Laporan Instalasi

LAPORAN DAN EVALUASI INSTALASI PELAYANAN MEDIS :
1. Instalasi Gawat Darurat

2. Instalasi Kamar Operasi
3. Instalasi Kamar Bersalin
4. Instalasi Pelayanan Intensif
5. Instalasi Perina
6. Instalasi Rawat Inap
7. Instalasi Rawat Jalan
8. Instalasi Rehabilitasi Medik
TRIWULAN .... TAHUN ......

RS/RSIA HERMINA .....
I. INSTALASI GAWAT DARURAT
A. EVALUASI DAN ANALISA

I. DATA KINERJA :
1. Pelayanan IGD :
Jumlah (A) Jumlah (B) Response Time Pem. Penunjang Penatalaksanaan

Penolaka
Level I, II, Rujukan dari Kecelaka Rujuk
Bulan A+B Level IV, V VeR n
I II III DOA ∑ IV V ∑ III luar RS an Rad Lab RJ RI VK OK ke luar †
(> 30') RI
(> 10') RS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
.... % %
....
....
TW ....
EVALUASI DAN ANALISA :

....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
2. POLA PENYAKIT
NO. DIAGNOSA .... .... .... TW ... Peringkat

I BEDAH & KECELAKAAN
1 Fraktur
2 Vulnus
3 Combustio
4 Trauma capitis
5 Trauma thorax
6 Trauma abdomen
7 Appendisitis
8 Hernia
9 Invaginasi
10 Emergency kebidanan
11 Retensio urine
12 Corpus alienum
II NON BEDAH
1 Sepsis neonatorum
2 HMD
3 PPHN
4 Neonatal fit
5 APCD
6 DSS
7 Bronkhopneumonia
8 GED
9 Stroke
10 Hipertensi Berat
11 Keto acidosis diabeticum
12 Kejang
13 Keracunan
14 Tentamen suicide
15 Status asmaticus
16 Heart attack
17 Syok
18 Tetanus
19 Anemia

....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
II. ORGANISASI DAN KETENAGAAN (sumber data : absensi/jadwal dinas, lembur, cuti, laporan diklat) :
1. Struktur Organisasi :
.........................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................
(memadai/tidak memadai/.......)
2. Jumlah Tenaga :
..........................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................
(kurang/mencukupi/......)
3. Pelaksanaan program Orientasi Karyawan Baru :
.........................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................
(sesuai/tidak sesuai dengan rencana)
4. Pelaksanaan program Diklat Pengembangan Staf :
..........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
III. PERALATAN (sumber data dari laporan pemeliharaan alat) :
1. Kegiatan perawatan rutin : (terlaksana/tidak terlaksana)
Alasan ............................................................................................................................................................................................................................................
2. Frekuensi kerusakan alat : .............................................................................................................................................................................................................
3. Pengadaan alat baru : ............................................................................................................................................................................................................
4. Lain – lain : .............................................................................................................................................................................................................................

....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
IV. STANDAR PELAYANAN :
1. Evaluasi Kebijakan : .....................................................................................................
2. Evaluasi Standar Pelayanan Medis : .................................................................................
No. Judul SPM No. SPM Hasil Evaluasi Rekomendasi
Standar Pelayanan Medis :

● Baru : ............ buah
● Revisi : ............ buah
● Tidak digunakan lagi : ............. buah
3. Evaluasi SPO : ...............................................................................................................
No. Judul SPO No. SPO Hasil Evaluasi Rekomendasi
SPO :
● Baru : ............ buah
● Revisi : ............ buah
V. MUTU PELAYANAN :
1. Pencapaian standar mutu :
NO NAMA PROGRAM DEFINISI OPERASIONAL STANDAR TW I TW II TW III TW IV

1 Penanganan pasien a. Response time
gawat darurat Penanganan pertama gawat darurat (level I, II, III) yang diberikan untuk menyelamatkan jiwa
manusia yang sedang terancam karena penyakit/luka-luka yang dideritanya (life saving)
0%
∑ penderita gawat darurat (level I, II, III) yang dilayani > 10 menit x 100%
∑ total penderita gawat darurat (level I, II, III)
b. Pasien emergency (level I, II, III) yang belum ditangani sesuai prosedur dalam waktu 30 menit
sejak pasien datang
0%
∑ penderita gawat darurat ( level I, II, III) yang dilayani sesuai prosedur > 30 menit x 100 %
∑ total penderita gawat darurat (level I, II, III)
2 Angka kematian di IGD ∑ kematian di IGD (tidak termasuk DOA) x 100%

∑ pasien IGD
0.00%
2. Response Time : Rata – rata kurang / sesuai / lebih baik dari standar......................................................................................................................................................

