formulir keluhan

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FORMULIR PENYELESAIAN KOMPLAIN, KELUHAN, KONFLIK ATAU PERBEDAAN PENDAPAT Nama Pasien/Keluarga : No :……………… Tanggal Lahir : Masalah : Baru Tanggal/Jam Komplain : Lama Ruangan/Bagian : URAIAN MASALAH : ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ..................................................... Penerima Komplain (..............................) TINDAKAN PENYELESAIAN SAAT KEJADIAN : .............................................................

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Formulir keluhan

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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