(tempel stiker identitas)

PENYAMPAIAN KELUHAN
PASIEN/ KELUARGA

RS MITRA BANGSA
PATI No. Kamar : Kelas:

Yang bertandatangan di bawah ini (penyampaian keluhan) :

Nama : .................................................................................................................................
Alamat : .................................................................................................................................
No. Telpon : .................................................................................................................................
Hubungan dengan pasien : diri sendiri/ orang tua/ anak/ wali *)
JENIS KELUHAN :
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Pati, .................................
Penyampai keluhan, Penerimaan keluhan

(____________________) (____________________)
Tanda tangan & nama jelas Tanda tangan & nama jelas

PENYELESAIAN KELUHAN :
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Keluhan dapat diselesaikan

Pihak pasien/ keluarga, Pihak Rumah Sakit

(____________________) (____________________)
Tanda tangan & nama jelas Tanda tangan & nama jelas

Keluhan tidak dapat diselesaikan, diteruskan ke ....................................................................

INVESTIGASI :
Tanggal : ......................................................................................................................................
Yang melakukan investigasi : .....................................................................................................
Hasil investigasi : ........................................................................................................................
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RENCANA TINDAK LANJUT :

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PENYELESAIAN KELUHAN :
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Keluhan dapat diselesaikan

Pihak pasien/ keluarga, Pihak Rumah Sakit

(____________________) (____________________)
Tanda tangan & nama jelas Tanda tangan & nama jelas

Keluhan tidak dapat diselesaikan, diteruskan ke ....................................................................