Instrumen 3 Standar Pelayanan Medis-gizi

8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi

1/82

Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas

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STANDAR PELAYANAN MEDIS – GIZI

3.1. LAYANAN KLINIS YANG BERORIENTASI PASIEN (LKBP)

3.1.1. PROSES PENDAFTARAN PASIEN

STANDAR 3.1.1.a

PROSEDUR PENDAFTARAN DILAKSANAKAN DENGAN EFEKTIF DAN EFISIEN

DENGAN MEMPERHATIKAN KEBUTUHAN PELANGGAN

( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,

NO ELEMEN PENILAIAN ADATIDAK

ADASKOR

KETE-

RANGAN

1 2 3 4 5 6

1. Terse!" #r$se%r #e&"'"r"&.

2. Terse!" "*"& "+%r #e&"'"r"&

3. Pe%*"s ,e&*e"%! "& ,e&*!%!

#r$se%r erse%

4. Pe+"&**"& ,e&*e"%! "& ,e&*!%! "+%r

/"&* !e"#"&

5. Ter"#" 0"r" ,e&*e"%! ""

#e+"&**"& #%"s er""# #r$ses

#e&"'"r"&

6. Ter"#" !&"+"&% !" #e+"&**"& !"

#%"s

. Kese+",""& #e+"&**"& er",!& ! e,#"

#e&"'"r"&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

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N","

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:"""& 888888888

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100


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STANDAR 3.1.1.*

INFORMASI TENTANG PENDAFTARAN TERSEDIA DAN TERDOKUMENTASI PADA

/AKTU PENDAFTARAN


NO ELEMEN PENILAIAN ADA

TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Terse!" ,e!" !&'$r,"s! e&"&* #e&"'"r"&

! e,#" #e&"'"r"&

2. Se,%" #!" /"&* ,e,%%"& !&'$r,"s!

#e&"'"r"& ,e,#er$+e !&'$r,"s! ses%"!

e&*"& /"&* !%%"&

3. Pe+"&**"& "#" ,e,#er$+e !&'$r,"s! +"!&

e&"&* s"r"&" #e+"/"&"&7 "&"r" +"!& "r!'7 e&!s

#e+"/"&"&7 r%%"&7 eerse!""& e,#" !%r

%&% P%ses,"s #er"""& r"" !&"# "&

!&'$r,"s! +"!& /"&* !%%"&

4. Pe+"&**"& ,e&"#" "&**"#"& ses%"! /"&*

!%%"& e!" ,e,!&" !&'$r,"s! e#""

#e%*"s

5. Terse!" !&'$r,"s! e&"&* er"s"," e&*"&'"s!+!"s r%%"& +"!&

6. Terse!" !&'$r,"s! e&"&* e&% er"s","

e&*"& '"s!+!"s r%%"& +"!&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

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N","

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:"""& 888888888

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N","

888888888.

:"""& 888888888

.

T"&"

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101


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STANDAR 3.1.1.0

HAK DAN KE/AIBAN PASIEN2 KELUARGA2 DAN PETUGAS DIPERTIMBANGKANDAN DIINFORMASIKAN PADA SAAT PENDAFTARAN



ADASKOR

KETE-

RANGA

N

1. ;" "& e"!"& #"s!e&e+%"r*"

!!&'$r,"s!"& se+"," #r$ses #e&"'"r"&

e&*"& 0"r" "& ""s" /"&* !#"",! $+e

#"s!e& "&e+%"r*"

2. ;" "& e"!"& #"s!e&e+%"r*"

!#er"!"& $+e #e%*"s se+"," #r$ses#e&"'"r"&

3. Ter"#" %#"/" "*"r #"s!e&e+%"r*" "&

#e%*"s ,e,"",! " "& e"!"&

,"s!&*-,"s!&*

4. Pe&"'"r"& !+"%"& $+e #e%*"s /"&*

er+"! e&*"& ,e,#er"!"& "-"

#"s!e& e+%"r*" #"s!e&

5. Ter"#" r!er!" #e%*"s /"&* er%*"s !

r%"&* #e&"'"r"&

6. Pe%*"s erse% eer" e&*"& e'!s!e&7r","7 "& res#$&s!' er""# e%%"&

#e+"&**"&

. Ter"#" ,e"&!s,e $$r!&"s! #e%*"s !

r%"&* #e&"'"r"& e&*"& %&! +"!&%&! er"!

"*"r #"s!e&e+%"r*" #"s!e& ,e,#er$+e

#e+"/"&"&


4/82


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N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.1.TAHAPAN PELAYANAN KLINIS DIINFORMASIKAN KEPADA PASIEN UNTUK

MENAMIN KESINAMBUNGAN PELAYANAN.



ADASKOR

KETE-

RANGA

N

1.Terse!" ""#"& "& #r$se%r

#e+"/"&"& +!&!s /"&* !#"",! $+e

#e%*"s2.

Se" ""+ #"s!e&e+%"r*" ,e,#er$+e

!&'$r,"s! "& #"", er""# ""#"&

"& #r$se%r #e+"/"&"& +!&!s

3.Terse!" "'"r e&!s #e+"/"&"& !

P%ses,"s erser" "%"+ #e+"/"&"&

4.Ter"#" er"s"," e&*"& s"r"&"

ese""& +"!& %&% ,e&",!&

e+"&*s%&*"& #e+"/"&"& +!&!s (r%%"&

+!&!s7 r%%"& !"*&$s!7 "& r%%"&

$&s%+"!')

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

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:"""& 888888888

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103


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N","

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:"""& 888888888

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T"&"

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STANDAR 3.1.1.e

KENDALA FISIK2 BAHASA2 BUDAYA DAN PENGHALANG LAIN

DALAM MEMBERIKAN PELAYANAN DIUSAHAKAN DIKURANGI.



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1.P!,#!&"& "& s"' P%ses,"s ,e&*!e&!'!"s!

",""& ""s"7 %"/"7 e!"s""&7 "&

#e&*"+"&* /"&* #"+!&* ser!&* er"! #""

,"s/"r"" /"&* !+"/"&!

2. A" %#"/" !&" +"&% %&% ,e&*""s! ""%

,e,""s! ",""& #"" "%

#"s!e& ,e,%%"& #e+"/"&"& ! P%ses,"s.

3.=#"/" erse% e+" !+"s"&""&.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

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N","

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:"""& 888888888

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N"," 888888888. :"""& 888888888 T"&" 88888

104


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3.1.2. PENGKA:IAN

STANDAR 3.1..a

PROSES KAIAN A/AL DILAKUKAN SE4ARA PARIPURNA2

MEN4AKUP BERBAGAI KEBUTUHAN DAN HARAPAN PASIEN-KELUARGA( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,


ADASKOR

KETE-

RANGAN

1 2 3 4 5 6

1. Ter"#" #r$se%r #e&*"!"& ""+ /"&*

#"r!#%r&" (,e+!#%!

"&",es!s"++$"&",&es!s7 #e,er!s"& '!s!

"& #e,er!s""& #e&%&"&* ser" "!"&

s$s!"+) %&% ,e&*!e&!'!"s! er"*"!

e%%"& "& "r"#"& #"s!e& "&

e+%"r*" #"s!e& ,e&0"%# #e+"/"&"&

,e!s7 #e&%&"&* ,e!s "& e#er"""&

2. Pr$ses "!"& !+"%"& $+e e&"*" /"&*

$,#ee& %&% ,e+"%"& "!"&

3. Pe,er!s""& "& !"*&$s!s ,e&*"0% #""

s"&"r #r$'es! "& s"&"r "s%"&

4. Pr$se%r #e&*"!"& /"&* "" ,e&",!&

!" er"! #e&*%+"&*"& /"&* !" #er+%

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

105


7/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

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N","

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:"""& 888888888

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STANDAR 3.1..*

HASIL KAIAN DI4ATAT DALAM 4ATATAN MEDIS DAN MUDAH DIAKSES OLEHPETUGAS YANG BERTANGGUNG5A/AB TERHADAP PELAYANAN PASIEN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. D!+"%"& !e&!'!"s! !&'$r,"s! "#" s"" /"&*

!%%"& "+", #e&*"!"& "& "r%s !0""

"+", re", ,e!s

2. I&'$r,"s! erse% ,e+!#%! !&'$r,"s! /"&*

!%%"& %&% "!"& ,e!s7 "!"&

e#er"""&7 "& "!"& +"!& /"&* !#er+%"&

3. D!+"%"& $$r!&"s! e&*"& #e%*"s

ese""& /"&* +"!& %&% ,e&",!& #er$+e"&

"& #e,"&'"""& !&'$r,"s! erse% se0"r"

e#" "%

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N"," 888888888. :"""& 888888888 T"&" 88888

106


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Check List

. T"&*"&

N","

888888888.