....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
B. REKOMENDASI DAN RENCANA TINDAK LANJUT
1. .................................................................................................................................................................................................
2. .................................................................................................................................................................................................
3. .................................................................................................................................................................................................
4. .................................................................................................................................................................................................
5. .................................................................................................................................................................................................
6. ..................................................................................................................................................................................................
...................., ...................................
_________________________ ______________________
Kepala Perawat Instalasi Gawat Darurat Kepala Instalasi Gawat Darurat
II. PELAYANAN KAMAR OPERASI

I. DATA KINERJA :
1. Jenis Operasi
No Jenis Operasi ... ... .... TW ...
I Kebidanan dan Kandungan :
1 Sectio Caesaria
2 Dilatasi dan Kuretase
3 Laparatomi Kebidanan
4 Laparascopy kebidanan
5 Incisi / ekstirpasi / marsupialisasi
6 Minilap / Pomoroy
7 Hidrotubasi
8 Aff IUD
9 Pemasangan laminaria
10 Pemasangan shirocart (Mc Donald)
Eksplorasi perdarahan / re-hecting /

11
plasenta manual
II Bedah Anak :
1 Appendictomy
2 Circumsisi
3 Herniotomy
4 Colostomy
5 Laparatomi anak
III Bedah Umum / Tumor :
1 Appendictomy
2 Herniotomy
3 Haemorrhoidectomy
4 Laparatomi dewasa
5 Laparascopy
6 Ekstirpasi / incisi / mastektomi
7 Strumeidectomy
8 Repair luka
IV THT :
1 Tonsilektomi
2 FESS
3 Irigasi sinus
V MATA :
1 Katarak
2 Incisi
VI Bedah lain – lain :
1 Bedah Orthopaedi
2 Bedah Plastik
3 Bedah mulut
4 Bedah syaraf
5 Bedah urologi

........................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................
2. DATA OPERASI BERDASARKAN PERENCANAAN
Cito
Jml Keterlambatan Op.
Bulan Op. Bersih (%) Elektif (%) SC Non- SC
Operasi Elektif Jml (%)
Jml < 30 menit (%) > 30 menit (%) Jml < 6 jam (%) > 6 jam (%)
60 54 (90 %) 40 ( ... %) 4 (10 %) 20 (... %) 10 8 (80 %) 2 (20%) 10 5 (50 %) 5 (50 %)

....
....
....
TW ....

...................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
3. SECTIO CESAREA
SC Hasil Operasi Kematian di Meja Op

Jml Kelahiran Σ Infeksi
Bulan Sesuai Indikasi Tidak Sesuai
(Data dari VK) Tot % SC Pasca Operasi Ibu Bayi
(Pre-Op) Indikasi (Pre-Op)
.... 100 40 40.00%
.....
....
TW .....

...................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
4. JENIS ANESTESI YANG DIGUNAKAN
Anestesi spinal
Jml Anestesi / epidural Anestesi spinal Anestesi
Bulan
Pasien Umum menjadi umum Lokal
1x >1x
... 50 30 (60 %) 10 5 3 2 (... %)

....
....
....

...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
5. UTILISASI DAN DATA RUJUKAN KAMAR OPERASI
Jml Total Jumlah Tindakan Rujukan Dari Luar RS

Bulan
Operasi OK I OK II OK III Jml Pasien RS Lain / Bidan
....
....
....
TW ....

.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
6. UTILISASI ALAT
Frekuensi Pemakaian
No. Jenis Alat
.... .... .... TW ....
I Alat RS
1 Set SC 1
2 Set SC 2
3 Set Histerektomi
4 ............
5 ............
II Alat dari Luar

1 Set THT
2 Set Mata
3 Set Orthopedi
4 ...............

.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
7. PEMINJAMAN ALAT
Jenis alat yang

Frekuensi Peminjaman Frekuensi
No. Jenis alat No. Jenis Alat No. dibawa oleh Frekuensi
Ke luar dipinjam keluar
dokter

.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
8. KOMPLIKASI
Kesesuaian Diagnosa Awal dan Akhir Komplikasi Pasca

Bedah
(di RR)
Tidak sesuai
Jml
Bulan Kesalahan
Operasi
Diagnosa Pre Op
MeninggalElektif Cito Elektif Cito Elektif Cito
Durante Op
.... 50 40 4 2 2 1 1
....
....
TW ....

