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  • Formulir Keluhan

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    sri wahyuni
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    FORMULIR KELUHAN

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    28 tayangan2 halaman

    Formulir Keluhan

    Diunggah oleh

    sri wahyuni

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 2

    FORMULIR KELUHAN

    Nama Pasien/Keluarga : No. RM :………………


    Tanggal Lahir : Masalah : Baru
    Tanggal/Jam Komplain : Lama
    Ruangan/Bagian :
    (DIISI OLEH PASIEN/KELUARGA)
    URAIAN KELUHAN :
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    .....................................................................................................................................................

    TINDAKAN APA YANG DIHARAPKAN DARI RUMAH SAKIT UNTUK MENYELESAIKAN


    MASALAH TERSEBUT :
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................

    (DIISI PENERIMA KOMPLAIN)


    TINDAKAN PENYELESAIAN SAAT KEJADIAN :
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................................
    ................................................................................................................................................................
    Penerima Komplain

    (..............................)
    EVALUASI/TINDAK LANJUT :
    Tidak perlu tindak lanjut
    Perlu tindak lanjut
    Evaluasi oleh

    (...................................)

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