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FORMULIR PENYELESAIAN KOMPLAIN, KELUHAN, KONFLIK ATAU

PERBEDAAN PENDAPAT

Nomor :

Nama pasien/keluarga :

Tanggal lahir :

Tanggal/Jam Komplain :

Ruangan/bagian :

URAIAN MASALAH :

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TINDAKAN PENYELESAIAN KOMPLAIN

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Pihak Komplain Yang Menyelesaikan

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EVALUASI/TINDAK LANJUT:

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