PEDOMAN TATA NASKAH

AKREDITASI UPTD
PUSKESMAS
PADA DINAS KESEHATAN KABUPATEN ASAHAN

Nomor : .........................................................

DINAS KESEHATAN KABUPATEN ASAHAN

TAHUN 2018
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DAFTAR ISI

PEDOMAN TATA NASKAH AKREDITASI UPTD PUSKESMAS PADA DINAS KESEHATAN

KABUPATEN ASAHAN

BAB I PENDAHULUAN ............................................................................................... 1

A. Latar Belakang .................................................................................................. 1
B. Maksud dan Tujuan .......................................................................................... 1
C. Sasaran .............................................................................................................. 1
D. Dasar Hukum ................................................................................................... 2
BAB II DOKUMEN AKREDITASI UPTD PUSKESMAS ............................................... 3
A. Jenis Dokumen berdasarkan Sumber ............................................................. 3
B. Jenis Dokumen Akreditasi ............................................................................. 3
C. Jenis Dokumen Yang Perlu Disesiakan .......................................................... 4
1. Penyelenggaraan manajemen UPTD Puskesmas ...................................... 4
2. Penyelenggaraan Upaya Kesehatan Masyarakat (UKM) .......................... 4
3. Penyelenggaraan Upaya Kesehatan Perorangan (UKP) ........................... 4
BAB III PENYUSUNAN DOKUMEN AKREDITASI ...................................................... 5
A. Tata Naskah ..................................................................................................... 5
1. Pengertian .................................................................................................. 5
2. Asas Naskah Dinas .................................................................................... 6
3. Prinsip Naskah Dinas ................................................................................ 6
4. Penyelenggaraan Naskah Dinas ................................................................ 6
5. Kecepatan Proses Surat ............................................................................. 6
6. Kepala Naskah ........................................................................................... 7
Contoh format kepala naskah yaitu kop surat keputusan Kepala UPTD
Puskesmas beserta cara pembuatan isinya, susunannya. .......................... 7
7. Metode Penomoran .................................................................................... 8
8. Penulisan .................................................................................................... 8
B. Kebijakan ......................................................................................................... 9
Contoh Format Surat Keputusan ................................................................ 11
Contoh Format Lampiran Keputusan ........................................................ 12
C. Pedoman (Manual) Mutu ................................................................................ 13
D. Rencana Lima Tahunan Puskesmas ................................................................ 13
1. Sistematika Rencana Kinerja Lima Tahunan Puskesmas (Rencana
Strategi 14
Bisnis) ..........................................................................................................
2. Langkah-langkah Penyusunan Rencana Kinerja Lima Tahunan Puskesmas.. 15
3. Matriks Rencana Kinerja Lima Tahunan..............................................................15
4. Penutup....................................................................................................................... 16
E. Perencanaan Tingkat Puskesmas (PTP) Tahunan......................................................16
1. Mekanisme Perencanaan Tingkat Puskesmas.......................................................16
2. Tahap Penyusunan Perencanaan Tingkat Puskesmas (PTP)................................17
3. Tahap penyusunan RUK............................................................................................17
4. Penyusunan Rencana Pelaksanaan Kegiatan..........................................................18
5. Sistematika Penulisan Perencanaan Tingkat Puskesmas (PTP)...........................18
F. Pedoman / Panduan........................................................................................................... 19
a. Format Pedoman Pengorganisasian Unit Kerja...............................................20
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G. Penyusunan Kerangka Acuan Program / Kegiatan......................................................23

H. Standar Operasional Prosedur (SOP) ............................................................. 24
Format SOP................................................................................................................ 26
I. Rekam Implementasi......................................................................................................30
J. Naskah Dinas Penugasan................................................................................................30
1. Instruksi..................................................................................................... 30
Contoh Format Instruksi......................................................................................32
2. Surat Perintah Tugas..................................................................................................32
Contoh Format Surat Perintah Tugas (A)..........................................................34
Contoh Format Surat Perintah Tugas (B)..........................................................35
K. Naskah Dinas Khusus..................................................................................................... 35
1. Surat Perjanjian.......................................................................................................... 35
Contoh Fomat Perjanjian Antar Instansi Dalam Negeri................................36
2. Surat Kuasa / Pendelegasian Wewenang................................................................38
Contoh Format Surat Kuasa / Pendelegasian Wewenang............................39
3. Berita Acara................................................................................................................ 40
Contoh Format Berita Acara .............................................................. 41
4. Surat Keterangan ...................................................................................... 42
Contoh Format Surat Keterangan.....................................................................43
5. Surat Pengantar.......................................................................................................... 43
Contoh Format Surat Keterangan ...................................................... 45
6. Pengumuman............................................................................................................. 45
Contoh Format Pengumuman..........................................................................47
7. Laporan........................................................................................................................ 47
Contoh Format Laporan....................................................................................48
8. Telaahan Staf.............................................................................................................. 49
Contoh Format Telaahan Staf...........................................................................50
9. Notulen........................................................................................................................ 51
Contoh Format Notulen....................................................................................52
10. Formulir...................................................................................................................... 52
11. Naskah Dinas Elektronik..........................................................................................52