.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................
(memadai/tidak memadai/........)
2. Jumlah Tenaga :
a. Tenaga perawat :
● Jumlah operasi : .............
● Yang didampingi oleh 3 atau lebih perawat : ..............
● Yang didampingi < 3 perawat : ..............
● Kesimpulan : Ketenagaan kurang
b. Tenaga dokter :
● Dokter anestesi : ................................
● Dokter bedah : ................................
● Dokter obgyn : .................................

................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................

................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................
1. ...........................................................................................................................................................................................................................................
2. ...........................................................................................................................................................................................................................................
3. ..........................................................................................................................................................................................................................................
Alasan ....................................................................................................................................................................................................................................
2. Frekuensi kerusakan alat : ......................................................................................................................................................................................................
4. Lain – lain : .............................................................................................................................................................................................................................

1. .................................................................................................................................................................................................................................................
2. .................................................................................................................................................................................................................................................
3. .................................................................................................................................................................................................................................................
IV. RUANGAN :
.................................................................................................................................................................................................................................................
.................................................................................................................................................................................................................................................
.................................................................................................................................................................................................................................................
V. KEBIJAKAN DAN STANDAR PELAYANAN:

 Baru : ............ buah
 Revisi : ............ buah
 Tidak digunakan lagi : ............. buah
3. Evaluasi SPO : ...............................................................................................................
SPO :
 Baru : ............ buah
 Revisi : ............ buah
VI. MUTU PELAYANAN :
Evaluasi dan Analisa dari Pencapaian standar mutu tahun 2009 :
NAMA PROGRAM STANDAR TW I TW II TW III TW IV

1 Angka Sectio Caesaria < 30%
2 Angka infeksi luka operasi / AILO (wound infection rate) 0%
3 Angka komplikasi pasca bedah (surgical complication rate) < 1%
4 Respon time operasi cito (non SC) 0%
5 Respon time operasi cito SC 0%
6 KTD durante atau pasca operasi. 0%
7 Pembatalan / penundaan operasi elektif akibat persiapan pre 0%
operasi yang tidak optimal (akibat tidak terdeteksinya penyakit,
persiapan alat)
8 Presentase ketidaklengkapan pengisian BRM anestesi dalam 0%
rekam medis pasien yang dilakukan operasi.

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
1. ...............................................................................................................................................................................................................................................
2. ...............................................................................................................................................................................................................................................
3. ...............................................................................................................................................................................................................................................
4. ...............................................................................................................................................................................................................................................
5. ...............................................................................................................................................................................................................................................
6. ...............................................................................................................................................................................................................................................
...................., ....................................
____________________________ __________________________
Kepala Perawat Kamar Operasi Kepala Instalasi Kamar Operasi
III. INSTALASI KAMAR BERSALIN
I. DATA KINERJA
1. DATA KELAHIRAN DILIHAT DARI JENIS KRT DAN DATA IMD
Jumlah Kelahiran Rujukan Rujukan Keluar

Bulan Σ KRT Σ KRT IMD
ΣT Σ KRT VK Dari Luar OTM Fasilitas Dr. Spesialis
POLI VK Luar
1 2 3 4 5 6 7 8 9
....
....
....
TW ....
Keterangan :
-ΣT : Jumlah total persalinan di VK/OK
- Σ KRT : Jumlah KRT stempel baru dari RJ
- Σ KRT B : Jumlah KRT terdeteksi di VK yang ANC di Hermina (stempel baru dilakukan di VK)
- Σ KRT B Luar : Jumlah KRT terdeteksi di VK yang ANC di luar RS Hermina
- Kolom 14 diisi jika pasien membawa surat pengantar / rujukan dari luar RS/RSIA Hermina
- Kolom 15 diisi jika pasien akan dirujuk keluar dari RS/RSIA Hermina

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
2. JENIS KASUS
.... ..... .... TW ....

No. Jenis Kasus
ΣT Σ KRT ΣT Σ KRT ΣT Σ KRT ΣT Σ KRT
1 HPP 10 2
2 Gawat janin 6 0
3 Eklampsi 0 0
4 PEB 5 5
5 KPD
6 HAP
7 Prematur
8 Postmatur
9 IUGR
10 Kelainan kongenital
Total 120 15
KETERANGAN :
Σ T : Jumlah kasus yang melakukan ANC di Hermina
Σ KRT : Jumlah KRT yang distempel di poli

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................
(memadai/tidak memadai/........)
2. Jumlah Tenaga :
................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................

