MASTERLIST KAK

T DISTRIBUSI DOKUMEN
G
R L
E 01 02 03 04 05 06
V T
NO NO DOKUMEN JUDUL PEDOMAN
I E A B C D A B C D A B C D E F G H I J K L M
K A
S R A U S R
K
S U
U I P I U L G S F R
I B P D P E K K O
U
I K A
G
L
O
I U A L
R S M M M R M I B
I U I T
V I K
P
P
E
U
M K
M U
L I N
Z
A
A
S G N I
T S T P E U E
M
U A I
I
B
T
I D A N
E K P U M T T T O P
G
I O S
1 001/KAK/425.102.4/2016 KAK POSBINDU

2 002/KAK/425.102.4/2016
KAK PELACAKAN BALITA GIZI 00 √ √ √ √
BURUK
3 003/KAK/425.102.4/2016 KAK GARAM BERYODIUM

4 004/KAK/425.102.4/2016 KAK KONSELING GIZI

5 005/KAK/425.102.4/2016
KAK PEMANTAUAN STATUS
GIZI
6 006/KAK/425.102.4/2016 KAK KADARZI

7 007/KAK/425.102.4/2016 KAK PEMBINAAN KP ASI

8 008/KAK/425.102.4/2016 KAK KELAS IBU PINTAR

9 009/KAK/425.102.4/2016 KAK PMT PENYULUHAN

10 010/KAK/425.102.4/2016 KAK PEMULIHAN

11 011/KAK/425.102.4/2016 KAK PEMBERIAN VIT A

12 012/KAK/425.102.4/2016
KAK PEMBERIAN Fe REMAJA
PUTRI
13 013/KAK/425.102.4/2016 KAK AUDIT INTERNAL 00

14 014/KAK/425.102.4/2016 KAK PMKP 00

15 015/KAK/425.102.4/2016 KAK PTP 00

16 016/KAK/425.102.4/2016 KAK KIA 00

17 017/KAK/425.102.4/2016 KAK GIZI 00

18 018/KAK/425.102.4/2016 KAK DBD 00

19 019/KAK/425.102.4/2016 KAK TB 00

20 020/KAK/425.102.4/2016 KAK IMUNISASI 00

21 021/KAK/425.102.4/2016 KAK HIV/AIDS 00

22 022/KAK/425.102.4/2016 KAK KECACINGAN 00

23 023/KAK425.102.4/2016 KAK DIARE 00

24 024/KAK/425.102.4/2016 KAK ISPA 00

25 025/KAK/425.102.4/2016 KAK SURVEILANCE 00

26 026/KAK/425.102.4/2016 KAK PHN 00

27 027/KAK/425.102.4/2016 KAK STBM 00

28 028/KAK/425.102.4/2016 KAK KADER KESLING

29 029/KAK/425.102.4/2016
KAK SURVEY PHBS RUMAH 00
TANGGA
30 030/KAK/425.102.4/2016 KAK PEMBINAAN POSYANDU

31 031/KAK/425.102.4/2016
KAK PELAKSANAAN
POSYANDU
32 032/KAK/425.102.4/2016 KAK REFRESING KADER

33 033/KAK/425.102.4/2016 KAK MMD

34 034/KAK/425.102.4/2016 KAK KELAS IBU HAMIL 00

35 035/KAK/425.102.4/2016 KAK KELAS IBU BALITA

36 036/KAK/425.102.4/2016 KAK JIWA 00

37 036/KAK/425.102.4/2016 KAK OLAH RAGA 00

38 036/KAK/425.102.4/2016 KAK INDERA 00

39 036/KAK/425.102.4/2016 KAK LANSIA 00

40 036/KAK/425.102.4/2016 KAK PROLANIS

KAK JEJARING DAN
41 036/KAK/425.102.4/2016 00
JARINGAN
42 036/KAK/425.102.4/2016 KAK SISTEM INFOMASI 00

43 036/KAK/425.102.4/2016 KAK UMUM DAN SARPRAS 00

44 036/KAK/425.102.4/2016 KAK PROGRAM ORIENTASI 00

45 036/KAK/425.102.4/2016 KAK HAJI 00

46 036/KAK/425.102.4/2016 KAK UMPAN BALEK 00

47 036/KAK/425.102.4/2016
KAK IDENTIFIKASI 00
KEBUTUHAN MASYARAKAT
48 036/KAK/425.102.4/2016 KAK KRR 00

49 036/KAK/425.102.4/2016
KAK SCRENING DAN 00
BERKALA

50 036/KAK/425.102.4/2016 KAK UKGM

51 036/KAK/425.102.4/2016 KAK UKGS

52 036/KAK/425.102.4/2016 KAK DOKCIL

53 036/KAK/425.102.4/2016 KAK UKS

54 036/KAK/425.102.4/2016
KAK PEMBERDAYAAN 00
MASYARAKAT
55 036/KAK/425.102.4/2016 KAK KAJI BANDING 00

56 036/KAK/425.102.4/2016
KAK PELATIHAN PETUGAS 00
UGD
57 036/KAK/425.102.4/2016 KAK SURVEI IKM 00

58 036/KAK/425.102.4/2016
KAK KEBUTUHAN 00
PUSKESMAS
59 036/KAK/425.102.4/2016
KAK KESELAMATAN 00
/KEAMANAN LABORAT
60 036/KAK/425.102.4/2016 KAK MALARIA 00

