KISI-KISI DAFTAR KEBIJAKAN, PANDUAN, SOP Dari Thers- AKREDITASI 2012

KISI – KISI DOKUMEN UNTUK AKREDITASI 2012

"UNIT "KEBIJAKAN "PEDOMAN "PEDOMAN "PROGRAM KERJA 2011 "LAPORAN PROGRAM "PROGRAM KERJA "
" " "PENGORGANISASIAN "PELAYANAN " "KERJA 2011 "2012 "
"Rumah Sakit " " " " " " "
"IGD " " " " " " "
"Kamar Operasi " " " " " " "
"IPI " " " " " " "
"Rawat Jalan " " " " " " "
"Rekam Medis " " " " " " "
"CSSD " " " " " " "
"Farmasi " " " " " " "
"Laboratorium " " " " " " "
"Radiologi " " " " " " "
"Rehabiltasi Medis " " " " " " "
"Gizi " " " " " " "
"Keperawatan " " " " " " "
"Keuangan " " " " " " "
"Umum " " " " " " "
"Administrasi " " " " " " "
"PSDM " " " " " " "
"PPIRS " " " " " " "
"K3 " " " " " " "
"Panitia Farmasi dan " " " " " " "
"Terapi " " " " " " "
"Komite medis " " " " " " "
"BAB "KEBIJAKAN "PEDOMAN "PANDUAN "SPO "DOKUMEN IMPLEMENTASI "
"SASARAN "Sasaran "Keselamatan "Identitas Pasien "Pemasangan Gelang "Surgical Safety Checklist "
"KESELAMATAN "Keselamatan "Pasien " "Identitas " "
"PASIEN "Pasien " " " " "
" " " "Komunikasi "Komunikasi Via Telpon "Rekam Medis "
" " " "Efektif " " "
" " " "Obat High alert "Pemberian Obat High "Daftar Obat Norum "
" " " " "Alert "Daftar Elektrolit Konsentrat "
" " " "Tepat Operasi "Cuci Tangan "Pengajuan Pasien Risiko Jatuh "
" " " "Hand Hygiene "Pemasangan Gelang Pasien"Daftar Obat Dengan Efek Mengantuk "
" " " " "Resiko Jatuh " "
" " " "Risiko Jatuh "Seleksi " "
" " " " "Pengadaan " "
" " " " "Penyimpanan " "
" " " " "Pemesanan/Peresepan " "
" " " " "Pencatatan (transecribe)" "
" " " " "Pendistribusian " "
" " " " "Persiapan (preparing) " "
" " " " "Penyaluran (dispensing) " "
" " " " "Pemberian " "
" " " " "Pendukemntasian " "
" " " " "Pemantauan (monitoring) " "

"Tata Kelola "TKP "Hospital By "Pendelegasian "Pendelegasian Kewenangan"Pembentukan Panitia Etik RS "
"Kepemimpinan " "Laws "Kewenangan " " "
" " "Etik Pegawai " "Pelayanan "Pencanaan Asuhan dan Pelayanan RS dalam "
" " " " " "Profi RS "
" " " "Kriteria "Asesmen Kebutuhan "Orentasi staf "
" " " "Pendidikan, "Pasien " "
" " " "Ketrampilam, " " "
" " " "Pengetahuan dan " " "
" " " "Pengalaman " " "
" " " " "Pengadaan alat dan Obat "Dokumen SOTK "
" " " " "RS " "
" " " " "Penilaian Kinerja "Dokumen Kredensial "
" " " " "Profesional " "
" " " " " "Dokumen Perjanjian Kontrak "
" " " "Yang dibutuhkan " "Persyaratan Jabatan dan dokumen Pendukung "
" " " "Staf Profesional " " "
" " " " " "Laporan bulanan Kepala Dewan Pengawas "
" " " " " "Hasil Inspeksi dan Rekomendasi "
" " " " " "Dokumen Bukti Proses Penetapan Misi RS "
" " " " " "Bukti Pelaksanaan Rapat Koordinasi dengan "
" " " " " "Tokoh Masyarakat "
" " " " " "Dokumen Pelaksanaan Surat tugas "
" " " " " "Profil RS dan Brosur RS "
" " " " " "Dokumen Pengadaan Fasilitas RS, Obat alat "
" " " " " "Komite Medis Dala, dokumen Kontrak Terkait "
" " " " " "Pelayanan Klinis "
" " " " " "Para Manajer dalam dokumen Kontrak Terkait "
" " " " " "pelayanan klinis "
" " " " " "SK Pemilik tentang Restra dan Program kerja"
" " " " " "SK Direktur dan pejabat lainnya "
" " " " " "Tim Mutu dan KPRS, program kerja, laporan "
" " " " " "Penilian kinerja "
" " " " " "SK Ijin RS "
" " " " " "Undangan rapat DINKES "
" " " " " "Rapat – rapat seluruh RS "
" " " " " "MOU Dokter "
" " " " " "Audit Kinerja "
" " " " " "Laporan Indikator Mutu "