1. ...........................................................................................................................................................................................................................................
2. ...........................................................................................................................................................................................................................................
3. ..........................................................................................................................................................................................................................................
Alasan ....................................................................................................................................................................................................................................
4. Lain – lain : .............................................................................................................................................................................................................................

1. .................................................................................................................................................................................................................................................
2. .................................................................................................................................................................................................................................................
3. .................................................................................................................................................................................................................................................
IV. RUANGAN :
.................................................................................................................................................................................................................................................
.................................................................................................................................................................................................................................................
.................................................................................................................................................................................................................................................
V. KEBIJAKAN DAN STANDAR PELAYANAN:

 Baru : ............ buah
 Revisi : ............ buah
3. Evaluasi SPO : ...............................................................................................................
SPO :
 Baru : ............ buah
 Revisi : ............ buah
VI. MUTU PELAYANAN :
Evaluasi dan Analisa dari Pencapaian standar mutu tahun 2009 :
NAMA PROGRAM STANDAR TW I TW II TW III TW IV

1 Jumlah pasien yang mengalami KTD di VK yang sebelumnya < 10%
sudah terdeteksi KRT di poliklinik
2 Kejadian Pre Eklampsi menjadi Eklampsi 0

3 Angka Kematian ibu karena Eklampsi/AKIE (Echlampsia Death
Rate) 0.00%
4 Angka Kematian ibu karena perdarahan / AKIP (Maternal
Haemorrhagia Death Rate) :
a. Kematian ibu karena perdarahan yang terjadi pada kala IV 0.00%
(HPP) dalam persalinan
b. ∑ kematian ibu karena perdarahan, baik meninggal di RS 0
maupun meninggal setelah dirujuk dalam waktu < 24 jam,
pada semua kasus dalam persalinan

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
1. .................................................................................................................................................................................................
2. .................................................................................................................................................................................................
3. .................................................................................................................................................................................................
4. .................................................................................................................................................................................................
5. .................................................................................................................................................................................................
6. ..................................................................................................................................................................................................
...................., ....................................
_________________________ _____________________
Kepala Perawat Kamar Bersalin Kepala Instalasi Kamar Bersalin
IV. INSTALASI PELAYANAN INTENSIF

I. DATA KINERJA (sumber data laporan bulanan) :
1. DATA BOR
... ... ... TW ...

 Pasien :
1. Neonatus
2. Anak
3. Dewasa
BOR ICU
LOS
Ka. Prwt
Ka. Inst.
Ket : Data BOR dan LOS diambil dari data rekam medis

........................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................
2. JENIS DAN JUMLAH KASUS
PERINGKAT
NO. DIAGNOSA ... ... ... TW ...
KASUS
I NICU
1 Sepsis neonatorum
2 HMD
3 PPHN
4 Neonatal fit
5 APCD
6 Post laparatomy
II PICU
1 DSS
2 Meningoencephalitis
3 BP berat
4 Pasca operasi
5 Anemia gravis
6 GEDB
III ICU
1 PEB/eklampsi/hellp syndrome
2 Stroke
3 Hipertensi Berat
4 KAD
5 DSS
6 Post laparatomy
7 Post TUR
8 Post craniotomy
...................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................
3. ANGKA KEMATIAN
JML JML KEMATIAN < 48 JAM KEMATIAN > 48 JAM

NO. DIAGNOSA
KASUS KEMATIAN (%) ... ... ... TW ... ... ... ... TW
I NICU
1 Sepsis neonatorum
2 HMD
3 PPHN
4 Neonatal fit
5 APCD
6 Post Operasi
II PICU
1 DSS
2 Meningoencephalitis
3 BP berat
4 Pasca operasi
5 Anemia gravis
6 GEDB
III ICU
1 PEB/eklampsi/hellp syndrome
2 Stroke
3 Hipertensi Berat
4 KAD
5 DSS
6 Post laparatomy
7 Post TUR
8 Post craniotomy

...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
4. PELAYANAN PERISTI :
A. PELAYANAN MATERNAL-PERINATAL
... ... ... TW ...