61 036/KAK/425.102.4/2016 KAK MENEJEMEN RESIKO 00

KAK PENILAIAN
62 036/KAK/425.102.4/2016 00
AKUNTABILITAS PARA PJ
KAK SURVEI DAN
63 036/KAK/425.102.4/2016 00
PENANGANAN KELUHAN
64 036/KAK/425.102.4/2016 KAK PROMKES 00
65 036/KAK/425.102.4/2016 KAK PTM 00

66 036/KAK/425.102.4/2016 KAK KB 00

67 036/KAK/425.102.4/2016 KAK KUSTA 00

68 036/KAK/425.102.4/2016 KAK BATRA 00

69 036/KAK/425.102.4/2016 KAK TIM MUTU 00

70 036/KAK/425.102.4/2016 KAK KEPEGAWAIAN 00

KAK UNTUK MEMPEROLEH

71 036/KAK/425.102.4/2016
ASUPAN PELAKSANAAN 00
PROGRAM UKM(KAK
KEPUASAN)

72 036/KAK/425.102.4/2016
KAK PEMERIKSAAN 00
BERKALA

73 036/KAK/425.102.4/2016
KAK KEBUTUHAN DAN 00
HARAPAN

74 036/KAK/425.102.4/2016 KAK JKN 00

75 036/KAK/425.102.4/2016 KAK BOX 00

76 036/KAK/425.102.4/2016 KAK UPPKM 00

77 036/KAK/425.102.4/2016 KAK MALARIA 00

78 00

79 00

80 00

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 MASTERLIST BAB 5

T DISTRIBUSI DOKUMEN
G
R L
E 01 02 03 04 05 06
V T
NO EP YANG DIBUTUHKAN
I E A B C D A B C D A B C D E F G H I J K
K A
S R A U S R
K
S U
U I P I U L G S F
I B P D P E K K O
U
I K A
G
L
O
I U
R S M M M R M I B
I U I T P E M K
M U
L I N
Z
A
A
S G
V I K P U E U A I B I D
T S T P E U M I T
E K P U M T T T O
G
I O S
1 5.1.1.1 FC SK PJ UKM + URAIAN TUGAS(ADMEN)

2 5.1.1.2 FC SK PJ UKM + URAIAN TUGAS(ADMEN) 00 √ √

MEMBUAT MATRIX KOMPETENSI PEGAWAI

3 5.1.1.3 (ADMEN)
00

MEMBUAT MATRIX KOMPETENSI PEGAWAI

4 5.1.1.4. (ADMEN)
00

5 5.12.1 SK PJ UKM (MB RISKA) 00

6 5.1.2.2 KAK ORIENTASI 00

7 5.1.2.3 MATRIK HASIL KEGIATAN ORIENTASI 00

DAN LAPORAN HASIL KEGIATAN (WAHYU) 00

LAPORAN HASIL KEGIATAN

8 5.1.2.4 ORIENTASI(WAHYU)
00

9 5.1.3.1 FC KAK

10 5.1.3.2 FC UANF BULAN JAN LINPROG ( BU YENI) 00

FC UANF BULAN JAN LINSEK ( BU INDAH)

