PEMERINTAH KABUPATEN BONDOWOSO DINAS KESEHATAN
PUSKESMAS GRUJUGAN Jl. Raya Jember No. 29 0332 !23"02 #r$%$&a' Bo'(o)o*o 0332 Website Website : http: // www.puskesmas-gruuga!.b"#gsp#t.$#m www.puskesmas-gruuga!.b"#gsp#t.$#m e-mai" : puskesmasgruuga!%gmai".$#m&
KE+AMATAN #RUJU#AN
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PERJANJ*AN KERJASAMAAN+ARA PUSKESMAS GRUJUGAN )ENGAN RSU ,r..K(ESNAS* '(N)(W(S( +EN+ANG PEAANAN PEAANAN AUN)R RUMA SAK*+
Nomor , !!0- 0." -!30."0.2."3-20"/ -!30."0.2."3-20"/ Nomor,
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Per% Per%a' a'%a %a' ' Ker%a Ker%a*am *amaa Pelay Pelaya' a'a' a' la$' la$'(ry (ry r$ma r$ma1 1 *a *a44 (b$ (b$a a (a' (a' (a (a'( '(aa aa'& '&a' a' ( Bo'(o)o*o4 5a(a 1ar Se''4 a'&&al! Ja'$ar 20"/4 5ara 51a ya'& bera'(a a'&a' (ba)a1 ' , Nama
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U' Ker%a , P$*e*ma* #r$%$&a' Dalam 1al ' ber'(a $'$ (a' aa* 'ama P$*e*ma* #r$%$&a' *ela'%$'ya (*eb$ P*AK PER+AMA PER+AMA
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U' Ker%a , RSU (r. H Koe*'a( Bo'(o)o*o Dalam 1al ' ber'(a $'$ (a' aa* aa * 'ama Dre$r R$ma1 Sa Um$m (r. H Koe*'a( Bo'(o)o*o*ela'%$'ya (*eb$ P*AK KE)UA Para P1a erleb1 (a1$l$ me'era'&a' , ". Ba1)a P*AK PER+AMAa(ala1 *eb$a1 U' Pela*a'a Te'* D'a* Ke*e1aa' ( ab$ ab$5a 5ae' e' Bo'( Bo'(o) o)o* o*o o ya'& ya'& bera bera'& '&&$ &$'& '& %a)ab %a)ab me'y me'yele ele'& '&ar ara aa' a' 5elay 5elaya' a'a' a'
e*e1aa' e*e1aa' 5rmer ( )laya1 )laya1 er%a'ya. P*AK KE)UA a(ala1 *$a$ R$ma1 Sa ya'& ya'& mem meml l $*a1 $*a1aa ya'& ya'& (alam (alam b(a b(a'& '& 5elay 5elaya' a'a' a' e*e1 e*e1aa aa' ' erm erma*$ a*$ %a*a %a*a 5elaya'a' 6a$'(ry. 6a$'(ry. 2. Ba1)a Ba1)a e($a bela1 bela1 51a 51a *e5aa *e5aa $'$ $'$ me'&a(a me'&a(aa' a' er%a*am er%a*amaa (alam (alam 5elaya'a' 5elaya'a' la$'(ry R$ma1 Sa Um$m (r. H. Koe*'a( Bo'(o)o*o. Pasa" 0 Maksu, ,a! ,a ! +uua! +uua!
P1a Perama aa' me'&a'ar l'e' e5a(a P1a Ke($a4 (ma'a P1a Ke($a aa' me'erm me'ermaa ma*$( ma*$( er*eb$ er*eb$ (e'&a' (e'&a' mela* mela*a'a a'aa' a' 5e'7$7 5e'7$7a' a' aa$ aa$ la$'(ry la$'(ry *e*$a *e*$a (e'&a' (e'&a' 5erm'aa' P1a Perama (a' ber(a*ara' ba'ya l'e' ya'& ela1 ( *era1a' e5a(a P1a Ke($a. Pasa" 1 +ata 2ara Pe"aksa!aa!
