Banaran Sambungmacan Sragen
Telp (0351) 671294, Kode pos 57253

FORMULIR LAPORAN INSIDEN INTERNAL di PUSKESMAS


SAMBUNGMACAN II
(RAHASIA TIDAK BOLEH DIFOTOCOPY, DI LAPORKANMAXIMAL2 x24 JAM)

LAPORAN INSIDEN INTERNAL


A. DATA PASIEN
Nama : ................................................................................................................
No RM : ................................................................................................................
Umur : ................................................................................................................
Jenis kelamin : ................................................................................................................
Alamat :................................................................................................................
No. HP : ................................................................................................................

B. RINCIAN KEJADIAN
1. Tanggal dan waktu kejadian
: ............................................................................................................................
.............
2. Insiden : ....................................................................................................
.....................................
3. Kronologi kejadian : ....................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
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 :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
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 :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

Pembuat laporan : Penerima laporan :

Paraf pelapor: Paraf penerima :

Tanggal terima : Tanggal lapor :


PEMERINTAH KABUPATEN SRAGEN
DINAS KESEHATAN KABUPATEN SRAGEN
UPTD PUSKESMAS SAMBUNG MACAN II
Jalan Raya Timur km 15 Banaran Sambungmacan Sragen
Telp (0351) 671294, Kode pos 57253

Laporan Kasus KTD, KPC dan KNC


No Tangg Nama

. al Korban Insiden Kejadian Lokasi Keterangan

Mengetahui,
Kepala Puskesmas Sambungmacan II

dr. UDAYANTI PROBORINI, M.Kes


NIP. 19740409 200312 2 002