Kebijakan Pelayanan Keperawatan

KEPUTUSAN DIREKTUR UTAMA RUMAH SAKIT MARDI RAHAYU  NOMOR : 048/SK/DIRUT/X-2014 048/SK/DIRUT/X-2014 TENTANG KEBIJAKA KEBI JAKAN N PELAYANAN PELAYANAN KEPERAW KEPE RAWATAN DI RUMAH SAKIT MARDI RAHAYU

DENGAN RAHMAT TUHAN YANG YANG MAHA M AHA ESA

Menimb Menimbn! n! M&i

DIREKTUR RUMAH SAKIT MARDI RAHAYU " #$% #$% &'m &'m ()* ()* menin! menin!+, +,+n +n m(,( m(,( )e'* )e'*n nn n R(m R(m$ $ S+i S+i,,

R$*( *n! mn. &en!n mem)e$,i+n +ee'm,n )ien e, +e)(n )e'n!!n. m+ &i)e'(+n )emnein )e'*nn +e)e%,n *n! bem(,( ,in!!i &i e'(($ (ni, )e'*nn  b" #$% ! )e'*nn +e)e%,n &i R(m$ S+i, M&i R$*( &), &i,e)+n &n &) ,e'+n &en!n bi+. )e'( &n* +ebi+n Die+,( R(m$ S+i, M&i R$*( eb!i 'n&n b!i )e'*nn +e)e%,n &i R(m$ S+i, M&i R$*( " #$% be&+n )e,imbn!n eb!imn &im+(& &'m  &n b m+ )e'( &i,e,)+n Kebi+n Pe'*nn Ke)e%,n &i R(m$ S+i, M&i R$*( &en!n Ke)(,(n Die+,( R(m$ S+i, M&i R$*(" Men!i Men!in! n!, , : 1" 1" Un& Un&n n!!-Un Un& &n! n! n3 5 ,$(n ,$(n 2006 2006 ,en, ,en,n n! ! Ke Kee$ e$, ,n n"" 2" Un&n!-Un&n! RI n3m3 n3m3 44 ,$(n 2006 Ten,n! Ten,n! R(m$ S+i, " Pe,(n Men,ei Kee$,n n3 17 ,$(n 201 ,en,n! iin &n Pen*e'en!!n P+,i+ Pe%," 4" Ke)(,(n Ke)(,(n Men,ei Kee$,n Kee$,n Re)(b'i+ In&3nei In&3nei n3m3 HK"07"05/III/ HK"07"05/III/ 40/06 ,en,n! Iin Pen*e'en!!n R(m$ S+i, M &i R$*( 9" Ke)(,(n Pen!(( YKKMR YKKMR n3m3 084/I/XI-2010 084/I/XI-2010 ,en,n! Reii O!nii &n T, T, Ke R(m$ S+i, M&i R$*(" 5" SK Die+,( R(m$ S+i, M&i R$*( n3m3 05 /RS/DIR/SK/X-2010 ,en,n! S,(+,( O!nii R(m$ S+i, M&i R$*("  

MEMUTUSKAN

Mene,)+n : Ke,( Ke, ( : KEPUTUSAN DIREKTUR UTAMA UTAMA RUMAH SAKIT MARDI RAHAYU RAHAYU TENTANG KE#I;AKA KE#I ;AKAN N PE
Ke&(

Ke,i!

: Kebi+n )e'*nn +e)e%,n &i R(m$ S+i, M&i R$*( eb!imn ,en,(m &'m 'm)in )e,(n ini" : Pembinn &n Pen!%n ,e$&) )e'*nn +e)e%,n &i R(m$ S+i, M&i R$*( &i'+n+n 3'e$ Ke)' #i&n! Ke)e%,n &n

em( Ke)' Uni, +e ,e+i," : Ke)(,(n ini be'+( e+ ,n!!' &i,e,)+n &n )bi' &i

Keem), +em(&in $i ,e&), +e+e'i(n &'m )ene,)n ini. +n &i&+n )ebi+n eb!imn me,in*"

Di,e,)+n &i K(&( P& ,n!!' 0 O+,3be 2014 P'," Die+,( U,m.

