Form-15 CheckList Audit Internal Akreditasi Puskesmas

CECKLIST AUDIT INTERNAL PUSKESMAS : SEMPAJA UNIT: UNIT: IMUNISASI IMU NISASI Form-18 SEK MUTU/2015

Action Plan Ruangan

CONFORMITY

No.

CONTROL OF QUALITY SYSTEM

A

(PENGENDALIAN DOKUMEN)



A!a"a# A!a"a# Do"u$en Do"u$en %ang %ang a&a a&a su&a su&a# # &is%a# &is%a#"an "an ole# To! $ana $ana'e$e 'e$en( n(

)

A!a"a# &o"u$en &i*e+ie, seca*a -e*"ala(



A!a"a# &o"u$en te*se&ia "eti"a &i-utu#"an( /te*si$!an &engan -ai"0

1

A!a"a# &o"u$en $u&a# &ii&enti2i"asi(

3

A!a"a# A!a"a# &o"u$e &o"u$en n &a*i lua*4*e lua*4*e2e*e 2e*ensi4nsi4-u"u u"u #asil #asil !elati#a !elati#an n su&a# &ila!o &ila!o*"a *"an n "e se"*eta se"*eta*iat *iat MUTU( MUTU(

5

A!a"a# &ata &an *e"a$an te*si$!an &engan *a!i( /Ce" le$a*i &an *a" !en%i$!an a*si!0

6

A!a"a A!a"a# # &ata7&a &ata7&ata ta te*" te*"ait ait &enga &engan n !*og*a !*og*a$ $ te*ca te*catat tat leng" leng"a!( a!(

8

A!a"a# A!a"a# &ata &ata &a!at &a!at te*se& te*se&ia ia te!at te!at ,a"tu( ,a"tu( /ce" /ce" "e "e !etugas !etugas *e"a! *e"a! &ata9 &ata9 $isal: $isal: -agia -agian n TU0

B

/TAN /TAN UN UN  JA; JA;AB MANA MANAJE JEME MEN0 N0

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A!a" A!a"a# a# KeKe-i' i'a" a"an an $ut $utu u su&a su&a# # &i$en &i$enge ge*t *ti( i(

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A!a"a A!a"a# # 'o- &esc &esc*i! *i!tio tions ns su&a su&a# # 'elas 'elas &an te*s te*se& e&ia ia (



A!a"a# A!a"a# 'o- &esc &esc*i!ti *i!tions ons su&a# su&a# &i'alan &i'alan"an "an &engan &engan -ai" -ai" (

)

A!a"a# "o$!lain !elanggan su&a# &i&o"u$ent asi"an( Dan &i"o$uni" asi"an "e!a&a TOP TOP Manage$ent &an -agian %ang te*"ait(



A!a"a A!a"a# # sasa sasa*a *an n $utu $utu su&a su&a# # &itet &iteta!" a!"an( an(

1

A!a"a# A!a"a# sasa*a sasa*an n $utu $utu &ie+alua &ie+aluasi si seca*a seca*a -e*"ala -e*"ala( (

3

A!a"a# A!a"a# Ko$uni Ko$uni"as "asii &an "oo*&ina "oo*&inasi si te*ca te*catat tat &i -u"u "onsultas "onsultasi( i(

C

/SUM /SUMBE BER R DA> DA>A DAN DAN LIN LINKU KUN NAN AN KER KERJA JA00

5

A!a" A!a"a# a# ala alatt &an &an -a#a -a#an n te*s te*se& e&ia ia( (

6

A!a"a A!a"a# # alat alat -e*2un -e*2ungs gsii &eng &engan an -ai"( -ai"(

8

A!a"a# *uangan cu"u! -e*si#( /Ce" "e-e*si#an "e-e*si#an &in&ing9 &in&ing9 lantai9 lantai9 langit7langit9 *a"9 le$a*i9 $e'a9 "u*si0

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A!a" A!a"a# a# *uan *uanga gan n ti&a ti&a" " -e* -e*-a -au( u(

