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ULIR PENYELESAIAN KOMPLAIN, KELUHAN , KONFLIK ATAU PE

Nama Pasien/Keluarga : .. No :..


Tanggal Lahir : .. Masalah : Baru
Tanggal/Jam Komplain : .. Lama
Ruangan/Bagian : ..
URAIAN MASALAH

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Penerima Komplain

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TINDAKAN PENYELESAIAN SAAT KEJADIAN

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Yang Menyelesaikan

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EVALUASI/TINDAK LANJUT

Tidak Perlu Tindak Lanjut Evaluasi Oleh

Perlu Tindak Lanjut dengan Corrective Action Request (CAR)

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