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 :
Evaluasi oleh
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