)=

Ce" Ce" ?ung ?ungsi si &an &an KeKe-e* e*si# si#an an ;asta ;asta2el 2el( (

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K*an K*an ai* ai*9 -e*2 -e*2un ungs gsi( i(

))

SaSa-un9 un9 te* te*se&ia &ia (

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@an& to,el to,el te*se te*se&ia &ia &an -e*si#( -e*si#( 4 Tissu Tissue e te*s te*se&ia e&ia( (

)1

Kese Keset9 t9 te* te*se se&i &ia a &an &an -e*s -e*si# i# (

)3

Te$!at e$!at sa$!a# sa$!a# $e&is4no $e&is4non n $e&is $e&is te*se&ia te*se&ia &an -e*si# -e*si# (

)5

Pe*alata Pe*alatan n "e*'a "e*'a &isi$! &isi$!an an !a&a !a&a te$!atn% te$!atn%a a 'i"a 'i"a ti&a" ti&a" &i!a" &i!a"ai ai

MAJOR

MINOR

OBS

REMARKS AUDIT

Due Date

Status


)6

Ba#an Ba#an &an alat alat &isi &isi$!a $!an n &engan &engan -ai" -ai" &an &an te*atu te*atu* *

D

/REA /REALI LIS SASI ASI PELA PELA> >ANAN ANAN00

)8

A!a" A!a"a# a# !et !etuga ugas s $en $enun' un'u"" u""an an si" si"a! a! S( S(

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Dala$ "ea&aan "ea&aan e$e*genc% e$e*genc% a!a"a# a!a"a# su&a# a&a a&a tin&a"an tin&a"an antisi! antisi!asi( asi( /conto# /conto# $ati $ati la$!u0 la$!u0 ce" ce" "esia!an "esia!an !etugas !etugas

=

A!a"a# A!a"a# la$a la$a ,a"t ,a"tu u su&a# su&a# sesuai sesuai sasa*a sasa*an n $utu( $utu(



A!a" A!a"a# a# *uan *uang g tungg tunggu u -e*s -e*si# i# &an &an n%a n%a$a $an( n(

)

A!a"a# A!a"a# ,a"tu ,a"tu !ela%a !ela%anan nan i$unis i$unisasi asi te!at te!at !a&a !a&a ,a"tun% ,a"tun%a( a(



A!a" A!a"a# a# !etu !etuga gas s -e*a -e*a&a &a &ite$ &ite$!a !at( t(

1

A!a"a# A!a"a# !etu !etugas gas $ela $ela"u" "u"an an #an& #an& #%gien #%giene e se-elu se-elu$ $ i$unis i$unisasi asi( (

3

A!a"a# A!a"a# !etuga !etugas s $e$a"a $e$a"aii #an&sc# #an&sc#oen oen !a&a !a&a saat saat $ela" $ela"u"a u"an n tin&a"a tin&a"an( n(

5

A!a"a# A!a"a# Petugas Petugas $ela"u"an $ela"u"an ana$nesa ana$nesa a,al a,al !a&a !a&a -a%i -a%i &an !e$e*i"saa !e$e*i"saan n 2isi"( 2isi"(

6

A!a"a# A!a"a# !etugas !etugas $e$-e* $e$-e*i"an i"an in2o*$asi in2o*$asi %ang cu"u! cu"u! tentang tentang tin&a"an tin&a"an %ang %ang a"an a"an &ila"u"an &ila"u"an( (

8

A!a"a# A!a"a# !etuga !etugas s $en%ia! $en%ia!"an "an in2o*$ in2o*$ concen concentt se-elu$ se-elu$ $ela" $ela"u"a u"an n tin&a"an tin&a"an( (

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A!a"a# A!a"a# se-elu$ se-elu$ i$unisasi i$unisasi !etugas $e$asti"an $e$asti"an "on&isi +a"sin +a"sin &ala$ &ala$ "ea&aa "ea&aan n -ai"( -ai"(

