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FORMULIR LAPORAN LAPORAN KTD, KTC, KPC, dan KNC

PUSKESMAS KELURAHAN PLUIT

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2 x 24 JAM

LAPORAN INSIDEN
(INTERNAL)

I. DATA PASIEN
Nama : ............................................................................................................
No RM : ............................................................................................................
Ruangan : ............................................................................................................
Umur * : 􀂅 0-1 bulan 􀂅 1 bulan – 1 tahun
􀂅 1 tahun – 5 tahun 􀂅 5 tahun – 15 tahun
􀂅 15 tahun – 30 tahun 􀂅 30 tahun – 65 tahun
􀂅 > 65 tahun
Jenis kelamin : 􀂅 Laki-laki 􀂅 Perempuan
Penanggung biaya pasien :
􀂅 Pribadi 􀂅 Asuransi Swasta
􀂅 ASKES Pemerintah 􀂅 Perusahaan*
􀂅 JAMKESMAS 􀂅 JAMKESDA
Tanggal Masuk : . ...........................................................................................................
Jam : ............................................................................................................

II. RINCIAN KEJADIAN
1. Tanggal dan Waktu Insiden
Tanggal : ................................................................................................................
Jam : ................................................................................................................

2. Insiden : ................................................................................................................
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3. Kronologis Insiden
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..................... (sebutkan) (Tempat pasien berada) 9........................................... Insiden terjadi pada pasien* : (sesuai kasus penyakit) 􀂅 Pendaftaran 􀂅 Pelayanan tindakan 􀂅 Poli umum 􀂅 Poli gigi 􀂅 Pelayanan anak 􀂅 Pelayanan ibu hamil dan KB 􀂅 Pelayanan obat 􀂅 Lain-lain ................................................................................................ Tempat Insiden Lokasi kejadian : ....................................................... (sebutkan) 8.............................. Jenis Insiden* : 􀂅 Kejadian Tidak diharapkan / KTD 􀂅 Kejadian Tidak cedera / KTC 􀂅 Kejadian Potensi Cedera / KPC 􀂅 Kejadian Nyaris Cedera / KNC 5..... Insiden menyangkut pasien* : 􀂅 Pasien rawat jalan 􀂅 Pasien rawat inap 􀂅 Pasien UGD 􀂅 Pasien VK 􀂅 Lain-lain : ......... (sebutkan) 10.................................................................................................... ......................................... (sebutkan) Mis : karyawan / Pengunjung / Pendamping / Keluarga pasien 7.......................................4............................................... Unit / Departemen yang terkait insiden Unit kerja : ....... Insiden terjadi pada* : 􀂅 Pasien 􀂅 Lain-lain : .......... Orang Pertama Yang Melaporkan Insiden* : 􀂅 Staf : Dokter / Perawat / Bidan / Petugas lainnya 􀂅 Pasien 􀂅 Keluarga / Pendamping pasien 􀂅 Pengunjung 􀂅 Lain-lain : ................................ (sebutkan) 6............................................................

........................................................................................................................................................................................................... 13........................... ........................................................................................................................................................................................................................ ..................... ......................................................................................................... . .................................................................11................................................................................................... .............................................................................................. ............................................. .................................................................................................................................................................................................................................................................................... Apakah kejadian yang sama pernah terjadi sebelumnya di Unit Kerja yang sama atau di unit kerja yang lain?* 􀂅 Ya 􀂅 Tidak Apabila ya............................. .................................................................................................................................................. ............................... .............................................................................................................................................. ...................................................................................................................... .............................................................................................................................................................................................. .................................................................... Akibat Insiden Terhadap Pasien* : 􀂅 Kematian 􀂅 Cedera Irreversibel / Cedera Berat 􀂅 Cedera Reversibel / Cedera Sedang 􀂅 Cedera Ringan 􀂅 Tidak ada cedera 12.................... ..... Tindakan yang dilakukan segera setelah kejadian............................................................................................................................................................................................................................................................................. Kapan dan langkah / tindakan apa yang telah diambil pada Unit kerja tersebut untuk mencegah terulangnya kejadian yang sama? ....................... ..................................................................................................................................... .......................................... 14............................................................................................................................... isi bagian dibawah ini................... ................................................................................... Tindakan dilakukan oleh* : 􀂅 Dokter 􀂅 Perawat 􀂅 Bidan 􀂅 Petugas lainnya : ................................................... ....................................................................................... ........................................................................................................................................................... ............................................................................................................................. dan hasilnya : ..................

....... Paraf : ............. Indra Dharma Imam Pujiono NIP......................................................... Tgl terima : ... Tgl Lapor : ............ Laporan Laporan Paraf : .................................................................................. Kepala Puskesmas Kelurahan Pluit Ketua Tim PMKP dr.... Unit Kerja : .................................... 196101041988031006 ............. Unit Kerja : ........Pembuat Penerima : …………………………………........... * = pilih satu jawaban dengan tanda rumput Mengetahui.................. NB......................................................... : ......................