". 6'e' 6'e' ya'& ya'& ela1 (a'ar (a'ar ole1 P1a P1a Perama Perama e5a(a e5a(a P1a P1a Ke($a ber$5a ber$5a a' a' l'e' aa$ *5re ya'& ela1 (&$'aa' aa$ oor. 2. 6'e' aa$ aa$ *5re ya'& ya'& ( a'ar a'ar ole1 P1a P1a Perama Perama 1ar$* (em5a (em5aa' a' e(alam e(alam b$'&$* b$'&$* Pla* ya'& *$(a1 (be(aa' me'%a( ($a4 ya$ l'e' ya'& '8e*$* (a' l'e' ya'& (a '8e*$*. 3. D(alam D(alam b$'&$* b$'&$* 5la* 5la* ya'& ya'& ( a'ar a'ar ole1 P1a P1a Perama Perama 1ar$* 1ar$* er(a5a er(a5a $l*a' $l*a' , Nama P$*e*ma* • J$mla1 6'e' ya'& a(a ( (alam )a(a1 • Ta'&&al Ta'&&al (a' %am l'e' ( a'ar e P1a Ke($a • Keera'&a' '8e*$* (a' (a '8e*$* • ! A5abl A5ablaa 6'e' 6'e' ya'& (er (erma ma ole1 ole1 P1a P1a Ke($a Ke($a (ar P1a P1a Perama Perama (a (a meme'$ meme'$1 1 5er*yaraa' aa$ (a le'&a54maa P1a Ke($a ber1a mela$a' 1al1al *eba&a ber$ , Mela$a' o'8rma*4 a5abla (aa ber$5a %$mla1 l'e'4 eera'&a' '8e*$* (a' (a (a '8e* '8e*$* $*44 er1a(a5 er1a(a5 ea(aa ea(aa' ' '. '. P1a P1a Peram Peramaa aa' aa' mele'& mele'&a5 a5 (aa (aa ya'& ya'&
(b$$1a' ole1 P1a Ke($a *e7ara er$l*. 6'e' 6'e' aa$ *5re *5re ya'& ya'& aa' (7$7 (7$7 aa' ( a'ar a'ara' a' ole1 ole1 P1a P1a Perama Perama e5a(a e5a(a P1a P1a
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e($a ( loa* la$'(ry RSU (r. H.Koe*'a( Bo'(o)o*o Wa$ Wa $ 5e'ermaa 5e'ermaa' ' ba1a' ba1a' 5emer*aa' 5emer*aa' ole1 P1a P1a Ke($a Ke($a a(ala1 a(ala1 *eba&a *eba&a ber$ ber$ , Har Se'' *.( Sab$ : P$$l 0;.30 *.( 20.30 WIB Har M'&&$ - 6b$r , P$$l 0.00 *.(
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"3.00 WIB Ke($a Ke($a bela1 bela1 51a 51a )a%b )a%b mela*a' mela*a'aa aa' ' - mema$1 mema$1 ee'$a' ee'$a' (alam (alam 5er%a' 5er%a'%a' %a' ' ' (e'&a' 5e'$1 a'&&$'& %a)ab (a' ee'$a' la''ya ya'& berla$ *eba&a *a'(ar 5elaya'a' 6a$'(ry aa$5$' *a'(ar 5ro*e($r ya'& ya'& berla$.
Pasa" 3 Pe!a!ggu!g Jawab ,a! A"amat K#resp#!,e!si
". Pe'a'& Pe'a'&&$ &$'& '& Ja)ab Ja)ab 1ara' 1ara' P1a P1a Peram Peramaa a(ala1 a(ala1 , Nama , N*. DIAN A
". P1a P1a Ke($a Ke($a aa' membera membera1$ 1$a' a' a5a' a5a' l'e' aa$ *5re *5re b*a ( ambl ambl ole1 P1a P1a Perama 5a(a *aa P1a Perama me'&a'ar l'e' aa$ *5re 2. 6'e 6'e' ' aa$ aa$ *5re *5re ya'& ya'& *$(a *$(a1 1 ( 7$7 b*a ( amb ambll ole1 ole1 P1a P1a Per Peram amaa eba eba& &a' a' 6a$'(r 6a$'(ry y RSU (r.H (r.H.Ko .Koe*' e*'a( a( Bo'(o) Bo'(o)o*o o*o aa$ ( a'ar a'ar e5a(a e5a(a P$*e P$*e*ma* *ma* P1a P1a Perama (e'&a' baya ra'*5ora* ya'& ela1 ( *e5aa.