No. JENIS KASUS
ΣT Σ KRT ΣT Σ KRT ΣT Σ KRT ΣT Σ KRT
I PELAYANAN PERINATAL IBU
1 Eklampsi
2 HELLP syndrome
3 HPP
4 Sepsis
Persalinan dengan penyulit (DM, Peny. Jantung,
5
dll)
Total
II PELAYANAN PERINATAL DI NICU

1 HMD
2 PPHN
3 Asfiksia
4 MAS
5 Bayi Prematur
6 Broncho Pulmonary Dysplasia
7 Sepsis
8 Kelainan kongenital
Total
III RUJUKAN KASUS PERISTI

1 Dari dalam RS (VK, OK, KBBL, Perawatan)
2 Dari luar RS (VK emergency, IGD, Poliklinik)
3 Merujuk ke luar RS/RSIA Hermina ......
KETERANGAN :
Σ T : Jumlah kasus yang melakukan ANC di Hermina
Σ KRT : Diisi untuk kasus yang memiliki stempel KRT baru di poliklinik

...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
B. KEGIATAN KUNJUNGAN RUMAH KASUS PERISTI PASCA PERAWATAN
Bulan .... .... .... TW ....

IBU
Σ PERSALINAN
Σ KONFIRMASI KESEDIAAN KR
Σ KEGIATAN KR
BAIK
HASIL KR IBU
KRG BAIK
BAIK
HASIL KR BAYI
KRG BAIK
BAYI
Σ PASIEN POST RAWAT PERINA/NICU
Σ KONFIRMASI KESEDIAAN KR
Σ KEGIATAN KR
HASIL KR IBU BAIK
KRG BAIK
HASIL KR BAYI BAIK
KRG BAIK

...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
5. DATA RUJUKAN :
Rujukan Dari Luar Rujukan Ke Luar
Bulan Jml Asal Rujukan Jml Alasan Merujuk

Pasien R.S. RB / Perorangan Pasien OTM Fasilitas Dokter Sp. APS
...
...
...
TW ...

.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
6. JUMLAH RAWAT ULANG :
BULAN Jml Rawat Ulang KET

...
...
...
TW ... -

.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
(memadai/tidak memadai/.........)
2. Jumlah Tenaga :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

1. ...........................................................................................................................................................................................................................................
2. ...........................................................................................................................................................................................................................................
3. ..........................................................................................................................................................................................................................................
a. Kegiatan perawatan rutin : (terlaksana/tidak terlaksana)
Alasan ....................................................................................................................................................................................................................................
b. Frekuensi kerusakan alat : ......................................................................................................................................................................................................
c. Pengadaan alat baru : ............................................................................................................................................................................................................
d. Lain – lain : .............................................................................................................................................................................................................................

1. .................................................................................................................................................................................................................................................
2. .................................................................................................................................................................................................................................................
3. .................................................................................................................................................................................................................................................

● Baru : ............ buah
● Revisi : ............ buah
3. Evaluasi SPO : ...............................................................................................................
SPO :
● Baru : ............ buah
● Revisi : ............ buah
V. MUTU PELAYANAN :
Evaluasi dan analisa dari Pencapaian standar mutu :
NO INDIKATOR MUTU Standar Mutu TW I TW II TW III TW IV

1 Kejadian perawatan ulang di perawatan intensif 0
2. Angka Kematian bayi karena gawat janin < 10%
3. Angka Kematian bayi dengan ketuban hijau kental 0%
4 Angka kematian bayi dengan BB > 2000 gram 0%
5 Angka kematian bayi dengan BB > 1500 - 2000 gram 0%
6 Angka kematian bayi dengan BB 1000 - 1500 gram 0%
7 Angka kematian bayi dengan < BB 1000 gram
8 Angka kematian di ICU/PICU 25 %
9 Angka kejadian infeksi nosokomial di ICU 25 %
10 Angka Kematian Ibu karena Sepsis/AKIS (Maternal 0%
Septicaemia Death Rate)

1. .................................................................................................................................................................................................................................................
2. .................................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................................
1. ...............................................................................................................................................................................................................................................
2. ...............................................................................................................................................................................................................................................
3. ...............................................................................................................................................................................................................................................
4. ...............................................................................................................................................................................................................................................
5. ...............................................................................................................................................................................................................................................
6. ...............................................................................................................................................................................................................................................
...................., ....................................
_____________________________ _______________________
Kepala Perawat Pelayanan Intensif Kepala Instalasi Pelayanan Intensif
V. INSTALASI PERINA

I. DATA KINERJA
1. PELAYANAN KBBL
Jml BBL Tindak Lanjut Screening Rawat

Bulan Gabung /
Spontan SC Plg Pulpak Rawat Perina / OAE Bil TSH Gol. G6PD
ASI Eksklusif
NICU Drh
.....
.....
.....
TW ....

