FORMULIR PENYELESAIAN KOMPLAIN, KELUHAN, KONFLIK ATAU PERBEDAAN PENDAPAT

Nama Pasien/Keluarga:No :Tanggal Lahir:Masalah : Baru Tanggal/Jam Komplain: LamaRuangan/Bagian:

URAIAN MASALAH:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Penerima Komplain

(..............................)TINDAKAN PENYELESAIAN SAAT KEJADIAN :.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Yang Menyelesaikan

(...............................)EVALUASI/TINDAK LANJUT :

Tidak perlu tindak lanjutPerlu tindak lanjut dengan Corrective Action Request

Evaluasi oleh

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MH/1289/10/2008-03