:"""& 888888888

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N","

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STANDAR 3.1..0

PASIEN DENGAN KEBUTUHAN DARURAT2 MENDESAK2 ATAU SEGERA

DIBERIKAN PRIORITAS UNTUK ASESMEN DAN PENGOBATAN



ADASKOR

KETE-RANGA

N

1. Pe%*"s G"" D"r%r" P%ses,"s

,e+"s"&""& #r$ses r!"se

%&% ,e,#r!$r!"s"& #"s!e& e&*"&

e%%"& e,er*e&s!.

2. Pe%*"s erse% !+"!

,e&**%&""& r!er!" !&!.

3. P"s!e& !#r!$r!"s"& ""s "s"r %r*e&s!

e%%"&.

4. P"s!e& e,er*e&s! !#er!s" "& !%"

s"!+ er+e! "%+% ses%"!

e,",#%"& P%ses,"s see+%, !r%%

e #e+"/"&"& /"&* ,e,#%&/"!

e,",#%"& +e! !&**!

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

107


9/82


10/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

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N","

888888888.

:"""& 888888888

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N","

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:"""& 888888888

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T"&"

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STANDAR 3.1.3.*

TERDAPAT PERALATAN DAN TEMPAT YANG MEMADAI UNTUK MELAKUKAN KAIANA/AL PASIEN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1.Terse!" #er"+""& "& e,#" #e,er!s""&

/"&* ,e,""! %&% ,e+"%"& #e&*"!"&

""+ #"s!e& se0"r" #"r!#%r&"

2. A" ",!&"& %"+!"s er""# #er"+""& !

e,#" #e+"/"&"&

3. Per"+""& "& s"r"&" #e+"/"&"& /"&*!*%&""& ,e&",!& e","&"& #"s!e& "&

#e%*"s

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N"," 888888888.

:"""& 888888888.

T"&"T"&*"& 88888

109


11/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

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:"""& 888888888

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T"&"

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3.1.4. RENANA LAYANAN KLINIS

STANDAR 3.1.'.a

TERDAPAT PROSEDUR YANG EFEKTIF UNTUK MENYUSUN REN4ANA LAYANANBAIK LAYANAN MEDIS MAUPUN LAYANAN TERPADU IKA PASIEN MEMBUTUHKAN

PENANGANAN OLEH TIM KESEHATAN YANG TERKOORDINASI



ADASKOR

KETE-

RANGA

N

1.Ter"#" e!""& "& #r$se%r /"&* e+"s %&% ,e&/%s%& re&0"&" +"/"&"&

,e!s "& re&0"&" +"/"&"& er#"% !"

!#er+%"& #e&"&*"&"& se0"r" !,.

2.Se!"# #e%*"s /"&* er"! "+",

#e+"/"&"& +!&!s ,e&*e"%! e!""&

"& #r$se%r erse% ser" ,e&er"#"&

"+", #e&/%s%&"& re&0"&" er"#!

"&""% re&0"&" +"/"&"& er#"%

3.D!+"%"& e>"+%"s! eses%"!"&

#e+"s"&""& re&0"&" er"#! "&""%

re&0"&" "s%"& e&*"& e!""& "&

#r$se%r

4.D!+"%"& !&" +"&% !" er"!

e!"ses%"!"& "&"r" re&0"&" +"/"&"&

e&*"& e!""& "& #r$se%r

5.D!+"%"& e>"+%"s! er""#

#e+"s"&""& "& "s!+ !&" +"&%.

T$"+ S$r

Kes!,#%+"& """&

110


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Check List

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

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N","

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:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.'.*

REN4ANA LAYANAN KLINIS DISUSUN BERSAMA PASIEN DENGAN MEMPERHATIKANKEBUTUHAN BIOLOGIS2 PSIKOLOGIS2 SOSIAL2 SPIRITUAL DAN TATA NILAI BUDAYA

PASIEN( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,


TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1.Pe%*"s ese""& "&""% !, ese""&

,e+!""& #"s!e& "+", ,e&/%s%& re&0"&"

+"/"&"&

2. Re&0"&" +"/"&"& !s%s%& %&% se!"# #"s!e&e&*"& ee+"s"& %%"& /"&* !&*!& !0"#"!

3.Pe&/%s%&"& re&0"&" +"/"&"& erse%

,e,#er!,"&*"& e%%"& !$+$*!s7

#s!$+$*!s7 s$s!"+7 s#!r!%"+ "& "" &!+"! %"/"

#"s!e&

4.B!+" ,e,%&*!&"& "& erse!"7

#"s!e&e+%"r*" #"s!e& !#er$+e"& %&%

,e,!+! e&"*" #r$'es! ese""&

T$"+ S$r Kes!,#%+"& """&

Be"s!7 88 Me! 2915

111


13/82


Check List

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

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T"&"

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N","

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T"&"

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STANDAR 3.1.'.0

REN4ANA LAYANAN TERPADU DISUSUN SE4ARA KOMPREHENSIF OLEH TIMKESEHATAN ANTAR PROFESI DENGAN KEELASAN TANGGUNG A/AB DARI

MASING5MASING ANGGOTANYA



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1.L"/"&"& !+"%"& se0"r" #"r!#%r&" %&%

,e&0"#"! "s!+ /"&* !!&*!&"& $+e e&"*"

ese""& "& #"s!e&e+%"r*" #"s!e&

2. Re&0"&" +"/"&"& erse% !s%s%& e&*"&

""#"& "% /"&* e+"s

3.Re&0"&" +"/"&"& erse% !+"s"&""&

e&*"& ,e,#er!,-"&*"& e'!s!e&s!

#e,"&'"""& s%,er "/" ,"&%s!"

4.R!s!$ /"&* ,%&*!& er"! #"" #"s!e&

!#er!,"&*"& se" ""+ "+", ,e&/%s%&

re&0"&" +"/"&"&

5.E'e s",#!&* "& r!s!$ #e&*$""&

!!&'$r,"s!"&6.

Re&0"&" +"/"&"& erse% !$%,e&"s!"&

"+", re", ,e!s

.Re&0"&" +"/"&"& /"&* !s%s%& %*" ,e,%"

#e&!!"& #e&/%+%"& #"s!e&.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

112


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Check List

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

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N","

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STANDAR 3.1.'.

PERSETUUAN TINDAKAN MEDIK DIMINTA SEBELUM PELAKSANAAN TINDAKANBAGI YANG MEMBUTUHKAN PERSETUUAN TINDAKAN MEDIK



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. P"s!e&e+%"r*" #"s!e& ,e,#er$+e !&'$r,"s!

,e&*e&"! !&""& ,e!s#e&*$""& ere&%

/"&* er!s!$ /"&* ""& !+"%"&

2. Terse!" '$r,%+!r #erse%%"& !&""&

,e!s#e&*$""& ere&% /"&* er!s!$

3. Terse!" #r$se%r %&% ,e,#er$+e

#erse%%"& erse%

4. Pe+"s"&""& !&'$r,e 0$&se&

!$%,e&"s!"&.