11 5.1.3.3 EVALUASI FORM KUISIONER HASIL DI BULAN 00

FEBRUARI (LINSEK) TANG JWB ADMEN 00

12 5.1.4.1 PRA MINILOG 00

 FC BUKU PEMBINAAN DR PJ BERKALA 00

FOTO PERTEMUAN 00

13 5.1.4.2 FC NOTULEN PJ BERISI CATATAN 00

TUJUAN,TAHAPAN,PELAKSANAAN 00

14 5,1,4,3 FC NOTULEN BERISIKAN MATRIX JADWAL 00

PEMBINAAN 00

15 5,1,4.4 SAMA DGN BAB 4.2.2.1 00

FC NOTULEN DST 00

16 5.1.4.5 FOTO FOTO + NOTULEN LINPROG + LINSEK 00

17 5.1.4.6 KHUSUS LOGMIN PROGRAM BLN JANUARI 00

DITAMBAH ANALISA PERAN 00

18 5.1.4.7 FC KEGIATAN HARIAN 00

19 5.15.1 HASIL KEGIATAN DR MANAGEMENT RESIKO 00

YANG MEMBUAT TIM MAGEMENT RESIKO 00

MELIPUTI ADMEN,UKM,UKP 00

20 5.1.5.2 00

21 5.1.5.3 00

22 5.1.5.4 00

23 5.1.5.5 00

24 5.1.5.6 00

25 00
39 00

40 00

41 00

42 00

43 00

44 00

45 00

47 00

48 00

49 00

50 00

51 00

52 00

53 00

54 00

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56 00

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L M
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√ √
 MASTERLIST SK
T
G DISTRIBUSI DOKUMEN
R L
01 02 03 04 05 06
E
A B C D A B C D A B C D E F G H I J K L M
V T K A S R S
NO NO DOKUMEN JUDUL SK A U K U
I E P
U I P
E
I
K
U L G S F R
P D R S M M M K O U I A G O I A
S R T P E K M L K N I L B S U N L
U I V I K P U M
I B S T P
E K P
E
U
U
M
E R U U I I Z A A I G A I
I G T M M T A T I B T O D P N
I O S
T

√ √
1 CONTOH SK PJ UKM 00

2 SK PROMKES 00 05 A.1

3 00

4 00

5 00

6 00

7 00

8 00

9 00

10 00

11 00

12 00

13 00

14 00

15 00

16 00

17 00

18 00

19 00

20 00

21 00

22 00

23 00
 T
G DISTRIBUSI DOKUMEN
R L
01 02 03 04 05 06
E
A B C D A B C D A B C D E F G H I J K L M
V T K A S R S
NO NO DOKUMEN JUDUL SK A U K U
I E P
U I P
E
I
K
U L G S F R
P D R S M M M K O U I A G O I A
S R T P E K M L K N I L B S U N L
U I V I K P U M
I B S T P
E K P
E
U
U
M
E R U U I I Z A A I G A I
I G T M M T A T I B T O D P N
I O S
T
24 00

25 00

26 00

27 00

28 00

29 00

30 00

31 00

32 00

33 00

34 00

35 00

36 00

37 00

38 00

39 00

40 00

41 00

42 00

43 00

44 00

45 00

46 00

47 00

48 00
 T
G DISTRIBUSI DOKUMEN
R L
01 02 03 04 05 06
E
A B C D A B C D A B C D E F G H I J K L M
V T K A S R S
NO NO DOKUMEN JUDUL SK A U K U
I E P
U I P
E
I
K
U L G S F R
P D R S M M M K O U I A G O I A
S R T P E K M L K N I L B S U N L
U I V I K P U M
I B S T P
E K P
E
U
U
M
E R U U I I Z A A I G A I
I G T M M T A T I B T O D P N
I O S
T
49 00

50 00

51 00

52 00

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 T
G DISTRIBUSI DOKUMEN
R L
01 02 03 04 05 06
E
A B C D A B C D A B C D E F G H I J K L M
V T K A S R S
NO NO DOKUMEN JUDUL SK A U K U
I E P
U I P
E
I
K
U L G S F R
P D R S M M M K O U I A G O I A
S R T P E K M L K N I L B S U N L
U I V I K P U M
I B S T P
E K P
E
U
U
M
E R U U I I Z A A I G A I
I G T M M T A T I B T O D P N
I O S
T
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 T
G DISTRIBUSI DOKUMEN
R L
01 02 03 04 05 06
E
A B C D A B C D A B C D E F G H I J K L M
V T K A S R S
NO NO DOKUMEN JUDUL SK A U K U
I E P
U I P
E
I
K
U L G S F R
P D R S M M M K O U I A G O I A
S R T P E K M L K N I L B S U N L
U I V I K P U M
I B S T P
E K P
E
U
U
M
E R U U I I Z A A I G A I
I G T M M T A T I B T O D P N
I O S
T
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 MASTERLIST SOP

T DISTRIBUSI DOKUMEN
G
R L
E 01 02 03 04 05 06
V T
NO NO DOKUMEN JUDUL SOP
I E A B C D A B C D A B C D E F G H I J K L
K A
S R A U S R
K
S U
U I P I U L G S F R
I B P D P E K K O
U
I K A
G
L
O
I U A
R S M M M R M I B
I U I T
V I K
P
P
E
U
M K
M U
L I N
Z
A
A
S G N
T S T P E U E
M
U A I
I
B
T
I D A
E K P U M T T T O P
G
I O S

1
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DARAH

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 PEMERINTAH KOTA PROBOLINGGO
DINAS KESEHATAN
PUSKESMAS KETAPANG
jl. Raya Bromo 1B Ketapang
PROBOLINGGO-67222

No Dokumen : FR-MR-01-03
Revisi : 00
DAFTAR INDUK FORMULIR Tanggal Terbit : 30 Mei 2009
Halaman : 1 dari 5

