LAPORAN SPM RAWAT INAP 2021

NO INDIKATOR STANDAR JAN PEB MAR APR MEI JUN JUL

1 Pemberi pelayanan rawat inap

a. Dokter spes 100% 100% 100% 100% 100% 100% 100% 100%
b. Tenaga mi 100% 100% 100% 100% 100% 100% 100% 100%
2 Dokter penan 100% 100% 100% 100% 100% 100% 100% 100%
3 Ketersediaan pelayanan rawat inap
a. Penyakit A 100% 100% 100% 100% 100% 100% 100% 100%
b. Penyakit 100% 100% 100% 100% 100% 100% 100% 100%
c. Obsgyn 100% 100% 100% 100% 100% 100% 100% 100%
d. Penyakit 100% 100% 100% 100% 100% 100% 100% 100%
e. Syaraf 100% 100% 100% 100% 100% 100% 100% 100%
f. Mata 100% 100% 100% 100% 100% 100% 100% 100%
g. THT 100% 100% 100% 100% 100% 100% 100% 100%
h. Rehab Med 100% 100% 100% 100% 100% 100% 100% 100%
i. Psikologi 100% 100% 100% 100% 100% 100% 100% 100%

Jam Visite
dokter jam
4 08.00 s/d 100% 100% 100% 100% 100% 100% 100% 100%
14.00 WIB

Tidak ada
kejadian
pasien Jatuh
5 yang 100%
berakibat
kecacatan/
kematian

6 Kematian pas < 0,24 %

7 Kejadian Pul <5%

Tingkat
kepatuhan
petugas
8 melaksanak 100%
an
identifikasi
pasien
 Tingkat
kepatuhan
petugas
melaksanak
an upaya
9 pencegahan 75%
resiko
cidera
akibat
pasien jatuh

Tingkat
kepatuhan
petugas
10 terhadap 75%
Clinical
Pathway

Tingkat
kepatuhan
petugas
melaksanak
11 an 80%
komunikasi
efektif
(CABAK,
SBAR)

JUMLAH PASIEN/ KUNJUNGAN

NO RUANG
1 2 3 4 5 6 7 8
1 Menur 92 109 103 116 131 135 138 117
2 Kenanga 127 135 177 159 154 166 83 129
3 Wijaya Ku 56 71 90 114 147 121 76 78
4 Bougenvill 43 60 76 81 123 102 124 34
5 Dahlia 71 125 190 202 206 191 115 116
6 Mawar
7 Soka 102 56 97 94 115 . . .
8 Anyelir
9 Teratai/ obs 133 143 157 190 215 183 141 183
10 Bayi rawat 63 94 79 104 115 98 82 33
JUMLAH 687 793 969 1060 1206 996 759 690

JUMLAH PASIEN YG DI OPERASI

NO RUANG
1 2 3 4 5 6 7 8
1 Menur 18 12 20 19 7 17 22 17
2 Kenanga 99 100 123 115 105 128 42 96
3 Wijaya Ku 6 12 15 14 10 10 12 16
4 Bougenvill 0 0 0 0 0 0 0 0
5 Dahlia 0 0 0 0 0 0 0 0
6 Mawar
7 Soka 0 0 0 1 1 . . .
8 Anyelir
9 Teratai 30 36 33 39 32 28 29 33
JUMLAH 153 160 191 188 155 183 105 162

JUMLAH PASIEN INFEKSI PASCA OP

NO RUANG
1 2 3 4 5 6 7 8
1 Menur 0 0 0 0 0 0 0 0
2 Kenanga 0 0 0 0 0 0 0 0
3 Wijaya Ku 0 0 0 0 0 0 0 0
4 Bougenvill 0 0 0 0 0 0 0 0
5 Dahlia 0 0 0 0 0 0 0 0
6 Mawar
7 Soka 0 0 0 0 0 . . .
8 Anyelir
9 Teratai 1 0 0 0 0 0 0 0
JUMLAH 1 0 0 0 0 0 0 0

INDETIFIKASI PASIEN
NO RUANG
1 2 3 4 5 6 7 8
1 Menur 100% 100% 100% 100% 100% 100% 100% 100%

2 Kenanga 100% 100% 100% 100% 100% 100% 100% 100%

3 Wijaya Ku 100% 100% 100% 100% 100% 100% 100% 100%

4 Bougenvill 100% 100% 100% 100% 100% 100% 100% 100%

5 Dahlia 100% 100% 100% 100% 100% 100% 100% 100%

6 Mawar 100%

7 Soka 100% 100% 100% 100% 100% . . .

8 Anyelir 100%

9 Teratai 100% 100% 100% 100% 100% 100% 100% 100%

JUMLAH 9 7 7 0 0 0 0 0

JUMLAH PASIEN JATUH

NO RUANG
1 2 3 4 5 6 7 8
1 Menur 0 0 0 0 0 0 0 0
2 Kenanga 0 0 0 0 0 0 0 0
3 Wijaya Ku 0 0 0 0 0 0 0 0
4 Bougenvill 0 0 0 0 0 0 0 0
5 Dahlia 0 0 0 0 0 0 0 0
6 Mawar
7 Soka 0 0 1 0 0 . . .
8 Anyelir
9 Teratai 0 0 0 0 0 0 0 0
JUMLAH 0 0 1 0 0 0 0 0