D" K$in N(!$ =i&


K EPUTUSAN DIREKTUR  UTAMA RS MARDI R AHAYU  N3m3 : 048/SK/DIRUT/X-2014 Tn!!' : 0 O+,3be 2014

KEBIJAKAN PELAYANAN KEPERAWATAN  DI RUMAH SAKIT MARDI RAHAYU

I.

KEBIJAKAN UMUM

1" Pe'*nn +ee$,n *n! &i e'en!!+n &i (m$ +i, M&i R$*( me()+n  )e'*nn ,e$&) mn(i e (,($. &i'+(+n eb!i %((& ()n *(+( , +(ni +ee'm,n *n! ,e'$ +i, ,eim &i T($n Ye( Ki,(" 2" Pe'*nn *n! &ibei+n +e)& )ien $( be3ien,i )& +ee'm,n )ien &n ()* )enin!+,n m(,(. e(i &en!n ii . mii &n ni'i & *n! & &i (m$ +i, M&i R$*( > Cin, T($n.H!i 3n! 'in. A+( m( )e&('i. N*,+n *(+( &'m e!' $'. Gembi me'*ni T($n &n em ? " Se'(($ ,@ (m$ +i, M&i R$*( $( be+e e(i &en!n ,n&  )3@ei.)e&3mn.)n&(n &n ,n& )3e&( 3)ei3n' *n! be'+(. e, e(i &en!n e,i+ )3@ei. e,i+ (m$ +i, e, )e,(n )e($n *n! be'+(" 4" Pe'*nn (m$ +i, &i'+n+n &'m 24 m . +e('i &i (ni,- (ni, ,e,en,(" 9" R(m$ +i, membei+n )e'*nn *n! e!m b!i em( )ien &n &i,, &'m e+m me&i )ien" 5" Pe'*nn (m$ +i, &i e,i) (ni, +e $( e''( be@3+( )& )ien &en!n me'+n+n +e )e'*nn &n +3n,in(i, e, &en!n membei+n e&(+i +e)& )ien &n +e'(!" 7" R(m$ +i, M&i R$*( e''( membei+n )e'*nn ,e'ebi$ &$('( ,n) mem(n!(, (n! m(+" 8" R(m$ +i, membei+n )e'*nn 3i' b!i )ien *n! ,i&+ mm)(" 6" Se'(($ +*%n (m$ +i, M&i R$*( &'m me'+n+n )e+enn* %ib e(i &en!n +e,en,(n K > Kee'm,n &n Kee$,n Ke ?. ,em(+ &'m  )en!!(nn APD > A', Pe'in&(n! Dii ? 10" R(m$ +i, &'m membei+n )e'*nn men!$3m,i $+ )ien &n +e'(! e(i &en!n (n&n!-(n&n! &n ni'i-ni'i e, +e)e*n *n! &in(, 3'e$  )ien" 11" D'm membei+n )e'*nn +e)& )ien e,i) )e,(! $( mem)e$,i+n  )ii )ien" 12" Sem( )e,(! *n! ,e'ib, &'m membei+n )e'*nn +e)& )ien %ib me'+(+n hand hygiene &en!n   five moment  &n 5 'n!+$ (i ,n!n  1" Sem( )e,(! %ib memi'i+i iin . 'ieni. e,i@i+i e(i &en!n ,n& )3@ei &n +e,en,(n *n! be'+( &i (m$ +i, M&i R$*(" 14" Pen*e&in ,en! &i e,i) (ni, +e $( men!( )& )3' +e,en!n" 19" Pe',n &i (ni, +e $( e''( i) )+i &n &i'+(+n )eme'i$n &n +'ibi e e(i &en!n +e,en,(n *n! be'+( " 15" D'm me'+n+n @(n!i +33&ini &n e'(i m+ e,i) (ni, +e %ib me'+n+n ), (,in b('nn minim' 1 +'i &'m 1 b('n" 17" Sem( +e)' e+i. +e)' b!in . mn!e &n &ie+i %ib (n,(+ memb(, ')3n b('nn &n ,$(nn" 18" R(m$ +i, men'n+n )3!m +ee'm,n )ien me''(i 7 ,n& +ee'm,n  )ien. 7 'n!+$ +ee'm,n )ien . &n 5 n +ee'm,n )ien"