1=

A!a"a# A!a"a# !etugas !etugas $e$-e*i $e$-e*i "onseli "onseling ng setela# setela# i$unisas i$unisasii &an $e$-e* $e$-e*ita#u ita#u 'a&,al 'a&,al i$unisa i$unisasi si selan'ut selan'utn%a( n%a(

1

A!a"a# !etugas $ela"u"an #an& #%giene &engan -ena* se-elu$ &an setela# $ela"u"an i$unisasi( PRAKTEKKAN

1)

Bagai$ana ting"at !e$a#a$an !e$o#on te*#a&a! in2o*$asi %ang &i-e*i"an !etugas(/tan%a"an !a&a !e$o#on a!a"a# $enge*ti !en'elasan !etugas0

1

A!a"a# A!a"a# !etugas $a$!u $a$!u $ela"u"a $ela"u"an n tin&a"an tin&a"an "eti"a "eti"a te*'a&i te*'a&i KTD($isal KTD($isal Ana2ila"ti Ana2ila"ti" " s#oc"( P*a"te P*a"te""an ""an

11

A!a"a# A!a"a# !etuga !etugas s $ela"u" $ela"u"an an !engece !engece"an "an *utin *utin sto" sto" +a"sin +a"sin( ( /ce" -u"u -u"u sto"0 sto"0

13

A!a"a# A!a"a# !etuga !etugas s $engece $engece" " 'u$la# 'u$la# &an "ualit "ualitas as saat saat !ene*i !ene*i$aa $aan n +a"sin( +a"sin(

15

A!a"a# A!a"a# !etuga !etugas s $enan&at $enan&atanga angani ni su*at su*at !ene*i$a !ene*i$aan4 an4!eng !engelu elua*a a*an n +a"sin( +a"sin(

16

Action Plan Ruangan

CONFORMITY

No.

A!a"a# !etugas su&a# $en%i$!an +a"sin sesuai &engan atu*an !en%i$!anan( /tata leta" +a"sin &i &ala$ 2*eee*0 7 a"sin BC9 Ca$!a" &an !olio9 &ileta""an &i te$!at !aling &e"at &engan 2*eee*. 7 a"sin DPT DPT Co$-o9 TT9 TT9 DT9 DT9 TD &an @-9 &ileta""an &i -agian tenga# atau aga" 'au# &a*i 2*eee*

18

A!a"a# A!a"a# !etugas !etugas $encata $encatatt #a*ian #a*ian su#u 2*eee 2*eee*( *( Di'aga Di'aga ) 7 8 &e*a'at &e*a'at Celsius Celsius

1<

A!a"a# A!a"a# !*insi !*insi! ! ?I?O4?E ?I?O4?E?O ?O +a"sin +a"sin &i'ala &i'alan"a n"an( n(

3=

A!a"a# A!a"a# +a"si +a"sin n *usa" *usa" &an e!i*e e!i*e& & su&a# &ii&e &ii&enti nti2i" 2i"asi asi &an &an &i"en&a &i"en&ali" li"an( an(

3

A!a"a# A!a"a# Petugas Petugas $encatat $encatat +a"sin +a"sin %ang *usa" *usa" atau atau "a&alua*s "a&alua*sa a "e -u"u -u"u catatan catatan o-at *usa" &an "a&alua* "a&alua*sa sa

3)

A!a"a# A!a"a# sisa sisa +a"s +a"sin in !os% !os%an&u an&u &i"elo &i"elola la &engan &engan -ai" -ai"( (

3

A!a"a# A!a"a# !etugas !etugas $ela"u" $ela"u"an an !e*a,ata !e*a,atan n 2*eee* 2*eee* &an "ul"as "ul"as +a"sin( +a"sin( /ce" /ce" "on&isin% "on&isin%a( a(

31

A!a" A!a"a# a# -unga -unga es $ele $ele-i -i#i #i =.3 =.3 c$( c$(

MAJOR

MINOR

OBS

REMARKS AUDIT

Due Date

Status

Action Plan Ruangan

CONFORMITY

No.


