POKJA PMKP

IGD
1. KEPATUHAN IDENTIFIKASI PASIEN
IGD – Identifikasi Pasien
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Pemberian Obat = 0 Pemberian Obat = 0 Pemberian Obat = 7 Pemberian Obat = -
Pengambilan Pengambilan 1=6 41
Specimen = 0 Specimen = 0 0=1 1 = 31
Sebelum melakukan Sebelum melakukan Pengambilan 0 = 10
Tindakan Diagnstik = Tindakan Diagnstik = Specimen (Darah) = Pengambilan
0 0 8 Specimen (Darah) =
1=8 24
0=0 1 = 22
Sebelum melakukan 0=2
Tindakan Diagnstik =
0 Sebelum melakukan
Tindakan Diagnstik =
0
67/80 x 100% =
83,75 %
2. IGD - Kepatuhan Cuci Tangan
IGD- Kepatuhan Cuci tangan
01/01/2022 02/01/2022 03/01/2022 04/01/2022
Indikasi = 10 Indikasi = 10 Indikasi = 9
M1=6 M 1 = 10 M1 = 7
M2 = 0 M2 = 0 M2 = 0
M3=0 M3=0 M3=0
M4 = 0 M4 = 0 M4 = 0
M5 = 10 M5 = 8 M5 = 9

Profesi ? Profesi ?
Indikasi = 8 Indikasi = 11
1= 3 1=9
0=5 0=2
N/D x 100% = 23 + 27 =50 /3= 17/29 x 100% = 58,6 %
PERAWATAN INAP 1
1. Kepatuhan Identifikasi Pasien
Rawat Inap 1 – Kepatuhan Identifikasi Pasien
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Pemberian Obat = Pemberian Obat = Pemberian Obat = Pemberian Obat = -
15 15 15 24
Pemberian Nutrisi = Pemberian Nutrisi = Pemberian Nutrisi = Pemberian Nutrisi =
10 10 10 0

Pengambilan Pengambilan Pengambilan Pengambilan

Specimen = 0 Specimen = 0 Specimen = 0 Specimen = 0

Sebelum melakukan Sebelum melakukan Sebelum melakukan Sebelum melakukan

Tindakan Diagnstik = Tindakan Diagnstik = Tindakan Diagnstik = Tindakan Diagnstik =
0 0 0 0
1. Kepatuhan Identifikasi Pasien
Minggu 1 :
n = ∑1 x 100%
∑ Denominator
n = 99 x 100%
99
= 100 %
2. Kepatuhan Cuci Tangan
Ranap 1, Kepatuhan Cuci Tangan
? 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Indikasi = 3 - - - -
M1 = 3
M2 = 3
M3 = 3
M4 = 3
M5 = 3
Minggu 1
n = ∑1 x 100%
∑ Denominator
n = 3 x 100%
3
= 100 %
3. Kepatuhan Waktu Visite Dokter
Ranap 1 – Visite Dokter
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022
≤ 14.00 = 2 ≤ 14.00 = 3 ≤ 14.00 = 3 ≤ 14.00 = 2 -
≥ 14.00 = 0 ≥ 14.00 = 0 ≥ 14.00 = 0 ≥ 14.00 = 0

N/D x 100 % = 10/10 x 100 % = 100 %

Rawat Inap 2 – Kepatuhan Identifikasi Pasien
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Pemberian Obat = 0 Pemberian Obat = 0 Pemberian Obat = Pemberian Obat = 0 Pemberian Obat = 4
Pemberian Nutrisi = Pemberian Nutrisi = DP/DS= 12 Pemberian Nutrisi = 1= 3
0 0 DM = - 0 0= 1
Pemberian Nutrisi = Pemberian Nutrisi =
Pengambilan Pengambilan 0 Pengambilan 1
Specimen = 0 Specimen = 0 Specimen = 0
Pengambilan Pengambilan
Sebelum melakukan Sebelum melakukan Specimen = 0 Sebelum melakukan Specimen = 0
Tindakan Diagnstik = Tindakan Diagnstik = Tindakan Diagnstik =
0 0 Sebelum melakukan 0 Sebelum melakukan
Tindakan Diagnstik = Tindakan Diagnstik =
0 0
100% 80 %
Rawat Inap 2
1.Kepatuhan indentifikasi
Ranap 2 – Visite Dokter
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Libur Libur ≤ 14.00 = 5 ≤ 14.00 = 2 ≤ 14.00 = 5
≥ 14.00 = 0 ≥ 14.00 = 0 ≥ 14.00 = 0