JUMLAH PASIEN MENINGGAL > 48 JAM

NO RUANG
1 2 3 4 5 6 7 8
1 Menur 0 0 0 0 0 0 0 0
2 Kenanga 0 0 0 0 0 1 1 1
3 Wijaya Ku 0 1 0 3 0 3 2 1
4 Bougenvill 0 0 0 0 0 0 0 0
5 Dahlia 0 4 3 6 12 12 8 6
6 Mawar
7 Soka 0 0 0 0 0 . . .
8 Anyelir
9 Teratai 0 0 0 0 0 0 0 0
JUMLAH 0 5 3 9 12 16 11 8

JUMLAH PASIEN APS

NO RUANG
1 2 3 4 5 6 7 8
1 Menur 0 0 1 0 1 0 0 2
2 Kenanga 1 3 1 1 1 3 0 0
3 Wijaya Ku 0 3 6 2 5 8 4 4
4 Bougenvill 2 3 6 3 11 9 2 0
5 Dahlia 2 9 4 3 12 10 12 6
6 Mawar
7 Soka 0 3 2 0 4 . . .
8 Anyelir
9 Teratai 0 0 1 0 1 0 0 0
JUMLAH 5 21 21 13 24 20 18 12

UPAYA PENCEGAHAN PASIEN JATUH

NO RUANG
NO RUANG
1 2 3 4 5 6 7 8
1 Menur 100% 100% 100% 100% 100% 100% 100% 100%

2 Kenanga 100% 100% 100% 100% 100% 100% 100% 100%

3 Wijaya Ku 100% 100% 100% 100% 100% 100% 100% 100%

4 Bougenvill 100% 100% 100% 100% 100% 100% 100% 100%

5 Dahlia 75% 75% 75% 75% 75% 75% 75% 75%

6 Mawar 75%

7 Soka 75% 75% 75% 75% 75% . . .

8 Anyelir 100%

9 Teratai 75% 75% 75% 75% 75% 75% 75% 75%

JUMLAH 8 6.25 6.25 6.25 6.25 5.5 5.5 5.5

CLINICAL PATHWAY
NO RUANG
1 2 3 4 5 6 7 8
1 Menur 75% 75% 75% 75% 75% 75% 75% 75%

2 Kenanga 100% 100% 100% 100% 100% 100% 100% 100%

3 Wijaya Ku 100% 100% 100% 100% 100% 100% 100% 100%

4 Bougenvill 100% 100% 100% 100% 100% 100% 100% 100%

5 Dahlia 75% 75% 75% 75% 75% 75% 75% 75%

6 Mawar 75%

7 Soka 100% 100% 100% 100% 100% . . .

8 Anyelir 75%

9 Teratai 75% 75% 75% 75% 75% 75% 75% 75%

JUMLAH 7.75 6.25 6.25 6.25 6.25 5.25 5.25 5.25

JUMLAH PASIEN RUJUKAN

NO RUANG
1 2 3 4 5 6 7 8
1 Menur 0 0 0 0 0 0 1 1
2 Kenanga 4 0 2 2 3 0 1 1
3 Wijaya Ku 0 0 2 2 3 1 0 0
4 Bougenvill 0 0 2 2 0 0 0 0
5 Dahlia 0 0 2 1 2 0 0 4
6 Mawar
7 Soka 0 0 0 0 0 . . .
8 Anyelir
9 Teratai 0 1 0 0 1 0 0 0
JUMLAH 4 1 8 7 9 1 2 6
NO RUANG JUMLAH PASIEN MENINGGAL < 48 JAM
1 2 3 4 5 6 7 8
1 Menur 0 0 0 0 0 0 0 0
2 Kenanga 1 1 1 1 0 0 1 1
3 Wijaya Ku 2 4 0 3 1 1 6 1
4 Bougenvill 1 2 5 1 7 9 24 0
5 Dahlia 0 6 4 5 3 7 13 6
6 Mawar
7 Soka 1 0 0 0 0 . . .
8 Anyelir
9 Teratai 0 0 0 0 0 0 0 0
JUMLAH 5 13 10 10 11 17 44 8