MAJOR

E

/MONITORIN DAN PENUKURAN0

33

A!a"a# !etugas seca*a *utin &an te!at ,a"tu $engi*i$ &ata !*og*a$(

35

A!a"a# !etugas #asil au&it inte*nal &itin&a" lan'uti(

36

A!a"a# "eti&a"sesuaian !ela%anan &i unitn%a su&a# &ii&enti2i"asi(

38

A!a"a# !etugas $encatatat &an $en&o"u$entasi"an "eti&a"sesuaian te*se-ut(

3<

A!a"a# !etugas su&a# $e$!e*-ai"i "eti&asesuaian !ela%anan te*se-ut(

5=

A!a"a# !etugas $e*encana"an "egiatan !encega#an aga* "eti&a"sesuaian ti&a" te*'a&i "e$-ali(

5

A!a"a# "egiatan !e*-ai"an &an !encega#an &ila!o*"an(

MINOR

OBS

REMARKS AUDIT

Samarinda...............

Mengetahui,

Menyetujui,

Lead Auditor

Koordinator Unit

Kepala Puskesmas

Due Date

Status

CECKLIST AUDIT INTERNAL PUSKESMAS : SEMPAJA UNIT: ?ARMASI

No.

Form-18 SEK MUTU/2015


A




A!a"a# Do"u$en %ang a&a su&a# &is%a#"an ole# To! $ana'e$en(

)





1


3

A!a"a# &o"u$en &a*i lua*4*e2e*ensi4-u"u #asil !elati#an su&a# &ila!o*"an "e se"*eta*iat MUTU(

5


6

A!a"a# &ata7&ata te*"ait &engan !*og*a$ te*catat leng"a!(

8

A!a"a# &ata &a!at te*se&ia te!at ,a"tu( /ce" "e !etugas *e"a! &ata9 $isal: -agian TU0

B

/TANUN JA;AB MANAJEMEN0

<

A!a"a# Ke-i'a"an $utu su&a# &i$enge*ti(

=  )

A!a"a# 'o- &esc*i!tions su&a# 'elas &an te*se&ia ( A!a"a# 'o- &esc*i!tions su&a# &i'alan"an &engan -ai" (



A!a"a# sasa*an $utu su&a# &iteta!"an(

1 3

A!a"a# "o$!lain !elanggan su&a# &i&o"u$entasi"an( Dan &i"o$uni"asi"a n "e!a&a TOP Manage$ent &an -agian %ang te*"ait(

A!a"a# sasa*an $utu &ie+aluasi seca*a -e*"ala( A!a"a# Ko$uni"asi Ko$uni"asi &an "oo*&inasi te*catat &i -u"u "onsultasi(

C

KLAUSUL 5

5

A!a"a# alat &an -a#an te*se&ia(

6

A!a"a# alat -e*2ungsi &engan -ai"( A!a"a# *uangan cu"u! -e*si#( /Ce" "e-e*si#an &in&ing9 l antai9 langit7langit9 *a"9 l e$a*i9 $e'a9 "u*si0

8 <

A!a"a# *uangan ti&a" -e*-au(

)=

Ce" ?ungsi &an Ke-e*si#an ;asta2el(

)

K*an ai*9 -e*2ungsi(

))

Sa-un9 te*se&ia (

)

@an& to,el te*se&ia &an -e*si#( 4 Tissue te*se&ia(

)1

Keset9 te*se&ia &an -e*si# (

)3

Te$!at sa$!a# $e&is4non $e&is te*se&ia &an -e*si# (

)5

Pe*alatan "e*'a &isi$!an !a&a te$!atn%a 'i"a ti&a" &i!a"ai

)6

Ba#an &an alat &isi$!an &engan -ai" &an te*atu*

CONFORMITY

MAJOR

MINOR

OBS

REMARKS AUDIT

Action Plan Ruangan

Due Date

Status

No.