16" R(m$ +i, men'n+n )3!m PONEK > Pe'*nn Ob,e,i Ne3n,' Eme!en* K3m)e$eni@ ? (n,(+ men((n+n n!+ +em,in b*i &n ib( e, menin!+,+n +ee$,n ib(" 20" R(m$ +i, me'+n+n )enn!!('n!n T# e(i &en!n )e&3mn ,,e!i DOTS" 21" R(m$ +i, me'+n+n )enn!!('n!n HIB /AIDS e(i &en!n )e&3mn ODHA e, &ie(i+n &en!n +emm)(n (m$ +i, M&i R$*(" 22" R(m$ +i, M&i R$*( +n me((+ )ien i+ &i)e'(+n )e'*nn &n @i'i, *n! ,i&+ ,ee&i &i (m$ +i, M&i R$*( ,( , )emin,n )ien / +e'(! II. KEBIJAKAN KHUSUS

1" Mne Ke)e%,n &'$ e3n! )im)inn +e)e%,n *n! be,(! &n  be,n!!(n!%b &'m men!e'3' e'(($ +e!i,n )e'*nn +e)e%,n &i R(m$ S+i, M&i R$*(" 2" Mn!e Pe%,n &'m men'n+n ,(!n* &ibn,( 3'e$ Ai,en Mne Ke)e%,n *n! ,e&ii &i Ai,en Mn!e SDM &n Sn Pn Ke)e%,n e, Ai,en Pe'*nn &n M(,( Ke)e%,n " 3. Ke)' R(n! Pe%,n &'$ e3n! )e%, *n! &ibei ,n!!(n! %b (n,(+ men!e'3' )e'*nn +e)e%,n ,( men!,( +e!i,n 3)ei3n' )e'*nn +e)e%,n me''(i )eennn +e. )en!%n e, e'(i ,e$&) +ine ,@ .e, me'+(+n )embinn e,i+ )3@ei +e)e%,n &n )en!embn!n ,@ (n,(+ menin!+,+n +emm)(n &n m3,ii +e )e%, e, m(,( ($n +e)e%,n &i (ni, +en* . 4" S()ei3 Pe%,n ,( Pe,(! Pen!% Pe%,n &'$ e3n! )e%, *n! &ibei ,(! (n,(+ men!!n,i+n ,(! Mn!e Pe%,n )& $i 'ib( &'m men!,(. men!+33&ini+n &n men!%i e'(($ +e!i,n 3)ei3n' (m$ +i, e men*e'(($ e, mem,i+n ,e'+nn* 3)ei3n' (m$ +i, e(i &en!n )3e&( *n! be'+(" 9" C'ini' In,(,3 >CI? &'$ e3n! )e%, eni3 *n! be,n!!(n!%b (n,(+ men!+33&ini. membimbin!  me'+n+n )3e )embinn )e%, ,e$&)  )en!e,$(n. +e,em)i'n &n i+) e ,e( mene( &en!n be)e&3mn +e)& ,n& +3m)e,eni *n! ,e'$ &i,e,)+n (n,(+ memben,(+ )e%, *n! be+('i, 5" Dn mn&ii "e, me'+(+n )embinn e,i+ )3@ei +e)e%,n &n  )en!embn!n ,@ (n,(+ menin!+,+n +emm)(n &n m3,ii +e )e%, e, m(,( ($n +e)e%,n. 7" Pe%, Penn!!(n!%b S$i@, >Ke)' ;!? &'$ e3n! )e%, eni3 *n!  be,n!!(n!%b (n,(+ me'+(+n &n men!+33&ini ($n +e)e%,n )& $i@,n*" 8" Pe%, / #i&n Seni3 &'$ e3n! )e%, /#i&n *n! ,e'$ memi'i+i m +e  4 ,$(n &en!n ', be'+n! )en&i&i+n S1/Ne &n minim' DIII Ke)e%,n &en!n m +e 9 ,$(n *n! &), me'+(+n in,eeni &'m )3e ($n +e)e%,n mn&ii &n &), men'n+n ()eii m()(n mnemen (n!n"

