JUDUL SOP :

Nomor :
Terbit ke :
No.Revisi :
SOP Tgl.Terbit :
Dinkes.Kab. Halaman : UPT
Karanganyar Puskesmas
Matesih

Ditetapkan Kepala UPT

Puskesmas Matesih

Pengertian
Tujuan
Kebijakan

Referensi
Langkah- ........ ( Isinya kalimat perintah ) .............. !!!
langkah/
Prosedur
Unit Terkait

RekamanHistoris:

Diberlakukan
No Halaman Yang dirubah Perubahan Tgl.
 Judul SOP
No.Kode :
Terbitan :
Dinkes.Kab. Daftar No.Revisi : UPT
Karanganyar Tilik TglMulaiBerlaku :
Puskesmas
Matesih
Halaman :

Unit : ………………………………………………………………..
Nama Petugas : ………………………………………………………………..
TanggalPelaksanaan : ………………………………………………………………..

No Kegiatan Ya Tdk TidakBe

rlaku

Jumlah

Matesih, ………………..2016

Pelaksana / Ouditor

( ………………….)
 PEMERINTAH KABUPATEN KARANGANYAR
DINAS KESEHATAN
UPT PUSKESMAS MATESIH

Alamat :Jln. Raya TP Joko Songo MatesihTelp. (0271) 662670

Website .puskesmatesih.karanganyarkab.go.id
email.puskesmasmatesih@gmail.com KodePos 57781.

KEPUTUSAN KEPALA UPT.PUSKESMAS MATESIH

NOMOR ………………………………..

TENTANG

XXX………………………………………………………..

KEPALA UPT. PUSKESMAS MATESIH,

Menimbang : a. bahwa ………;

b. bahwa ……………..;
c.danseterusnya …………;
Mengingat : 1. Undang – Undang ……………….;
2. Peraturan Pemerintah……………………………;
3. danseterusnya ………………………..;
MEMUTUSKAN :

Menetapkan :XXX..........................................................................

KESATU :
KEDUA :
Dst :

Ditetapkan di :

Pada tanggal :

KEPALA UPT.PUSKESMAS MATESIH

 PEMERINTAH KABUPATEN KARANGANYAR
DINAS KESEHATAN
UPT PUSKESMAS MATESIH

Alamat :Jln. Raya TP Joko Songo MatesihTelp. (0271) 662670

Website .puskesmatesih.karanganyarkab.go.id
email.puskesmasmatesih@gmail.com KodePos 57781.

KERANGKA ACUAN

A.PENDAHULUAN
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B.LATAR BELAKANG
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C.TUJUAN UMUM DAN TUJUAN KUSUS
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D. CARA MELAKSANAKAN KEGIATAN

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E. SASARAN
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F. JADWAL PELAKSANAAN KEGIATAN
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G. SUSUNAN ACARA TERLAMPIR
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H. EVALUASI PELAKSANAAN KEGIATAN DAN PELAPORAN
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I.PENCATATAN , PELAPORAN DAN EVALUASI KEGIATAN
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KEPALA UPT. PUSKESMAS MATESIH