CONFORMITY


MAJOR

D

/REALISASI PELA>ANAN0

)8

A!a"a# !etugas $enun'u""an si"a! S(

)<

Dala$ "ea&aan e$e*genc% a!a"a# su&a# a&a tin&a"an antisi!asi( /conto# $ati la$!u0 ce" "esia!an !etugas

=

A!a"a# la$a ,a"tu su&a# sesuai sasa*an $utu(



A!a"a# *uang tunggu -e*si# &an n%a$an(

)

A!a"a# ,a"tu !ela%anan o-at te!at !a&a ,a"tun%a(



A!a"a# !etugas -e*a&a &ite$!at(

1

3 5 6 8

Action Plan Ruangan

A!a"a# !etugas selalu $e$-e*i"an !eno$o*an !a&a "e*tas *ese!( A!a"a# !etugas $e$-e*i"an in2o*$asi %ang cu"u! tentang o-at( /ca*a !e$a"aian9 e2e" sa$!ing9 &s-0 Bagai$ana ting"at !e$a#a$an !e$o#on te*#a&a! in2o*$asi %ang &i-e*i"an !etugas(/tan%a"an !a&a !e$o#on a!a"a# $enge*ti !en'elasan !etugas0 A!a"a# !etugas $ela"u"an !engece"an *utin sto" o-at( A!a"a# !etugas $engece" 'u$la# &an "ualitas o-at saat !ene*i$aan o-at(

1

A!a"a# !etugas $enan&atangani su*at !ene*i$aan4!engelua*an o-at( A!a"a# !etugas su&a# $en%i$!an o-at sesuai &engan atu*an !en%i$!anan( /Su#u9 "ele$-a-a-9 !enca#a%aan0 A!a"a# !etugas $en%i$!an o-at sesuai a-'a& untu" $e$!e*$u&a# !enga$-ilan(

11

A!a"a# !*insi! ?I?O4?E?O &i'alan"an(

13

A!a"a# o-at e!i*e& su&a# &ii&enti2i"asi &an &i"en&ali"an(

15

A!a"a# o-at nea*l% e!i*e& su&a# &ii&enti2i"asi &an &i"en&ali"an (

16

A!a"a# Petugas $encatat o-at  o-at %ang *usa" atau "a&alua*sa "e -u"u catatan o-at *usa" &an "a&alua*sa

18

A!a"a# !etugas $e$-uat la!o*an usulan !e$usna#an o-at "a&alua*sa(

1<

REMARKS AUDIT

A!a"a# Petugas $ela"u"an ce" i&entitas !elanggan &isesuai"an &engan i&entitas &i *ese!

1=

1

OBS

A!a"a# !etugas $encatat seca*a *utin !engelua*an o-at &i -u"u *egiste*( /ce" a!a"a# sesuai atau ti&a"0

<

1)

MINOR

A!a"a# Petugas $encatat !ene*i$aan &an !engelua*an o-at !a&a "a*tu sto"(

3=

A!a"a# Petugas $e$antau su#u &an "ele$-a-an *uangan seca*a *utin(

3

A!a"a# !en%i$!anan o-at &ileta""an &i atas +alet(

E


3) 3


31 33 35 36 38

A!a"a# "eti&a"sesuaian !ela%anan &i unitn%a su&a# &ii&enti2i"asi( A!a"a# !etugas $encatatat &an $en&o"u$entasi"an "eti&a"sesuaian te*se-ut( A!a"a# !etugas su&a# $e$!e*-ai"i "eti&asesuaian !ela%anan te*se-ut( A!a"a# !etugas $e*encana"an "egiatan !encega#an aga* "eti&a"sesuaian ti&a" te*'a&i "e$-ali( A!a"a# "egiatan !e*-ai"an &an !encega#an &ila!o*"an(


Samarinda...............

Mengetahui,

Menyetujui,

Lead Auditor

Koordinator Unit

Kepala Puskesmas

Due Date

Status

CECKLIST AUDIT INTERNAL PUSKESMAS : SEMPAJA UNIT: LOKET

No.



