DAFTAR ISI

Halaman

LEMBAR PENGESAHAN

KATA PENGANTAR

DAFTAR ISI

BAB 1 Pendahuluan

1.1. Latar Belakang .................................................................................................1

1.2. Manfaat dan tujuan HBL...................................................................................2
1.3. Manfaat HBL....................................................................................................3

BAB II PERATURAN INTERNAL KORPORASI (CORPORATE BYLAWS)

2.1. Defenisi ............................................................................................................4
2.2. Batasan .............................................................................................................4

BAB III IDENTITAS

3.1. Bagian pertama .................................................................................................7
3.1.1. Nama Dan Kedudukan RS......................................................................7
3.1.2. Logo dan motto.......................................................................................7
3.1.3. Bagian Kedua (Visi, Misi, fungsi dan tujuan )........................................8
3.2. Fungsi Peraturan Rumah Sakit .........................................................................8
3.3. Tujuan Peraturan Internal Rumah Sakit ............................................................9
3.3.1. Tujuan Umum ........................................................................................9
3.3.2. Tujuan Khusus .......................................................................................9
3.4. Bagian Ketiga, Nilai-Nilai Dasar ......................................................................9

BAB IV LANDASAN HUKUM

4.1. Landasan Hukum Penyusunan Peraturan Internal Rumah Sakit .....................11
4.2. Asas Dan Tujuan Rumah Sakit Umum sembiring ...........................................12
4.3. Tujuan RSUS Delitua .....................................................................................12
4.4. Fungsi Dan Kegiatan ......................................................................................13
4.4.1. Fungsi Dan Kegiatan Rumah Sakit Umum Sembiring .........................13

BAB V DEWAN PENGAWAS

5.1. Bagian Pertama, Kedudukan Dan Keanggotaan .............................................14
5.5.1. Syarat keanggotaan Dan Unsur Pengurus Dewan Pengawas ...............14
5.2. Prosedur Pemilihan, Pengangkutan Dan Masa Bakti Dewan Pengawas .........14
5.3. Aturan Merangkap Jabatan .............................................................................15
5.4. Pemberhentian Dewan Pengawas ...................................................................15
5.5. Bagian Kedua, Tugas Dan Wewenang ............................................................16
5.5.1. Tugas Pokok, Kewajiban, Hak Dan Wewenang Dewan .......................16
5.6. Ketua Dewan Pengawas .................................................................................16
5.6.1. Tugas Ketua Deewan Pengawas ..........................................................16
5.7. Sekretaris Dewan Pengawas ...........................................................................17
5.8. Bagian Ketiga,Rapat-Rapat.............................................................................17
5.8.1. Rapat Rutin ..........................................................................................17
5.8.2. Rapat Khusus .......................................................................................17
5.8.3. Rapat Tahunan .....................................................................................18
5.8.4. Undangan rapat ....................................................................................18
5.8.5. Peserta Rapat .......................................................................................18
5.8.6. Pejabat Ketua .......................................................................................18

5.8.7. Kuorum ................................................................................................18

5.8.8. Risalah Rapat .......................................................................................19
5.8.9. Pengambilan Putusan Rapat .................................................................19
5.8.10. Pembatalan Putusan Rapat..................................................................19
BAB VI PERATURAN INTERNAL KORPORAT PENGURUS YAYASAN
PENGELOLA
6.1. Tugas Dan Wewenang Pengurus Yayasan /Pengelola......................................20
6.2. Rapat Pengurus Yayasan .................................................................................21

BAB VII DIREKTUR RUMAH SAKIT

7.1. Pengangkatan Direktur ...................................................................................22
7.2. Persyaratan Direktur .......................................................................................22
7.3. Prosedur Perekrutan Calon Direktur ...............................................................22
7.4. Test kepatuhan Dan Kelayakan Calon Direktur ..............................................22
7.5. Masa Bakti Direktur .......................................................................................23
7.6. Pengankatan Dan Pemberhentian Direktur .....................................................23
7.7. Aturan Merangkap Jabatan .............................................................................24
7.8. Tugas Dan Wewenang Direktur ......................................................................24
7.9. Tanggung Jawab Direktur ...............................................................................25
7.10. Hak Direktur .................................................................................................25

BAB VIII KOMITE MEDIK DAN KOMITE KEPERAWATAN

8.1.Komite Medik .................................................................................................26
8.2. Komite Keperawatan ......................................................................................26

BAB IX SATUAN PENGAWAS INTERNAL

9.1. Keanggotaan, Syarat Dan Masa Bakti ............................................................28
9.2. Tugas, Tanggung Jawab, Tugas Pokok Dan wewenang..................................28
9.3. Aturan Merangkap Jabatan Pemberhentian SPI...............................................29
9.3.1. Aturan Merangkap Jabatan ..................................................................29
9.3.2. Pemberhentian Kepala Satuan Pengawas Internal ...............................29
9.3.3. Tata Cara Pemberhentian kepala Satuan Pengawas Internal Sebelum Habis
Masa Jabatannya ..................................................................................29