NO RUANG MELAKSANAKAN KOMUNIKASI EFEKTIF

1 2 3 4 5 6 7 8
1 Menur 80% 80% 80% 80% 80% 80% 80% 80%

2 Kenanga 80% 80% 80% 80% 80% 80% 80% 80%

3 Wijaya Ku 100% 100% 100% 100% 100% 100% 100% 100%

4 Bougenvill 100% 100% 100% 100% 100% 100% 100% 100%

5 Dahlia 80% 80% 80% 80% 80% 80% 80% 80%

6 Mawar 80%

7 Soka 80% 80% 80% 80% 80% . . .

8 Anyelir 80%

9 Teratai 80% 80% 80% 80% 80% 80% 80% 80%

JUMLAH 7.6 6 6 6 6 5.2 5.2 5.2

KEMATIAN IBU
NO RUANG MENUR
BULAN
1 2 3 4 5 6 7 8
1 PERDARA 0 0 0 1 0 0 0 0
2 PRE-EKLA 0 0 0 0 0 0 0 0
3 SEPSIS 0 0 0 0 0 0 0 0
4 LAIN-LAIN 0 0 0 0 0 0 12 5
JUMLAH 0 0 0 1 0 0 12 5

BULAN
NO RUANG MENUR
NO RUANG MENUR
1 2 3 4 5 6 7 8
1 TIM PONE 19 17 24 25 13 26 28 27

JUMLAH 19 17 24 25 13 26 28 27

BULAN
NO RUANG MENUR
1 2 3 4 5 6 7 8
1 DR SPOG 18 12 20 19 7 17 22 17

JUMLAH 18 12 20 19 7 17 22 17

BULAN
NO RUANG MENUR
1 2 3 4 5 6 7 8
1 JUMLAH
IUFD 4 5 0 2 1 4 8 5
LAHIR MATI 0 0 1 0 1 0 0 0
IPFD 2 1 0 0 1 0 0 1

JENIS
PERSALI BULAN
NO NAN
RUANG
MENUR 1 2 3 4 5 6 7 8
1 SPONTAN 74 93 81 93 119 109 112 92
2 SC 18 12 3 19 7 17 22 17
3 VAKUM EK 1 1 1 3 3 5 1 8
4 PATOLOGI 0 4 3 3 3 4 5 2
5 FORSEP E 0 0 0 0 0 0 0 0
JUMLAH 93 110 88 118 132 135 140 119

JENIS
PERSALI BULAN
NO NAN
RUANG
MENUR 1 2 3 4 5 6 7 8
1 LAKI 61 67 62 58 72 69 74 56
2 PEREMPU 32 43 43 60 60 67 66 63
JUMLAH 93 110 105 118 132 136 140 119

JENIS
PERSALI BULAN
NO NAN
RUANG
MENUR
 JENIS
PERSALI
NO NAN
RUANG
MENUR 1 2 3 4 5 6 7 8
1 BAYI RAW 55 64 64 78 98 73 64 66
2 BAYI MD 30 34 41 34 40 41 39 33
JUMLAH 85 98 105 112 138 114 103 99

JENIS
PERSALI BULAN
NO NAN
RUANG
MENUR 1 2 3 4 5 6 7 8
Pemasan
1 18 16 17 18 15 19 18 17
gan IUD
mow 3 4 2 5 4 2 3 1
21 20 19 23 19 21 21 18

JENIS
PERSALI BULAN
NO NAN
RUANG
MENUR 1 2 3 4 5 6 7 8
1 < 2500 11 17 12 13 7 18 21 27
2 2500 -3000 37 39 34 47 43 42 52 37
3 > 3000 39 48 58 56 79 71 59 49
JUMLAH 87 104 104 116 129 131 132 113

bayi lahir BULAN

NO
mati 1 2 3 4 5 6 7 8
1 < 2500 3 5 12 1 3 4 6 5
2 2500 -3000 2 0 34 1 0 0 0 1
3 > 3000 1 1 58 0 0 0 2 0
JUMLAH 6 6 104 2 3 4 8 6
NAP 2021
AGT SEP OKT NOP DES TOTAL

100% 100% 100% 100% 100%

100% 100% 100% 100% 100%
100% 100% 100% 100% 100%

100% 100% 100% 100% 100%

100% 100% 100% 100% 100%
100% 100% 100% 100% 100%
100% 100% 100% 100% 100%
100% 100% 100% 100% 100%
100% 100% 100% 100% 100%
100% 100% 100% 100% 100%
100% 100% 100% 100% 100%
100% 100% 100% 100% 100%

100% 100% 100% 100% 100%

,
GAN
JML
9 10 11 12
95 101 113 111 1361
153 146 208  203 1637
84 121 142 177 1277
44 61 79 120 947
136 136 164 194 1846
104  173 0
76 136 159 209 1044
28 69 -   - 97
158 171 194 200 2068
78 82 86 74 988
852 1023 1145 1085 11555

