Formulir Pengajuan Spo_sk_form Rm_dokumen_ Revisi.docx
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BAGIAN MUTU & AKREDITASI RUMAH SAKIT MARDI RAHAYU KUDUS JL. AKBP R.AGIL KUSUMADYA 110 KUDUS, 59346 Telp. (0291) 438234,ext 841. Email : [email protected]
PENGAJUAN SPO/KEBIJAKAN/ FORMULIR REKAM MEDIS /DOKUMEN RESMI RS 1. NAMA UNIT
: ........................................................................................
2. Jenis Pengajuan SPO /Kebijakan/ Formulir Rekam Medis: (Pilih Salah Satu) BARU (Tulis Judul ) : .......................................................................................... REVISI : o JUDUL LAMA : .......................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... o NOMOR & TAHUN PEMBUATAN LAMA : .......................................................................................................................... .......................................................................................................................... ......................................................................................................................... 3. ALASAN PENGAJUAN SPO/REVISI SPO : (deskripsikan dengan jelas) ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................
KUDUS, ................................................
NB : Harap disertakan dokumen lama dan rancangan dokumen baru.
Jabatan
Nama Tanda Tangan
Ka.Unit/KaRu/ Ka.Bag/ Ka.Komite
Mengetahui Manajer/KaBag/ Direktur
Mengetahui Ketua BMA dr. Sonny, M.Kes
Direktur Utama
Dr. Pujianto, M.Kes
PENGAJUAN SPO/KEBIJAKAN/ FORMULIR REKAM MEDIS /DOKUMEN RESMI RS 1. NAMA UNIT
: ........................................................................................
2. Jenis Pengajuan SPO /Kebijakan/ Formulir Rekam Medis: (Pilih Salah Satu) BARU (Tulis Judul ) : .......................................................................................... REVISI : o JUDUL LAMA : .......................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... o NOMOR & TAHUN PEMBUATAN LAMA : .......................................................................................................................... .......................................................................................................................... ......................................................................................................................... 3. ALASAN PENGAJUAN SPO/REVISI SPO : (deskripsikan dengan jelas) ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................
KUDUS, ................................................
NB : Harap disertakan dokumen lama dan rancangan dokumen baru.
Jabatan
Nama Tanda Tangan
Ka.Unit/KaRu/ Ka.Bag/ Ka.Komite
Mengetahui Manajer/KaBag/ Direktur
Mengetahui Ketua BMA dr. Sonny, M.Kes
Direktur Utama
Dr. Pujianto, M.Kes
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