5. D!+"%"& e>"+%"s! "& !&" +"&% er""#

#e+"s"&""& !&'$r,e 0$&se&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

113


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Check List

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888



3.1.5. RENANA R=:=KAN

STANDAR 3.1.6.a

TERDAPAT PROSEDUR RUUKAN YANG ELAS



ADASKOR

KETE-

RANGA

N

1. Terse!" #r$se%r r%%"& /"&* e+"sser" e"r!&* '"s!+!"s r%%"&

2. Pr$ses r%%"& !+"%"& er"s"r"&

e%%"& #"s!e& %&% ,e&",!&

e+"&*s%&*"& +"/"&"&

3. Terse!" #r$se%r ,e,#ers!"#"&

#"s!e& e+%"r*" #"s!e& %&% !r%%

4. D!+"%"& $,%&!"s! e&*"& '"s!+!"s

ese""& /"&* ,e&"! %%"& r%%"&

%&% ,e,"s!"& es!"#"& '"s!+!"s

erse% %&% ,e&er!," r%%"&.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

114


16/82


Check List

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

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.

T"&"

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N","

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.

T"&"

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STANDAR 3.1.6.*

REN4ANA RUUKAN DAN KE/AIBAN MASING5MASING

DIPAHAMI OLEH TENAGA KESEHATAN DAN PASIEN-KELUARGA PASIEN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. I&'$r,"s! e&"&* r%%"& !s",#"!"& e&*"&

0"r" /"&* ,%" !#"",! $+e

#"s!e&e+%"r*" #"s!e&

2. I&'$r,"s! erse% ,e&0"%# "+"s"& r%%"&7

s"r"&" %%"& r%%"&7 "& "#"& r%%"& "r%s

!+"%"&

3. D!+"%"& er"s"," e&*"& '"s!+!"s

ese""& +"!& %&% ,e&",!& e+"&*s%&*"&

"s%"&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

115


17/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.6.0

FASILITAS RUUKAN PENERIMA DIBERI RESUME TERTULIS MENGENAI KONDISIKLINIS PASIEN DAN TINDAKAN YANG TELAH DILAKUKAN OLEH PUSKESMAS PADA

SAAT MENGIRIM PASIEN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. I&'$r,"s! +!&!s #"s!e& ""% res%,e +!&!s #"s!e&

!!r!, e '"s!+!"s ese""& #e&er!,"

r%%"& ers"," #"s!e&.

2. Res%,e +!&!s ,e,%" $&!s! #"s!e&.

3. Res%,e +!&!s ,e,%" #r$se%r "& !&""&-!&""& +"!& /"&* e+" !+"%"&

4. Res%,e +!&!s ,e,%" e%%"& #"s!e& ""&

#e+"/"&"& +e! +"&%

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N"," 888888888. :"""& 888888888 T"&" 88888

116


18/82


Check List

. T"&*"&

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.6.

SELAMA PROSES RUUKAN PASIEN SE4ARA LANGSUNG2 STAF YANG KOMPETENTERUS MEMONITOR KONDISI PASIEN



TIDA

K

ADA

SKOR

KETE-

RANGA

N

1 2 3 4 5 6

1. Se+"," #r$ses r%%"& se0"r" +"&*s%&* se,%"

#"s!e& se+"+% !,$&!$r $+e s"' /"&*

$,#ee&.

2. K$,#ee&s! s"' /"&* ,e+"%"& ,$&!$r

ses%"! e&*"& $&!s! #"s!e&.

T$"+ S$r Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

117


19/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888



3.1.6. PELAKSANAAN LAYANAN

STANDAR 3.1.7.a

PEDOMAN PELAYANAN DIPAKAI SEBAGAI DASAR UNTUK MELAKSANAKAN

LAYANAN KLINIS



ADASKOR

KETE-

RANGA

N

1. Terse!" #e$,"& "& #r$se%r #e+"/"&"&

+!&!s

2. Pe&/%s%&"& "& #e&er"#"& re&0"&" +"/"&"&

,e&*"0% #"" #e$,"& "& #r$se%r /"&*

er+"%

3. L"/"&"& !+"s"&""& ses%"! e&*"&

#e$,"& "& #r$se%r /"&* er+"%

4. L"/"&"& !er!"& ses%"! e&*"& re&0"&"

+"/"&"&

5. L"/"&"& /"&* !er!"& e#"" #"s!e&

!$%,e&"s!"&

6. Per%""& re&0"&" +"/"&"& !+"%"&

er"s"r"& #ere,"&*"& #"s!e&.

. Per%""& erse% !0"" "+", re",,e!s


20/82


Check List

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.7.*

PELAKSANAAN LAYANAN BAGI PASIEN GA/AT DARURAT DAN-ATAU BERISIKOTINGGI DIPANDU OLEH KEBIAKAN DAN PROSEDUR YANG BERLAKU



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. K"s%s-"s%s *"" "r%r" "&""% er!s!$

!&**! /"&* !"s" er"! !!e&!'!"s!

2. Terse!" e!""& "& #r$se%r #e&"&*"&"&

#"s!e& *"" "r%r" (e,er*e&s!)

3. Terse!" e!""& "& #r$se%r #e&"&*"&"&

#"s!e& er!s!$ !&**!

4. Ter"#" er"s"," e&*"& s"r"&" ese""&

/"&* +"!&7 "#"!+" !" erse!" #e+"/"&"&

*"" "r%r" 24 ",

5. Terse!" #r$se%r #e&0e*""& (e"s#"""&

%&!>ers"+) er""# er"!&/" !&'es! /"&*

,%&*!& !#er$+e "!" #e+"/"&"& /"&*

!er!"& "! "*! #e%*"s ,"%#%& #"s!e&

"+", #e&"&*"&"& #"s!e& er!s!$ !&**!.

T$"+ S$r Kes!,#%+"& """&

Be"s!7 88 Me! 2915

119


21/82


Check List

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.7.0

PENANGANAN2 PENGGUNAAN2 DAN PEMBERIAN DARAH DAN PRODUK DARAHDIPANDU DENGAN KEBIAKAN DAN PROSEDUR YANG ELAS



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Pe&"&*"&"&7 #e&**%&""& "& #e,er!"&

"r" "& #r$% "r" !"r""& $+e

e!""& "& #r$se%r /"&* "%

2. D"r" "& #r$% "r" !er!"& ses%"!

e!""& "& #r$se%r

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

120


22/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.7.

HASIL PEMANTAUAN PELAKSANAAN LAYANAN DIGUNAKAN UNTUKMENYESUAIKAN REN4ANA LAYANAN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. D!e"#"& I&!"$r %&% ,e,"&"% "&

,e&!+"! #e+"s"&""& +"/"&"& +!&!s.

2. Pe,"&"%"& "& #e&!+"!"& er""# +"/"&"&

+!&!s !+"%"& se0"r" %"&!"!' ,"%#%&

%"+!"!'

3. Terse!" "" /"&* !%%"& %&%,e&*e"%! #e&0"#"!"& %%"& "& "s!+

#e+"s"&""& +"/"&"& +!&!s

4. D!+"%"& "&"+!s!s er""# !&!"$r /"&*

!%,#%+"&

5. D!+"%"& !&" +"&% er""# "s!+ "&"+!s!s

erse% %&% #er"!"& +"/"&"& +!&!s.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

121


23/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.7.e

SELURUH PETUGAS KESEHATAN MEMPERHATIKAN DAN MENGHARGAIKEBUTUHAN DAN HAK PASIEN SELAMA PELAKSANAAN LAYANAN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Terse!" #r$se%r %&% ,e&*!e&!'!"s!

e+%"& #"s!e&e+%"r*" #"s!e& ses%"!

e&*"& e%%"& "& " #"s!e& se+","

#e+"s"&""& "s%"&

2. Terse!" #r$se%r %&% ,e&"&*"&! "&

,e&!&"+"&%! e+%"& erse%3. Ke+%"& #"s!e&e+%"r*" #"s!e& !!&" +"&%!

