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Formulir Laporan Insiden ke Tim KP di PuskesmasPuskesmas Alas

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2 x 24 AM

LAPORAN INSIDEN!INTERNAL"

I. DATA PASIENNama

# $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$No MR # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Ruangan# $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$%mu& ' # ()* +ula - * +ula . * /a0u

- * /a0u . 1 /a0u - 1 /a0u . *1 /a0u

- *1 /a0u . ( /a0u - ( /a0u . 31 /a0u - 31 /a0u

es kelam # Lak)lak Pe&em5uaPea66u6 +a7a 5ase #

P&+a8 Asu&as S9as/a BPS Pe&usa0aa' AMKESMAS AMKESDA

Ta66al Masuk # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$am $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

II. RINCIAN KEADIAN*$ Ta66al 8a :ak/u Is8e

Ta66al # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$am $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

2$Is8e # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

$ K&;;l;6s Is8e$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

4$ es Is8e' # Ke


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Ke


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**. Aki"a# Insiden Ter-adap Pasien 'Kema/aCe8e&a I&&ee&s+el = Ce8e&a Be&a/Ce8e&a Ree&s+el = Ce8e&a Se8a6Ce8e&a R6a

T8ak a8a e8e&a

*/. Tindakan (ang dilakukan segera se#ela- ke&adian0 dan -asiln(a '$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

*1. Tindakan dilakukan ole- 'Tm # /e&8&

8a& # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$D;k/e&Pe&a9a/Pe/u6asla7a $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

*2. Apaka- ke&adian (ang sama perna- #er&adi di ,ni# Ker&a lain3Ya T8akA5a+la 7a, s +a6a 8+a9a0 $

Kapan 3 dan Langka- ) #indakan apa (ang #ela- diam"il pada ,ni#ker&a #erse"u#un#uk men4ega- #erulangn(a ke&adian (ang sama3$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Pem+ua/ La5;&a# $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Pee&ma La5;&a# $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Pa&a# $$$$$$$$$$$$$$$$$$$$$$$$$$$

$$$$$$$$

Pa&a# $$$$$$$$$$$$$$$$$$$$$$$$$$$

$$$$$$$$T6l La5;&

# $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

T6l /e&ma# $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

5rading Risiko Ke&adian !Ds ;le0 a/asa 5ela5;&" # 6IR, 7IA, K,NIN5 MERA7NB$ ' 5l0 sa/u


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FORMULIR PELAPORAN EFEK SAMPING OBAT Kode Sumber Data :

PENDERITA

Nama (Sin!atan"#########Umur :###Su!u :#######Berat Badan :

######

Pe!er$aan :

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