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
2. JENIS DAN JUMLAH KASUS
PERINGKAT
NO. DIAGNOSA ... ... ... TW ...
KASUS
1
2
3
4
5
6

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
(memadai/tidak memadai/.........)
2. Jumlah Tenaga :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

1. ...........................................................................................................................................................................................................................................
2. ...........................................................................................................................................................................................................................................
3. ..........................................................................................................................................................................................................................................
Alasan ....................................................................................................................................................................................................................................
4. Lain – lain : .............................................................................................................................................................................................................................

1. .................................................................................................................................................................................................................................................
2. .................................................................................................................................................................................................................................................
3. .................................................................................................................................................................................................................................................

● Baru : ............ buah
● Revisi : ............ buah
3. Evaluasi SPO : ...............................................................................................................
SPO :
● Baru : ............ buah
● Revisi : ............ buah
1. .................................................................................................................................................................................................
2. .................................................................................................................................................................................................
3. .................................................................................................................................................................................................
4. .................................................................................................................................................................................................
5. .................................................................................................................................................................................................
6. ..................................................................................................................................................................................................
...................., ....................................
_________________________ _____________________
Kepala Perawat Perina / KBBL Kepala Instalasi Perina
VI. INSTALASI RAWAT INAP
I. DATA KINERJA
1. POLA PENYAKIT
NO. DIAGNOSA .... .... .... TW ... Peringkat

I IBU
1
2
3
4
5
ANAK
1
2
3
4
5
UMUM
1
2
3
4
5
1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
2. RUJUKAN
ALASAN MERUJUK
BULAN RUJUKAN
OTM FASILITAS DR. SPESIALIS
....
....
....
TW ....

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
3. PELAYANAN PERISTI : INFEKSI POST PARTUM
No. JENIS KASUS .... .... .... TW ....

1 Pasien Post Partum
2 Infeksi luka perineum
3 Mastitis
4 Infeksi luka operasi
5 Lain – Lain :
.......................
Total

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
4. KEGIATAN PENDIDIKAN DAN PENYULUHAN
Kursus Merawat Bayi Kursus Senam Nifas Kursus Pija Bayi
Bulan  Kunjungan  Kunjungan  Kunjungan

 Bayi Baru  Kelahiran
Kursus  Persalinan Kursus Kursus
Lahir Bayi
Merawat Bayi Senam Nifas Pijat Bayi
....
....
....
TW ...

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
II. MUTU PELAYANAN :
Evaluasi dan analisa dari Pencapaian standar mutu :
NO INDIKATOR MUTU Standar Mutu TW I TW II TW III TW IV

1 Perpanjangan masa rawat ibu melahirkan (Prolonged LOS of 1.00%
Maternal Delivery)
2. Kejadian perawatan ulang umum 0.00%
3. Mortalitas Pasien DHF 0.00%
4 Diagnosa yang belum ditegakkan setelah 3 hari 0

1. .................................................................................................................................................................................................................................................
2. .................................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................................
1. .................................................................................................................................................................................................
2. .................................................................................................................................................................................................
3. .................................................................................................................................................................................................
4. .................................................................................................................................................................................................
5. .................................................................................................................................................................................................
6. ..................................................................................................................................................................................................
...................., ....................................
____________________________ _________________
Kepala Perawat Rawat Inap Kepala Instalasi Rawat Inap
VII. INSTALASI RAWAT JALAN
A. EVALUASI DAN ANALISA DATA KINERJA
1. REKAPITULASI KRT YANG MENDAPAT STEMPEL BARU
Σ Ibu Hamil Rujukan Rujukan Keluar

Bln Σ KRT
ANC I Dari Luar OTM Fasilitas Dr. Spesialis
...
...
...
TW ...