4. D!+"%"& $%,e&"s! e&"&* e+%"& "&

!&" +"&% e+%"& #"s!e&e+%"r*" #"s!e&.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

122


24/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.7.8

PELAKSANAAN LAYANAN DILAKUKAN UNTUK MENAMIN KELANGSUNGAN DANMENGHINDARI PENGULANGAN YANG TIDAK PERLU



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Terse!" e!""& "& #r$se%r %&%

,e&*!&"r! #e&*%+"&*"& /"&* !" #er+%

"+", #e+"s"&""& +"/"&"&

2. Terse!" e!""& "& #r$se%r %&%

,e&",!& es!&",%&*"& #e+"/"&"&

3. L"/"&"& +!&!s "& #e+"/"&"& #e&%&"&* /"&*

!%%"& !#"%"& e&*"& "!7 se!&**"

!" er"! #e&*%+"&*"& /"&* !" #er+%.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

123


25/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.7.9

PASIEN DAN KELUARGA PASIEN MEMPEROLEH PENELASAN TENTANG HAK DANTANGGUNG A/AB MEREKA BERHUBUNGAN DENGAN PENOLAKAN ATAU TIDAK

MELANUTKAN PENGOBATAN2 TERMASUK PENOLAKAN UNTUK DIRUUK KEFASILITAS KESEHATAN YANG LEBIH MEMADAI


NO ELEMEN PENILAIAN ADA TIDAK

ADA

SKOR

KETE-RANGA

N

1 2 3 4 5 6

1. Pe%*"s #e,er! #e+"/"&"& ,e,er!"%"&

#"s!e& "& e+%"r*"&/" e&"&* " ,ere"

%&% ,e&$+" ""% !" ,e+"&%"&

#e&*$""&.

2. Pe%*"s #e,er! #e+"/"&"& ,e,er!"%"&

#"s!e& "& e+%"r*"&/" e&"&* $&se%e&s!

"r! e#%%s"& ,ere".

3. Pe%*"s #e,er! #e+"/"&"& ,e,er!"%"&

#"s!e& "& e+%"r*"&/" e&"&* "&**%&*

"" ,ere" er"!"& e&*"& e#%%s"&

erse%.

4. Pe%*"s #e,er! #e+"/"&"& ,e,er!"%"&

#"s!e& "& e+%"r*"&/" e&"&* erse!"&/"

"+er&"!' #e+"/"&"& "& #e&*$""&.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N"," 888888888. :"""& 888888888 T"&" 88888

124


26/82


Check List

. T"&*"&

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888



3.1.. PELAYANAN ANESTESI LOKAL7 SEDASI DAN PEMBEDA;AN

STANDAR 3.1.:.aPELAYANAN ANESTESI LOKAL DAN SEDASI DI PUSKESMAS DILAKSANAKAN

MEMENUHI STANDAR DI PUSKESMAS2 STANDAR NASIONAL2 UNDANG5UNDANG2DAN PERATURAN SERTA STANDAR PROFESI SESUAI DENGAN KEBUTUHAN PASIEN



ADASKOR

KETE-

RANGA

N

1. Terse!" #e+"/"&"& "&eses! +$"+ "&

se"s! ses%"! e%%"& ! P%ses,"s

2. Pe+"/"&"& "&eses! +$"+ "& se"s!

!+"%"& $+e e&"*" ese""& /"&*

$,#ee&

3. Pe+"s"&""& "&eses! +$"+ "& se"s!

!#"&% e&*"& e!""& "& #r$se%r

/"&* e+"s

4. Se+"," #e,er!"& "&eses! +$"+ "&

se"s! #e%*"s ,e+"%"& ,$&!$r!&*

s"%s '!s!$+$*! #"s!e&5. A&eses! +$"+ "& se"s!7 e&!

"&eses! +$"+ "& se"s! !%+!s "+",

re", ,e!s #"s!e&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

125


27/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N"," 888888888.

:"""& 888888888.

T"&"T"&*"& 88888

STANDAR 3.1.:.*

PELAYANAN BEDAH DI PUSKESMAS DIREN4ANAKAN DAN DILAKSANAKANMEMENUHI STANDAR DI PUSKESMAS2 STANDAR NASIONAL2 UNDANG5UNDANG2

DAN PERATURAN SERTA STANDAR PROFESI SESUAI DENGAN KEBUTUHAN PASIEN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. D$er ""% $er *!*! /"&* ""& ,e+"%"&

#e,e""& ,!&$r ,e+"%"& "!"& see+%,

,e+"s"&""& #e,e""&

2. D$er ""% $er *!*! /"&* ""& ,e+"%"&

#e,e""& ,!&$r ,ere&0"&""& "s%"&

#e,e""& er"s"r "s!+ "!"&.

3. D$er ""% $er *!*! /"&* ""& ,e+"%"&

#e,e""& ,!&$r ,e&e+"s"& r!s!$7 ,"&'""7

$,#+!"s! #$e&s!"+7 "& "+er&"!' e#""

#"s!e&e+%"r*" #"s!e&

4. See+%, ,e+"%"& !&""& "r%s ,e&"#""&

#erse%%"& "r! #"s!e&e+%"r*" #"s!e&

5. Pe,e""& !+"%"& er"s"r"& #r$se%r /"&*

!e"#"&

6. L"#$r"&0"""& $#er"s! !%+!s"& "+", re",

,e!s

. S"%s '!s!$+$*! #"s!e& !,$&!$r er%s ,e&er%s

se+"," "& se*er" see+" #e,e""& "&

!%+!s"& "+", re", ,e!s

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N"," 888888888. :"""& 888888888 T"&" 88888

126


28/82


Check List

. T"&*"&

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888



3.1.!"s#e&/",#"!"& !&'$r,"s! e#"" #"s!e&e+%"r*"

#"s!e& "*"r ,ere" "#" er#er"& "!' "+",

#r$ses +"/"&"& "& ,e,"",! $&se%e&s!

+"/"&"& /"&* !er!"&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR127


29/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N"," 888888888.

:"""& 888888888.

T"&"T"&*"& 88888



3.1.?. MAKANAN DAN TERAPI N=TRISI @)

STANDAR 3.1.


30/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.


31/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.>,



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. P"s!e& /"&* #"" "ses,e& er"" #"" r!s!$

&%r!s!7 ,e&"#" er"#! *!!.

2. S%"% #r$ses er"s"," !#""! %&%

,ere&0"&""&7 ,e,er!"& "& ,e,$&!$r

er"#! *!!

3. Res#$& #"s!e& er""# er"#! *!! !,$&!$r

4. Res#$& #"s!e& er""# er"#! *!! !0""

"+", re", ,e!s&/"

T$"+ S$r

**) kriteria ini juga berlaku untuk Puskesmas yang menjalankan home-care pada pasien

yang memerlukan terapi gizi.

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N"," 888888888. :"""& 888888888 T"&" 88888

130


32/82


Check List

. T"&*"&



3.1.19. PEM=LANGAN DAN TINDAK LAN:=T @)

STANDAR 3.1.1?.a

PEMULANGAN DAN-TINDAK LANUT PASIEN2 BAIK YANG BERTUUAN UNTUKKELANGSUNGAN LAYANAN2 RUUKAN MAUPUN PULANG DIPANDU OLEH

PROSEDUR YANG STANDAR



TIDA

K

ADA

SKOR

KETE-

RANGA

N

1 2 3 4 5 6

1. Terse!" #r$se%r #e,%+"&*"& "&!&" +"&%

#"s!e&

2. A" #e&"&**%&*"" "+", #e+"s"&""&

#r$ses #e,%+"&*"& "&!&" +"&% erse%

3. Terse!" r!er!" /"&* !*%&""& %&%

,e&e"#"& s"" #e,%+"&*"& "&!&"

+"&% #"s!e&

4. Terse!" %,#"& "+! "r! s"r"&" ese""&

+"!& /"&* ,e&er!," #"s!e&7 "#"!+" !+"%"&

#e,%+"&*"& "&!&" +"&% #"s!e& "&"r

s"r"&" ese""&.

