Corrective Action Request

Organisation: PUSKESMAS JUATA LAUT

Organisation Representative: Mr. Madenur

Site(s) audited: Jl. Pelijan Rt 09, Juata Laut, Tarakan, Kalimantan Timur
Auditor(s): dr. Ratiningsih Date(s) of audit(s): 12 February 2011

CAR No: 1 of 5 Category: Major Minor

Standards: ISO 9001:2008 Standard Ref.: Clause 7.5.1

Area/Department/Process: Poli KB Document Ref./ Issue no: QM

CAR Close out date: Next visit

Details of Non-Conformity:

Lack of evidence was found that implementation of process external referral patient was properly
conducted, with evidence :
Mrs.L, #MR.0305, installation IUD, with Diagnosis Breast Tumor

Organization Representative: Mr. Madenur Auditor: RN

ACTION PLAN (to eliminate the cause of non-conformity in order to prevent recurrence):

-Membuat kriteria spesifik rujukan external untuk KB dan Kebidanan.

-Melakukan pemantaun rujukan external dengan menambahkan kolom rujukan pada buku register.

Organization Representative: Date:

Acceptance of Corrective Action / Comments (use additional sheets if necessary):

Seen on :
1. Procedure IK-74/PKM-JL/II-07
2. Implementation of process external referral and internal referral patient rev.03
3. Medical record e.g. Mrs.H, #MR.5409, Mrs. M, #MR.420, Diagnosis Hypertension

Auditor: RN Date: 17-9-2011

Response required: Major Minor 

Corrective Action must be addressed within time frame stated. Define Close Out Define Close Out
Verification of action will occur at next visit. Additional follow up
may be required as indicated.

Job n°: ID-1689 Report date: 12 February 2011 Visit Type: REC Visit n°: 1
CONFIDENTIAL Document: GS0401_I Issue n°:3_Rev.2 Page n°: 1 of 3
 Corrective Action Request

Organisation: PUSKESMAS JUATA LAUT

Organisation Representative: Mr. Madenur

Site(s) audited: Jl. Pelijan Rt 09, Juata Laut, Tarakan, Kalimantan Timur
Auditor(s): dr. Ratiningsih Date(s) of audit(s): 12 February 2011

CAR No: 2 of 5 Category: Major Minor

Standards: ISO 9001:2008 Standard Ref.: Clause 7.5.1

Area/Department/Process: Poli Umum & Tindakan Document Ref./ Issue no: QM

CAR Close out date: Next visit

Details of Non-Conformity:

Inadequate evidence was found that process physical examination patient was properly complete, with
example : Mr.H, #MR.0867, Diagnosis Vulnus Laceratum Digiti Manus

Organization Representative: Mr. Madenur Auditor: RN

ACTION PLAN (to eliminate the cause of non-conformity in order to prevent recurrence):

-Membuat frame pemeriksaan fisik lengkap pada pasien ruang tindakan.

-Membuat checklist kelengkapan pemeriksaan fisik pasien gawat darurat Ruang tindakan

Organization Representative: Date:

Acceptance of Corrective Action / Comments (use additional sheets if necessary):

Seen on :
1. Check list record physical examination patient on March until September 2011
2. Physical examination patient in medical record e.g.
- Mr.A, #MR.6290, Diagnosis Ileus unspesific
- Mr.H, #MR.6364, Diagnosis Combutio
- Ms.E, #MR.2039, Diagnosis Vulnus Laceratum

Auditor: RN Date: 17-9-2011

Response required: Major Minor 

Corrective Action must be addressed within time frame stated. Define Close Out Define Close Out
Verification of action will occur at next visit. Additional follow up
may be required as indicated.

Job n°: ID-1689 Report date: 12 February 2011 Visit Type: REC Visit n°: 1
CONFIDENTIAL Document: GS0401_I Issue n°:3_Rev.2 Page n°: 2 of 3
 Corrective Action Request

Organisation: PUSKESMAS JUATA LAUT

Organisation Representative: Mr. Madenur

Site(s) audited: Jl. Pelijan Rt 09, Juata Laut, Tarakan, Kalimantan Timur
Auditor(s): dr. Ratiningsih Date(s) of audit(s): 12 February 2011

CAR No: 3 of 5 Category: Major Minor

Standards: ISO 9001:2008 Standard Ref.: Clause 6.4

Area/Department/Process: Poli Gigi Document Ref./ Issue no: QM

CAR Close out date: Next visit

Details of Non-Conformity:

It was found during audit that implementation of medical waste management was not properly performed,
example : placement of medical waste in non medical place, e.g. masker

Organization Representative: Mr. Madenur Auditor: RN

ACTION PLAN (to eliminate the cause of non-conformity in order to prevent recurrence):
-Melakukan sosialisasi management pengelolaan sampah .
-Memisahkan letak tempat sampah medis dan non medis.

