Formulir Tindak Lanjut Komplain ( HPK 3 )

LIR PENYELESAIAN KOMPLAIN, KELUHAN , KONFLIK ATAU P

 Nama Pasien/Keluarga Tanggal Lahir Tanggal/Jam Komplain Ruangan/Bagian

: ………………………….. ………………………….. No :……………….. : ………………………….. Mas Masalah : Baru : ………………………….. Lama : …………………………..

URAIAN MASALAH

............................................................................................................................................................................................................. ............................................................................................................................................................................................................. ............................................................................................................................................................................................................. ......................................................................................................................................................................................................... Penerima Komplain

(..............................) TINDAKAN PENYELESAIAN SAAT KEJADIAN

............................................................................................................................................................................................................. ............................................................................................................................................................................................................. ............................................................................................................................................................................................................. ......................................................................................................................................................................................................... Yang Menyelesaian

(...............................) EVALUASI/TINDAK EVALUASI/TINDAK LANJUT

Ti!a Perlu Tin!a Lan"u# Perlu Tin!a Lan"u# !engan Corrective Action Request  ('R)  ('R)

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