5. Terse!" #r$se%r "& "+er&"!' #e&"&*"&"&

"*! #"s!e& /"&* ,e,er+%"& !&" +"&%

r%%"& ""& e"#! !" ,%&*!& !+"%"&

T$"+ S$r

*) untuk Puskesmas dengan rawat inap

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

131


33/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.1?.*PASIEN- KELUARGA PASIEN MEMPEROLEH PENELASAN YANG MEMADAI

TENTANG TINDAK LANUT LAYANAN SAAT PEMULANGAN ATAU SAAT DIRUUK KESARANA KESEHATAN YANG LAIN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. I&'$r,"s! /"&* !%%"& ,e&*e&"! !&"+"&% +"/"&"& !er!"& $+e #e%*"s e#""

#"s!e&e+%"r*" #"s!e& #"" s"" #e,%+"&*"&

""% !" !+"%"& r%%"& e s"r"&" ese""&

/"&* +"!&

2. Pe%*"s ,e&*e"%! "" !&'$r,"s! /"&*

!s",#"!"& !#"",! $+e #"s!e&e+%"r*"

#"s!e&

3. D!+"%"& e>"+%"s! #er!$! er""# #r$se%r

#e+"s"&""& #e&/",#"!"& !&'$r,"s! erse%

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N"," 888888888. :"""& 888888888. T"&"T"&*"& 88888

132


34/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3.1.1?.0PELAKSANAAN RUUKAN DILAKUKAN

ATAS DASAR KEBUTUHAN DAN PILIHAN PASIEN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. D!+"%"& !e&!'!"s! e%%"& "& #!+!"&

#"s!e& (,!s"+&/" e%%"& r"&s#$r"s!7

#e%*"s $,#ee& /"&* ,e&",#!&*!7 s"r"&"

,e!s "& e+%"r*" /"&* ,e&e,"&!) se+","

#r$ses r%%"&

2. A#"!+" erse!" +e! "r! s"% s"r"&" /"&*

"#" ,e&/e!""& #e+"/"&"& r%%"& erse%7

#"s!e&e+%"r*" #"s!e& !er! !&'$r,"s! /"&*

,e,""! "& !er! ese,#""& %&% ,e,!+!

s"r"&" #e+"/"&"& /"&* !!&*!&"&3. Kr!er!" r%%"& !+"%"& ses%"! e&*"& SPO

r%%"&7

4. D!+"%"& #erse%%"& r%%"& "r!

#"s!e&e+%"r*" #"s!e&.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

133


35/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888


3.2. MANA:EMEN PEN=N:ANG LAYANAN KLINIS (MPLK)

3.2.1. PELAYANAN LABORATORI=M

STANDAR 3..1.a

PEMERIKSAAN LABORATORIUM DILAKUKAN OLEH PETUGAS YANG KOMPETEN

DAN BERPENGALAMAN UNTUK MELAKUKAN DAN-ATAU MENGINTERPRETASIKANHASIL PEMERIKSAAN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. D!e"#"& e&!s-e&!s #e,er!s""& +"$r"$r!%,

/"&* "#" !+"%"& !P%ses,"s

2. Terse!" e&!s "& %,+" #e%*"s ese""&/"&* $,#ee& ses%"! e%%"& "& ", %"

#e+"/"&"&

3. Pe,er!s""& +"$r"$r!%, !+"%"& $+e

"&"+!s#e%*"s /"&* er+"! "& er#e&*"+","&

4. I&er#er"s! "s!+ #e,er!s""& +"$r"$r!%,

!+"%"& $+e #e%*"s /"&* er+"! "&

er#e&*"+","&.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N"," 888888888. :"""& 888888888 T"&" 88888

134


36/82


Check List

. T"&*"&

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..1.*

TERDAPAT KEBIAKAN DAN PROSEDUR SPESIFIK UNTUK SETIAP ENISPEMERIKSAAN LABORATORIUM



TIDA

K ADA

SKO

R

KETE-

RANGAN

1 2 3 4 5 6

1. Terse!" e!""& "& #r$se%r %&% #er,!&""&

#e,er!s""&7 #e&er!,""& s#es!,e&7 #e&*",!+"&

"& #e&/!,#"& s#es!,e&

2. Terse!" #r$se%r #e,er!s""& +"$r"$r!%,

3. D!+"%"& #e,"&"%"& se0"r" er"+" er""#

#e+"s"&""& #r$se%r erse%

4. D!+"%"& e>"+%"s! er""# ee#""& "%

#e&/er""& "s!+ #e,er!s""& +"$r"$r!%,

5. Terse!" e!""& "& #r$se%r #e,er!s""& ! +%"r

", er" (#"" P%ses,"s r"" !&"# ""% #""

P%ses,"s /"&* ,e&/e!""& #e+"/"&"& ! +%"r

", er")

6. A" e!""& "& #r$se%r %&% #e,er!s""&

/"&* er!s!$ !&**! (,!s"+&/" s#e0!,e& s#%%,7

"r" "& +"!&&/")

. Terse!" #r$se%r ese""& "& ese+",""& er"7

"& "+" #e+!&%&* !r! "*! #e%*"s +"$r"$r!%,


37/82


Check List

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..1.0

HASIL PEMERIKSAAN LABORATORIUM SELESAI DAN TERSEDIA DALAM /AKTUSESUAI DENGAN KETENTUAN YANG DITETAPKAN



TIDA

K ADA

SKO

R

KETE-

RANGAN

1 2 3 4 5 6

1. P!,#!&"& P%ses,"s ,e&e"#"& "% /"&*

!"r"#"& %&% +"#$r"& "s!+ #e,er!s""&.

2. Kee#""& "% ,e+"#$r"& "s!+ #e,er!s""&

/"&* %r*e&*"" "r%r" !%%r.

3. ;"s!+ +"$r"$r!%, !+"#$r"& "+", er"&*"

"% *%&" ,e,e&%! e%%"& #"s!e&

T$"+ S$r Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N"," 888888888. :"""& 888888888 T"&" 88888

136


38/82


Check List

. T"&*"&

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..1.

ADA PROSEDUR MELAPORKAN HASIL TES DIAGNOSTIK YANG KRITIS



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 61. Me$e $+"$r"!' !*%&""& %&%

,e&*e,"&*"& #r$se%r %&% #e+"#$r"&

"s!+ /"&* r!!s "& #e,er!s""& !"*&$s!

2. Pr$se%r erse% ,e&e"#"& &!+"! ","&*

r!!s %&% se!"# es

3. Pr$se%r erse% ,e&e"#"& $+e s!"#" "&

e#"" s!"#" "s!+ /"&* r!!s "r! #e,er!s""&

!"*&$s! "r%s !+"#$r"&

4. Pr$se%r erse% ,e&e"#"& "#" /"&* !0""!"+", re", ,e!s #"s!e&

5. Pr$ses !,$&!$r %&% ,e,e&%! ee&%"&

"& !,$!'!"s! er"s"r"& "s!+ ,$&!$r!&*

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

137


39/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..1.e

REAGENSIA ESENSIAL DAN BAHAN LAIN YANG DIPERLUKAN SEHARI5HARI SELALUTERSEDIA DAN DIE=ALUASI UNTUK MEMASTIKAN AKURASI DAN PRESISI HASIL



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. D!e"#"& re"*e&s!" ese&s!"+ "& ""&+"!& /"&* "r%s erse!"

2. Re"*e&s!" ese&s!"+ "& ""& +"!& erse!"7

"& "" #r$ses %&% ,e&/"""& !" re"*e&

!" erse!".

3. Se,%" re"*e&s!" !s!,#"& "& !!sr!%s!

ses%"! #e$,"& "r! #r$%se& ""%

!&sr%s! #e&/!,#"&"& "& !sr!%s! /"&*

"" #"" e,"s"&

4. Terse!" #e$,"& er%+!s /"&* !+"s"&""&

%&% ,e&*e>"+%"s! se,%" re"*e&s!" "*"r

,e,er!"& "s!+ /"&* "%r" "& #res!s!.

5. Se,%" re"*e&s!" "& +"r%"& !er! +"e+

se0"r" +e&*"# "& "%r".

6. D!e"#"& re"*e&s!" ese&s!"+ "& ""&

+"!& /"&* "r%s erse!"

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

138


40/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..1.8

DITETAPKAN NILAI NORMAL DAN RENTANG NILAI YANG DIGUNAKAN UNTUKINTERPERTASI DAN PELAPORAN HASIL LABORATORIUM



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Ke#"+" P%ses,"s ,e&e"#"& &!+"!

re&"&* &!+"! r%%"& %&% se!"# #e,er!s""&

/"&* !+"s"&""&.

