PEMERINTAH KABUPATEN MOJOKERTO

DINAS KESEHATAN
UPT. PUSKESMAS MODOPURO
Jl. S.Parman No. 10, Modopuro Telp. (0321) 593130
M O J O K E R T O 61382
Email :pkmmodopuro@yahoo.com

Batasan Kinerja Klinis Rendah

No. Pelayanan/ Tindakan Standar Analisa

Contoh

1. Sembuh Hathing Extremitas 20Hari Pasien tidak kontrol

2. Sembuh Hething kepala dan badan 15 Hari

3. Dst.

Ditetapkan di : Modopuro,...................
Kepala UPT Puskesmas Modopuro
Kab. Mojokerto

dr. Angky Meilin Widi Sumijayanti

NIP. 19840501 201412 2 001
 PEMERINTAH KABUPATEN MOJOKERTO
DINAS KESEHATAN
UPT. PUSKESMAS MODOPURO
Jl. S.Parman No. 10, Modopuro Telp. (0321) 593130
M O J O K E R T O 61382
Email :pkmmodopuro@yahoo.com

LAPORAN HASIL MONITORING MUTU LAYANAN KLINIS DAN

KESELAMATAN PASIEN YANG DISUSUN SECARA PERIODIK

Tanggal : .....................................................................................
Waktu : .....................................................................................
Kasus : .....................................................................................
Daftar Hadir : ..................................................................................... (terlampir)
Identitas Pasien : .....................................................................................
Nomor RM : .....................................................................................
Kronologis : .....................................................................................
Masalah : .....................................................................................

Evaluasi : .....................................................................................

N TIDAK
URAIAN SESUAI KETERANGAN
O SESUAI

1 Pelaksanaan SOP kasusu tersebut

2 Diagnosis kerja

3 Rencana Tindakan Penunjang

4 Diagnosis Pasti

5 Terapi

Saran : .....................................................................................

Kesimpulan : .....................................................................................