6" Pe%, / #i&n Me&i3 &'$ e3n! )e%, *n! ,e'$ memi'i+i m +e 2-4 ,$(n &en!n ', be'+n! )en&i&i+n S1/ Ne &n DIII Ke)e%,n &en!n m +e -9 ,$(n *n! &), me'+(+n )3e ($n +e)e%,n mn&ii &n  )embinn +e)& )e%, (ni3 &n &), me'+(+n ,(! eb!i Ke,( Tim /Pe%, Pime" 10" Pe%, / #i&n ;(ni3 &'$ e3n! )e%, *n! ,e'$ memi'i+i m +e 0-2 ,$(n &en!n ', be'+n! )en&i&i+n S1/ Ne &n DIII Ke)e%,n &en!n m +e 0- ,$(n *n! &), me'+(+n )3e ($n +e)e%,n e(i ,n& ($n +e)e%,n *n! be'+(" 11" Pembn,( Pe%, > POS ? &'$ ee3n! &en!n ', be'+n! )en&i&i+n 1 ,$(n )embn,( Pe%, &n/,( SHi!$ De)en&e* N(in!? &'$ )e'*nn +e)e%,n *n! &ibei+n +e)& )ien *n! meme'(+n )e%,n +$(( ,( intermedite care &n &ibei+n 3'e$ )e%, &en!n )e',i$n in,eni@ e" 18" Pe'*nn !%, &(, &'$ b!in &i )e'*nn +ee$,n *n! &ibei+n 3'e$  )e%, *n! ,e'$ &i',i$ &'m Pen&i&i+n Pe%, G%, D(, >PPGD? &n/,( ,e'$ memi'i+i e,i@i+, )e',i$n #i T(m #TC
+e)& Die+,( (m$ +i, &n Mn!e Ke)e%,n &'m n!+ men(nn!  )enin!+,n &n )en!embn!n )e'*nn &i (m$ +i, M&i R$*(" 2" T((n Pemben,(+n K3mi,e Ke)e%,n: " Membei+n +ee'n +e%enn!n +'ini b!i ,en! +e)e%,n  b" Me'in&(n!i +ee'm,n )ien &en!n menmin b$% ,en! +e)e%,n memi'i+i +3m)e,eni &n +e%enn!n +'ini" " Pen!+(n &n )en!$!n ,e$&) ,en! )e%, &n bi&n &i e,i) 'ee' " 24" S,(+,( O!nii K3mi,e Ke)e%,n RS" M&i R$*( ,e&ii &i : Ke,( K3mi,e Ke)e%,n " S(b K3mi,e Ke&eni'  b" S(b K3mi,e M(,( P3@ei " S(b K3mi,e E,i+ P3@ei 29" H(b(n!n K3mi,e Ke)e%,n &en!n Mn!e Pe%,n b(+n $(b(n!n ,n &en!n b%$n. me'in+n $(b(n!n +e. +33&ini. +emi,n &n 'in! men!(,+n" 25" Pe'*nn +e)e%,n &i (m$ +i, me()+n +e!i,n *n! ,e( mene( &n  be-+einmb(n!n. ,( +e!i,n *n! &i'+(+n e'm 24 m " A! )e'*nn +e)e%,n &), &ibei+n e bi+. ,m)i' &n bem(,(. m+ &i)e'(+n &n* )embe+'n )en!e,$(n &n +e,m)i'n b!i ,@ +e)e%,n me''(i  )3!m )e',i$n &n )en!embn!n ,@ " 27" P3!m )en!embn!n ,@ me'i)(,i +e!i,n )en&i&i+n &n )e',i$n bi+ *n! &i&+n &i &'m (m$ +i, en&ii m()(n +e!i,n *n! &ii+(,i &i '( (m$ +i," 28" Peneimn )e%, b( &i (m$ +i, M&i R$*( &i'+(+n me''(i )3e  )en!(n ,en! . e+(i,men ,en! m)i m 3ien,i " 26" Si,im ;enn! Ki Pe%, &i R(m$ +i, M&i R$*( . mi$ be3ien,i )&  Job / Pe+en . ,in* e3n! )e%, 3'e$ +en +e$'inn* &ibei+n ,(! ,( )3ii / b,n *n! ,e+i, $(b(n!n ,n &n b%$n e, men&),+n imb'n be() (n!"