N/D x 100 % = 12/12 x 100 % = 100 %

Rawat Inap 2
Kepatuhan Waktu Visit Dokter
RANAP 2- Kepatuhan Cuci tangan
01/01/2022 02/01/2022 03/01/2022 04/01/2022 ?
- - Indikasi = 3 Indikasi = 0 Indikasi = 2 (Visite
M1=3 M1=0 Dokter )
M2 = 3 M2 = 0 M1 = 2
M3=3 M3=0 M2 = 0
M4 = 3 M4 = 0 M3=0
M5 = 3 M5 = 0 M4 = 2
M5 = 2
Profesi 0 Profesi 0
Indikasi = 0 Indikasi = 0
1= 0 1=0
0=0 0=0
N/D x 100% = 5/5 x 100 % = 100%
APOTEK– Kepatuhan Identifikasi Pasien
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Pemberian Obat = Pemberian Obat = Pemberian Obat = Pemberian Obat = -
38 32 81 67

218/218 x 100% =
100 %
APOTEK
1. Kepatuhan Identifikasi Pasien
APOTEK – CUCI TANGAN
? 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Indikasi = 6 - - - -
M1 = 6
M2 = 0
M3 = 0
M4 = 6
M5 = 0

N/D x 100 % = 6/6 x

100 %
2. Kepatuhan Cuci Tangan
Loket Pendaftaran – Kepatuhan Cuci Tangan
? 02/01/2022 03/01/2022 04/01/2022 05/01/2021
Indikasi = 7 - - -
M1=7
M2 = 0
M3=0
M4 = 0
M5 = 7

Profesi 0
Indikasi = 0
1= 0
0=0

N/D x 100% = 7/7 x 100 % = 100%

LOKET PENDAFTARAN / RM
1. Kepatuhan Cuci Tangan
Rawat Jalan – Waktu Tunggu Pasien
03/01/2022 05/01/2022
≤ 1 jam ≥ 1 jam ≤ 1 jam ≥ 1 jam
3 52 12 12
N/D x 100 % = 3/55 x 100% = 5,4 % 12/24 x 100% = 50 %
Rawat jalan – Kepatuhan Cuci Tangan
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022

- - - - -
Radiologi – Identifikasi Pasien
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Libur Libur Sebelum melakukan Sebelum melakukan Sebelum melakukan
Tindakan Diagnstik = Tindakan Diagnstik = Tindakan Diagnstik =
3 2 0

1=2 1=1
0=1 0=0
33,3 % 50% 0
Radiologi - Kepatuhan Cuci Tangan
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Liibur Libur Indikasi = 3 Indikasi = 2 -
M1 = 3 M1 = 2
M2 = NA M2 = NA
M3 = NA M3 = NA
M4 = 3 M4 = 2
M5 = 3 M5 = 2

Profesi : Profesi : -
Radiografer : Radiografer :
Indikasi 3 Indikasi 2
1=3 1=2
VK-Perina Kepatuhan Cuci Tangan
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Liibur Libur Indikasi = 3 Indikasi = 4 -
M1 = 3 M1 = 3
M2 = 3 M2 = 4
M3 = 1 M3 = 3
M4 = 3 M4 = 4
M5 = 3 M5 = 4

Profesi : -
Dokter spesialis
1=1
0=0
Dokter umum
1=1
0=0
3. Pelaporan Hasil Kritis Laboratorium
3. Pelaporan Hasil Kritis Laboratorium
Minggu 1 Minggu 2
n = ∑1 x 100% n = ∑1 x 100%
∑ Denominator ∑ Denominator
n = 6 x 100% n = 3 x 100%
6
3
= 100 %
= 100 %
Kamar Operasi – Identifikasi Pasien
05 /01/2022
Pemberian Obat = 1

Kamar Operasi – Cuci Tangan

05/01/2022 05/01/2022
Indikasi = 5 Profesi :
M1 = 5 Indikasi = 2
M2 = 5 Dokter = 2
M3 = 0 Perawat = 2
M4 = 5
M5 = 5