"Manajemen " "Pedoman K3 "Panduan K3 "Penanggulangan, "K3 "
"Fasilitas dan "MFK " "Konstruksi "Kebakaran bencana dan " "
"Keselamatan " " " "Evakuasi " "
" " " "Panduan "Prosedur : Emergency "Sertifikat surat Kompetensi "
" " "Pedoman "pengelolaan Bahan"Gangguan Listrik dan air" "
" " "Standar "dan limbah " " "
" " "Fasilitas "berbahaya " " "
" " " " "Identifikasi Staf "Hasil Pemeriksaan fisik "
" " " " "Pengunjung Pedagang dan " "
" " " " "semua area yang berisiko" "
" " " " "keamanan " "
" " " "Panduan "Identifikasi fasilitas "Identifikasi/Daftar/Lokasi B3 "
" " " "Penanggulangan "Fisik " "
" " " "kebakaran " " "
" " " "Kewaspadaan " " "
" " " "bencana dan " " "
" " " "EvaKuasi " " "
" " " " "Identifikasi B3 "Buku Pemeliharaan / kalibrasi "
" " " " "Penanganan B3 "Surat Edaran, Spanduk Stiker dilarang "
" " " " " "merokok di lingkungan RS "
" " " " "Penyimpanan B3 "Daftar Inventaris seluruh peralatan medis "
" " " " "Penggunaan B3 "Berita Acara penarikan alat Medis "
" " " "Pembelian Alat "Pemasangan Label B3 "Identifikasi Area Beresiko Paling tinggi "
" " " "medis " "bila terjadi kegagalan listrik atau air "
" " " " " "Minun yang terganggu "
" " " "Pemeliharaan alat"Pelaporan dan "Program K3 B3, manajemen Emergency, "
" " " "medis "intesvigasi tumpahan, "pengamanan "
" " " " "paparan dan insiden lain" "
" " " "Pemeliharaan alat"Pembuangan limbah "Kebakaran, Peralatan medissistem utilitas, "
" " " "transportasi "berbahaya "APD, Pelatihan manajemen resiko "
" " " "Pemeliharaan Non "APD "Daftar Area Berisiko terjadi gangguan air "
" " " "Medis " "dan listrik "
" " " "Penarikan Produk "Pengadaan alat Medis "Daftar Sumber air dan listrik alternatif "
" " " "atau Peralatan " " "
" " " "medis " " "
" " " " "Pemeliharaan dan "Bukti Pemeliharaan air, listrik, ventilasi,"
" " " " "Kalibrasi alat "gas Medis, sistem kunci "
" " " "Alat pelindung "Penarikan alat " "
" " " "diri " " "
" " " "Larangan merokok "Identifikasi Area " "
" " " " "berisiko terjadi " "
" " " " "gangguan air dan Listrik" "
" " " "Sistem Utiliti "Penggunaan sumber Air, " "
" " " " "Listrik " "
" " " " "Identifikasi Ventilasi " "
" " " " "Identifikasi Gas Medis " "
" " " " "Identifikasi sistem " "
" " " " "kunci " "
" " " " "Pemeliharaan air, " "
" " " " "Listrik, ventilasi, gas " "
" " " " "medis, sistem kunci " "