BAB X PENGORGANISASIAN STAF MEDIS FUNGSIONAL

10.1. Kedudukan Dan Keanggotaan Staf Medis Fungsional
10.1.1. Secara Administratif SMF Berada Dibawah Direktur Umum ....................31
10.1.2. Staf Medis Fungsional RSUS ....................................................................31
10.1.3. Kewajiban Kewenangan Kelompok Staf Medis Fungsional (SMF)...........31
10.1.4. Staf Medis .................................................................................................32

BAB XI KEWENANGAN KLINIS (CLINICAL PRIVILAGE)

BAB XII DOKTER PENANGGUNG JAWAB PELAYANAN (DPJP)

12.1. Bagian Kesatu,UMUM .................................................................................36
12.2. Bagian Kedua, Tujuan ..................................................................................36
12.3. Bagian Ketiga, Kebijakan .............................................................................36

BAB XIII PENUGASAN KLINIS (CLINICAL APPOINMENT)

BAB XIV KOMITE MEDIK

14.1. Nama Dan Susunan Organisasi.....................................................................38
14.2. Tugas Dan Fungsi .........................................................................................38
14.3. Kewenangan Komite Medik .........................................................................39
14.4. Pola Hubungan Komite Medik Dengan Direktur ..........................................40
14.5. Panitia Adhoc ...............................................................................................40
14.6. Rapat Komite Medik ....................................................................................40
14.6.1. Jenis Rapat.................................................................................................40
14.6.2. Rapat Rutin Komite Medik ........................................................................40
14.6.3. Rapat Khusus Komite Medik ....................................................................41
14.6.4. rapat Pleno Komite Medik .........................................................................41
14.6.5. Kuorum .....................................................................................................41
14.6.6. Pengambilan Keputusan Rapat ..................................................................42
14.6.7. Tata Tertib rapat .........................................................................................42
14.6.8. Notulen rapat .............................................................................................42

BAB XV SUB KOMITE KREDENSIAL

15.1. Tujuan ..........................................................................................................43
15.2. Konsep Kredensial .......................................................................................43
 15.3. Keanggotaan .................................................................................................43
15.4. Mekanisme Kredensial Dan Pemberian Kewenangan Klinis ........................44

BAB XVI SUBKOMITE MUTU PROFESI

16.1. Bagian Kesatu Tujuan ..................................................................................47
16.2. Bagian Kedua, Konsep Mutu Profesi ...........................................................47
16.3. Bagian Ketiga, Keanggotaan ........................................................................47
16.4. Bagian Keempat, Mekanisme Kerja .............................................................48

BAB XVII SUBKOMITE ETIKA DAN DISIPLIN PROFESI

17.1 Bagian Kesatu, Tujuan ..................................................................................51
17.2. Bagian Kedua, Konsep Etika Dan Disiplin Profesi ......................................51
17.3. Bagian Ketiga, keanggotaan .........................................................................52
17.4 Bagian Keempat, Mekanisme Kerja ..............................................................52

BAB XVII KEPERAWATAN

18.1. Nama Dan Susunan Organisasi ....................................................................55
18.2. Prinsip Kegiatan, Tujuan Dan Peran .............................................................55
A. Prinsip Kegiatan komite Keperawatan ...................................................55
B. Tujuan Pembentukan Komite Keperawatan ............................................55
C. Peran Komite Keperawatan ....................................................................55
18.3. Fungsi Komite Keperawatan ........................................................................56
A. Dalam Kaitan Dengan Pelayanan Keperawatan Di RS............................56
B. Dalam Kaitan Dengan Keanggotaan .......................................................56
18.4. Tugas Dan Peran Komite Keperawatan ........................................................57
18.4.1. Gariis Besar Komite Keperawatan ............................................................57
18.4.2. Peran Organisasi Komite Keperawatan .....................................................57
1. Ketua Komite ..........................................................................................57
2. Sub Komite Kredensial ...........................................................................57
3. Sub Komite Pengembangan Profesi ........................................................58
4. Sub Komite Mutu Keperawatan ..............................................................58
18.4.3. Bagian Kelima, Hubungan Dengan Direktur .............................................58

BAB XIX PEMBINAAN PROFESIONALIS MEDAN ETIKA

19.1. Pembinaan Profesionalisme Kedokteran ......................................................60

BAB XX MUTU ASUHAN PROFESIONAL KEPADA PASIEN

20.1. Pemeliharaan rekam Medis ..........................................................................61
20.2. Pengiriman Jaringan Unit Pemeriksaan Patologi ..........................................61
20.3. Persetujuan Tindakan Medis .........................................................................61

BAB XXI AMANDEMEN ............................................................................................63

BAB XXII PENGESAHAN ..........................................................................................64

BAB XXIII ATURAN PERALIHAN ...........................................................................65

BAB XXIV KETENTUAN PENUTUP ........................................................................66