2. Re&"&*-&!+"! r%%"& !&! "r%s !ser""& "+",

0"""& +!&!s #"" "% "s!+ #e,er!s""&

!+"#$r"&.

3. Pe,er!s""& /"&* !+"%"& $+e +"$r"$r!%,

+%"r "r%s ,e&0"&-%,"& re&"&* &!+"!.

4. Re&"&*-&!+"! !e>"+%"s! "& !re>!s! er"+"

se#er+%&/".

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N"," 888888888. :"""& 888888888 T"&" 88888

139


41/82


Check List

. T"&*"&

STANDAR 3..1.9

PENGENDALIAN MUTU DILAKUKAN2 DITINDAKLANUTI DAN DIDOKUMENTASIUNTUK SETIAP PEMERIKSAAN LABORATORIUM



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Terse!" e!""& "& #r$se%r #e&*e&"+!"&

,%% #e+"/"&"& +"$r"$r!%,

2. D!+"%"& "+!r"s! ""% >"+!"s! !&sr%,e&"+"%%r e#" "% "& $+e #!" /"&* $,#ee&

ses%"! #r$se%r

3. Ter"#" %! $%,e&"s! !+"%"&&/"

"+!r"s! ""% >"+!"s!7 "& ,"s! er+"%

4. A#"!+" !e,%"& #e&/!,#"&*"& !+"%"&

!&""& #er"!"&

5. D!+"%"& #e,"&"#"& ,%% eser&"+ er""#

#e+"/"&"& +"$r"$r!%, $+e #!" /"&*

$,#ee&.

6. Ter"#" ,e"&!s,e r%%"& s#es!,e& "&

#"s!e& !+" #e,er!s""& +"$r"$r!%, !"

!+"%"& ! P%ses,"s7 "& P%ses,"s

,e,"s!"& "" #e+"/"&"& erse%

!er!"& ses%"! e&*"& e%%"& #"s!e&.

. Ter"#" %! $%,e&"s! !+"%"&&/"

#e,"&"#"& ,%% !&er&"+ "& eser&"+

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

140


42/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..1.@

UPAYA KESELAMATAN (SAFETY, DIREN4ANAKAN2 DILAKSANAKAN2 DANDIDOKUMENTASIKAN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Ter"#" %#"/" ese+",""& e","&"&

+"$r"$r!%, /"&* ,e&*"%r r!s!$ ese+",""&/"&* #$e&s!"+ ! +"$r"$r!%, "& ! "re" +"!&

/"&* ,e&"#" #e+"/"&"& +"$r"$r!%,.

2. =#"/" !&! ""+" "*!"& "r! %#"/"

ese+",""& ! P%ses,"s

3. Pe%*"s +"$r"$r!%, ,e+"#$r"& e*!""&

#e+"s"&""& %#"/" ese+",""& e#""

#e&*e+$+" %#"/" ese+",""& ! P%ses,"s

se%r"&*-%r"&*&/" se"%& se"+! "& !+"

er"! !&s!e&s ese+",""&.

4. Ter"#" e!""& "& #r$se%r er%+!s

e&"&* #e&"&*"&"& "& #e,%"&*"& ""&

er""/"

5. D!+"%"& !e&!'!"s!7 "&"+!s!s "& !&"

+"&% r!s!$ ese+",""& ! +"$r"$r!%,

6. S"' +"$r"$r!%, !er!"& $r!e&"s! %&%

#r$se%r "& #r"e ese+",""&e","&"&

er"

. S"' +"$r"$r!%, ,e&"#" #e+"!"&

#e&!!"& %&% #r$se%r "r% "&

#e&**%&""& ""& er""/" /"&* "r%7

,"%#%& #er"+""& /"&* "r%.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

141


43/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888



3.2.2. PELAYANAN OBAT

STANDAR 3...a

BERBAGAI ENIS OBAT YANG SESUAI DENGAN KEBUTUHAN TERSEDIA DALAMUMLAH YANG MEMADAI



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Ter"#" ,e$e /"&* !*%&""& %&% ,e&!+"! "&

,e&*e&"+!"& #e&/e!""& "& #e&**%&""& $"

2. Ter"#" ee+"s"& #r$se%r #e&/e!""& "&

#e&**%&""& $"

3. A" ee+"s"& s!"#" /"&* er"&**%&*""4. A" e!""& "& #r$se%r /"&* ,e&",!&

eerse!""& $"-$" /"&* se"r%s&/" ""

5. Terse!" #e+"/"&"& $"-$""& se+"," %% "r!

"+", se,!&**% "& 24 ", #"" P%ses,"s /"&*

,e,er!"& #e+"/"&"& *"" "r%r"

6. Terse!" "'"r '$r,%+"r!%, $" P%ses,"s

. D!+"%"& e>"+%"s! "& !&" +"&% eerse!""&

$" !"&!&*"& e&*"& '$r,%+"r!%,

"+%"s! "& !&" +"&% eses%"!"&

#erese#"& e&*"& '$r,%+"r!%,.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N"," 888888888.

:"""& 888888888.

T"&"T"&*"& 88888

142


44/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3...*

PERESEPAN2 PEMESANAN DAN PENGELOLAAN OBAT DIPANDU KEBIAKAN DANPROSEDUR YANG EFEKTIF



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 61. Ter"#" ee&%"& #e%*"s /"&* er"

,e,er!"& rese#

2. Ter"#" ee&%"& #e%*"s /"&* ,e&/e!""&

$" e&*"& #ers/"r""& /"&* e+"s

3. A#"!+" #ers/"r""& #e%*"s /"&* !er!

ee&"&*"& "+", #e&/e!""& $" !"

"#" !#e&%!7 #e%*"s erse% ,e&"#"

#e+"!"& %s%s.

4. Terse!" e!""& "& #r$ses #erese#"&7

#e,es"&"&7 "& #e&*e+$+""& $"

5. Ter"#" #r$se%r %&% ,e&"*" !"

er"!&/" #e,er!"& $" /"&* e"+%"rs"

e#"" #"s!e&

6. D!+"%"& #e&*""s"& er""# #e&**%&""&

"& #e&*e+$+""& $" $+e D!&"s Kese""&

K"%#"e&K$" se0"r" er"%r

. Ter"#" ee&%"& s!"#" /"&* er"

,e&%+!s"& rese# %&% $"-$" ere&%

(,!s"+ #s!$r$#!" "& &"r$!")


45/82


Check List

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3...0

ADA AMINAN KEBERSIHAN DAN KEAMANAN DALAM PENYIMPANAN2 PENYIAPAN2DAN PENYAMPAIAN OBAT KEPADA PASIEN SERTA PENATALAKSANAAN OBAT

KEDALU/ARSA-RUSAK


NO ELEMEN PENILAIAN ADATIDA

K

ADA

SKO

R

KETE-RANGA

N

1 2 3 4 5 6

1. Ter"#" #ers/"r""& #e&/!,#"&"& $"

2. Pe&/!,#"&"& !+"%"& ses%"! e&*"&

#ers/"r""&

3. Pe,er!"& $" e#"" #"s!e& !ser"! e&*"&

+"e+ $" /"&* e+"s (,e&0"%# &","7 $s!s7

0"r" #e,""!"& $" "& 're%e&s!

#e&**%&""&&/")

4. Pe,er!"& $" !ser"! e&*"& !&'$r,"s!#e&**%&""& $" /"&* ,e,""! e&*"&

""s" /"&* "#" !,e&*er! $+e

#"s!e&e+%"r*" #"s!e&

5. Pe%*"s ,e,er!"& #e&e+"s"& e&"&*

e,%&*!&"& er"! e'e s",#!&* $" ""%

e'e /"&* !" !"r"#"&

6. Pe%*"s ,e&e+"s"& #e%&% e&"&*

#e&/!,#"&"& $" ! r%,"

. Terse!" e!""& "& #r$se%r #e&"&*"&"&

$" /"&* e"+%"rs"r%s"


46/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3...