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
2. KASUS KRT
No. KASUS KRT .... .... .... TW ... Peringkat

1. Primagravida muda (<16 tahun)
2. Primagravida tua (>35 tahun)
3. Multipara >4 atau umur >40 tahun
4. Riwayat kehamilan; abortus; partus prematurus
5. Riwayat kematian janin; lahir mati
6. Bekas SC ; myomectomia
7. Riwayat perdarahan postpartum
8. Penyakit jantung ; hati ; ginjal
9. Anemia (< 10 g%)
10. Eph. Gestosis, hypertensi; Pyelonephritis
11. Diabetes mellitus
12. Inkompatibilitas Abo / Rhesus
13. Partus prematurus membakat; Incompetent cervix
14. Postmatur : umur kehamilan tidak jelas
15. Kelainan letak janin : kehamilan ganda
16. Disproporsi janin panggul; janin besar; panggul patologi
17. Perdarahan antepartum
18. Pertumbuhan janin terhambat (IUGR)
19. TORCH

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
3. Kegiatan Pendidikan dan Penyuluhan
Kursus Pra Persalinan Kegiatan Senam Hamil Konsultasi Laktasi
Bulan  Kunjungan  Kunjungan

 Ibu Hamil  Ibu  Kunjungan
Kursus  Persalinan Konsultasi
Baru Hamil Senam Hamil
Pra Persalinan Laktasi
....
....
....
TW ...

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
1. .................................................................................................................................................................................................
2. .................................................................................................................................................................................................
3. .................................................................................................................................................................................................
4. .................................................................................................................................................................................................
5. .................................................................................................................................................................................................
6. ..................................................................................................................................................................................................
...................., ....................................
____________________________ _________________
Kepala Perawat Rawat Jalan Kepala Instalasi Rawat Jalan
VIII. INSTALASI REHABILITASI MEDIS

I. DATA KINERJA (sumber data laporan bulanan)
1. ASAL PASIEN :
Asal Pasien
Jumlah Pasien TOTAL
IGD (%) RJ (%) RI (%) LUAR RS (%)
....
....
....
TW ...

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
2. JUMLAH TINDAKAN :
TINDAKAN .... ..... .... TW ....

Inhalasi
MWD
SWD
TENS
US
ES
EXC
MSG
IRR
SUC

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
3. DIAGNOSA (10 TERBANYAK)
.... ..... ..... TW ....

DIAGNOSA JML DIAGNOSA JML DIAGNOSA JML DIAGNOSA JML
1
2
..........
10

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
II. EVALUASI DAN ANALISA KETENAGAAN (sumber data : absensi/jadwal dinas, lembur, cuti, laporan diklat) :
1. Struktur Organisasi : .......................................................... (revisi / tidak ada perubahan)

2. Jumlah Tenaga : ............................................................................................. (kurang/mencukupi/......)
3. Pelaksanaan program orientasi karyawan baru :
............................................................................................. (sesuai/tidak sesuai dengan rencana)
4. Pelaksanaan program diklat
............................................................................................. (sesuai/tidak sesuai dengan rencana)
III. EVALUASI DAN ANALISA TERHADAP KEBIJAKAN, SPO DAN SPM
2. Evaluasi Standar Pelayanan : ............................................................................................
No. Judul SP No. SP Hasil Evaluasi Rekomendasi
Standar Pelayanan :
● Baru : ............ buah
● Revisi : ............ buah
3. Evaluasi SPO :
SPO :
● Baru : ............ buah
● Revisi : ............ buah
IV. EVALUASI DAN ANALISA PERALATAN (sumber data dari laporan pemeliharaan alat) :
1. Utilisasi Peralatan :
NO FUNGSI PELAYANAN PERALATAN KETERANGAN

1 Chest Therapy : Nebulizer
Suction
Oksigen
Vibrator
2 Muskuloskeletal Diathermi
Ultra Sound
TENS
3 Neuromuscular Diathermi
Ultrasound
Traksi Dirujuk
4 Obgyn Diathermi
5 THT Diathermi
2. Kegiatan perawatan rutin : (terlaksana/tidak terlakasana)

Alasan ..................................................................................
3. Frekuensi kerusakan alat : ..................................................

