LAMPIRAN-LAMPIRAN LAMPIRAN 1 PERSETUJUAN UMUM PELAYANAN KESEHATAN ( GENERAL CONSENT ) Pengertian : Peret!"!an U#!# Pe$a%anan Kee&atan ( Genera$ C'nent 'r Treat#ent) Treat#ent) aa$a& aa$a& *eret!"!an *eret!"!an %ang i+eri,an'$e& i+eri,an'$e& *aien *aien ata! ,e$!arga ,e$!arga tere,at tere,at ete$a& #ena*at *en"e$aan eara $eng,a* #engenai *e$a%anan ,ee&atan %ang a,an i$a,!,an ter&aa* *aien ter,ait engan *r'e *e#eri,aan . *era/atan an *eng'+atan0 T!"!an T!"!an : 10 Se+agai a!an a$a# *e$a,anaan *eret!"!an !#!# ter&aa* *e$a%an ,ee&atan %ang a,an i+eri,an *aa *aien0 0 Mening,at,an *artii*ai *aien an ,e$!arga a$a# renana tata$a,ana0 20 Agara *aien an ,e$!argan%a #ena*at,an in'r#ai %ang te*at an a,!rat0 30 Me#*er'$e& i4in ari *aien an ,e$!arga a$a# *r'e *era/atan an *eng'+atan0 Ke+i"a,an : Ke*!t!an 5ire,t!r Uta#a RSUPN 5r Ci*t' Mang!n,!!#' Tentang *eret!"!an !#!# *e$a%anan ,ee&atan ,ee&atan ( Genera$ C'nent C'nent 'r treat#ent ) i RSUPN RSUPN 5r Ci*t' Mang!n$,!!#'0 Pr'e!r : 10 Pet!ga %ang #e#+eri,an *en"e$aan #e#*er,ena$,an iri ,e*aa *aien ata! ,e$!argan%a an #en%a#*ai,an *en"e$aan tentang in'r#ai %ang i+!t!&,an0 0 In'r#ai %ang ia#*ai,an '$e& *et!ga aa$a& *e$a%anan *e$a%anan ,ee&atan %ang a,an i+eri,an ,e*aa *aien i !nit *e$a%anan e!ai *en%a,it an ,'nii *aien aat +er,!n"!ng %ang #e$i*!ti : a0 Pe#eri,aan 6i, %ang i$a,!,an '$e& *era/at an ',ter0 +0 Pe#aangan a$at ,ee&atan ( Ke!a$i %ang #e#+!t!&,an *eret!"!an ,&!!)0 0 A!&an ,e*era/atan0 0 Pe#eri,aan $a+'rat'ri!#0 e0 Pe#eri,aan 7 Ra%0 0 Pe#+ia%aan 8 Ja#inan ,ee&atan0 20 Pen"e$aan &ar! i+eri,an eara $eng,a* engan +a&aa %ang #!a& i#engerti ata! engan ara $ain agar a*at #e#*er#!a& *e#a&a#an0 30 Paien 8 Ke$!arga i+eri ,ee#*atan !nt!, +ertan%a ata! #ena*at *en"e$aan !$ang ari Pet!ga0 9 Paien8 Paien8 Ke$!arga #engii an #enanatangani 'r#!$ir *eret!"!an !#!#0 9 Pet!ga *e#+eri in'r#ai #e#+!+!&,an tana tangan0 0 Pert!"!an U#!# a*at i+eri,an '$e& *aien 8 ,e$!arga ,e$!arga tere,at ete$a& ete$a& #ena*at in'r#ai an #e#a&a#i #e#a&a#i tentang *e$a%anan ,ee&atan %ang a,an i+eri,an engan ega$a ,'ne,!enin%a ,'ne,!enin%a erta #en%et!"!in%a0 ;0 Peret!"!an ter&aa* *e$a%anan ,ee&atan &ar! !a& iii engan itanatangani e+e$!# *aien #a!, !nit *e$a%anan0 <0 ='r#!$ir *eret!"!an U#!# Yang !a& itanatangani i#a!,,an ,ea$a# +er,a Re,a# Mei *aien0 >0 Pet!ga #enatat i',!#entai,an a$a# +er,a Re,a# Mei engan #enant!#,an tangga$ . /a,t! . na#a an tanatangan *e#+eri an *eneri#a *en"e$aan0 ?0 Unit ter,ait : 10 Penataran Unit Ra/at Ja$an ( URJT . RSCM Kenana . RSCM Kirana. IG5 ) 0 A#initrai Rat Ina* Se$!r!