"PENCEGHAN DAN "PPI "Pedoman PPIRS "Hand hygiene "Hand hygiene "Program PPIRS "
"PENGENDALIAN " " " " " "
"INFEKSI " " " " " "
" "Tim PPI "Pedoman "Pnaduan "Penghitungan linen "Assemen resiko infeksi "
" " "Pengorganisasian"Sterilisasi " " "
" " "PPIRS " " " "
" " " "Panduan "Pembersiahan Cairan tubuh "Sertifikat Pelatihan PPI "
" " " "manajemen Linen " " "
" " " "dan Laundry " " "
" " "Pedoman "Panduan kamar "Pemakaian APD "Laporan hasil pemetaan Kuman dan "
" " "Pelayanan PPIRS "Operasi " "Resistensi Antibiotik "
" " "Pedoman Kamar "Panduan APD "Pengelolaan peralatan yang"Hasil Pemeriksaan Air "
" " "isolasi " "Kaduluwarsa " "
" " " "Pembuangan "Peralatan Single Use yang "Laporan kultur Kuman, analisa Outbreak "
" " " "sampah medis , "di Reuse " "
" " " "non medis " " "
" " " "Sanitasi Dapur "PPI terkait Dampak "Ceklist Pemakian alat "
" " " "dan Penyiapan "Renovasi terhadap Kualitas" "
" " " "makanan "udara " "
" " " "Edukasi PPIRS "Penanganan pasien Isolasi "MOU dengan RS Pemilik Incinerator "
" " " "Pembongkaran "Penanganan pasien dengan "Perbandingan Angka Infeksi dengan RS lain"
" " " "Kamar "infeksi Airborne " "
" " " " "Identifikasi Risiko "Pelatihan cuci Tangan "
" " " " "Infeksi " "
" " " " "Pembuangan Benda Tajam dan" "
" " " " "jarum " "
" " " " "Pemisahan antara pasien " "
" " " " "dengan penyakit menular " "
" " " " "dari pasien lain yang " "
" " " " "berisiko tinggi yang renta" "
" " " " "karena Imunosupresed " "

"Kualifikasi dan"KEBIJAKAN "Pedoman SDM "Pemberian "Kredensial Staf "Program Kerja Penempatan Staf RAB, Orentasi "
"Pendidikan Staf " " "Vaksinasi dan "Keperawatan "staf pelatihan "
" " " "Imunisasi Bagi " " "
" " " "Staf " " "
" " "(termasuk "Tindak Lanjut "Kredensial Staf "Pemberian Vaksinasi dan Imunisasi Staf "
" " "panduan "terhadap staf "profesional kesehatan " "
" " "diklat) "yang terpapar " " "
" " " "penyakit " " "
" " " "Infeksius " " "
" " " "Merivew "Penerimaan Staf "STR, SIK, SIP, Ijasah staf daftar nama staf "
" " " "Kredensial staf " " "
" " " "medis " " "
" " " "Kewenangan klinis"Pengangkatan Staf "Audit Medis "
" " " "Evaluasi Praktek "Penilaian Kinerja "Rapat Komite Medis "
" " " "profesional " " "
" " " "Panduan Standar " "Vertifikasi kredensial "
" " " "Fasilitas " " "
" " " "Penilian Kinerja " "Laporan Program kerja "
" " " "dokter, perawat " " "
" " " "dan staf lain " " "
" " " "Penerimaan Staf " "Jadwal MCU staf "
" " " "ketenagaan " " "

"MANAJEMEN KOMUNIKASI "MKI "Pedoman "Identifikasi Komunitas dan "Pemberian Informasi "Program Kerja PKRS "
"DAN INFORMASI " "Perorganisasian "Populasi yang menjadi " " "
" " "Rekam Medis "perhatian RS " " "
" " "Pedoman "Komunikasi Efektif dalam "Pelaporan Data Cakupan"Produk PKRS "
" " "pengorganisasian "Pemberian informasi dan "RS " "
" " "PKRS "Edukasi " " "
" " "Pedoman pelayanan " "Penyimpanan/Retensi "Bahan materi Edukasi "
" " "PKRS " "Berkas RM " "
" " "Pedoman pelayanan " "Perlindungan RM dari "Program kerja Edukasi "
" " "Rekam Medis " "Kehilangan dan " "
" " " " "Kerusakan " "
" " " " "Perlindungan RM dan "Program kerja Rekam medis"
" " " " "Akses penggunaan tidak" "
" " " " "sah " "
" " " " " "Daftar simbol dan "
" " " " " "singkatan termasuk yang "
" " " " " "tidak boleh digunakan "
" " " " " "Data Cakupan rekam medis "
" " " " " "Sertifikat pelatihan "
" " " " " "manajemen Informasi "
" " " " " "Dokumen Informasi lengkap"
" " " " " "RS "

