KATA PENGANTAR

Segala puji dan syukur kami panjatkan kehadirat Allah SWT, Tuhan Yang Maha
Kuasa karena berkat rahmat dan inayah-Nya kami dapat menyelesaikan penyusunan
“Pedoman pelayanan Laboratorium ” dengan lancar .
Pedoman Pelayanan Laboratorium ini disusun agar Rumah Sakit Umum Harapan
Bersama digunakan untuk menjalankan kegiatan pelayanan bagi petugas yang ada di
Rumah Sakit Umum Harapan Bersama.
Ucapan terima kasih dan penghargaan selayaknya disampaikan kepada semua
pihak yang telah membantu penyusunan dan penerbitan pedoman ini. Semoga keinginan
untuk dapat lebih meningkatkan mutu dan keselamatan pasien dapat tercapai, seiring
dengan pemberdayaan para pelaksananya.
Kami sangat menyadari banyak terdapat kekurangan dalam penyusunan , semoga
kekurangan ini secara berkesinambungan akan terus diperbaiki sesuai dengan tuntutan
dalam pengembangan rumah sakit ini.

Singkawang, 17 Januari 2020

Tim Penyusun

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 DAFTAR ISI
KATA PENGANTAR................................................................................................i

DAFTAR ISI.............................................................................................................ii

BAB I PENDAHULUAN........................................................................................1

A. Latar Belakang....................................................................................................1
B. Tujuan..................................................................................................................1
C. Ruang Lingkup....................................................................................................1
D. Batasan Operasional............................................................................................1
E. Landasan Hukum.................................................................................................2

BAB II STANDAR KETENAGAAN......................................................................3

A. Kualifikasi Sumber daya manusia...............................................................3

B. Distribusi Ketenagaan.................................................................................3

C. Pengaturan Jaga...........................................................................................3

BAB III STANDAR FASILITAS.............................................................................5

A. Denah Ruang.......................................................................................................5

B. Standar Fasilitas..................................................................................................5

BAB IV TATA LAKSANA PELAYANAN............................................................7

A. Pendaftaran dan pencatatan.................................................................................7

B. Pengelolaan Spesimen.........................................................................................8

C. Pemeriksaan Laboratorium................................................................................10

D. Pelayanan Pemeriksaan.....................................................................................11

E. Daftar Nilai Normal dan Nilai Kritis.................................................................12

F. Waktu pelayanan pemeriksaan laboratorium....................................................21

G. Laporan Hasil dan Arsip....................................................................................23

H. Parameter yang di Rujuk...................................................................................23

I. Pemeliharaan dan Kalibrasi...............................................................................23

J. Troubleshooting.................................................................................................23
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BAB V LOGISTIK.................................................................................................24

A. Alur permintaan.................................................................................................24

B. Perencanaan.......................................................................................................24

BAB VI KESELAMATAN PASIEN......................................................................25

A. Pengertian..........................................................................................................25

B. Tujuan................................................................................................................25

C. Tata laksana keselamatan pasien.......................................................................26

BAB VII KESELAMATAN KERJA......................................................................28

A. Pengertian..........................................................................................................28

B. Tujuan................................................................................................................28

C. Tata laksana.......................................................................................................28

BAB VIII PENGENDALIAN MUTU....................................................................31

A. Pra Analitik........................................................................................................31

B. Analitik..............................................................................................................31

C. Pasca Analitik....................................................................................................32

D. Pemantapan Mutu Eksternal..............................................................................32

BAB IX PENUTUP.................................................................................................33

LAMPIRAN............................................................................................................34

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