Berita Acara Komplain Pasien

BERITA ACARA KOMPLAIN KOMPL AIN PASIEN RUMAH SAKIT UNIVERS UNIVERSITA ITAS S BRAWIJA BRAWIJAY YA Nomor : _____________________________ 

 Yang  Yang bertanda tangan tangan di bawah ini , Nama

:

 Jenis Kelamin Kelamin Pekerjaan

:

Laki – Laki

Perempuan Perempuan

:

Alamat No Telp  !P : "

: #$



!P %&'

(ersama dengan ini disampaikan sarankeluhan kami mengenai pela)anan *umah +akit ni-ersitas (rawija)a tentang hal$hal )ang dialami oleh kami sendirikeluarga sendirikeluarga dari pasien.

Kronologis / komplain : ..................................................... ................................................................................ ....................................................... ....................................................... ................................. ...... ........... ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................ ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................ ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................ ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................ ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................ ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................ ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................

Penanganan Komplain : ..................................................... ................................................................................ ....................................................... ....................................................... ................................. ...... ........... ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................ ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................ ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................ ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................ ....................................................... .................................................................................. ....................................................... ....................................................... ........................................... ................ ........................................

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

Dengan ini saya telah memahami segala penjelasan yang telah diberikan oleh petugas dan saya bersedia untuk komplain ini di proses sesuai dengan prosedur penanganan komplain Rumah Sakit Universitas Brawijaya.

/alang, '012

Petugas

Pasien / Keluarga Pasien

______________________________

______________________________