RASI
JML
9 10 11 12
13 10 10 16 181
101 89 158 168  1156
14 16 24 15 164
 0 3 0 0 3
0 0 0 0 0
0  0 0
1 0 0 0 3
0 0 -  - 0
36 33 39 38 406
165 151 231 69 1913

CA OP
JML
9 10 11 12
0 0 0 0 0
0 0 0  0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0
0 0 0 0 0
0 0 -  -  0
0 0 1 1 2
0 0 1 1 2

JML
9 10 11 12
100% 100% 100% 100% 12
100% 100% 100% 100% 12
100% 100% 100% 100% 12
100% 100% 100% 100% 12
100% 100% 100% 100% 12
100% 100% 1
100% 100% 100% 100% 9
100% 100% - - 5
100% 100% 100% 100% 12
0 0 0 0 0

H
JML
9 10 11 12
0 0 0 0 0
 0 0 0 0  0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
 0 0 0
0 1 0 0 2
0 0 -  - 0
0 0 0 0 0
0 0 0 0 1

> 48 JAM
JML
9 10 11 12
0 0 0 0 0
0 1 0 2 4
2 3 3 0 18
0 0 0 0 0
9 1 1 5 67
 0 0  0
1 1 1 0 3
0 0  - - 0
0 0 0 0 0
12 6 5 5 92

JML
9 10 11 12
0 0 0 1 5
4 1 2  5 17
2 3 1 1 39
1 1 1 4 43
5 4 2 6 75
 1  6 0
0 4 2 3 18
0 1 -  -  1
0 0 0 0 2
12 14 8 15 183

JATUH
JML
 JML
9 10 11 12
100% 100% 100% 100% 12
100% 100% 100% 100% 12
100% 100% 100% 100% 12
100% 100% 100% 100% 12
75% 75% 75% 75% 9
75%  75%  0.75
75% 75% 75% 75% 6.75
100% 100% - - 5
75% 75% 75% 75% 9
7.25 7.25 7.25 7.25 78.5

JML
9 10 11 12
75% 75% 75% 75% 9
100% 100% 100% 100% 12
100% 100% 100% 100% 12
100% 100% 100% 100% 12
75% 75% 75% 100% 9.25
75%  75%  0.75
100% 100% 100% 100% 9
50% 50% - - 2.75
75% 75% 75% 75% 9
6.75 6.75 6.75 7 75.75

AN
JML
9 10 11 12
0 0 0 0 2
2 1 1 2  17
0 0 1 0 9
0 0 0 0 4
1 1 0 0 11
 0 1  0
0 0 1 1 2
0 1  -  - 1
0 1 0 0 3
3 4 3 1 49
< 48 JAM JML
9 10 11 12
0 0 0 0 0
1 0 0 1  7
1 1 2 6 28
4 5 3 4 65
6 2 3 6 61
 4  6 0
0 0 0 0 1
0 6  -  - 6
0 0 0 0 0
12 14 8 16 168

EFEKTIF JML
9 10 11 12
80% 80% 80% 80% 9.6
80% 80% 80% 80% 9.6
100% 100% 100% 100% 12
100% 100% 100% 100% 12
80% 80% 80% 80% 9.6
80%  80%  0.8
80% 80% 80% 80% 7.2
80% 80% - - 4
80% 80% 80% 80% 9.6
6.8 6.8 6.8 6.8 74.4

JMH
9 10 11 12
0 0 0 0 1
0 0 0 0 0
0 0 0 0 0
2 0 0 1 20
2 0 0 1 21

JMH
 JMH
9 10 11 12
20 18 17 16 250

20 18 17 16 250

JMH
9 10 11 12
13 10 10 16 181

13 10 10 16 181

JMH
9 10 11 12

3 2 0 4 38
0 0 1 0 3
1 0 1 1 8

JMH

9 10 11 12
75 84 97 88 1117
13 10 10 16 164
3 5 5 5 41
4 3 2 2 35
0 0 0 0 0
95 102 114 111 1357

JMH

9 10 11 12
53 50 74 62 758
42 52 40 49 617
95 102 114 111 1375

JMH
 JMH

9 10 11 12
60 66 72 63 823
28 28 31 31 410
88 94 103 94 1233

JMH

9 10 11 12

19 17 21 30 225
2 7 1 2 36
21 24 22 32 261

JMH

9 10 11 12
7 17 13 17
22 34 30 33 340
62 49 69 56 550
91 100 112 106 1030

JMH
9 10 11 12
4 2 1 5 51
0 0 1 0
0 0 0 0
4 2 2 5 152