EFEK SAMPING YANG TERADI AKIBAT PEMBERIAN OBAT5OBAT YANGDIRESEPKAN ATAU RI/AYAT ALERGI TERHADAP OBAT5OBATAN TERTENTU HARUS

DIDOKUMENTASIKAN DALAM REKAM MEDIS PASIEN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Terse!" #r$se%r #e+"#$r"& e'e s",#!&* $"

2. E'e s",#!&* $" !$%,e&"s!"& "+",

re", ,e!s

3. Terse!" e!""& "& #r$se%r %&%

,e&0""7 ,e,"&"%7 "& ,e+"#$r"& !+"

er"! e'e s",#!&* #e&**%&""& $" "&

KTD7 er,"s% es"+""& #e,er!"& $"

4. Ke"!"& e'e s",#!&* $" "& KTD

!!&"+"&%! "& !$%,e&"s!"&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N"," 888888888. :"""& 888888888 T"&" 88888

145


47/82


Check List

. T"&*"&

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3...e

KESALAHAN OBAT (MEDIKATION ERRORS, DILAPORKAN MELALUI PROSES DANDALAM KERANGKA /AKTU YANG DITETAPKAN OLEH PUSKESMAS



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Ter"#" #r$se%r %&% ,e&*!e&!'!"s! "&

,e+"#$r"& es"+""& #e,er!"& $" "&

KN

2. Kes"+""& #e,er!"& $" "& KN !+"#$r"&

e#" "% ,e&**%&""& #r$se%r "%

3. D!e"#"& #e%*"s ese""& /"&*

er"&**%&*"" ,e&*",!+ !&""& %&%

#e+"#$r"& !!e&!'!"s!

4. I&'$r,"s! #e+"#$r"& es"+""& #e,er!"& $"

"& KN !*%&""& %&% ,e,#er"!! #r$ses

#e&*e+$+""& "& #e+"/"&"& $".

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N"," 888888888.

:"""& 888888888.

T"&"T"&*"& 88888

146


48/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3...8

OBAT5OBATAN EMERGENSI TERSEDIA2 DIMONITOR DAN AMAN BILAMANADISIMPAN DI LUAR FARMASI



TIDA

K

ADA

SKO

R

KETE-

RANGA

N1 2 3 4 5 6

1. O" e,er*e&s! erse!" #"" %&!-%&! !,"&"

""& !#er+%"& ""% "#" er"ses se*er"

%&% ,e,e&%! e%%"& /"&* ers!'"

e,er*e&s!

2. A" e!""& /"&* ,e&e"#"& "*"!,"&"

$" e,er*e&s! !s!,#"&7 !"*" "& !+!&%&*!

"r! e!+"&*"& ""% #e&0%r!"&

3. O" e,er*e&s! !,$&!$r "& !*"&! se0"r"

e#" "% ses%"! e!""& P%ses,"s

see+" !*%&""& ""% !+" ""+%"rs" ""%

r%s"

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N"," 888888888.

:"""& 888888888.

T"&"T"&*"& 88888

147


49/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888



3.2.3. PELAYANAN RADIODIAGNOSTIK (:IKA TERSEDIA)

STANDAR 3..3.a

PELAYANAN RADIODIAGNOSTIK DISEDIAKAN UNTUK MEMENUHI KEBUTUHAN

PASIEN2 DAN MEMENUHI STANDAR NASIONAL2 PERUNDANG5UNDANGAN DANPERATURAN YANG BERLAKU



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Pe+"/"&"& r"!$!"*&$s! ,e,e&%! s"&"r

&"s!$&"+

2. Pe+"/"&"& r"!$!"*&$s! !+"%"& se0"r"

"e%"

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

148


50/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..3.*

ADA UPAYA PENGAMANAN RADIASI2 DILAKSANAKAN DAN DIDOKUMENTASI



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Ter"#" %#"/" e","&"& r"!"s! /"&*

,e&*"%r r!s!$ e","&"& "& "&!s!#"s!

""/" /"&* !s" er"! ! "+", ""% ! +%"r

%&! er"

2. =#"/" e","&"& ,er%#""& "*!"& "r! %#"/"

ese+",""& ! P%ses,"s7 "& "!

!+"#$r"& se%r"&*-%r"&*&/" se"+! se"%&

""% !+" "" e"!"&

3. Ke!""& "& #r$se%r er%+!s /"&* ,e&*"%r

"& ,e,e&%! s"&"r er"!7 %&"&*-%&"&*

"& #er"%r"& /"&* er+"%.4. Ke!""& "& #r$se%r er%+!s /"&* ,e&*"%r

#e&"&*"&"& "& #e,%"&*"& ""& !&'es!%s

"& er""/".

5. R!s!$ e","&"& r"!"s! /"&* !!e&!'!"s!

!!,"&*! e&*"& #r$se%r ""% #er"+""&

%s%s %&% ,e&*%r"&*! r!s!$ (se#er! "#r$&

!,"7 "*e r"!"s! "& /"&* see&!s)

6. Pe%*"s #e,er! #e+"/"&"& r"!$!"*&$s-

! !er! $r!e&"s! e&"&* #r$se%r "& #r"e

ese+",""&

. Pe%*"s #e,er! #e+"/"&"& r"!$!"*&$s-

! ,e&"#" #e&!!"& %&% #r$se%r "r%

"& ""& er""/"

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N"," 888888888. :"""& 888888888 T"&" 88888

149


51/82


Check List

. T"&*"&

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..3.0

STAF YANG KOMPETEN DENGAN PENGALAMAN MEMADAI2 MELAKSANAKANPEMERIKSAAN RADIO DIAGNOSTIK MENGINTERPRETASI HASIL2 DAN

MELAPORKAN HASIL PEMERIKSAAN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. D!e"#"& #e%*"s /"&* ,e+"%"&

#e,er!s""& !"*&$s!

2. Terse!" #e%*"s /"&* $,#ee& "&

#e&*"+","& /"&* ,e,""! ,e+"s"&""&

#e,er!s""& r"!$!"*&$s!.

3. Pe%*"s /"&* $,#ee& "& #e&*"+","& /"&*

,e,""! ,e&*!&er#re"s! "s!+ #e,er!s""&.4. Pe%*"s /"&* $,#ee& /"&* ,e,""!7

,e,>er!'!"s! "& ,e,%" +"#$r"& "s!+

#e,er!s""&

5. Terse!" s"' "+", %,+" /"&* "e%" %&%

,e,e&%! e%%"& #"s!e&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N"," 888888888. :"""& 888888888 T"&" 88888

150


52/82


Check List

. T"&*"&

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..3.

HASIL PEMERIKSAAN RADIOLOGI TERSEDIA TEPAT /AKTU SESUAIKETENTUAN YANG DITETAPKAN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Ke#"+" P%ses,"s ,e&e"#"& e&"&*"r"#"& "% #e+"#$r"& "s!+ #e,er!s""&.

2. Kee#""& "% #e+"#$r"& "s!+ #e,er!s""&

!%%r7 !,$&!$r7 "& !!&"+"&%!

3. ;"s!+ #e,er!s""& r"!$+$*! !+"#$r"& "+",

er"&*" "% %&% ,e,e&%! e%%"&

#"s!e&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

151


53/82


Check List

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..3.eSEMUA PERALATAN YANG DIGUNAKAN UNTUK PEMERIKSAAN RADIOLOGI DAN

DIAGNOSTIK IMAING DIPERIKSA2 DIRA/AT DAN DI KALIBRASI SE4ARA TERATUR2DAN DISERTAI 4ATATAN MEMADAI YANG DIPELIHARA DENGAN BAIK



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. A" %#"/" #e,e+!"r""&

#er"+""& r"!$+$*! "& !+"s"&"-"&

2. =#"/" er,"s% !&>e&"r!s"s! #er"+""&

3. =#"/" er,"s% !&s#es! "& es!&* #er"+""&

4. =#"/" er,"s% "+!r"s! "& #er"""&

#er"+""&

5. =#"/" er,"s% ,$&!$r!&* "& !&" +"&%

6. A" $%,e&"s! /"&* "e%" %&% se,%"

es!&*7 #er"""& "& "+!r"s! #er"+""&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N"," 888888888. :"""& 888888888 T"&" 88888

152


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Check List

. T"&*"&

STANDAR 3..3.8

FILM 5RAY DAN PERBEKALAN LAIN TERSEDIA SE4ARA TERATUR



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. -r"/ '!+,7 re"*e&s!" "& se,%" #ere"+"&

#e&!&* !e"#-"&.