0" P3!m Oien,i &n M K3n,+ Pe%, #( " Se,i) )e%, b( +n &ibei+n )embe+'n 3'e$ b!in SDM &n  b!in- b!in be+i, &en!n m,ei )embe+'n e)e,i &i Y*n . SDM .PPI.&n K"  b" Se,i) )e%,/ bi&n b( +n &ibei+n b(+( +3m)e,eni )e%, 3ien,i " *n! me()+n &@, +3m)e,eni *n! &i$)+n &), &i)i / &i'+(+n e'm m 3ien,i 5 b('n" &" Se'm m 3ien,i )e%, b( +n &ibimbin! 3'e$ C'ini' In,(,3  e" Peni'in )& m 3ien,i me'i)(,i DP. Pen*e'ein +3m)e,eni &n Peen,i ,(&* +(" @" Se,e'$ )e%, 3ien,i &in*,+n '('(. m+ *n! ben!+(,n +n &i +3n,+ e'm 5 b('n " Pe%, *n! ,e'$ menn&,n!ni +3n,+ &i eb(, eb!i )e%, +3n,+" !" Se'm m +3n,+ )e%, $( men*e'ei+n +3m)e,eni +3n,+ 

$" Se'm m +3n,+ )e%, b( mi$ &ibimbin! 3'e$ CI i" Peni'in m +3n,+ me'i)(,i DP &n +3m)e,eni +3n,+"  " Yn! membei+n )eni'in e'm m 3ien,i &n +3n,+ &'$ +e)' (n!. %+i' +e)' (n! &n CI". +$(( (n,(+ )een,i &i'+(+n 3'e$ ,im" 1" A($n +e)e%,n *n! &ibei+n +e)& )ien men!( )& S,n& A($n 2" Ke)e%,n *n! me'i)(,i Pen!+in Ke)e%,n / Aemen +e)e%,n. Di!n3 Ke)e%,n . Peennn Ke)e%,n" E'(i +e)e%,n &n D3+(men,i +e)e%,n" " Uni,-(ni, )e'*nn +e)e%,n *n! & &i (m$ +i, M&i R$*( &'$ eb!i bei+(, : " R(n! Ke)e%,n D'm &n #e&$ : 1" R(n! Mn,$ 1 2" R(n! Mn,$ 2 " R(n! Mn,$  4" R(n! Kn 9" R(n! Immn(e' 5" R(n! #e,$e&  b" R(n! Ke)e%,n An+ : R(n! Kme' " R(n! Ke)e%,n S,3+e : Uni, S,3+   &" R(n! Ke)e%,n Pe'inn &n Kebi&nn : R(n! E e" R(n! Ke)e%,n Pein,'3!i : R(n! Pee,i @" R(n! Ke)e%,n D'm &n #e&$ +$(( %ni, : R(n! #e,ni A !" R(n! Ke)e%,n D'm &n #e&$ +$(( )i : R(n! #e,ni # $" R(n! Ke)e%,n In,eni@ : ICU i" R(n! Ke)e%,n Semi In,eni@ : HDN Di,e,)+n &i K(&( P& ,n!!' 0 O+,3be 2014 P'," Die+,( U,m

D" K$in N(!$ =i&