LAMPIRAN PROSEDUR MUTU

NO NO. FORM NAMA FORM REVISI TANGGAL TERBIT
MR
PENGENDALIAN DOKUMEN
1 FR-MR-01-01 DAFTAR INDUK DAN DISTRIBUSI DOKUMEN TERKENDALI 00 5/30/2009
2 FR-MR-01-02 DAFTAR DISTRIBUSI DOKUMEN TIDAK TERKENDALI 00 5/30/2009
3 FR-MR-01-03 DAFTAR INDUK FORMULIR 00 5/30/2009
4 FR-MR-01-04 DAFTAR INDUK DOKUMEN ACUAN 00 5/30/2009
5 FR-MR-01-05 TINJAUAN DOKUMEN 00 5/30/2009
6 FR-MR-01-06 PERMINTAAN PERUBAHAN DOKUMEN 00 5/30/2009
7 FR-MR-01-07 RIWAYAT PERUBAHAN DOKUMEN 00 5/30/2009
8 FR-MR-01-08 SURAT PERNYATAAN 00 5/30/2009
9 FR-MR-01-09 TANDA TERIMA DISTRIBUSI DOKUMEN TERKENDALI
10 FR-MR-01-10 TANDA TERIMA DISTRIBUSI DOKUMEN REVISI
11 TABEL I : KODE DOKUMEN 00 5/30/2009
12 TABEL II : SISTEM PENOMORAN DOKUMEN 00 5/30/2009
13 TABEL III : KEWENANGAN PENGESAHAN DOKUMEN 00 5/30/2009
14 CONTOH STEMPEL DOKUMEN 00 5/30/2009
15 FR-MR-01-11 RENCANA PROGRAM TAHUNAN SMM 00 1/12/2013
16 FR-MR-01-12 SELF ASSESSMENT CHECKLIST 00 12/12/2012

AUDIT INTERNAL
1. FC-MR-02-01 FLOWCHART AUDIT INTERNAL 00 5/30/2009
2. FR-MR-02-01 PROGRAM AUDIT INTERNAL TAHUNAN 00 5/30/2009
3. FR-MR-02-02 RENCANA PELAKSANAAN AUDIT INTERNAL 00 5/30/2009
4. FR-MR-02-03 LAPORAN KETIDAKSESUAIAN 00 5/30/2009
5. FR-MR-02-04 OBSERVASI 00 5/30/2009
6. FR-MR-02-05 LOG STATUS AUDIT INTERNAL 00 5/30/2009
7. FR-MR-02-06 CONTOH SURAT PERINGATAN 00 5/30/2009
8. FR-MR-02-07 CONTOH SPK 00 5/30/2009

PENGENDALIAN PRODUK TIDAK SESUAI

1. FR-MR-03-01 DAFTAR PRODUK TIDAK SESUAI 00 5/30/2009

TINDAKAN PERBAIKAN DAN PENCEGAHAN

1. FC-MR-04-01 FLOWCHART TINDAKAN PERBAIKAN DAN PENCEGAHAN 00 5/30/2009
2. FR-MR-04-01 FORM PERMINTAAN PERBAIKAN DAN PENCEGAHAN 00 5/30/2009
3. FR-MR-04-02 FORM MONITORING PERBAIKAN DAN PENCEGAHAN 00 5/30/2009
00 5/30/2009
KOMUNIKASI
1. FC-MR-05-01 FLOWCHART RAPAT TINJAUAN MANAJEMEN 00 5/30/2009
2. FR-MR-05-01 CONTOH UNDANGAN RAPAT 00 5/30/2009
3. FR-MR-05-02 DAFTAR HADIR RAPAT 00 5/30/2009
4. FR-MR-05-03 NOTULEN RAPAT 00 5/30/2009
5. FR-MR-05-04 STATUS LOG RAPAT TINJAUAN MANAJEMEN 00 5/30/2009

EVALUASI KEPUASAN PELANGGAN

1. FR-MR-06-01 KUISIONER IKM 00 5/30/2009

PENGENDALIAN ARSIP NON MEDIS

1. FR-MR-07-01 DAFTAR INDUK ARSIP NON MEDIS 00 5/30/2009
2. FR-MR-07-02 DAFTAR ARSIP YANG AKAN DIMUSNAHKAN 00 5/30/2009
3. FR-MR-07-03 BUKU AGENDA SURAT MASUK 00 5/30/2009
4. FR-MR-07-04 LEMBAR DISPOSISI 00 5/30/2009
5. FR-MR-07-05 BUKU AGENDA SURAT KELUAR 00 5/30/2009
 LAMPIRAN PROSEDUR MUTU
NO NO. FORM NAMA FORM REVISI TANGGAL TERBIT
PENGENDALIAN ARSIP MEDIS
1. FR-YANKES-01-01 KARTU REGISTER BEROBAT 00 5/30/2009
2. FR-YANKES-01-02 REKAM MEDIK RAWAT JALAN 00 5/30/2009
3. FR-YANKES-02-03 BUKU REGISTER UGD 00 5/30/2009
4. FR-YANKES-03-04 REKAM MEDIK RAWAT INAP 00 5/30/2009
5. FR-MR-08-01 BON PINJAM CATATAN MEDIK 00 5/30/2009
6. FR-MR-08-02 BUKU PINJAM REKAM MEDIK 00 5/30/2009
7. FR-YANKES-02-01 SURAT PERSETUJUAN TINDAKAN MEDIK 00 5/30/2009

