CHECLIST MONITORING DAN EVALUASI

PELAYANAN RUJUKAN PROVINSI NTB TAHUN 2021

a. Nama Rumah Sakit :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

b. Kelas Rumah Sakit :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
c. Pejabat yang ditemui :_________________

I. MANAJEMEN
a. Izin operasional : _________________________________________
b. Tata Kelola : _________________________________________
__________________________________________________________
c. Jenis Pelayanan : _________________________________________
__________________________________________________________
__________________________________________________________
d. Layanan Unggulan : _________________________________________
__________________________________________________________
e. Ketersediaan Sumber Daya
1) Sumber Daya Manusia : ___________________________________
_______________________________________________________
2) Pengelolaan Anggaran :____________________________________
_______________________________________________________
f. Pengelolaan SIM RS : ____________________________________
__________________________________________________________
__________________________________________________________
g. Pengelolaan SPA : _________________________________________
__________________________________________________________
h. Ketersediaan Ruang Pelayanan Khusus
1) Ruang Instalasi Gawat Darurat :

No Indikator Kondisi
.
1. Ruang Triase Sedang

2. Ruang Tindakan Sedang

Resusitasi

3. Ruang Tindakan Sedang

Pelayanan lain (Anak,
Obsgyn, Dalam)

4. Ruang Observasi Sedang

5. Ruang Dekontaminasi Sedang

6. Akses langsung Sedang

dengan penunjang,
OK, PONEK, BDRS
7. Outlet gas medik (O2, Sedang
udara tekan medik,
 vakum medik)
2) Ruang Isolasi :

No. Indikator Kondisi

1. Ukuran
2. Jumlah TT
3. Outlet oksigen
&Vakum medik
4. Wastafel dan toilet
5. Ruang bertekanan
negatif
6. Pertukaran udara,
baik alami/ mekanik
7. Pencahayaan alami
8. Nurse call
9. Non Ventilator a. Bedsite monitor
b. Oksigen portable
c. Infuse pump
d. Syringe pump
e. Anteroom (air-lock)
10. Ventilator a. Bedsite monitor
b. Oksigen portable
c. Infuse pump
d. Syringe pump
e. Defibrilator
f. EKG
11. SDM Ahli
12. SDM Terlatih PPI

3) Ruang Intensive care (HCU/ICU)

No. Indikator Keterangan

1. Lokasi (akses
mudah)
2. Kualitas udara a. Kelembaban udara
b. Tekanan positif
3. Outlet gas medik (O2,
udara tekan medik,
vakum medik)
4. Sentral monitor
( Nurse station)

4) Ruang OK

No. Indikator Keterangan

1. Jumlah Ruangan
2. Zonasi
3. Outlet gas medik (O2,
udara tekan medik,
vakum medik)
4. Persyaratan Tata a. Tekanan udara
 Udara b. Suhu ruangan
c. Kelembaban
d. Pertukaran udara
e. Hepa filter
5. Ruangan
II. PELAKSANAAN PROGRAM
a. Program Pelayanan KIA (PONEK)

No. Indikator Keterangan

1. Regulasi Direktur

2. Tim PONEK

3. Program Kerja

4. Hasil kegiatan
program

b. TELEMEDICINE

No. Indikator Keterangan

1. Regulasi

2. Penanggung Jawab
Telemedicine

3. Dukungan a. Alat
infrastruktur b. jaringan
4. Rujukan dengan
Telemedicine

5. Kendala

c. Dukungan terhadap Kegiatan PSC 119

No. Indikator Keterangan

1. Regulasi

2. Koordinasi dengan
PSC/ Ambulance lain

3. Infrastruktur a. Jaringan
b. Ambulance
c. Lain-lain

4. Tenaga terlatih

5. Kendala
III. PELAYANAN
a. Pelayanan Medik :____________________________________
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_
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b. Penunjang Medik :
1. Laboratorium pemeriksa Antigen
________________________________________________________
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2. Laboratorium pemeriksa PCR
________________________________________________________
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 3. UTDRS/BDRS
________________________________________________________
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c. Penunjang Non Medik : ____________________________________
__________________________________________________________
_
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
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IV. PELAPORAN
a. Pelaporan ke SIRS Online : ____________________________________
__________________________________________________________
_
__________________________________________________________
_
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
____
b. Kinerja Pelayanann 2021 :

No. Indikator kinerja Tahun 2020

1. Kunjungan rawat jalan
2. Kunjungan rawat inap
3. BOR
4. LOS
5. BTO
6. TOI
7. Pasien Hidup
8. Pasien Meninggal
9. GDR/ NDR

Mengetahui,
 _____________________

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