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PEMERINTAH KOTA PASURUAN

RUMAH SAKIT UMUM DAERAH Dr. R. SOEDARSONO


Jalan Dr. Wahidin Sudiro Husodo No. 1–4 (Kode Pos 67117)
Tlp 0343-421073 e-mail:rsudsoedarsono@pasuruankota.go.id

FORM B. LAPORAN BULANAN INDIKATOR MUTU DAN KESELAMATAN


PASIEN DARI UNIT KE KOMITE MUTU DAN KESELAMATAN PASIEN

NAMA UNIT : KAMAR OPERASI (OK)


INDIKATOR SASARAN MUTU : Surgery Safety Checklist (SSC)
AREA :
NUMERATOR :
DENUMERATOR :
FORMULA :
TARGET : %
HASIL INDIKATOR UNIT : %
KESIMPULAN :
ANALISA

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Target Tercapai
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Rekomendasi
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Tidak Lanjut
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Pasuruan,…...................,.........
Mengetahui Kepala Ruangan
Kepala Instalasi

Pelapor
(........................................) 1.U M A R ( ROCHMAD SUHARI,Skep.Ns )
2................... Nip : 19741117 199703 1 005

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