Form Penyelesaian Komplain.docx

KOP FORMULIR PENYELESAIAN KOMPLAIN, KELUHAN, KONFLIK ATAU PERBEDAAN PENDAPAT Nama Pasien/Keluarga :

No

Tanggal Lahir

Masalah : Baru

:

Tanggal/Jam Komplain : Ruangan/Bagian

:...........................

Lama

:

URAIAN MASALAH : .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... Penerima Komplain (.............................) TINDAKAN PENYELESAIAN SAAT KEJADIAN : .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... Yang Menyelesaikan (................................) EVALUASI TINDAK LANJUT : Tidak perlu tindak lanjut Perlu tindak lanjut dengan Correction Action Request Evaluasi oleh (...............................)