Pasa" 6 Pe!gu"a!ga! au!,r5 ,a! Pe!gga!tia! i!e!
A5abla me'$r P1a Perama er(a5a 1a*l 5e'7$7a' l'e' ya'& (a mem$a*a' aa$ e1la' e1la'&a' &a' aa$ er%a( er%a( er$*a er$*aa' a' *5re-l *5re-l'e 'e' ' *e1'& *e1'&&a &a (5erl (5erl$a $a' ' 5e'7$7 5e'7$7a' a' $la'& $la'& aa$ 5e'&&a'a' l'e'4 maa P1a Perama $'$ mela$a' 5e'7$7'a $la'& aa$ 5e'&&a'a' l'e' (e'&a' ee'$a' , 6'e' aa$ *5re ya'& ela1 (7$7 er'yaa ma*1 oor aa$5$' ba$ • J$mla1 l'e' ya'& ela1 melal$ 5ro*e* la$'(ry embal (e'&a' %$mla1 ya'& $ra'& • (ar %$mla1 l'e' ya'& ( a'ar ole1 P1a Perama (a' ela1 ( $l* *e7ara %ela* 5a(a •
era* A5abla er%a( er$*aa' =robe4&o*o'&4ber$ba1 )ar'a> 5a(a l'e'-*5re
Pasa" 7 +ari8 Pemeriksaa!
". Tar8 Tar8 la$'(ry la$'(ry (e'$a' (e'$a' 5er 5er lo&ram lo&ram ya'& *e*$a *e*$a (e'&a' ya'& ya'& ela1 (ea5 (ea5a' a' 2. Dalam Dalam 1al P1a Ke($a Ke($a aa' mela$ mela$a' a' 5er$ba1 5er$ba1a' a' ar84 maa maa P1a P1a Ke($a Ke($a aa' memb$a *$ra 5embera1$a' e5a(a P1a Perama 5al'& lamba 30 =&a 5$l$1 > 1ar *ebel$m ar8 bar$ er*eb$ (berla$a'. 3. A5abl A5ablaa P1a P1a Perama Perama (a (a me'ye$% me'ye$%$ $ 5er$ba1a' 5er$ba1a' ar8 ar8 =*eba&a =*eba&ama ma'a 'a ( a$r a$r (alam (alam aya 2 5a*al ' > (a' a'ara e($a bela1 51a (a er7a5a e*e5aaa' me'&e'a 1al '4 maa 5er%a'%a' ' me'%a( 5$$* (a' bera1r (e'&a' *e'(r'ya. Pem$$*a' 5er%a'%a' er%a*ama 1al ' (a *era mera me'&1a5$* *e&ala e)a%ba' ya'& bel$m er*ele*aa'.
Pasa" 9 +ata 2ara Pemba5ara!
". P1a P1a Per Peram amaa aa' aa' memb membay ayar ar *eela *eela1 1 *em$a *em$a 5ro* 5ro*e* e* la$' la$'(ry (ry er*eb er*eb$ $ *ele*a *ele*a (a' (a' l'e'-*5re *$(a1 (erma ole1 P1a Perama. 2. Har&a Har&a ya'& ya'& (e'aa (e'aa' ' ber(a*ar ber(a*ara' a' bera = 5er lo&ram lo&ram>> l'e' ya'& ya'& ( la$'(ry la$'(ry RSU RSU (r.H.Koe*'a( (r.H.Koe*'a( Bo'(o)o*o.
Pasa" 0 Ja!gka Waktu Pera!ia!
