Sk Akreditasi 2016

8/17/2019 Sk Akreditasi 2016

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PEMERINTAH KABUPATEN BERAUDINAS KESEHATAN

PUSKEMAS TELUK BAYURJl.Kandang Muntik RT. 007 Kode Pos. 7731 Teluk Ba!u"

#o.Tel$ % 0&1'&(37(7')E*ail. $uskes*as.teluk+a!u",!a-oo.o*

KEPUTUSA# KEPALA PUSKESMAS TELUK BAYUR

#/M/R TAU# '01

TE#TA#2

JE#S 4 JE#S PEMERKSAA# LAB/RAT/RUM YA#2 TERSE5A 5

PUSKESMAS TELUK BAYUR

KEPALA PUSKESMAS TELUK BAYUR

Menimbang : a. bahwa penyelenggaraan laboraori!m "e#ehaan $i In$one#ia

$i#elenggara"an oleh berbagai %eni# laboraori!m $an pa$a berbagai

%en%ang !paya pelayanan "e#ehaan& yang $ianaranya

$i#elenggara"an oleh 'aboraori!m P!#"e#ma#(

b. bahwa penyelenggaraan laboraori!m p!#"e#ma# $i"la#i)i"a#i"an

men!r! %eni# pemeri"#aan laboraori!m yang er#e$ia #ehingga

ma#yara"a mengeah!i #an$ar pelayanan laboraori!m p!#"e#ma#(

Menginga : *. Un$ang + Un$ang Nomor ,- Tah!n //0 enang Ke#ehaan

. Pera!ran Meneri Ke#ehaan Rep!bli" In$one#ia Nomor

1**2MENKES2PER2III2/*/ enang 'aboraori!m Klini"(

,. Pera!ran Meneri Ke#ehaan Rep!bli" In$one#ia Nomor ,3

Tah!n /* Tenang Penyelenggaraan 'aboraori!m P!#a

Ke#ehaan Ma#yara"a(

MEMUTUSKA# 6

Meneap"an : KEPUTUSAN KEPA'A PUSKESMAS TE'UK BA4UR TENTAN5

6ENIS + 6ENIS PEMERIKSAAN 'AB7RAT7RIUM 4AN5 TERSEDIA

DI PUSKESMAS TE'UK BA4UR(


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KESATU : bahwa 'aboraori!m P!#"e#ma# Tel!" Bay!r ber$a#ar"an %eni#

pelayanannya erma#!" 'aboraori!m Klini" Um!m(

K E D U A : bahwa 'aboraori!m Klini" Um!m P!#"e#ma# Tel!" Bay!r

$i"la#i)i"a#i"an men%a$i 'aboraori!m Klini" Um!m Praama(

KETI5A : 6eni# + %eni# pemeri"#aan yang er#e$ia erlampir(

Dieap"an $i :Pa$a angga :

Ke$ala Puskes*as Teluk Ba!u"

$r.H%.Ha#biahPang"a :PenaaTK I& III2DNIP:*08*/3/3 //-/1 /*-


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La*$i"an (

Jenis 4 Jenis Pe*e"iksaan !ang te"sedia di Puskes*as Teluk Ba!u" 61. e*oglo+in'. Leoosit3. T"o*+osit(. LE5. 55R. idal7. 25S 8 25P&. 9-oleste"ol:. Asa* U"at10.5L11. L5L1'.T"iglise"ida13.2olongan 5a"a-1(.U"in Lengka$1.PPT1.BTA17.U"eu*1&.9"eatinin

Dieap"an $i :999999Pa$a anggal :999999.


$r.H%.Ha#biah

Pang"a :PenaaTK I& III2DNIP:*08*/3/3 //-/1 /*-


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#/M/R ................ TAU# ................