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
V. ANALISA DAN EVALUASI TERHADAP MUTU PELAYANAN
Standar
No Indikator Mutu TW I TW II TW III TW IV
Mutu
1 Angka kesalahan tindakan 0.00%
2 Angka kecepatan menjawab konsul (responstime) 0.00%
3 Komplain dokter spesialis pengirim dan pasien mengenai pelayanan 0
Rehab Medik
4 Frekuensi kerusakan alat 0
5 Angka KTD pada pasien yang dilakukan terapi karena faktor alat 0%
6 Prosentase Drop Out pasien KTK 0.00%
7 Presentasi ketidakhadiran pasien KTK yang sudah terjadwal 20.00%
8 Presentase kepuasan pasien akan pelayanan di KTK 80%

1. .............................................................................................................................................................................................................................................
2. ..............................................................................................................................................................................................................................................
3. .............................................................................................................................................................................................................................................
B. REKOMENDASI / RENCANA TINDAK LANJUT :
1. .................................................................................................................................................................................................
2. .................................................................................................................................................................................................
3. .................................................................................................................................................................................................
4. .................................................................................................................................................................................................
5. .................................................................................................................................................................................................
6. ..................................................................................................................................................................................................
..................., ................................
.................................... dr. .................................

Kepala Terapis Kepala Instalasi Rehabilitasi Medik

Laporan Instalasi

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Laporan Instalasi

Enviado por

Direitos autorais:

Formatos disponíveis

LAPORAN DAN EVALUASI INSTALASI PELAYANAN MEDIS :

1. Instalasi Gawat Darurat

TRIWULAN .... TAHUN ......

A. EVALUASI DAN ANALISA

Jumlah (A) Jumlah (B) Response Time Pem. Penunjang Penatalaksanaan

EVALUASI DAN ANALISA :

NO. DIAGNOSA .... .... .... TW ... Peringkat

EVALUASI DAN ANALISA :

EVALUASI DAN ANALISA :

EVALUASI DAN ANALISA :

No. Judul SPM No. SPM Hasil Evaluasi Rekomendasi

Standar Pelayanan Medis :

3. Evaluasi SPO : ...............................................................................................................

No. Judul SPO No. SPO Hasil Evaluasi Rekomendasi

NO NAMA PROGRAM DEFINISI OPERASIONAL STANDAR TW I TW II TW III TW IV

2 Angka kematian di IGD ∑ kematian di IGD (tidak termasuk DOA) x 100%

EVALUASI DAN ANALISA :

A. EVALUASI DAN ANALISA

No Jenis Operasi ... ... .... TW ...

I Kebidanan dan Kandungan :

2 Dilatasi dan Kuretase

5 Incisi / ekstirpasi / marsupialisasi

10 Pemasangan shirocart (Mc Donald)

Eksplorasi perdarahan / re-hecting /

III Bedah Umum / Tumor :

6 Ekstirpasi / incisi / mastektomi

VI Bedah lain – lain :

EVALUASI DAN ANALISA :

60 54 (90 %) 40 ( ... %) 4 (10 %) 20 (... %) 10 8 (80 %) 2 (20%) 10 5 (50 %) 5 (50 %)

EVALUASI DAN ANALISA :

SC Hasil Operasi Kematian di Meja Op

EVALUASI DAN ANALISA :

... 50 30 (60 %) 10 5 3 2 (... %)

EVALUASI DAN ANALISA :

Jml Total Jumlah Tindakan Rujukan Dari Luar RS

EVALUASI DAN ANALISA :

II Alat dari Luar

EVALUASI DAN ANALISA :

Jenis alat yang

EVALUASI DAN ANALISA :

Kesesuaian Diagnosa Awal dan Akhir Komplikasi Pasca

MeninggalElektif Cito Elektif Cito Elektif Cito

EVALUASI DAN ANALISA :

3. Pelaksanaan program Orientasi Karyawan Baru :

4. Pelaksanaan program Diklat Pengembangan Staf :

EVALUASI DAN ANALISA :

No. Judul SPM No. SPM Hasil Evaluasi Rekomendasi

Standar Pelayanan Medis :

3. Evaluasi SPO : ...............................................................................................................

No. Judul SPO No. SPO Hasil Evaluasi Rekomendasi

NAMA PROGRAM STANDAR TW I TW II TW III TW IV

EVALUASI DAN ANALISA :

1. DATA KELAHIRAN DILIHAT DARI JENIS KRT DAN DATA IMD

Jumlah Kelahiran Rujukan Rujukan Keluar

EVALUASI DAN ANALISA :

.... ..... .... TW ....

EVALUASI DAN ANALISA :

EVALUASI DAN ANALISA :

EVALUASI DAN ANALISA :

No. Judul SPM No. SPM Hasil Evaluasi Rekomendasi

Standar Pelayanan Medis :

3. Evaluasi SPO : ...............................................................................................................

No. Judul SPO No. SPO Hasil Evaluasi Rekomendasi