"BAB "KEBIJAKAN"PEDOMAN "PANDUAN "SPO "DOKUMEN IMPLEMENTASI "
"MANAJEMEN "MPO "Pedoman "Pengelolaan Obat"Penggunaan Obat di RS "Program Pelatihan teknik "
"PENGGUNAAN OBAT " "pelayanan "emergengsi " "Aseptik "
" " "Farmasi " " " "
" " "Pedoman "Penarikan obat "Cara Identifikasi dan penyimpanan obat yang "Daftar stok obat di RS "
" " "Pengorganisasian" "dibawa oleh pasien " "
" " " " "Cara penyimpanan yang tepat bagi produk "Rekam Medis "
" " " " "Nutrisi " "
" " " " "Cara Obat Sample Disimpan dan dikendalikan "Laporan Narkotik, "
" " " " " "psikotropik "
" " " "PIO dan "Penggunaan Obat yang diketahui kadaluwarsa "Ijasah, Sertifikat "
" " " "Konseling "atau ketinggalan jaman "pelatihan, surat Ijin kerja"
" " " " "Pemusnahan obat yang diketahui kadaluwarsa "Formularium "
" " " " "atau ketinggalan jaman " "
" " " " "Peresepan , pemesanan, dan pencatatan obat "MOU dengan pihak luar "
" " " " "yang aman di RS " "
" " " " "Prosedur yang mengatur Tindakan yang terkait"Form Usulan obat baru, "
" " " " "dengan penulisan Resep dan pemesanan yang "daftar obat baru "
" " " " "tidak terbaca " "
" " " " "Mengidentifikasi Efek yang tidak diharapkan "Bukti permintaan yang tidak"
" " " " "pasien dan yang harus dilaporkan ke RS "tersedia di RS "
" " " " "Penanggulangan Penulisan Resep dan "Berita acara pemusnahan "
" " " " "Pemesanaan yang tidak terbaca "Obat Kadaluwarsa, obat "
" " " " " "Kaduluwarsa "
" " " " "Penanganan obat Kadaluwarsa "Lihat Resep/ EPO "
" " " " "Pemusnahan obat "Laporan IKP/KTD "
" " " " "Waktu pemberian obat "Laporan KNC "
" " " " " " "

"BAB "KEBIJAKAN"PEDOMAN "PANDUAN "SPO "DOKUMEN IMPLEMENTASI "
"PELAYANAN ANESTESI"PAB "Pedoman "Sedasi "Asesmen Presedasi "Rekam medis "
"DAN BEDAH " "Pengorganisasian OK " " " "
" " "Pedomanan pelayanan "Panduan Bedah "Pemberian Sedasi Ringan, "Form Pemberian Edukasi "
" " "OK " "Modern,Dalam " "
" " " "Panduan pembuatan "Monitoring selama anestesi "Kriteria Pemindahahn Ruangan Paska "
" " " "laporan operasi " "Operasi "
" " " "Anestasi "Asesmen Praanestesi "Form Monitoring pasca Anestesi "
" " " "Asesmen Pra anestesi "Monitoring selama Pasca " "
" " " "dan Pra Induksi "anestesi " "
" " " "Manajemen Nyeri "Pelayanan Bedah " "

"PELAYANAN PASIEN "PP "Pelayanan "Komunikasi Lisan dan "Penanganan penggunaan "Rekam medis "
" " "kedokteran dan "tertulis "pemberian darah dan " "
" " " " "komponen darah " "
" " "Pelayanan "Pelayanan kasus "Pasien berisiko tinggi yang"Form Pemeriksaan Penunjang "
" " "Penyelamatan "emergengsi "memuat pasien dengan " "
" " " " "perawatan " "
" " "Pedoman Radiologi "Pelayanan Resusitasi "Pasien hidup dasar atau "Sertifikat Penangan pasien Risiko"
" " " " "koma "tinggi "
" " "Pedoman transfusi "Penanganan, "Pasien risiko tinggi yang "Program penanganan Pasien Resiko"
" " "Darah "penggunaan, pemberian "memuat pasien penyakit "Tinggi "
" " " "darah dan kompenen "menular atau Imuno " "
" " " "darah "suppressed " "
" " "Pedoman Gizi "Pasien Risiko Tinggi "Pasien risiko tinggi yang " "
" " " "yang memuat pasien "memuat pasien dengan " "
" " " "penyakit menular atau "peralatan yang kompleks " "
" " " "imumo suppressed " " "
" " "Pedoman Rekam Medis"Pasien risiko tinggi "Pasien Risiko tinggi yang " "
" " " "yang memuat pasien "memeuat pasien penggunaan " "
" " " "penggunaan alat "alat Pengikat " "
" " " "pengikat (Restraint) "Pasien yang rentan, lanjut " "
" " " " "usia dengan ketergantungan " "
" " " " "panduan " "
" " " " "Pasien dengankemoterapi " "
" " " " "atau pengobatan resiko " "
" " " " "tinggi lain " "
" " " " "Manajemen nyeri " "
" " " "Pasien yang rentan, "Kasus Emergengsi " "
" " " "lanjut usia dengan " " "
" " " "ketergantungan panduan" " "
" " " " " " "
" " " "Pasien " " "
" " " "dengankemoterapi atau " " "
" " " "pengobatan resiko " " "
" " " "tinggi lain " " "
" " " "Manajemen nyeri " " "
" " " "Tindakan pasien "Resusitasi " "
" " " "tentang pelayanan " " "
" " " " "Pasien Risiko tinggi dengan" "
" " " " "Dialisis " "
" " " " "Persiapan Gizi " "
" " " " "Penyimpanan Gizi " "
" " " " "Pendistribusian Gizi " "
" " " " "Penyapaan Gizi " "
" " " " "Pelayanan tahap terminal " "

