formulir keluhan
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Formulir keluhanTRANSCRIPT
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
(...................................)
MH/1289/10/2008-03