POKJA PMKP

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
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 /2= 25/29 x 100% = 86,2 %
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
Ranap 1, Kepatuhan Cuci Tangan
01/01/2022 02/01/2022 03/01/2022 04/01/2022 05/01/2022
Indikasi = 3 - - - -
M1 = 3
M2 = 3
M3 = 3
M4 = 3
M5 = 3
Ranap 1 – Visite Dokter
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≤ 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 %
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 %

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 – 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 %
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%