TE#TA#2

PERM#TAA# PEMERKSAA#;PE#ERMAA# SPESME#;PE#2AMBLA# 5A#

PE#YMPA#A# SPESME#


Menimbang : a. Seiap orang berha" memperoleh in)orma#i enang $aa "e#ehaan

$irinya erma#!" in$a"an $an pengobaan yang elah ma!p!n

yang a"an $ierimanya $ari enaga "e#ehaan.

b. bahwa penyelenggaraan laboraori!m "e#ehaan $i In$one#ia

$i#elenggara"an oleh berbagai %eni# laboraori!m $an pa$a

berbagai %en%ang !paya pelayanan "e#ehaan& yang $ianaranya

$i#elenggara"an oleh 'aboraori!m P!#"e#ma#(

. bahwa laboraori!m p!#"e#ma# menga!r perminaan pemeri"#aan&penerimaan #pe#imen & pengambilan $an penyimpanan #pe#imen

#e#!ai #an$ar yang elah $ieap"an

Menginga : *. Un$ang + Un$ang Nomor ,- Tah!n //0 enang Ke#ehaan(

. Pera!ran Meneri Ke#ehaan Rep!bli" In$one#ia Nomor(


,. Pera!ran Meneri Ke#ehaan Rep!bli" In$one#ia Nomor ,3 Tah!n

/* Tenang Penyelenggaraan 'aboraori!m P!#a Ke#ehaan

Ma#yara"a.

MEMUTUSKA# 6

Meneap"a : KEPUTUSAN KEPA'A PUSKESMAS TE'UK BA4UR TENTAN5

PERMINTAAN&PEMERIKSAAN&PENERIMAAN

SPESIMEN&PEN5AMBI'AN DAN PEN4IMPANAN SPESIMEN.


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KESATU : bahwa laboraori!m p!#"e#ma# menga!r perminaan

pemeri"#aan&penerimaan #pe#imen $an pengambilan $an penyimpanan

#pe#imen:

K E D U A : bahwa penga!ran $i#e#!ai"an $engan #an$ar pro#!$er opera#ional

!n!" men$apa"an ha#il pemeri"#aan yang epa.

Dieap"an $i : Tel!" Bay!rPa$a anggal : 1 Mare /*-




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#/M/R ................ TAU# ................

TE#TA#2

AKTU PE#YAMPAA# LAP/RA# ASL PEMERKSAA# LAB/RAT/RUM


Menimbang : a. Seiap orang berha" memperoleh in)orma#i enang $aa "e#ehaan

$irinya erma#!" in$a"an $an pengobaan yang elah ma!p!n

yang a"an $ierimanya $ari enaga "e#ehaan.

b. bahwa penyelenggaraan laboraori!m "e#ehaan $i In$one#ia

$i#elenggara"an oleh berbagai %eni# laboraori!m $an pa$a

berbagai %en%ang !paya pelayanan "e#ehaan& yang $ianaranya

$i#elenggara"an oleh 'aboraori!m P!#"e#ma#(. bahwa laboraori!m p!#"e#ma# menga!r perminaan pemeri"#aan&

penerimaan #pe#imen & pengambilan $an penyimpanan #pe#imen

#e#!ai #an$ar yang elah $ieap"an

Menginga : *. Un$ang + Un$ang Nomor ,- Tah!n //0 enang Ke#ehaan(

. Pera!ran Meneri Ke#ehaan Rep!bli" In$one#ia Nomor


,. Pera!ran Meneri Ke#ehaan Rep!bli" In$one#ia Nomor ,3 Tah!n

/* Tenang Penyelenggaraan 'aboraori!m P!#a Ke#ehaan

Ma#yara"a.

MEMUTUSKA# 6

Meneap"an : KEPUTUSAN KEPA'A PUSKESMAS TE'UK BA4UR TENTAN5AKTU PE#YAMPAA# LAP/RA# ASL PEMERKSAA#

LAB/RAT/RUM


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KESATU : bahwa wa"! penyampaian laporan ha#il pemeri"#aan laboraori!m pa#ien

!m!m(

K E D U A : bahwa wa"! penyampaian laporan ha#il pemeri"#aan laboraori!m pa#ien

!rgen ;io


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#/M/R ................ TAU# ................

TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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Pa$a anggal :999999.




#/M/R ................ TAU# ................

TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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KETI5A : 9999999999999999999..9(

KEEMPAT : .............................................................................(



$r.H%.Ha#biah



#/M/R ................ TAU# ................

TE#TA#2


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KESATU : 999999999999 ..99999999(

K E D U A : 99999999999999999999..(

KETI5A : 9999999999999999999..9(

KEEMPAT : .............................................................................(





#/M/R ................ TAU# ................

TE#TA#2


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Meneap"an : KEPUTUSAN KEPA'A PUSKESMAS TE'UK BA4UR

TENTAN5 .............................................................................................................

............

KESATU : 999999999999 ..99999999(

K E D U A : 99999999999999999999..(

KETI5A : 9999999999999999999..9(

KEEMPAT : .............................................................................(





#/M/R ................ TAU# ................

TE#TA#2


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MEMUTUSKA# 6


TENTAN5 .............................................................................................................

............

KESATU : 999999999999 ..99999999(

K E D U A : 99999999999999999999..(

KETI5A : 9999999999999999999..9(

KEEMPAT : .............................................................................(





#/M/R ................ TAU# ................

TE#TA#2


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...............................................................................................................(

,. $an #eer!#nya(

MEMUTUSKA# 6


TENTAN5 .............................................................................................................

............

KESATU : 999999999999 ..99999999(

K E D U A : 99999999999999999999..(

KETI5A : 9999999999999999999..9(

KEEMPAT : .............................................................................(





#/M/R ................ TAU# ................

TE#TA#2


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...............................................................................................................(

. Pera!ran Pemerinah

9999999999999999... ............

...............................................................................................................(

,. $an #eer!#nya(

MEMUTUSKA# 6


TENTAN5 .............................................................................................................

............

KESATU : 999999999999 ..99999999(

K E D U A : 99999999999999999999..(

KETI5A : 9999999999999999999..9(

KEEMPAT : .............................................................................(





#/M/R ................ TAU# ................TE#TA#2


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. $an #eer!#nya

Menginga : *. Un$ang=Un$ang 99999999......................................................

...............................................................................................................(


9999999999999999... ............

...............................................................................................................(

,. $an #eer!#nya(

MEMUTUSKA# 6


TENTAN5 .............................................................................................................

............

KESATU : 999999999999 ..99999999(

K E D U A : 99999999999999999999..(

KETI5A : 9999999999999999999..9(

KEEMPAT : .............................................................................(





#/M/R ................ TAU# ................

TE#TA#2


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b. bahwa 9999999999999999.............999 ...............

..............................................................................................................(

. $an #eer!#nya


...............................................................................................................(


9999999999999999... ............

...............................................................................................................(

,. $an #eer!#nya(

MEMUTUSKA# 6


TENTAN5 .............................................................................................................

............

KESATU : 999999999999 ..99999999(

K E D U A : 99999999999999999999..(

KETI5A : 9999999999999999999..9(

KEEMPAT : .............................................................................(





#/M/R ................ TAU# ................

TE#TA#2


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Menimbang : a. bahwa 999999999999999999.................... .....99

..............................................................................................................(

b. bahwa 9999999999999999.............999 ...............

..............................................................................................................(

. $an #eer!#nya


...............................................................................................................(


9999999999999999... ............

...............................................................................................................(

,. $an #eer!#nya(

MEMUTUSKA# 6


TENTAN5 .............................................................................................................

............

KESATU : 999999999999 ..99999999(

K E D U A : 99999999999999999999..(

KETI5A : 9999999999999999999..9(

KEEMPAT : .............................................................................(





#/M/R ................ TAU# ................