2. -r"/ '!+,7 re"*e&s!" "& #ere"+"& #e&!&*

+"!& erse!".

3. Se,%" #ere"+"& ! s!,#"& "& !!sr!%s!

ses%"! e&*"& #e$,"&

4. Se,%" #ere"+"& !e>"+%"s! se0"r" #er!$!

%&% "%r"s! "& "s!+&/".

5. Se,%" #ere"+"& !er! +"e+ se0"r" +e&*"#

"& "%r"T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

153


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Check List

STANDAR 3..3.9

PELAYANAN RADIOLOGI DIKELOLA2 DIPIMPIN2 DAN DILAKSANAKAN OLEHPETUGAS YANG KOMPETEN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Pe+"/"&"& r"!$+$*! !"" #!,#!&"& se$r"&*

/"&* $,#ee&

2. Pe+"/"&"& r"!$+$*! !+"s"&""& $+e #e%*"s

/"&* $,#ee&

3. Pe&"&**%&*"" #e+"/"&"& r"!$+$*!,e&*e,"&*"&7 ,e+"s"&""&7

,e,#er""&"& e!""& "& #r$se%r

!e"#"& "& !+"s"&""&.

4. Pe&"&**%&*"" #e+"/"&"& r"!$+$*!

,e+"%"& #e&*""s"& ",!&!sr"s! !e"#"&

"& !+"s"&""&.

5. Pe&"&**%&*"" #e+"/"&"& r"!$+$*!

,e,#er""&"& %#"/" $&r$+ ,%%

!e"#"& "& !+"s"&""&.

6. Pe&"&**%&*"" #e+"/"&"& ,e,"&"% "&

,ere>!e #e+"/"&"& r"!$+$*! /"&* !se!""&

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

154


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Check List

STANDAR 3..3.@

ADA PROSEDUR KONTROL MUTU2 DILAKSANAKAN DAN DIDOKUMENTASIKAN



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. A" %#"/" $&r$+ ,%% %&% #e+"/"&"&

r"!$!"*&$s!7 "& !+"s"&""&

2. =#"/" $&r$+ ,%% er,"s% >"+!"s! ,e$e

es.

3. =#"/" $&r$+ ,%% er,"s% #e&*""s"&"r!"& "s!+ #e,er!s""&.

4. =#"/" $&r$+ ,%% er,"s% #er"!"& 0e#"

!+" !e,%"& e%r"&*"&.

5. =#"/" $&r$+ ,%% er,"s% #e&$%,e&-

"s!"& "s!+ "& +"&*"-+"&*" #er"!"&.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888


155


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Check List


3.2.4. MANA:EMEN INFORMASI C REKAM MEDIS

STANDAR 3..'.a

ADA PEMBAKUAN KODE KLASIFIKASI DIAGNOSIS2 KODE PROSEDUR2

SIMBOL2 DAN ISTILAH YANG DIPAKAI



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. Ter"#" s"&"r!s"s! $e +"s!'!"s!

!"*&$s!s "& er,!&$+$*! +"!& /"&* $&s!se&"& s!se,"!s

2. Ter"#" s"&"r!s"s! $e +"s!'!"s! !"*&$s!s

"& er,!&$+$*/ /"&* !s%s%& $+e P%ses,"s

(,!&!,"+ 19 es"r #e&/"!)

3. D!+"%"& #e,"%"& s!&*""&-s!&*""& /"&*

!*%&""& "+", #e+"/"&"& ses%"! e&*"&

s"&"r &"s!$&"+ ""% +$"+.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..'.*

156


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Check List

PETUGAS MEMILIKI AKSES INFORMASI SESUAI DENGAN KEBUTUHAN

DAN TANGGUNGA/AB PEKERAAN



TIDA

K ADA

SKO

R

KETE-

RANGAN

1 2 3 4 5 6

1. D!e"#"& e!""& "& #r$se%r "ses

#e%*"s er""# !&'$r,"s! ,e!s

2. Ases #e%*"s er""# !&'$r,"s! /"&*

!%%"& !+"s"&""& ses%"! e&*"& %*"s

"& "&**%&* ""

3. Ases #e%*"s er""# !&'$r,"s! !+"s"&""&ses%"! e&*"& e!""& "& #r$se%r

4. ;" %&% ,e&*"ses !&'$r,"s! erse%

,e,#er!,"&*"& !&*" er""s!""& "&

e","&"& !&'$r,"s!

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..'.0

ADANYA SISTEM YANG MEMANDU PENYIMPANAN DAN PEMROSESAN

157


59/82


Check List

REKAM MEDIS



TIDA

K

ADA

SKO

R

KETE-

RANGA

N1 2 3 4 5 6

1. P%ses,"s ,e,#%&/"! re", ,e!s "*!

se!"# #"s!e& e&*"& ,e$" !e&!'!"s! /"&*

"%

2. S!se, #e&*$e"&7 #e&/!,#"&"&7 "&

$%,e&"s! ,e,%""& #e%*"s %&%

,e&e,%"& re", #"s!e& e#" "% ,"%#%&

%&% ,e&0"" #e+"/"&"& /"&* !er!"&

e#"" #"s!e&

3. A" e!""& "& #r$se%r #e&/!,#"&"&

er"s re", ,e!s e&*"& ee+"s"& ,"s"

ree&s! ses%"! #er"%r"& #er%&"&*"& /"&*

er+"%.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

N","

888888888.

:"""& 888888888

.

T"&"

T"&*"& 88888

STANDAR 3..'.

REKAM BERISI INFORMASI YANG MEMADAI DAN DIAGA KERAHASIAANNYA

158


60/82


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Check List

3.2.5. MANA:EMEN KEAMANAN LINGK=NGAN

STANDAR 3..6.a

LINGKUNGAN FISIK PUSKESMAS2 INSTALASI LISTRIK2 AIR2 =ENTILASI2 GAS DANSISTIM LAIN YANG DIPERSYARATKAN DIPERIKSA SE4ARA RUTIN2 DIPELIHARA2

DAN DIPERBAIKI BILA PERLU



TIDA

K

ADA

SKO

R

KETE-

RANGA

N

1 2 3 4 5 6

1. K$&!s! '!s! +!&*%&*"& P%ses,"s !#"&"%

se0"r" r%!&.

2. I&s"+"s! +!sr!7 %"+!"s "!r7 >e&!+"s!7 *"s "&

s!se, +"!& /"&* !*%&""& !#"&"% se0"r"

#er!$! $+e #e%*"s /"&* !er! "&**%&*

""

3. Terse!" s"r"&" %&% ,e&"&*"&! ,"s"+"

+!sr!"#! "#"!+" er"! e""r"&

4. Terse!" e!""& "& #r$se%r !&s#es!7

#e,"&"%"&7 #e,e+!"r""& "& #er"!"&

5. I&s#es!7 #e,"&"%"&7 #e,e+!"r""&7 "&

#er"!"& "+" !+"%"& ses%"! e&*"&

#r$se%r "& "%"+ /"&* !e"#"&

6. D!+"%"& $%,e&"s! #e+"s"&""&7 "s!+ "&

!&" +"&% !&s#es!7 #e,"&"%"&7

#e,e+!"r""& "& #er"!"& /"&* e+"

!+"%"&.

T$"+ S$r

Kes!,#%+"& """&

Be"s!7 88 Me! 2915

PENILAI - ASSESSOR

N","

888888888.

:"""& 888888888

.

T"&"

T"&am

Documents

Instrumen 3 Standar Pelayanan Medis-gizi