" " " " "Pengunaan Alat laboratorium " "
" " " " "Penyediaan Reagensia " "
" " " " "Penyimpanan Reagensia " "
" " " " "Distribusi Reagensia " "
" " " " "Pengetesan Reagensia " "
" " " " "Penerimaan Spesimen " "
" " " " "Identifikasi Spesimen " "
" " " " "Pengambilan Spesimen " "
" " " " "Pengiriman Spesimen " "
" " " " "Pembuangan Spesimen " "
" " " " "Pengawetan Spisimen " "
" " " " "Pencatatan Spesimen " "
" " " " "Kontrol mutu " "
" " " " "Penggunaan APD Radiologi " "
" " " " "Penanganan Bahan Infeksi Radiologi " "
" " " " "Pembuangan Bahan infeksi Radiologi " "
" " " " "Identifikasi Risiko keselamatan " "
" " " " "Radiologi " "
" " " " "Pelaporan Hasil Radiologi " "
" " " " "Pengadaan peralatan Radiologi " "
" " " " "Pemeliharaan alat Radiologi " "
" " " " "Penggunaan alat Radiologi " "
" " " " "Penyediaan X Ray " "
" " " " "Penyimpanan X Ray " "
" " " " "Distribusi X Ray " "
" " " " "Pemeliharaan X Ray " "
" " " " "Penyimpanan X Ray " "
" " " " "Kontrol Mutu Radiologi " "

"PELAYANAN PASIEN "AP "Pedoman "Asesmen Gizi "Asesmen Gizi "Formulir Asesmen di Rekam Medis"
" " "pengorganisasian " " " "
" "Radiologi "Pedoman pelayanan "Asesmen Nyeri "Asesmen Nyeri "Pelatihan dan sertifikat Staf "
" " "Pedoman "Asesmen Risiko Jatuh "Asesmen Risiko Jatuh "Program Kerja Lab, B3, K3 Lab "
" " "pengorganisasian " " " "
" " "Pedomanan pelayaan "Asesmen Individual "Asesmen Induvidual "Program Kerja Radiologi "
" " " "Asesmen Pasien Tahap "Asesmen Pasien Tahap "Penetapan hasil kritis dan "
" " " "terminal "terminal "ambang Nilai Kritis "
" " " "Asesmen Rencanan "Asesmen Rencanan pemulangan"Daftar Inventaris alat "
" " " "pemulangan pasien "pasien " "
" " " "Asesmen ulang untuk "Asesmen ulang untuk "Bukti Kalibrasi alat "
" " " "menetapkan respons "menetapkan respons terhadap" "
" " " "terhadap Pengobatan "Pengobatan " "
" " " "dan merencanakan "dan merencanakan pengobatan" "
" " " "pengobatan atau untuk "atau untuk pemulangan " "
" " " "pemulangan pasien "pasien " "
" " " "Asesmen Medis "Penggunaan APD Lab "Daftar Reagensia "
" " " "Asesmen keperawatan "Penanganan Bahan Infeksi " "
" " " "Asesmen Rawat Jalan "Pembuangan Bahahn infeksi " "
" " " "Asesmen Rawat Inap "Identifikasi risiko " "
" " " "Asesmen Pasien "keselamatan " "
" " " "Emergengsi "Pelaporan hasil " "
" " " "Asesmen sebelum "Pelaporan hasil test " "
" " " "tindakan anestesi "diagnostik yang krisis " "
" " " "Bedah "Pengadaan peralatan " "
" " " "Asesmen kebutuhan "laboratorium " "
" " " "khusus "Pemeliharaan alat " "
" " " " "laboratorium " "
" " " " " "Penerapan Rentang Nilai rujukan"
" " " " " "MOU LABORATORIUM LUAR "
" " " " " "Daftar nama dokter ahli "
" " " " " "Jadwal Dokter Ahli "