". Per%a' Per%a'%a' %a' er%a*a er%a*ama ma berla$ berla$ %a'&a %a'&a )a$ )a$ 2 =($a> =($a> a1$'4 a1$'4 er1$ er1$'& '& *e%a ( a'(a a'&a''ya *$ra 5er%a'%a' ' (a' aa' bera1r a'&&al 02 J$' 20" 2. A5ab 5abla la 5ara 5ara 51a 51a '& '&' ' me'a me'a1 1r r 5er%a 5er%a'% '%a' a' er%a* er%a*am amaa ' ' maa maa 5ara 5ara 51a 51a bere)a%ba' $'$ membera1$a' *a$ (e'&a' ya'& la''ya 5al'& lamba 2 =($a > b$la' *ebel$m bera1r'ya ma*a 5er%a'%a' '. 3. Bera1 Bera1r'y r'yaa ma*a ma*a berla berla$ $ 5er%a' 5er%a'%a' %a' er%a*am er%a*amaa ' (a *era mera me'1a5$ me'1a5$*a *a' ' e)a%ba' ma*'&ma*'& er1a(a5 51a la''ya ya'& bel$m ereal*a*a'. Pasa" 00 ;#r$e maeure
". Ke($ Ke($aa bela bela1 1 51a 51a *e5a *e5aa a a5ab a5abl laa ((a ((alam lam mela mela$ $a' a' 5e'7 5e'7$7 $7a' a' l'e l'e'4 '4 *e5er *e5er er*e er*eb$ b$ 5a(a 5a(a 5a*al 5a*al " =(a =(aa a** >4 P1a P1a Ke($ Ke($aa me'& me'&ala alam m eer eerla lamb mbaa aa' ' ya'& ya'& (*ebaba' ole1 ea(a' 8or7e ma%e$re4 maa P1a Ke($a 1ar$* membera1$a'
*e7ara er$l* me'&e'a ea(aa' er*eb$ e5a(a P1a Ke($a *elambalamba'ya 2 ? 2! %am *eela1 er%a('ya 8or7e ma%e$re er*eb$. 2. Kea(aa' Kea(aa' 8or7e ma%e$re ma%e$re *e5er *e5er er*eb$ er*eb$ 5a(a 5a(a aya " =*a$> =*a$> (aa* erma*$ erma*$ ea5 ea5 (a (a erbaa* 5a(a 1al1al *eba&a ber$ , 5e5era'&a'4 1$r$ 1ara4 $'%$ ra*a ma**a4 5erombaa'4 r** 'a*o'al4 ebaara'4 *aboa*e4 e5(em74 be'7a'a alam *e5er ba'%r4 &em5a &em5a b$m. 3. A5abl A5ablaa er%a( er%a( ea(a' ea(a' 8or7e 8or7e ma%e$re ma%e$re *e5er *e5er (aa*4 (aa*4 *e1'& *e1'&&a &a (a mem$'& mem$'&' 'a' a' P1a Perama (a' P1a Ke($a mela'%$a' 5er%a'%a' er%a*ama '4 maa Ke($a bela1 51a *e5aa $'$ me'yele*aa' *e&ala *e*$a$'ya *e7ara m$*ya)ara1. Pasa" 01 Pe!5e"esaia! Perse"isiha! ". Ja Ja er%a( er%a( 5er*el* 5er*el*1a' 1a' *eba&a *eba&a aba aba (ar 5ela* 5ela*a'a a'aa' a' 5er%a'%a' 5er%a'%a' '4 maa maa Ke($a Ke($a bela1 51a *e5aa $'$ me'yele*aa' 5erma*ala1a' er*eb$ *e7ara m$*ya)ara1 &$'a me'7a5a m$8aa. 2. A5abla A5abla (e'&a' (e'&a' m$*ya)ara1 m$*ya)ara1 (a (a er7a5a er7a5a m$8aa maa maa Ke($a Ke($a bela1 51a 51a *e5aa *e5aa $'$ me'yele*aa' 5erma*ala1a' Pe'&a(la' Ne&er Bo'(o)o*o. Pasa" 03 Pemutusa! / Pembata"a! Pera!ia!
