Form Pelaporan Ke Pihak Berwenang

Uploaded by

PASANEST

0% found this document useful (0 votes)

8 views1 page

Original Title

form pelaporan ke pihak berwenang

Copyright

Available Formats

DOCX, PDF, TXT or read online from Scribd

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Report this Document

Copyright:

Available Formats

Download as DOCX, PDF, TXT or read online from Scribd

Flag for inappropriate content

0% found this document useful (0 votes)

8 views1 page

Form Pelaporan Ke Pihak Berwenang

Uploaded by

PASANEST

Copyright:

Available Formats

Download as DOCX, PDF, TXT or read online from Scribd

Flag for inappropriate content

Jump to Page

You are on page 1of 1

Search inside document

PEMERINTAH KABUPATEN SORONG

RSUD DR. JHON P. WANANE KABUPATEN SORONG

Jl. Sorong Klamono Km.22 Kelurahan Klafma Distrik Aimas Kabupaten
Sorong – Papua Barat e-mail :rsud.kabsorong@gmail.com

FORMULIR LAPORAN INSIDEN DI RUMAH SAKIT

LAPORAN INSIDEN
(INTERVAL)
1. DATA PASIEN
Nama :
No Mr :
Umur :
Jenis Kelamin :
Penanggung Biaya Pasien :
o Pribadi
o BPJS
o Asuransi Swasta
o Perusahaan

Tanggal Masuk RS : Jam :

2. RINCIAN KEJADIAN
1. Tanggal dan Waktu Insiden
Tanggal : Jam :
2. Insiden :
3. Kronologi Insiden
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………

Aimas,
Pelapor

…………………………………….

The Iliad: A New Translation by Caroline Alexander
From Everand
The Iliad: A New Translation by Caroline Alexander
Homer
Rating: 4 out of 5 stars
4/5 (5734)
American Gods: The Tenth Anniversary Edition
From Everand
American Gods: The Tenth Anniversary Edition
Neil Gaiman
Rating: 4 out of 5 stars
4/5 (12954)
The Hobbit
From Everand
The Hobbit
J. R. R. Tolkien
Rating: 4.5 out of 5 stars
4.5/5 (25199)
Art of War: The Definitive Interpretation of Sun Tzu's Classic Book of Strategy
From Everand
Art of War: The Definitive Interpretation of Sun Tzu's Classic Book of Strategy
Stephen F. Kaufman
Rating: 4 out of 5 stars
4/5 (3321)
The Handmaid's Tale
From Everand
The Handmaid's Tale
Margaret Atwood
Rating: 4 out of 5 stars
4/5 (13228)
The Picture of Dorian Gray: Classic Tales Edition
From Everand
The Picture of Dorian Gray: Classic Tales Edition
Oscar Wilde
Rating: 4 out of 5 stars
4/5 (9763)
Life of Pi: A Novel
From Everand
Life of Pi: A Novel
Yann Martel
Rating: 4 out of 5 stars
4/5 (13473)
The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life
From Everand
The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life
Mark Manson
Rating: 4.5 out of 5 stars
4.5/5 (20097)
The Hobbit
From Everand
The Hobbit
J. R. R. Tolkien
Rating: 4.5 out of 5 stars
4.5/5 (25893)
The Odyssey: (The Stephen Mitchell Translation)
From Everand
The Odyssey: (The Stephen Mitchell Translation)
Stephen Mitchell
Rating: 4 out of 5 stars
4/5 (7771)
The Picture of Dorian Gray (The Original 1890 Uncensored Edition + The Expanded and Revised 1891 Edition)
From Everand
The Picture of Dorian Gray (The Original 1890 Uncensored Edition + The Expanded and Revised 1891 Edition)
Oscar Wilde
Rating: 4 out of 5 stars
4/5 (9054)
Pride and Prejudice: Bestsellers and famous Books
From Everand
Pride and Prejudice: Bestsellers and famous Books
Jane Austen
Rating: 4.5 out of 5 stars
4.5/5 (20479)
Wuthering Heights Complete Text with Extras
From Everand
Wuthering Heights Complete Text with Extras
Emily Brontë
Rating: 4 out of 5 stars
4/5 (9955)
The Art of War: A New Translation
From Everand
The Art of War: A New Translation
Sun Tzu
Rating: 4 out of 5 stars
4/5 (3045)
The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life
From Everand
The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life
Mark Manson
Rating: 4 out of 5 stars
4/5 (5813)
Stardust
From Everand
Stardust
Neil Gaiman
Rating: 4 out of 5 stars
4/5 (8157)
The 7 Habits of Highly Effective People Personal Workbook
From Everand
The 7 Habits of Highly Effective People Personal Workbook
Stephen R. Covey
Rating: 4 out of 5 stars
4/5 (2515)
The 7 Habits of Highly Effective People
From Everand
The 7 Habits of Highly Effective People
Stephen R. Covey
Rating: 4 out of 5 stars
4/5 (353)
Never Split the Difference: Negotiating As If Your Life Depended On It
From Everand
Never Split the Difference: Negotiating As If Your Life Depended On It
Chris Voss
Rating: 4.5 out of 5 stars
4.5/5 (3310)
The 7 Habits of Highly Effective People
From Everand
The 7 Habits of Highly Effective People
Stephen R. Covey
Rating: 4 out of 5 stars
4/5 (2571)
How To Win Friends And Influence People
From Everand
How To Win Friends And Influence People
Dale Carnegie
Rating: 4.5 out of 5 stars
4.5/5 (6538)
Wuthering Heights (Seasons Edition -- Winter)
From Everand
Wuthering Heights (Seasons Edition -- Winter)
Emily Brontë
Rating: 4 out of 5 stars
4/5 (9974)
Anna Karenina: Bestsellers and famous Books
From Everand
Anna Karenina: Bestsellers and famous Books
Leo Tolstoy
Rating: 4 out of 5 stars
4/5 (7503)
How to Win Friends and Influence People: Updated For the Next Generation of Leaders
From Everand
How to Win Friends and Influence People: Updated For the Next Generation of Leaders
Dale Carnegie
Rating: 4 out of 5 stars
4/5 (2327)
Oscar Wilde: The Unrepentant Years
From Everand
Oscar Wilde: The Unrepentant Years
Nicholas Frankel
Rating: 4 out of 5 stars
4/5 (10370)
Freakonomics Rev Ed
From Everand
Freakonomics Rev Ed
Steven D. Levitt
Rating: 4 out of 5 stars
4/5 (7866)
Habit 1 Be Proactive: The Habit of Choice
From Everand
Habit 1 Be Proactive: The Habit of Choice
Stephen R. Covey
Rating: 4 out of 5 stars
4/5 (2559)
Habit 3 Put First Things First: The Habit of Integrity and Execution
From Everand
Habit 3 Put First Things First: The Habit of Integrity and Execution
Stephen R. Covey
Rating: 4 out of 5 stars
4/5 (2507)
Habit 6 Synergize: The Habit of Creative Cooperation
From Everand
Habit 6 Synergize: The Habit of Creative Cooperation
Stephen R. Covey
Rating: 4 out of 5 stars
4/5 (2499)