"AKSES KE "APK " "Skrining pasien "Skrining triage pasien "Rekam Medis "
"PELAYANAN DAN " " " " " "
"KOMUNITAS " " " " " "
"PELAYANAN " " " " " "
" " " "Pendaftaran Pasien "Pendaftaran pasien Rawat "Ceklist kriteria tranfer pasien"
" " " "Rawat Jalan dan "Jalan dan penerimaan pasien" "
" " " "penerimaan pasien "Rawat inap " "
" " " "Rawat Inap " " "
" " " "Identifikasi Pasien "Pemasangan Gelang identitas"Sertifikat pelatihan skrining "
" " " " " "triage "
" " " "Penundaan pelayanan "Penundaan pelayanan dan "Sertifikat pelatihan tranfer "
" " " "dan pengelolaan "pengobatan "pasien "
" " " "Transfer didalam "Tranfer di dalam atau "MOU RS Rujukan "
" " " "atau ke luar RS "keluar RS " "
" " " "Rencanan pemulangan "Rencana pemulangan pasien "Buku pemeliharaan transportasi"
" " " "pasien " "RS "
" " " "Standar pelayanan "Pemberian informasi "Program Diklat pelatihan "
" " " "kedokteran "pelayanan (jenis, hasil, "skrining Triage "
" " " " "biaya) " "
" " " "Informasi pelayanan "Mengurangi atau membatasi "Program Diklat pelatihan "
" " " " "hambatan di populasi pasien"tranfer pasien "
" " " "Hambatan di populasi"Pemeliharaan Transportasi " Cek list dischange planing "
" " " "pasien "RS " "
" " " "Transportasi RS " " "
" " " "Triage " " "
" " " "Pelayanan unit " " "
" " " "Intensif " " "
" " " "Rujukan ke dalam " " "
" " " "atau ke luar RS " " "
" " " "Kriteria Pindah atau" " "
" " " "masuk unit " " "
" " " "Intensif/khusus " " "

"MILLINIUM "MDGS "Pedoman "Pelaksanaan "Rawat gabung "Rencana strategi MGDS "
"DIVELOPMEN " "pengorganisasian "kesehatan Maternal " " "
"GOULS " "Ponek "dan neonatus " " "
" " "Pedomanan pelayanan "Penyelenggaran Ponek"Ponek 24 jam "Rencana kerja dan anggaran MGDS"
" " "Ponek "24 jam di RS " " "
" "TIM PONEK "Pedoman HIV "Rawat gabung ibu "Inisiasi menyusun dini dan "Pelatihan tim ponek/HIV/DOTS "
" " " "dan bayi "asi eklusif " "
" "TIM HIV "Pedoman TB "Inisiasi menyusui "Metode kangguru "Pelatihan tim ponek HIV/DOTS "
" " " "dini dan ASI " "unit terkait "
" " " "Eksklusif " " "
" "TIM DOTS " "Perawatan metode "Rujukan ponek HIV TB "Laporan kegiatan ponek TB HIV "
" " " "kangguru pada BBLR " " "
" " " "Rumah Sakit sayang "Penerimaan pasien TB "Sertifikasi pelatihan "
" " " "ibu bayi " "ponek/HIV/DOTS "
" " " "Skrining HIV "Pembentukan jejaring "Muo Rujukan dengan RS rujukan "
" " " " "internal dan Eksternal RS " "
" " " "Manaterial pelayanan"Penyediaan obat anti TB "Program sayang ibu dan bayi "
" " " "TB dengan strategi " " "
" " " "DOTS " " "
" " " "Pelaksanaan rujukan "Pencatatan pasien mangkir " "
" " " "di Rumah Sakit " " "