& !nit Pe$a%anan0 20 P2RN 5',!#en ter,ait : ='r#!$ir Pe#+erian In'r#ai an Peret!"!an U#!# ( Genera$ C'nent ) LAMPIRAN PEM@ERIAN E5UKASI KEPA5A PASIEN 5AN KELUARGA 5ITEMPAT 5ITEMPAT PEN5A=TARAN PEN5A=TARAN Pengertian Pengertian : Pe#+erian e!,ai ,e*aa ,e*aa *aien an ,e$!arga ite#*at *enataran aa$a& !*a%a R!#a& Sa,it !nt!, #ening,at,an ,e#a#*!an *aien. ,e$!arga %ang i$a,!,an *aa aat *aien +ar! atang ( #e$a,!,an *enataran ) T!"!an : Paien an ,e$!arga #e#a&a#i tentang in'r#ai R!#a& Sa,it : 10 In'r#ai "eni *e$a%anan 0 Hari @!,a P'$i,$ini, 20 Pen"a#inan Paien 30 Ha, an ,e/a"i+an *aien Ke+i"a,an : SK 5ire,t!r Uta#a
RSUPN 5r Ci*t' Mang!n,!!#' N' 1?28TU0K8238II81 tentang e!,ai ,e*aa *aien an ,e$!arga i RSUPN 5r Ci*t' Mang!n,!!#'0 Pr'e!r : 10 Pet!ga !t!#er erBie #e$a,!,an ienti6,ai ,e+!t!&an e!,ai ter&aa* *aien 8 ,e$!arga0 0 K''rinai engan !nit8ti# ter,ait ( a#initrai0UPPJ.H!#a.PKRS8,$ini, e!,ai.$$) ter,ait *eria*an #ateri an #eia %ang a,an ig!na,an e!ai engan ,e+!t!&an *aien8,e$!arga($eaet. +r'!r. taning +anner. a!i' Bi!a$)0 20 Me#+!at $a*'ran ter,ait e!,ai %ang te$a& i+eri,an +er!*a : ana$ia ata. ,ei#*!$an an ana$ia tina, $an"!t0 Unit ter,ait : 10 PKRS 0 UPPJ 20 HUMAS 30 Unit Re,a# Mei an A#initrai Pe$a%anan Paien Ra/at Ina* LAMPIRAN 2 A5MINISTRASI PENERIMAAN PASIEN RADAT INAP Pengertian : Ketent!an %ang #engat!r tentang a#initrai *eneri#aan *aien ra/at ina* e+e$!# #a!, r!ang ra/at0 T!"!an : 10 Terti+ a#initrai *e$a%anan *aien ra/at ina* 0 Ke$anaran *e$a%an in'r#ai *aien ra/at ina* 20 Pe#anta!an ter&aa* tereian%a te#*at ti!r +agi *aien ra/at ina* Ke+i"a,an : 10 Setia* *aien %ang a,an ira/at ina* &ar! #enatar #e$a$!i P!at Peneri#aan Paien Ra/at Ina* ( P2RN) 0 Setia* Paien %ang a,an ira/at &ar! #e#ei$i,i !rat *engantar ra/at ( SPR) 20 Setia* *aien %ang ira/at i RSUPNCM &ar! #e#*!n%ai ientita Paien ra/at Ina* ( IPRI) 30 Setia* *aien &ar! #en%e$eai,an a#initrai ra/at ina* e+e$!# #a!, ,er!ang8,a#ar *era/atan Pr'e!r : 10 Meneri#a !rat *engantar ra/at ( SPR ) ari *aien ata! ,e$!argan%a %ang a,an ira/at 5I RSUPNCM0 0 Me#eri,a SPR !nt!, #ene#*at,an ,a#ar 8r!ang ra/at e!ai engan iagn'i *en%a,it8 "eni ,e$a#in 8!#!r8,e$a %ang ia"!,an0 20 Mengee, tereian%a te#*at ti!r e!ai *er#intaan SPR a$a# +!,! atatan te#*at ti!r ata! ,'#*!ter0 30 Meng&!+!ngi r!ang ra/at !nt!, #enan%a,an ata! ,'n6r#ai te#*at e!ai engan *er#intaan a$a# SPR0 0 Men%a#*ai,an ,a#ar ata! r!ang ra/at %ang tereia an #enin'r#ai,an &arga ,a#ar ata! r!ang ra/at an +ia%a $ain e!ai *r'e!r. erta tata terti+ R!