TINJAUAN MANAJEMEN
1. FR-MR-09-01 DAFTAR HADIR RAPAT TINJAUAN MANAJEMEN 00 5/30/2009
2. FR-MR-09-02 NOTULEN RAPAT TINJAUAN MANAJEMEN 00 5/30/2009
3. FR-MR-09-03 PEMANTAUAN PELAKSANAAN HASIL TINJAUAN MANAJEMEN 00 5/30/2009
4. FC-MR-05-01 FLOWCHART ALURPROSEDUR MUTU TINJAUAN MANAJEMEN 00 5/30/2009

BIDANG TU
PM PENGELOLAAN PEGAWAI
1. FR-TU-01-01 SURAT USULAN PENAMBAHAN TENAGA KESEHATAN 00 5/30/2009
2. FR-TU-01-02 BLANKO DP3 00 5/30/2009
3. FR- TU-01-03 SURAT PERMOHONAN CUTI 00 5/30/2009

PM PENDIDIKAN DAN PELATIHAN 00 5/30/2009

1. FR-TU-02-01 FORM EVALUASI PENDIDIKAN DAN PELATIHAN 00 5/30/2009
00 5/30/2009
PM PENGELOLAAN KEBERSIHAN LINGKUNGAN PUSKESMAS
1. FR-TU-03-01 KARTU KENDALI KEBERSIHAN 00 1/2/2013

PM PELENGELOLAAN KEAMANAN PUSKESMAS

1. FR-TU-04-01 SURAT LAPORAN KEHILANGAN 00 5/30/2009
2. FR-TU-04-02 BUKU LAPORAN KEAMANAN 00 5/30/2009

PM PENGELOLAAN LOGISTIK
1. FR-TU-05-01 SURAT BARANG KELUAR 00 5/30/2009
2. FR-TU-05-02 BUKU EKSPEDISI 00 5/30/2009
3. FR-TU-05-03 BUKU PENERIMAAN BARANG 00 5/30/2009
4. FR-TU-05-04 BUKU BARANG INVENTARIS 00 5/30/2009
5. FR-TU-05-05 SURAT PERMINTAAN BARANG 00 5/30/2009
6. FR-TU-05-06 KARTU INVENTARIS RUANG 00 5/30/2009

PEMELIHARAAN DAN PERBAIKAN SARANA

1. FR-TU-06-01 DAFTAR IDUK ALAT 00 5/30/2009
2. FR-TU-06-02 JADWAL PEMELIHARAAN 00 5/30/2009
3. FR-TU-06-03 LAPORAN PEKERJAAN 00 5/30/2009
4. FR-TU-06-04 PENGAJUAN PENGKALIBRASIAN ALAT 00 5/30/2009
5. FR-TU-06-05 DAFTAR ALAT UKUR YANG DIKALIBRASI 00 5/30/2009
6. FR-TU-06-06 FORM LAPORAN KERUSAKAN SARANA PASARANA 00 5/30/2009
7. FR-TU-06-07 FORM PERBAIKAN 00 5/30/2009
8. FR-TU-06-08 LEMBAR KERJA KALIBRASI SPHYGMOMANOMETER 00 5/30/2009
9 FR-TU-06-09 KARTU KENDALI 00 1/2/2014
10 FR-TU-06-10 LAPORAN HASIL PEMELIHARAAN 00 7/11/2014
11 FR-TU-06-11 SURAT PENUGASAN PERBAIKAN SARANA 00 7/11/2014

00
PM PENGELOLAAN KEUANGAN
1. FR-TU-07-01 BUKU SETORAN HARIAN 00 5/30/2009
2. FR-TU-07-02 BUKU REKAPITULASI HARIAN 00 5/30/2009
3. FR-TU-07-03 TANDA BUKTI SETORAN 00 5/30/2009
4. FR-TU-07-04 KAS UMUM 00 5/30/2009

PM PERENCANAAN ANGGARAN
1. FR-TU-08-01 RAK 00 5/30/2009

PM PELAPORAN DAN EVALUASI KEGIATAN

1. FR-TU-09-01 TABEL PENILAIAN P2KPUS 01 2/1/2010

PM TANGGAP DARURAT
1 FR-TU-10-01 FORM INVESTIGASI KEJADIAN DARURAT 00 12/11/2012
2 FR-TU-10-02 FORM EVALUASI EMERGENCY RESPONS 00 12/11/2012
3 FR-TU-10-03 FORM PENGECEKAN APAR 00 12/11/2012
4 FR-TU-10-04 STRUKTUR ORGANISASI 00 12/11/2012
 LAMPIRAN PROSEDUR MUTU
NO NO. FORM NAMA FORM REVISI TANGGAL TERBIT
BIDANG KESGA
KIA-KB
1 FR-KESGA-01-01 LAPORAN PERSALINAN 00 5/30/2009
2 FR-KESGA-01-02 LAPORAN LB3 KIA 00 5/30/2009
3 FR-KESGA-01-03 F2KB 00 5/30/2009
4 FR-KESGA-01-04 PWS KIA 00 5/30/2009
5 FR-KESGA-01-05 BUKU KIA 00 5/30/2009

