PEDOMAN

PELAYANAN INSTALASI LABORATORIUM

RUMAH SAKIT HAWARI ESSA

JL. RAYA SLAWI – PURWOKERTO RT 01 / RW 05
KAJEN
LEBAKSIU – KABUPATEN TEGAL

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 KATA PENGANTAR

Puji syukur kita panjatkan kehadirat Tuhan Yang Maha Esa yang telah
melimpahkan segala hidayah dan inayah Nya pada kita semua sehingga kita dapat
menyusun Buku Pedoman Pelayanan Laboratorium di Rumah Sakit Hawari Essa.
Buku Pedoman Pelayanan Instalasi Laboratorium ini diharapkan dapat menjadi
dasar dan pijakan bagi setiap staf di unit pelayanan Rumah Sakit Hawari Essa dalam
memberikan pelayanan kepada pasien khususnya yang berkaitan dengan pelayanan
laboratorium.
Akhirnya kami mengucapkan terimakasih yang sebesar-besarnya kepada semua
pihak yang telah berkontribusi dalam penyusunan Pedoman Pelayanan Laboratorium
Rumah Medika Lebaksiu. Semoga dapat menjadi amal kebaikan dalam mengembangkan
mutu pelayanan kesehatan di Rumah Sakit Hawari Essa.

Lebaksiu, 09 Juli 2019

Penyusun

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 SAMBUTAN DIREKTUR

Seiring dengan perkembangan hukum kesehatan di Indonesia, setiap tenaga

kesehatan dituntut agar patuh dan mengikuti kebijakan, pedoman dan standard
prosedur operasional yang telah ditetapkan dalam memberikan pelayanan kesehatan
kepada pasien di semua unit pelayanan.
Pelayanan Pasien merupakan salah satu standar yang harus disediakan setiap
pemberi layanan kesehatan termasuk Rumah Sakit Hawari Essa yang memiliki fungsi
utama melaksanakan pelayanan kesehatan terhadap pasien yang membutuhkannya.
Oleh karena itu, terbitnya Buku Pedoman Pelayanan Laboratorium ini merupakan
pedoman teknis yang harus dilaksanakan oleh semua staff di seluruh unit pelayanan
Rumah Sakit Hawari Essa dalam memberikan pelayanan kepada pasien.
Dalam kesempatan ini pula, kami memberikan apresiasi yang setinggi-tingginya
kepada pihak-pihak yang berkontribusi dalam penyusunan Buku Pedoman Pelayanan
Laboratorium ini. Semoga buku ini dapat dilaksanakan dengan sebaik-baiknya yang pada
akhirnya dapat membantu meningkatkan mutu pelayanan kesehatan di Rumah Sakit
Hawari Essa.

Lebaksiu, 09 Juli 2019

Direktur Rumah Sakit Hawari Essa

dr. Abdul Roni

NIP. 19.04.0001

DAFTAR ISI

KATA PENGANTAR...................................................................................................................................... ii
SAMBUTAN DIREKTUR ............................................................................................................................ iii
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DAFTAR ISI ................................................................................................................................................... iv
BAB I PENDAHULUAN............................................................................................................................... 1
A........................................................................................................................................................... Lat
ar Belakang...................................................................................................................................... 1
B........................................................................................................................................................... Ru
ang Lingkup..................................................................................................................................... 2
C........................................................................................................................................................... Bat
asan Operasional........................................................................................................................... 2
D........................................................................................................................................................... La
ndasan Hukum .............................................................................................................................. 3
BAB II STANDAR KETENAGAAN........................................................................................................... 4
A........................................................................................................................................................... Ku
alifikasi Sumber Daya Manusia................................................................................................ 4
B........................................................................................................................................................... Dis
tribusi Ketenagaan....................................................................................................................... 4
C........................................................................................................................................................... Pe
ngaturan Jaga.................................................................................................................................. 5
BAB III STANDAR FASILITAS .................................................................................................................. 6
A.......................................................................................................................................... De
nah Ruang dan Daftar Inventaris Alat Laboratorium.....................................................6
Daftar Inventaris Alat Laboratorium.................................................................................... 7
B.......................................................................................................................................... Sta
ndar fasilitas.................................................................................................................................... 8
BAB IV TATA LAKSANA PELAYANAN ................................................................................................ 9
A.......................................................................................................................................... Pe
ndaftaran dan Pencatatan......................................................................................................... 9
B.......................................................................................................................................... Kri
teria Pemeriksaan Laboratorium........................................................................................... 9
C........................................................................................................................................... Pro
sedur Verifikasi Sampel dan Verifikasi Hasil Laboratorium.......................................11
D.......................................................................................................................................... Pe
ngelolaan Spesimen..................................................................................................................... 12

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 E........................................................................................................................................... Pe
meriksaan Laboratorium .......................................................................................................... 17
F........................................................................................................................................... Pe
meriksaan Laboratorium Rujukan......................................................................................... 19
G.......................................................................................................................................... Pe
ngelolaan Limbah.......................................................................................................................... 20
H.......................................................................................................................................... La
poran Hasil dan Arsip.................................................................................................................. 20
I............................................................................................................................................ Pe
meliharaan dan Kalibrasi Alat................................................................................................. 25
J............................................................................................................................................
Trouble Shooting........................................................................................................................... 28
BAB V LOGISTIK........................................................................................................................................... 29
A........................................................................................................................................................... Pe
ngadaan Barang Logistik ( reagen ) di Laboratorium....................................................29
B........................................................................................................................................................... Pe
ngadaan barang alat tulis kantor, rumah tangga, alat-alat kesehatan.....................29

BAB VI KESELAMATAN PASIEN............................................................................................................. 31

A........................................................................................................................................................... Pe
ngertian............................................................................................................................................. 31
B........................................................................................................................................................... Tuj
uan...................................................................................................................................................... 31
C........................................................................................................................................................... Tat
a Laksana Keselamatan Pasien................................................................................................ 31
BAB VII KESELAMATAN KERJA.............................................................................................................. 33
A........................................................................................................................................................... PE
MAKAIAN KACA MATA................................................................................................................ 33
B........................................................................................................................................................... PE
MAKAIAN JAS LABORATORIUM.............................................................................................. 33
C........................................................................................................................................................... PE
MAKAIAN MASKER...................................................................................................................... 33

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 D........................................................................................................................................................... PE
MAKAIAN SARUNG TANGAN.................................................................................................... 34
BAB VIII PENGENDALIAN MUTU.......................................................................................................... 35
A........................................................................................................................................................... Pra
analitik............................................................................................................................................... 35
B........................................................................................................................................................... An
alitik.................................................................................................................................................... 35
C........................................................................................................................................................... Pas
ca analitik......................................................................................................................................... 35
D........................................................................................................................................................... Pe
mantapan Mutu Internal (PMI)............................................................................................... 36
E........................................................................................................................................................... Pe
mantapan Mutu Eksternal (PME)........................................................................................... 36
BAB IX PENUTUP......................................................................................................................................... 37