#a& Sa,it eara $ian an tert!$i0 ;0 A*a+i$a !a& *erna& +er'+at i RSCM. &!+!ngi *et!ga Re,a# Mei !nt!, #engiri#,an +er,a Re,a# Mei #e$a$!i *et!ga tran*'rtai ,e P2 RN0 <0 Me#+!at ientita *aien ra/at ina* ( IPRI ) engan #e/a/anarai *aien ata! ,e$!argan%a0 >0 Paien ata! ,e$!argan%a &ar! #e#+aa an #enanatangani !rat *eret!"!an ra/at an tata terti+ R!#a& Sa,it0 ?0 Paien ata! ,e$!argan%a i+eri *en"e$aan tentang *e#+a%aran !ang #!,a ata! *er%aratan $ain e*erti *aien "a#inan A,e. Ja#,e#a. Ga,in. SKTM $$0 10 5i$!ar "a# ,er"a ata! *aien #a!, ira/at #e$a$!i IG5. *e#+a%aran !ang #!,a a*at itangg!&,an e$a#a 2 3 "a# 0 110 Ji,a tia, aa te#*at . *aien iatat a$a# +!,! atar t!ngg! !nt!, ia$'n,an ,e#+a$i +eri,!tn%a iertai *en"e$aan e!ai engan at!ran 10 Sete$a& #en%e$eai,an a#initrai ,e!angan. *et!ga P2RN #e#eri,a ,e#+a$i ='r#!$ir9 'r#!$ir ari *et!ga ,e!angan0 120 @erita&! r!angan. "a# +era*a *aien i&ara*,an a,an ti+a ir!angan0 130 Me#erinta&,an *et!ga tran*'rtai !nt!, #engantar *aien ,er!ang *era/atan0 10 Seti+a *aien ir!ang ra/at. *era/at #enanatangani era& teri#a *aien ia$a# +!,! e,*eii. i$eng,a*i engan ,eterangan tangga$ an "a# *aien iteri#a Unit ter,ait : 5e*arte#en Mei. Inta$ai Ra/at Ja$an. Unit Ga/at 5ar!rat. R!ang ra/at ina*0 5',!#en ter,ait : Ientita Paien ra/at Ina* ( IPRI). S!rat Pengantar Ra/at ( SPR). @er,a Re,a#
Mei LAMPIRAN 3 =ORMULIR PEM@ERIAN IN=ORMASI 5AN PERSETUJUAN UMUM ( GENERAL CONCENT) UNTUK MENERIMA PELAYANAN KESEHATAN 10 Ha, an ,e/a"i+an e+agai *aien : 5engan #enanatangani ',!#en ini a%a #enga,!i +a&/a *aa *r'e *enataran !nt!, #ena*at,an *era/atan i RSUP Nai'na$ r Ci*t' Mang!n,!!#' te$a& #ena*at in'r#ai tentang &a,9&a, an ,e/a"i+an a%a e+agai *aien0 0 Sa%a #en%et!"!i an #e#+eri,an *eret!"!an !nt!, ira/at i RSUP Nai'na$ r Ci*t' Mang!n,!!#' an engan ini a%a #e#inta an #e#+eri,an ,!aa ,e*aa RSUP Nai'na$ r Ci*t' Mang!n,!!#'. ',ter an *era/at. ia#*ingi *ega/ai RSUP Nai'na$ r Ci*t' Mang!n,!!#' !nt!, #e#+eri,an a!&an *era/atan. *e#eri,aan 6i, %ang i$a,!,an '$e& ',ter an *era/at an #e$a,!,an *r'e!r iagn'ti, . rai'$'gi an8 ata! tera*i an tata$a,ana e!ai *erti#+angan ',ter %ang i*er$!,an ata! iaran,an *aa *era/atan a%a0 Ha$ ini #ena,!* e$!r!& *e#eri,aan an *r'e!r iagn'ti, r!tin. ter#a!, 79ra%. *e#+erian an.8 ata! *en%!nti,an *r'!, ar#ai an '+at9'+atan. *e#aangan a$at9a$at ,ee&atan ( ,e!a$i %ang #e#+!t!&,an *eret!"!an ,&!! ) an *enga#+i$an ara& !nt!, *e#eri,aan $a+'rat'ri!