KRR
1 FR-KESGA-02-01 LAPORAN BULANAN KRR 00 5/30/2009

GIZI
1 FR-KESGA-03-01 FORM REGISTER PSG 00 5/30/2009
2 FR-KESGA-03-02 FORM PENENTUAN UMUR 00 5/30/2009
3 FR-KESGA-03-03 FORM STANDART PATOKAN PENENTUAN STATUS GIZI 00 5/30/2009
4 FR-KESGA-03-04 FORM LAPORAN PSG TK KECAMATAN 00 5/30/2009
5 FR-KESGA-03-05 BUKU KEP 00 5/30/2009
6 FR-KESGA-03-06 FORM LAPORAN KLB GIZI 00 5/30/2009
7 FR-KESGA-03-07 FORM LB2 GIZI 00 5/30/2009
8 FR-KESGA-03-08 FORM F3 GIZI 00 5/30/2009
9 FR-KESGA-03-09 FORM LAPORAN HASIL INTERVENSI 00 5/30/2009
10 FR-KESGA-01-05 BUKU KIA 00 5/30/2009
11 FR-KESGA-03-10 REGISTER TABLET TAMBAH DARAH 00 5/30/2009
12 FR-KESGA-03-11 BUKU SIP 00 5/30/2009
13 FR-KESGA-03-12 FORM LAPORAN VITAMIN A 00 5/30/2009

USILA
1 FR-KESGA-04-01 LAPORAN KEGIATAN KESEHATAN USILA 00 5/30/2009

UKS
1 FR-KESGA-05-01 BUKU REGISTER SCREENING UKS 00 5/30/2009
2 FR-KESGA-05-02 LAPOPRAN BIAS 00 5/30/2009
3 FR-KESGA-05-03 BUKU REGISTER OBAT CACING 00 5/30/2009
4 FR-KESGA-05-04 FORM SCREENING UKS 00 5/30/2009

UKGS
1 FR-KESGA-06-01 FORM RUJUKAN KE PUSKESMAS 00 5/30/2009
2 FR-KESGA-06-02 BUKU KUNJUNGAN SEKOLAH 00 5/30/2009
3 FR-KESGA-06-03 LAPORAN UKGS 00 5/30/2009

PROMKES
1 FR-KESGA-07-01 JADWAL POSYANDU 00 5/30/2009
2 FR-KESGA-07-02 REKAPAN PHBS 00 5/30/2009
3 FR-KESGA-07-03 LAPORAN BULANAN PENYULUHAN 00 5/30/2009
4 FR-KESGA-07-04 LAPORAN PERAN SERTA MASYARAKAT 00 5/30/2009

BIDANG P2 DAN PKL

1 FR-P2PKL-P2-01-01 LAPORAN BULANAN P2 DIARE 00 5/30/2009

1 FR-P2PKL-P2-02-01 LAPORAN BULANAN P2 DBD 00 5/30/2009

1 FR-P2PKL-P2-03-01 LAPORAN BULANAN ISPA PNEUMONIA 00 5/30/2009

2 FR-P2PKL-P2-03-01 LAPORAN CARE SEEKING 00 5/30/2009

1 FR-P2PKL-P2-04-01 REGISTER TB PARU 00 5/30/2009

2 FR-P2PKL-P2-04-02 KARTU MONITORING 00 5/30/2009
3 FR-P2PKL-P2-04-03 KARTU PENDERITA 00 5/30/2009
4 FR-P2PKL-P2-04-04 FORM PERMOHONAN LAB TBC U/ PEMERIKSAAN DAHAK ( TB 05 ) 00 5/30/2009

1 FR-P2PKL-P2-05-01 LAPORAN BULANAN P2 MALARIA 00 5/30/2009

1 FR-P2PKL-P2-06-01 KARTU PENDERITA 00 5/30/2009

2 FR-P2PKL-P2-06-02 FORM PENCEGAHAN CACAT ( POD ) 00 5/30/2009
3 FR-P2PKL-P2-06-03 KARTU REGISTER / MONITORING PENDERITA 00 5/30/2009
4 FR-P2PKL-P2-06-04 FORM EVALUASI PENGOBATAN PREDNISON 00 5/30/2009
5 FR-P2PKL-P2-06-05 LAPORAN BULANAN P2 KUSTA 00 5/30/2009