A





)





1


3


5


6


8


B


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1

A!a"a# "o$!lain !elanggan su&a# &i&o"u$entasi"an( Dan &i"o$uni"asi"an "e!a&a TOP Manage$ent &an -agian %ang te*"ait(

A!a"a# sasa*an $utu &ie+aluasi seca*a -e*"ala( A!a"a# Ko$uni"asi &an "oo*&inasi te*catat &i -u"u "onsultasi(

C

/SUMBER DA>A DAN LINKUNAN KERJA0

3


5

A!a"a# alat -e*2ungsi &engan -ai"(

6

A!a"a# *uangan cu"u! -e*si#( /Ce" "e-e*si#an &in&ing9 lantai9 langit7langit9 *a"9 le$a*i9 $e'a9 "u*si0

8


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)=

Te$!at sa$!a# untu" !engun'ung te*se&ia &an -e*si# (

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))


CONFORMITY

MAJOR

MINOR

OBS

REMARKS AUDIT

Action Plan Ruangan

Due Date

Status

No.

CONFORMITY


D


)


MAJOR

MINOR

OBS

REMARKS AUDIT

Action Plan Ruangan

)1 A!a"a# sa*ana in2o*$asi -agi !elanggan te*se&ia( /@a" "e,a'i-an9 alu* !ela%anan9 ,a"tu !ela%anan9 &s-0 )3

A!a"a# &ata *e"a$ $e&is &isi$!an &engan -ai"(

)5

Bagai$ana ting"at !e$a#a$an !e$o#on te*#a&a! in2o*$asi %ang &i-e*i"an !etugas(/tan%a"an !a&a !e$o#on a!a"a# $enge*ti !en'elasan !etugas0

)6

A!a"a# !etugas selalu $engece" "eleng"a!an !e*s%a*atan se-elu$ in!ut &ata(

)8 Dala$ "ea&aan e$e*genc% a!a"a# su&a# a&a tin&a"an antisi!asi( /conto# $ati la$!u0 ce" "esia!an !etugas )<


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A!a"a# ,a"tu !ela%anan lo"et te!at !a&a ,a"tun%a(

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Kepala Puskesmas

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Status

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Menyetujui,

Lead Auditor

Koordinator Unit

Kepala Puskesmas

Due Date

Status

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Menyetujui,

Lead Auditor

Koordinator Unit

Kepala Puskesmas

Due Date

Status

CECKLIST AUDIT INTERNAL PUSKESMAS: UNIT: KIA Form-18 SEK MUTU/2015

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Menyetujui,

Lead Auditor

Koordinator Unit

Kepala Puskesmas

Due Date

Status

CECKLIST AUDIT INTERNAL PUSKESMAS : SEMPAJA UNIT: LAB Form-18 SEK MUTU/2015

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Koordinator Unit

Kepala Puskesmas

Due Date

Status

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Status

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Koordinator Unit

Kepala Puskesmas

Due Date

Status

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A!a"a# sa$!a# $e&is &i"i*i$  $inggu se"ali "e RSUD %ang &itun'u"( Ce" -e*ita aca*a !engi*i$an &an !ene*i$aan sa$!a# $e&is

)5

A!a"a# sa$!a# $e&is &iti$-ang &an &icatat +olu$en%a se-elu$ &ise*a# te*i$a"an(

)6

A!a"a# sa$!a# non $e&is &iang"ut setia! #a*i 'a$ =5.==(

)8

A!a"a# !etugas $ela"sana"an "egiatan !enga,asan TPM( Ce" #asil la!o*an

)<

A!a"a# !etugas $ela"sana"an "egiatan !enga,asan TTU( Ce" #asil la!o*an

=

A!a"a# !etugas $ela"sana"an "egiatan !enga,asan &e!o ai* $inu$( Ce" #asil la!o*an



A!a"a# &ata te*"ait !*og*a$ sanitasi leng"a!(

E 


)





1

MINOR


3


5


6


Samarinda...............

Mengetahui,

Menyetujui,

Lead Auditor

Koordinator Unit

Kepala Puskesmas

Due Date

Status

Form-15 CheckList Audit Internal Akreditasi Puskesmas

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