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RUMAH SAKIT IBU DAN ANAK SANTA ANNA

Jl. Hasanudin No. 27 Telukbetung _ Bandar Lampung (35211)


Telp. (0721) 482424 E-mail: rsia_st.anna@yahoo.co.id

FORMULIR PENYELESAIAN KOMPLAIN, KELUHAN,


KONFLIK ATAU PERBEDAAN PENDAPAT

Nama :
Tanggal Lahir :
No. RM :
Tanggal/Jam Komplain :
Ruangan/Bagian :

URAIAN MASALAH:
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Penerima Komplain

RENCANA PENYELESAIAN KELUHAN:


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Telukbetung,...................Pukul.........WIB

(..............................) (..............................)
Pasien/Keluarga Penerima Komplain
EVALUASI/TINDAK LANJUT :

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