PEMERINTAH KABUPATEN CIREBON

RUMAH SAKIT UMUM DAERAH WALED

Jl. Prabu Kian Santang No. 4 Telp. 0231-661126 Fax. 0231-664091 Cirebon
e-mail : brsud.waled@gmail.com

45187

RONDE MUTU DAN KESELAMATAN PASIEN (RKP)

 Wawancara dengan pasien mengenai pengalaman dan kepuasan selama dirawat :

Inisial nama pasien : ...............

Pengalaman pasien selama dirawat (terkait keselamatan pasien) :

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Kepuasan pasien selama dirawat (terkait mutu pelayanan) :

Kepuasan pasien terhadap pelayanan dokter ....................................................................
Kepuasan pasien terhadap pelayanan perawat...................................................................
Kepuasan pasien terhadap fasilitas pendukung pelayanan (farmasi/ pemeriksaan
penunjang ,dll.) ..................................................................................................................
Kepuasan pasien terhadap sarana prasarana (kebersihan toilet, kenyamanan ruangan,
AC,TV,kebersihan ruangan,dll) ..........................................................................................
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Petugas Ronde Mutu dan Keselamatan Pasien (RKP)

Nama : ________________________ Bagian / Unit Kerja : ________________________

Tanda tangan : ________________________ Tanggal RKP :________________________

 PEMERINTAH KABUPATEN CIREBON

RUMAH SAKIT UMUM DAERAH WALED

Jl. Prabu Kian Santang No. 4 Telp. 0231-661126 Fax. 0231-664091 Cirebon
e-mail : brsud.waled@gmail.com

45187

RONDE MUTU DAN KESELAMATAN PASIEN (RKP)

 Wawancara dengan keluarga pasien mengenai penilaian selama mengantar

atau mendampingi pasien ke Rumah Sakit :

Inisial nama pasien yang diantar / didampingi: ...............

Pengalaman selama mengantar / mendampingi pasien selama dirawat (terkait keselamatan pasien)
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Kepuasan pengantar / pendamping pasien selama dirawat :
Kepuasan pengantar / pendamping pasien terhadap pelayanan
dokter ....................................................................................................................................................
Kepuasan pengantar / pendamping pasien terhadap pelayanan
perawat ..................................................................................................................................................
...
Kepuasan pengantar / pendamping pasien terhadap fasilitas pendukung pelayanan (farmasi/
pemeriksaan penunjang ,dll.)
.............................................................................................................................................
Kepuasan pengantar / pendamping pasien terhadap sarana prasarana (kebersihan toilet, AC,
TV, kenyamanan ruangan, kebersihan ruangan,dll) .
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

Petugas Ronde Mutu dan Keselamatan Pasien (RKP)

Nama : ________________________ Bagian / Unit Kerja : ________________________

Tanda tangan : ________________________ Tanggal RKP :________________________

 PEMERINTAH KABUPATEN CIREBON

RUMAH SAKIT UMUM DAERAH WALED

Jl. Prabu Kian Santang No. 4 Telp. 0231-661126 Fax. 0231-664091 Cirebon
e-mail : brsud.waled@gmail.com

45187

RONDE MUTU DAN KESELAMATAN PASIEN (RKP)

 Wawancara dengan petugas / perawat tentang pelaksanaan tugas dan saran-saran

kepada manajemen :

Bagaimana pelaksanaan tugas pegawai / perawat di unit kerjanya ? (terkait keselamatan pasien)

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Adakah merasa puas dengan kondisi pekerjaannya ?
- Suasana kerja .................................................................................................................................
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- Tempat dan fasilitas kerja ...............................................................................................................
- Pendapatan yang diterima dibandingkan beban kerja ....................................................................
- Hubungan dengan unit kerja lain ....................................................................................................
- Perhatian dari atasan langsung maupun tidak langsung ................................................................
Lain-lain mengenai kondisi pekerjaannya : ................................................................................................
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Bagaimana saran-saran untuk manajemen dan pimpinan RSUD Waled ?

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Petugas Ronde Mutu dan Keselamatan Pasien (RKP)

Nama : ________________________ Bagian / Unit Kerja : ________________________

Tanda tangan : ________________________ Tanggal RKP :________________________