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Formulir Laporan Insiden ke Tim KP di RSRumah Sakit ...................................

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2 x 2 !AM

LAPORAN INSIDEN"INTERNAL#

I. DATA PASIENNama

$ .........................................................................................................No MR $ ......................................... Ruangan$ .............................................%mu& ' $ ()* +ua- * +ua- / * tahu-

* tahu- / 0 tahu- 0 tahu- / *0 tahu-

*0 tahu- / 1( tahu- 1( tahu- / 0 tahu- 0 tahu-

!3-i4 k3ami- $ Laki)aki P3&3m5ua-P3-a-66u-6 +ia7a 5a4i3- $

P&i+a8i A4u&a-4i S9a4ta ASKES P3m3&i-tah P3&u4ahaa-' !AMKESMAS

Ta-66a Ma4uk RS $ ............................................................................!am .....................................

II. RINCIAN KEADIAN*. Ta-66a 8a- :aktu I-4i83-

Ta-66a $ ........................................................................................!am ......................................

2.I-4i83- $ ..........................................................................................................................................

1. K&;-;;6i4 I-4i83-.......................................................................................................................................................

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. !3-i4 I-4i83-' $K3

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!i9a 8a- Su+4534iai4a4i-7aLai-)ai- ...........................................................................................................!se"u#kan$

*+. ,ni# ) Depar#emen #erkai# (ang men(e"a"kan insiden%-it k3&

7/23/2019 2a. Form Laporan Insiden Internal.doc

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T6. La5;&$ ...................................

T6. T3&ima$ ...................................

5rading Risiko Ke&adian "Dii4i ;3h ata4a- 53a5; $ 6IR, 7IA, K,NIN5 MERA7NB. ' 5iih 4atu