Formulir Penyelesaian Komplain.docx 1x266z
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FORMULIR PENYELESAIAN KOMPLAIN, KELUHAN, KONFLIK ATAU PERBEDAAN PENDAPAT Nama pasien/keluarga
:
Tanggal lahir
:
Tanggal/Jam Komplain
:
Ruangan/bagian
:
URAIAN MASALAH : ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Penerima komplain
(...........................)
TINDAKAN PENYELESAIAN KOMPLAIN ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Yang Menyelesaikan
(.......................)
EVALUASI/TINDAK LANJUT:
:
Tanggal lahir
:
Tanggal/Jam Komplain
:
Ruangan/bagian
:
URAIAN MASALAH : ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Penerima komplain
(...........................)
TINDAKAN PENYELESAIAN KOMPLAIN ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... Yang Menyelesaikan
(.......................)
EVALUASI/TINDAK LANJUT:
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