Organization Representative: Date:

Acceptance of Corrective Action / Comments (use additional sheets if necessary):

Seen on :
1. Socialisation date on 7/3/2011
2. Implementation medical waste management in unit Poli Gigi, Poli Tindakan, Poli KB is verified
and accepted.

Auditor: RN Date: 17-9-2011

Response required: Major Minor 

Corrective Action must be addressed within time frame stated. Define Close Out Define Close Out
Verification of action will occur at next visit. Additional follow up
may be required as indicated.

Job n°: ID-1689 Report date: 12 February 2011 Visit Type: REC Visit n°: 1
CONFIDENTIAL Document: GS0401_I Issue n°:3_Rev.2 Page n°: 3 of 3
 Corrective Action Request

Organisation: PUSKESMAS JUATA LAUT

Organisation Representative: Mr. Madenur

Site(s) audited: Jl. Pelijan Rt 09, Juata Laut, Tarakan, Kalimantan Timur
Auditor(s): Widiyanto Date(s) of audit(s): 12 February 2011

CAR No: 4 of 5 Category: Major Minor

Standards: ISO 9001:2008 Standard Ref.: Clause 8.2.3; 8.5.2; 8.5.3

Area/Department/Process: Tata Usaha / Document Ref./ Issue no: QM

Kepegawaian
CAR Close out date: Next visit

Details of Non-Conformity:

Evaluation of unachieved quality objectives was not consistently performed as required. i.e.:
- Unachieved quality objectives kelengkapan report from July-December 2010
- 5 minutes lead time service pelayanan SKD Month October, November 2010

Organization Representative: Mr. Madenur Auditor: WDY

ACTION PLAN (to eliminate the cause of non-conformity in order to prevent recurrence):

-Menetapkan pelaporan hasil pencapaian sasaran mutu tiap bulan pada magament melalui komunikasi
internal (rapat bulanan ).\

Organization Representative: Date:

Acceptance of Corrective Action / Comments (use additional sheets if necessary):

Seen on report and evaluation Quality Objective on February until August 2011 :
5 minutes Respond Time service for pelayanan SKD / Surat Keterangan Dokter

Auditor: RN Date: 17-9-2011

Response required: Major Minor 

Corrective Action must be addressed within time frame stated. Define Close Out Define Close Out
Verification of action will occur at next visit. Additional follow up
may be required as indicated.

Job n°: ID-1689 Report date: 12 February 2011 Visit Type: REC Visit n°: 1
CONFIDENTIAL Document: GS0401_I Issue n°:3_Rev.2 Page n°: 4 of 3
 Corrective Action Request

Organisation: PUSKESMAS JUATA LAUT

Organisation Representative: Mr. Madenur

Site(s) audited: Jl. Pelijan Rt 09, Juata Laut, Tarakan, Kalimantan Timur
Auditor(s): Widiyanto Date(s) of audit(s): 12 February 2011

CAR No: 5 of 5 Category: Major Minor

Standards: ISO 9001:2008 Standard Ref.: Clause 6.3

Area/Department/Process: Maintenance Document Ref./ Issue no: QM

CAR Close out date: Next visit

Details of Non-Conformity:

Maintenance planning program of power generator not always consistently implemented and applied the
PDCA i.e.: 2011 maintenance plan was not identified; maintenance cleaning and spark plug (6 monthly)
periods was not performed and recorded

Organization Representative: Mr. Madenur Auditor: WDY

ACTION PLAN (to eliminate the cause of non-conformity in order to prevent recurrence):

-Membuat kembali rencana preventive maintenance .

-membuat pemantauan pelaksanaan maintenance sesuai dengan jadwal maintenance.

Organization Representative: Date:

Acceptance of Corrective Action / Comments (use additional sheets if necessary):

Seen on planning program and schedule maintenance for :

1. Medical equipment e.g. Dental Unit, Sterilisator, Sphygmomanometer
2. Non medical equipment e.g. Genset, Ambulance, Computer

Auditor: RN Date: 17-9-2011

Response required: Major Minor 

Corrective Action must be addressed within time frame stated. Define Close Out Define Close Out
Verification of action will occur at next visit. Additional follow up
may be required as indicated.

Job n°: ID-1689 Report date: 12 February 2011 Visit Type: REC Visit n°: 1
CONFIDENTIAL Document: GS0401_I Issue n°:3_Rev.2 Page n°: 5 of 3