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LAPORAN KETIDAKSESUAIAN TINDAK PERBAIKAN DAN PENCEGAHAN

Nomor: …(1)/YANMED-KEP/LKTPP/…(2:bulan)/2022

NAMA
NIP/NIK
PERIHAL
UNIT
HARI/TGL./BLN./TH.
JAM KEJADIAN/SHIFT
KETIDAKSESUAIAN/
KELUHAN

KRONOLOGIS KEJADIAN (NAMA PASIEN, NO. RM)

PEDOMAN

AKAR MASALAH

TINDAKAN PERBAIKAN

BATAS WAKTU
PENYELESAIAN
Selesai Tidak Selesai Paraf: Paraf:
TINDAKAN PENCEGAHAN

Kasatpel Kepala Pembuat


Ruang/Koordinator (Tanggal/Bulan/Tahun)

………………………………… ………………………… …………………………………


…. … ….
NIP/NIK NIP/NIK NIP/NIK
Mengetahui,
Kepala Seksi Pelayanan Medis dan Keperawatan

dr.Indah Rachmawati, MKM


NIP. 197107222006042016
LAPORAN KRONOLOGIS
Nomor: …(1)/YANMED-KEP/TPP/…(2:bulan)/2022

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Pembuat

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NIP/NIK

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