TE#TA#2


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Menimbang : a. bahwa 999999999999999999.................... .....99

..............................................................................................................(

b. bahwa 9999999999999999.............999 ...............

..............................................................................................................(

. $an #eer!#nya


...............................................................................................................( . Pera!ran Pemerinah

9999999999999999... ............

...............................................................................................................(

,. $an #eer!#nya(

MEMUTUSKA# 6


TENTAN5 .............................................................................................................

............KESATU : 999999999999 ..99999999(

K E D U A : 99999999999999999999..(

KETI5A : 9999999999999999999..9(

KEEMPAT : .............................................................................(





#/M/R ................ TAU# ................


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TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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#/M/R ................ TAU# ................

TE#TA#2


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SURAT PER#TA

#/M/R


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SURAT =# KEPALA PUSKESMAS TELUK BAYUR

#/M/R


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SURAT PERJA#JA#

#/M/R


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SURAT PER#TA TU2AS

#/M/R


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SURAT PERINTAH PER6A'ANAN DINAS;S P P D<

*. Pe%aba yang memberi perinah

. Nama Pegawai yang $iperinah

,. a. Pang"a $an 5olongan men!r!

PP No. - Tah!n *003

b. 6abaan

. Ting"a men!r! pera!ran Per%alanan

1. Ma"#!$ Per%alanan Dina#

?. Ala ang"! yang $iperg!na"an

-. a. Tempa berang"a

b. Tempa !%!an

3. a.'amanya Per%alanan Dina#

b.Tanggal berang"a

. Tanggal har!# "embali

8. Pengi"!

0. Pembebanan Anggarana. In#an#i

b. Maa Anggaran

*/

.

Keerangan lain=lain

Di"el!ar"an $i:999999Pa$a anggal :999999.


$r.H%.Ha#biah Pang"a :PenaaTK I& III2D

NIP:*08*/3/3 //-/1 /*-

SPPD No : 999999Berang"a $ari;empa "e$!$!"an< : 999999Pa$a anggal : 999999Ke :9999999


d".>.as+ia-

#P. 1:&10707 '0000 ' 01

Tiba $i :99999999

Pa$a anggal : 9999999999

Kepala : 99999999999

Berang"a $ari : 99999999999

Ke : 99999999999

Pa$a anggal : 99999999999

Kepala


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III.Tiba $i : 99999999999

Pa$a anggal : 99999999999

Kepala : 99999999999

Berang"a $ari : 99999999999

Ke: 99999999999

Pa$a anggal : 99999999999

Kepala

I@. Tiba $i : 99999999999Pa$a anggal : 99999999999

Kepala : 99999999999

Berang"a $ari : 99999999999

Ke : 99999999999

Pa$a angga l : 99999999999

Kepala

@. Tiba $i : 99999999999Pa$a anggal : 99999999999

Telah $iperi"#a& $engan "eerangan bahwa Per%alanan er#eb! $iaa# benar $ila"!"an aa#

perinahnya $an #emaa=maa !n!" "epeningan %abaan $alam wa"! yang #e#ing"a=#ing"anya


d".>.as+ia-

#P. 1:&10707 '0000 ' 01

@I. ATATAN 'AIN='AIN

@II. PERHATIAN Pe%aba yang berwenang menerbi"an SPPD& pegawai yang mela"!"an

per%alanan $ina#& para pe%aba yang menge#ah"an anggal berang"a2iba #eraBen$aharawan berangg!ng %awab ber$a#ar"an pera!ran=pera!ran Ke!angan Negara

apabila Negara men$apa r!gi a"iba "e#alahan& "ealpaannya.

SURAT KUASA#o*o" . . . . . . . . . . . . . .


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4ang beran$aangan $ibawah ini :

a. Nama : ........................................................b. 6abaan : .....................................................

MEMBER KUASA

Ke$ada 6

a. Nama : ........................................................b. 6abaan : ......................................................... NIP. : ........................................................

Un!" :......................................................................................................................... .......