". Per%a' Per%a'%a' %a' ' ' me'%a( me'%a( baal (em 1$$m 1$$m aa$ aa$ (a5a ( 5$$*a 5$$*a' ' *ea5 *aa *aa *ebel$m *ebel$m )a$'ya4 (e'&a' erleb1 (a1$l$ me'yam5aa' *$ra 5embera1$a' - 5er'&aa'4 a5abla er%a( 1al1al *e5er ber$ ' , a. Dalam Dalam 1al 5ara 51a 51a (a (a5a (a5a meme'$1 meme'$1 e)a%b e)a%ba'' a''ya ya (a' aa$ mela$ mela$a' a' 5ela'&&ara' er1a(a5 ee'$a'ee'$a' (alam 5er%a'%a' '. b. Dalam 1al er%a('ya 8or7e ma%e$re *eba&ama'a (ma*$( (alam 5a*al "". 7. Para Para P1a ber1a ber1a me'&a1 me'&a1r r 5er%a'% 5er%a'%a' a' ' *ebel$m *ebel$m )a$'y )a$'yaa a5abl a5ablaa ( (alam 5el*a'aa' 5er%a'%a' *al1 *a$ aa$ e($a bela1 51a (a mam5$ meme'$1 ee' ee'$a' $a' ya'& ya'& ela1 ela1 ( a$r a$r ((alam ((alam 5er%a' 5er%a'%a' %a' ' berla' berla'&*$ &*$'& '& member membera' a' eera'&a' 5al*$ aa$ (5al*$a'. 2. Hal Hal ' ' (la (la$ $a' a' *e7ar *e7araa er er$l $l* * ole1 ole1 ma*' ma*'&m &ma* a*'& '& 51a 51a 30 =T& =T&aa P$l$ P$l$1> 1> 1ar 1ar *ebel$m 5er%a'%a' ' ('yaaa' (a1r. Pasa" 04 ai! < "ai!
Selam Selamaa berla berla'& '&*$ *$'& '&'y 'yaa er%a er%a*am *amaa '4 '4 1al 1al @1al @1al ya'& ya'& m$'& m$'& ' ' mb$ mb$ll *e1$b *e1$b$' $'&a &a' ' 5ela*a'aa' 5er%a'%a' (a' bel$m ( a$r (alam S$ra Per%a'%a' Ker%a*ama ' aa' (
*ele*a *ele*a a' a' (a' (a' ( a$r a$r aa* aa* (a*ar (a*ar 5er*e 5er*e$ $%$ %$a' a' ber*a ber*ama ma (alam (alam *eb$a *eb$a1 1 a((e a((e'( '($m $m ya'& ya'& mer$5aa' ba&a' ya'& me'&a *era (a er5*a1a' (ar 5er%a'%a' '.
Pasa" 06 Pe!utup
". S$ra 5er%a'%a' 5er%a'%a' ' ' (b$a ra'&a5 ra'&a5 2 =($a> =($a> (a'(aa'& (a'(aa'&a' a' ( aa* maera maera ya'& 7$$5 7$$5 (a' mem5$'ya e$aa' 1$$m ya'& *ama $a'ya4 ma*'& ma*'& $'$ P1a Perama (a' P1a Ke($a *era (a5a ( 5erba'ya *e*$a eb$$1a'. 2. S$ra Per%a'%a Per%a'%a' ' Ker%a*ma Ker%a*ma ' ( b$a (a' (a' (a'(aa'& (a'(aa'&a' a' ( Bo'(o)o Bo'(o)o*o *o 5a(a a'&&al a'&&al er*eb$ ( aa*.
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Puskesmas Gruuga!
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M(U = PERJANJ*AN KERJASAMA> AN+ARA RUMA SAK*+ UMUM ,r..K(ESNA)* '(N)(W(S( Dengan PUSKESMAS GRUJUGAN
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PEAANAN AUN)R )* RSU ,r. .K(ESNA)* '(N)(W(S(