1 FR-P2PKL-P2-07-01 LAPORAN BULANAN P2 PMS 00 5/30/2009

1 FR-P2PKL-P2-08-01 FORM PENYELIDIKAN EPIDEMIOLOGI PENDERITA 00 5/30/2009

2 FR-P2PKL-P2-08-02 LAPORAN P2 SURVEILENS 00 5/30/2009

1 FR-P2PKL-P2-09-01 BUKU REGISTER PENIMBANGAN 00 5/30/2009

2 FR-P2PKL-P2-09-02 KMS 00 5/30/2009
3 FR-P2PKL-P2-09-03 LAPORAN HASIL IMUNISASI, PEMAKAIAN VAKSIN DAN KIPI 00 5/30/2009

1 FR-P2PKL-P2-10-01 FORMAT LAPORAN PERMINTAAN DAN PENGGUNAAN VAKSIN 00 5/30/2009

2 2FR-P2PKL-P2-10-02 BUKU GRAFIK PENCATATAN SUHU 00 5/30/2009

1 FR-P2PKL-PKL-01-01 BLANKO INSPEKSI SANITASI 00 5/30/2009

2 FR-P2PKL-PKL-01-02 LAPORAN HASIL KEGIATAN KESLING 00 5/30/2009
3 FR-P2PKL-PKL-01-03 KARTU RUMAH 00 5/30/2009
4 FR-P2PKL-PKL-01-04 BLANKO PEMERIKSAAN TP2 00 5/30/2009
 LAMPIRAN PROSEDUR MUTU
NO NO. FORM NAMA FORM REVISI TANGGAL TERBIT
5 FR-P2PKL-PKL-01-05 BLANKO PEMERIKSAAN TPM 00 5/30/2009
6 FR-P2PKL-PKL-01-06 BLANKO PEMERIKSAAN TTU 00 5/30/2009
 LAMPIRAN PROSEDUR MUTU
NO NO. FORM NAMA FORM REVISI TANGGAL TERBIT
BIDANG YANKES
RAWAT JALAN
1. FR-YANKES-01-01 KARTU IDENTITAS BEROBAT 00 5/30/2009
2. FR-YANKES-01-02 REKAM MEDIK 00 5/30/2009
3. FR-YANKES-01-03 KERTAS RESEP OBAT 00 5/30/2009
4. FR-YANKES-01-04 FORM BUKU REGISTER POLI UMUM 00 5/30/2009
5. FR-YANKES-01-05 FORM BUKU REGISTER POLI GIGI/MULUT 00 5/30/2009
6. FR-YANKES-01-06 FORM BUKU REGISTER POLI KIA - KB ( KUNJUNGAN IBU ) 00 5/30/2009
7. FR-YANKES-01-07 FORM BUKU REGISTER POLI KIA - KB ( KUJUNGAN BAYI ) 00 5/30/2009
8. FR-YANKES-01-08 FORM BUKU REGISTER KILINIK SANITASI 00 5/30/2009
9. FR-YANKES-01-09 FORM BUKU REGISTER KLINIK GIZI 00 5/30/2009
10. FR-YANKES-01-10 KARCIS RETRIBUSI 00 5/30/2009
11. FR-YANKES-01-11 FORM RUJUKAN 00 5/30/2009
12. FR-YANKES-01-12 KWITANSI PEMBAYARAN 00 5/30/2009
13 FR-YANKES-01-13 FORM KUNJUNGAN RUMAH 00 12/6/2012
14 FR-YANKES-01-14 FORM RUJUKAN EKSTERNAL RAJAL 00 5/30/2009
FR-YANKES-01-15 KARTU STATUS PX ISPA 00 5/30/2009
FR-YANKES-01-16 KARTU STATUS PX DIARE 00 5/30/2009
FR-YANKES-01-17 KARTU STATUS PX KECACINGAN 00 5/30/2009
FR-YANKES-01-18 KARTU STATUS PX DHF 00 5/30/2009
FR-YANKES-01-19 KARTU STATUS PX KULIT 00 5/30/2009
KARTU STATUS PX MATA
UGD
1. FR-YANKES-02-01 SURAT PERSETUJUAN TINDAKAN MEDIS 00 5/30/2009
2. FR-YANKES-02-02 SURAT KETERANGAN KEMATIAN 00 5/30/2009
3. FR-YANKES-02-03 REGISTER UGD 00 5/30/2009
4. FR-YANKES-02-04 FORM RUJUKAN RAWAT INAP 00 5/30/2009
5. FR-YANKES-02-05 KARTU STATUS PENDERITA UGD 00 5/30/2009
6 FR-YANKES-02-06 LAPORAN PERJALANAN DINAS 00 6/2/2014
7 FR-YANKES-02-07 SURAT PERINTAH TUGAS 00 6/2/2014
8 FR-YANKES-02-08 RUJUKAN PASIEN JAMKESMAS/ JAMKESDA 00 6/2/2014
9 FR-YANKES-02-09 SURAT PEMAKAIAN KENDARAAN DINAS 00 6/2/2014