.............................................................................................................................

Demi"ian S!ra K!a#a ini $ib!a !n!" $apa $iperg!na"an #ebagaimaname#inya.

Tempa& Tanggal& B!lan $an Tah!n

4ang $iberi "!a#a 4ang memberi "!a#a

NAMA 6ABATAN Ke$ala Puskes*as Teluk Ba!u"

Nama$r.H%.Ha#biah Pang"aPang"a :PenaaTK I& III2DNIPNIP:*08*/3/3 //-/1 /*-


Kepa$aNomor : ....................... 4h. ..............................


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Si)a : ....................... .............................'ampiran : .......................Hal : Un$angan $i +

......................

...........................................

.....................................................................................................................

..........................................

Hari : ................................................

Tanggal : ................................................

P!"!l : ................................................

Tempa : ................................................

Aara : ................................................

.....................................................................................................................

......................................................................................



NIP:*08*/3/3 //-/1 /*-

aaan :

*. .................................................. .................................................

SURAT KETERA#2A# MELAKSA#AKA# TU2AS

#/M/R


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4ang beran$a angan $ibawah ini :

Nama : ...................................................NIP : ....................................................Pang"a25olongan : ....................................................6abaan : ....................................................

Dengan ini menerang"an $engan #e#!ngg!hnya bahwa :Nama : ...................................................NIP : ....................................................Pang"a25olongan : ....................................................6abaan : ....................................................

4ang $iang"a ber$a#ar"an Pera!ran ...............................................................

................. Nomor ......................... erhi!ng ......................................................

elah nyaa men%alan"an !ga# #ebagai ...............................................................

$i +

........................................................................................................................

Demi"ian #!ra "eerangan mela"#ana"an !ga# ini #aya b!a $engan

#e#!ngg!hnya $engan menginga #!mpah %abaan2pegawai negeri #ipil $an apabila

$i"em!$ian hari i#i #!ra pernyaaan ini ernyaa i$a" benar yang bera"iba "er!gian

bagi negara& ma"a #aya ber#e$ia menangg!ng "er!gian er#eb!.

Tempa& Tanggal& B!lan $anTah!n



NIP:*08*/3/3 //-/1 /*-L E M B A R D I S P O S I S I Surat dari : No. Surat : Tgl. Surat : Diterima Tgl : No.Agenda : Sifat : Sangat segera Segera Rahasia Perihal : Diterusan e!adaSdr.: ........................................... ........................................... ........................................... Dan seterusn"an"a ###. Dengan hormat hara!: Tangga!an dan Saran Proses

le$ih lan%ut &oordinasi'on(rmasian ########### ###########)atatan : Nama *a$atan Paraf dan tanggal Nama+


Kepa$a


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Nomor : ............................ 4h. ...........................Si)a : ............................ ...........................'ampiran : ............................Hal : Panggilan. $i +

.............................

Dengan ini $imina "e$aangan Sa!$ara $i Kanor ..................

.............................................................................................& pa$a:

Hari : ............................................................................

Tanggal : ............................................................................P!"!l : ............................................................................

Tempa : ............................................................................

Mengha$ap : ............................................................................

Kepa$a : ............................................................................

Alama : ............................................................................

Un!" : ............................................................................

............................................................................

Demi"ian !n!" $ila"#ana"an $an men%a$i perhaian #epen!hnya.


$r.H%.Ha#biah


TELAAA# STA?

Kepa$a : ...........................................................

Dari : ...........................................................Tanggal : ...........................................................Nomor : ...........................................................'ampiran : ...........................................................Hal : ..........................................................

CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC

I. Per#oalan.

II. Praanggapan


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III. a"a=a"a yang mempengar!h

I@. Anali#i#

@. Ke#imp!lan

@I.Saran


$r.H%.HASBIAH Pang"a :PenaaTK I& III2DNIP:*08*/3/3 //-/1 /*-

PE#2UMUMA##/M/R 6


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LAP/RA#

TE#TA#2

.............................................................................