"PENINGKATAN "PMKP "Pedoman PMKP "5 Area prioritas "Pelatihan PMKP "Program PMKP "
"MUTU DAN " " " " " "
"KESELAMATAN " " " " " "
"PASIEN " " " " " "
" " " "Proses validasi "Pengkajian asesmen pasien "Indikator KPRS "
" " " "internal "risiko " "
" " " "Sentinel "Peningkatan mutu RS "RCA "
" " " "KNC "Keselamatan pasien "Form laporan IKP "
" " " "Upaya peningkatan " "Bukti penyediaan alat untuk "
" " " "mutu pelayanan RS " "meningkatkan mutu "
" " " " " "Buku orentasi karyawan baru "
" " " " " "Laporan KTD "

"PENDIDIKAN "PPK "Pengorganisaian PKRS"Teknik komunikasi "Pemberian edukasi dan "Form pemberian edukasi "
"PASIEN DAN " " "yang efektif "informasi " "
"KELUARGA " " " " " "
" " "Pedoman pelayanan "Asesmen pasien "Verifikasi pemahaman pasien"Buku registrasi edukasi "
" " "PKRS "kebutuhan edukasi "dan keluarga terhadap " "
" " " " "materi edukasi " "
" " " "Cara penyampaian "Asesmen kebutuhan Edukasi "Rekam medis tentang asesmen "
" " " "informasi dan "pasien dan keluarga "pasien "
" " " "edukasi yang efektif" " "
" " " "Verifikasi pasien "SPO Pemberian edukasi dan "MOU UPK di komunitas "
" " " "memahamu edukasi "informasi " "
" " " "Bahan meteri edukasi"1. berkaitan dengan proses "SK Dir panitia PKRS "
" " " " "penyakit " "
" " " "Panduan rekam medis "2. berkaitan dengan obat "Program PKRS "
" " " " "3. berkaitan dengan "Bahan materi edukasi "
" " " " "peralatan medis yang " "
" " " " "digunakan " "
" " " " "4. berkaitan dengan diet " "
" " " " "dan nutrisi " "
" " " " "5. berkaitan dengan " "
" " " " "manajemen nyeri " "
" " " " "6. berkaitan dengan teknik " "
" " " " "rehabiltasi " "

"HAK PASIEN DAN"HPK "Pengorganisasian "Perlindungan "Melindungi kebutuhan "Rekam Medis "
"KELUARGA " " "kebutuhan privaci "privasi pasien " "
" " " "Perlindungan harta "Melindungai harta pasien "Hak dan kewajiban pasien "
" " " "Perlindungan "Melindungi terhadap "Form permintaan bimbingan "
" " " "kekerasan fisik "kekerasan fisik "rohani "
" " " "Hak Second Opinion "Mencari sccond opinion "Form pemberian edukasi "
" " " "Hak bantuan hidup "Memberi bantuan hidup dasar"Form persetujuan, penolakan "
" " " "dasar " "tindkan atau pengobatan "
" " " "Hak menolak "Penolaksan resusitasi "Form penolakan resusitasi "
" " " "resusitasi " " "
" " " "Hak pelayanan "Pemberian pelayanan "Survey kepuasan pasien "
" " " "kerohanian "kerohanian " "
" " " "Menanggapi keluhan "Menanggapi keluhan "Form pengkajian nyeri "
" " " "Persetujuan tindakan"Meminta persetujuan "Laporan penyelesaian keluhan "
" " " "kedokteran "tindakan kedokteran "pasien dan keluarga "
" " " "Asesmen dan "Perlindungan terhadap " "
" " " "manajemen nyeri "kelompok berisiko " "
" " " "Pelayanan tahap "Perlindungan kerahasian " "
" " " "terminal "informasi " "
" " "Pedoman informed "Penyelesaian keluhan"Penolakan pengobatan " "
" " "consent "pasien dan keluarga " " "
" " " "Pemberian informasi "Pengkajian nyeri " "
" " " "pelayanana dan " " "
" " " "pengambilan " " "
" " " "keputusan " " "
" " " "Penolakan pengobatan"Manajemen nyeri " "
" " " " "Pelayanan tahap terminal " "
" " " " "Pemberian informasi " "
" " " " "pelayanan (jenis,hasil " "
" " " " ",biaya) " "

KISI-KISI DAFTAR KEBIJAKAN, PANDUAN, SOP Dari Thers- AKREDITASI 2012

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