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FORMULIR PENYELESAIAN KOMPLAIN, KELUHAN,

KONFLIK ATAU PERBEDAAN PENDAPAT

Nama Pasien/Keluarga : No :
Tanggal Lahir : Masalah : Baru
Tanggal/Jam Komplain : Lama
Ruangan/Bagian :

URAIAN MASALAH :
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Penerima Komplain

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TINDAKAN PENYELESAIAN SAAT KEJADIAN :
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Yang Menyelesaikan

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EVALUASI/TINDAK LANJUT :

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Perlu tindak lanjut

Evaluasi oleh

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