I. Pen$ah!l!an. A. Um!m2laar bela"angB. 'an$a#an H!"!m. Ma"#!$ $an T!%!an

II. Kegiaan yang $ila"#ana"an&

III. Ha#il yang $iapai&

I@. Ke#imp!lan $an Saran

@. Pen!!p.

Dib!a $i :

Pa$a anggal :

Nama&

REK/ME#5AS ...............................

#/M/R


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a. 99999999999999999

b. .9999999999999999

999999999999999999999999999999999999999

999999999999999999999999999999999999999

999999999999999999999999999..




Tem!at+ Tanggal+ Bulan dan Tahun &e!ada+

,th .............................................. ...................................... di - ..................................

SRAT PEN/ANTAR NOMOR : ##### No. *enis "ang diirim Ban"an"a

&eterangan Diterima tanggal #####. Penerima Pengirim Nama *a$atan+ Nama

*a$atan+ Nama+ Nama+ Pangat Pangat NIP. NI


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BERITA A)ARA 000000000000000 NOMOR : ### Pada hari ini

tanggal ........................................................................................... ............................

.................................................... ami masing1masing:

2. ................................................................................................ "ang selan%utn"a

dise$ut Piha Pertama 3memuat nama+ NIP+ Pangat'/olongan+ *a$atan dan alamat4

5. ................................................................................................ "ang selan%utn"a

dise$ut Piha &edua 3memuat nama+ NIP+ Pangat'/olongan+ *a$atan dan alamat4

###################################

#######################################

################################### Berita A6ara

ini di$uat dengan sesungguhn"a dalam ranga!#.. untu di!ergunaan

se$agaimana mestin"a. Di$uat di ........................... Piha &edua NAMA+ Pangat NIP.

Piha Pertama BPATI BERA NAMA+

NOTLEN Sidang'Ra!at : ............................................................................

7ari'Tanggal : ............................................................................ 8atu

Panggilan : ............................................................................ 8atu

sidang'ra!at : ............................................................................ A6ara :

2. ........................................................................ 5. dan seterusn"a 9. Penutu!.

Pim!inan Sidang'Ra!at &etua : ............................................................................

Seretaris : ............................................................................

Pen6atat : ............................................................................ Peserta sidang'ra!at :

2. ........................................................................ 5. dan seterusn"a. &egiatan

Sidang'Ra!at : 2. ........................................................................ 5. dan seterusn"a.

2. &ata Pem$uaan : ##################### 5. Pem$ahasan :

##################### 9. Peraturan :


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#####################

################################. PIMPINAN

SIDAN/'RAPAT NAMA *ABATAN NAMA+ Pangat NIP.

M E M O Dari : ############################# &e!ada :

#############################

Isi : ..........................................................................................###############################

############################### ##########.

###############################

###############################

############################### ##########..

Tem!at+ Tanggal+ Bulan dan Tahun BPATI BERA Tanda Tangan atau Paraf

DATAR 7ADIR PERTEMAN RAPAT

7ari : ..........................................................................

Tanggal : ..........................................................................

8atu : ..........................................................................


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Tem!at : ..........................................................................

A6ara : ......................................................................... NO. NAMA *ABATAN' PAN/&AT

TANDA TAN/AN &ET 2. 5. 9. dan seterusn" a. Tem!at+ Tanggal+ Bulan dan Tahun

NAMA *ABATAN NAMA+ Pangat NIP.

DATAR 7ADIR BLAN : MIN// : NO. NAMA PAN/&AT' /OL TAN//AL &ET P S P S P

S P S 2 5 9 ; < = > ? @ 2 22 25 &EPALA SB BA/IAN' SE&RETARIS Tem!at+ Tanggal+

Bulan dan Tahun NAMA *ABATAN NAMA+ Pangat NIP

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Sk Akreditasi 2016