RAWAT INAP UMUM

1 FR-YANKES-01-11 FORM RUJUKAN 00 5/30/2009
2 FR-YANKES-02-01 SURAT PERSETUJUAN TINDAKAN MEDIS 00 5/30/2009
3 FR-YANKES-03-01 FORMULIR PERSETUJUAN RAWAT INAP 00 5/30/2009
4 FR-YANKES-03-02 BUKU REGISTER RAWAT INAP 01 12/12/2012
5 FR-YANKES-03-03 CATATAN PERAWAT 00 5/30/2009
6 FR-YANKES-03-04 REKAM MEDIK 00 5/30/2009
7 FR-YANKES-01-12 KWITANSI PEMBAYARAN 00 5/30/2009
8 FR-YANKES-03-05 SURAT PENOLAKAN TINDAKAN MEDIS 00 5/30/2009
9 FR-YANKES-03-06 LEMBAR PETUNJUK PASIEN PULANG / KONTROL 00 5/30/2009
10 FR-YANKES-03-07 SURAT PERNYATAAN PULANG PAKSA 00 5/30/2009
11 FR-YANKES-03-08 LEMBAR PERSETUJUAN PENYERAHAN OBAT 00 12/12/2012
12 FR-YANKES-03-09 RENCANA KEPERAWATAN 00 5/30/2009

RAWAT INAP BERSALIN

1. FR-YANKES-03-01 FORMULIR PERSETUJUAN RAWAT INAP 00 5/30/2009
2. FR-YANKES-03-04 REKAM MEDIK 00 5/30/2009
3. FR-YANKES-02-01 SURAT PERSETUJUAN TINDAKAN MEDIS 00 5/30/2009
4. FR-YANKES-01-11 FORM RUJUKAN 00 5/30/2009
5. FR-YANKES-03-06 LEMBAR PETUNJUK PASIEN PULANG / KONTROL 00 5/30/2009
6. FR-YANKES-03-07 SURAT PERNYATAAN PULANG PAKSA 00 5/30/2009
7. FR-YANKES-04-01 BUKU REGISTER KAMAR BERSALIN 00 5/30/2009
8. FR-YANKES-04-02 SURAT KETERANGAN LAHIR 00 5/30/2009
9. FR-YANKES-04-03 BUKU REGISTER PERSALINAN 00 5/30/2009
10 FR-YANKES-05 FORM PERMINTAAN AMBULANS 00 12/12/2012

AMBULANCE
1. FR-YANKES-01-11 FORM RUJUKAN 00 5/30/2009
2. FR-YANKES-01-12 KWITANSI PEMBAYARAN 00 5/30/2009
3 FR-YANKES-05-01 FORM PEMERIKSAAN RUTIN AMBULANS
OBAT
1. FR-YANKES-06-01 REGISTER OBAT 00 5/30/2009
2. FR-YANKES-06-02 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT ( LPLPO ) 00 5/30/2009
3. FR-YANKES-06-03 KARTU STOK OBAT 00 5/30/2009
4. FR-YANKES-06-04 BUKU OBAT KADALUARSA 00 5/30/2009

LABORATORIUM
1. FR-YANKES-07-01 FORM PERMINTAAN PEMERIKSAAN LABORATORIUM 00 5/30/2009
2. FR-YANKES-07-02 BUKU REGISTER LABORATORIUM 00 5/30/2009
3. FR-YANKES-07-03 BLANKO HASIL PEMERIKSAAN LABORATORIUM 00 5/30/2009
4. FR-YANKES-07-04 BUKU SETORAN LABORATORIUM 00 5/30/2009
5. FR-YANKES-01-12 KWITANSI PEMBAYARAN 00 5/30/2009

KESEHATAN JIWA
1. FR-YANKES-08-01 FORM PELAPORAN KASUS JIWA 00 5/30/2009
01 KAPUS 06 UKP

02 TIM AUDIT INTERNAL A LOKET

03 TIM MUTU A. TIM PERENCANAAN B REKAM MEDIK

B. TIM SURVEI DAN
PENANGANAN KELUHAN C UMUM

C. TIM MANAJEMEN RISIKO D GILUT

D. TIM PMKP E KIA

04 TU F SANITASI

A KEPEGAWAIAN G GIZI

B SISTEM INFORMASI H LAB

C KEUANGAN I FARMASI

D RUMAH TANGGA (UMUM DAN SARPRAS) J FISIOTERAPI

K UGD

L RANAP

M BERSALIN

05 UKM

A. ESENSIAL B. PENGEMBANGAN 06 JEJARING

1 PROMKES 1 JIWA

2 UKS 2 UKGM

3 PTM 3 BATRA

4 KB 4 OLAHRAGA

5 KIA 5 INDERA

6 GIZI 6 UKK

7 KESLING 7 LANSIA

8 DBD

9 MALARIA

10 TB PARU

11 KUSTA

12 IMUNISASI

13 HIV/AIDS

14 KECACINGAN

15 DIARE

16 ISPA

17 SURVEILLANCE

18 PHN