CEKLIST SUPERVISI FASILITATIF

DPM :
Alamat :
Tanggal :
No Indikator Temuan di Lapangan
A.    Indikator Mayor
1. Jam Pelayanan  

2. Surat Izin Praktik (SIP)  

3. Terdapat obat-obatan yang tidak kadaluarsa  

4. Terdapat obat emergency yang tidak  

kadaluarsa
5. MoU limbah medis padat dengan pihak ketiga  
yang berizin dan masih berlaku
6. Kalibrasi Alat Kesehatan  

7. Denah tempat praktik (tiap ruang terpisah)  

Ruang periksa : minimal 2 x 3 m  

Kamar mandi dan WC  

Ruang Tunggu  

8. MOU TBC

B.    Indikator Minor

1. Tidak melakukan recapping pada jarum spuit  

2. Kesesuaian alat dan cara sterilisasi  

3. Rekam Medis  

  a. Kelengkapan penulisan rekam medis  

  b. Penyimpanan rekam medis pada lemari  

tertutup dan terkunci
4. Instalasi Farmasi  
  a. Kelengkapan penulisan resep obat  

  Kondisi Ruang Pelayanan  

5. Tabung oksigen berwarna putih dan dilengkapi
penandaan isi/ kosong
 6. APAR (Alat Pemadam Api Ringan) ada dan  
tidak expired
7. Terdapat kartu pemeliharaan alkes dan sarpras  

8. Kebersihan dan kerapihan  

9. Sampah medis dan non medis terpisah  

10. APD  
Rekomendasi :

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Mengetahui : Team Pemeriksa :

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