# ata! *e#eri,aan *at'$'gi0 20 Sa%a #e#+eri ,!aa ,e*aa etia* an e$!r!& 'rang %ang #era/at a%a !nt!, #e#eri,a an ata! #e#+erita&!,an in'r#ai ,ee&atan a%a ,e*aa *e#+eri ,ee&atan $ain %an t!r!t #era/at a%a e$a#a i r!#a& a,it ini 30 Sa%a et!"! r!#a& a,it /a"i+ #en"a#in ,era&aiaan in'r#ai #ei a%a +ai, !nt!, ,e*entingan *era/atan an *eng'+atan. *enii,an #a!*!n *ene$itian ,e!a$i a%a #eng!ng,a*,an eniri ata! 'rang $ain %ang a%a +eri ,!aa !nt!, it! ( Orangt!a ,an!ng8 !a#i itri8 ,a,a, 8 ai, a%a)0 0 Sa%a #e#+eri ,!aa ,e*aa r!#a& a,it !nt!, #en"aga *riBai an ,era&aiaan *en%a,it a%a e$a#a a$a# *era/atan0 ;0 Sa%a #engeta&!i +a&/a RSUP Nai'na$ r Ci*t' #ang!n,!!#' #er!*a,an RS *enii,an %ang #en"ai te#*at *ra,te, ,$ini, +agi #a&ai/a ,e',teran an *'rrei *r'ei ,ee&atan $ainn%a 0 ,arena it!. #ere,a #!ng,in +er*artii*ai a ata! ter$i+at a$a# *era/atan a%a.0 Sa%a #en%et!"!i +a&/a .#a&ai/a ,e',teran an *r'ei ,ee&atan $ain *er*artii*ai a$a# *era/atan a%a e*an"ang i+a/a& !*erBii 5',ter *enangg!ng Ja/a+ Pe$a%anan ( 5PJP). <0 Sa%a tia, +'$e& #e#+a/a +arang +arang +er&arga %ang tia, i*er$!,an ( e*erti : *er&iaan. e$e,tr'ni, $$) ,e RSUP Nai'na$ r Ci*t' Mang!n,!!#' an "i,a a%a #e#+a/an%a #a,a RSUP Nai'na$ r Ci*t' Mnag!n,!!#' tia, +ertangg!ng "a/a+ ter&aa* ,e&i$angan . ,er!a,an ata! *en!rian0 NRM : Na#a : Jeni Ke$a#in : Tangga$ La&ir : >0 Sa%a #en%ata,an +a&/a a%a te$a& #eneri#a in'r#ai tentang aan%a tataara #enga"!,an an #engatai ,e$!&an ter,ait *e$a%anan #ei, %ang i+eri,an ter&aa* iri a%a0 Sa%a et!"! !nt!, #engi,!ti tataara #ernga"!,an ,e$!&an e!ai *r'e!r %ang aa0 ?0 Sa%a #en%ata,an et!"!. +ai, e+agai /a$i ata! e+agai *aien. +a&/a e!ai *erti#+angan *e$a%anan %ang i+eri,an ,e*aa *aien. #a,a a%a /a"i+ !nt!, #e#+a%ar t'ta$ +ia%a *era/atan %ang i+eri,an e!ai a!an +ia%a an ,etent!an RSUP Nai'na$ r Ci*t' Mang!n,!!#' engan "a#inan ata! *ri+ai. 10 Me$a$!i ',!#en ini. a%a #enega,an ,e#+a$i +a&/a a%a #e#*era%a,an ,e*aa e#!a tenaga ,ee&atan r!#a& a,it !nt!, #e#+eri,an *era/atan. iagn'ti, an tera*i
,e*aa a%a e+agai *aien ra/at ina* ata! ra/at "a$an ata! Inta$ai Ga/at 5ar!rat ( IG5 ). ter#a!, e#!a *e#eri,aan *en!n"ang. %ang i+!t!&,an !nt!, *e#g'+atan an tina,an %ang a#an0 5engan ini a%a #en%ata,an +a&/a a%a te$a& #eneri#a an #e#a&a#i in'r#ai e+agai#ana iata an #en%et!"!in%a0 Ja,arta. Paien8 ,e$!arga8
Pe#+eri (0000000000000000000000000000000) 000000000000)
Sa,i 1 (00000000000000000000000000000)
Sa,i Penangg!ng "a/a+ (0000000000000000000000000000) (0000000000000000000