BAB IV PENUTUP................................................................................................................................. 53

DAFTAR PUSTAKA.................................................................................................................................. 54
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PEDOMAN TATA NASKAH

AKREDITASI UPTD PUSKESMAS
PADA DINAS KESEHATAN KABUPATEN ASAHAN

BAB I
PENDAHULUAN

A. LATAR BELAKANG
Salah satu unsur penting dan sangat vital yang menentukan keberhasilan Akreditasi UPTD
Puskesmas adalah bagaimana mengatursistem pendokumentasian dokumen.
Pengaturan sistem dokumentasi dalam satu proses implementasi akreditasi UPTD Puskesmas
dianggap penting karena dokumen merupakan acuan kerja, bukti pelaksanaan dan penerapan
kebijakan, program dan kegiatan, serta bagian dari salah satu persyaratan Akreditasi.
Dengan adanya sistem dokumentasi yang baik dalam suatu institusi/organisasi diharapkan
fungsi-fungsi setiap personil maupun bagian-bagian dari organisasi dapat berjalan sesuai dengan
perencanaanbersama dalam upaya mewujudkan kinerja yang optimal.
Dokumen yang dimaksud dalam Akreditasi secara garisbesar dibagi atas dua bagian yaitu
dokumen internal dan dokumeneksternal. Dokumen tersebut digunakan untuk membangun dan
membakukan sistem manajemen mutu dan sistem manajemen pelayanan. Dokumen internal
tersebut berupa Kebijakan, Pedoman/Panduan, Standar operasional prosedur (SOP) dan dokumen
lain disusun berdasarkan peraturan perundangan dan pedoman-pedoman (regulasi) eksternal yang
berlaku.
Agar para pemangku kepentingan Akreditasi UPTD Puskesmas memilikiacuan dan
memudahkan dalam melakukan dokumentasi perlu disusun Pedoman Penyusunan Dokumen
Akreditasi UPTD Puskesmas Kabupaten Asahan.

B. MAKSUD DAN TUJUAN

1. Maksud
Pedoman ini dimaksudkan agar semua pemangku kepentingan memiliki acuan dalam
melakukan standarisasi tata naskah seluruh dokumen terkait akreditasi UPTD Puskesmas .
2. Tujuan
a. Tersedianya pedoman bagi Kepala, Penanggungjawab dan Pelaksana upaya kesehatan di
UPTD Puskesmas dalam menyusun dokumen-dokumen yang dipersyaratkan dalam standar
akreditasi,
b. Tersedianya Pedoman bagi pendamping akreditasi di Dinas Kesehatan Kabupaten Asahan
untuk melakukan pendampingan pada UPTD Puskesmas .
c. Tersedianya pedoman bagi Surveior dalam melakukanpenilaian Akreditasi UPTD Puskesmas
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D. DASAR HUKUM
1. Undang-Undang Republik Indonesia Nomor 29 Tahun 2004 tentang Praktik Kedokteran,
Lembaran Negara Republik Indonesia Tahun 2004 Nomor 116;
2. Undang-Undang Republik Indonesia Nomor 36 Tahun2009 tentang Kesehatan, Lembaran
Negara RepublikIndonesia Tahun 2009 Nomor 144;
3. Undang-Undang Republik Indonesia Nomor 25 Tahun2009 tetang Pelayanan Publik,
Lembaran NegaraRepublik Indonesia Tahun 2009 Nomor 112;
4. Undang-Undang Republik Indonesia Nomor 36 Tahun2009 tentang Tenaga Kesehatan;
5. Undang-Undang Republik Indonesia Nomor 23 Tahun2014 tentang Pemerintahan Daerah;
6. Peraturan Presiden Republik Indonesia Nomor 72Tahun 2012 tentang Sistem Kesehatan
Nasional;
7. Permenkes 1538 tahun 2011 tentang Pedoman Tata Naskah Dinas Kementrian Kesehatan;
8. Peraturan Menteri PAN dan RB Nomor 35 tahun 2012 tentang Pedoman Penyusunan
Standar Operasional Prosedur Administrasi Pemerintahan;
9. Peraturan Menteri Pendayagunaan Aparatur Negara dan Reformasi Birokrasi Republik
Indonesia Nomor 80 Tahun 2012 tentang Pedoman Tata Naskah Dinas Instansi Pemerintah
10. Peraturan Menteri Kesehatan Nomor 71 tahun 2013tentang Pelayanan Kesehatan pada
Jaminan KesehatanNasional;
11. Peraturan Menteri Kesehatan Nomor 9 tahun 2014 tentang Klinik;
12. Peraturan Menteri Kesehatan Nomor 75 tahun 2014 tentang Puskesmas;
13. Keputusan Menteri Kesehatan Nomor 59 tahun 2015 tentang Komisi Akreditasi FKTP;
14. Peraturan Menteri Kesehatan Nomor 46 tahun 2015 tentang Akreditasi Puskesmas,
Klinik Pratama,Tempat Praktik Mandiri Dokter, Dan Tempat Praktik Mandiri Dokter
Gigi;
15. Peraturan Menteri Dalam Negeri Republik Indonesia Nomor 78 Tahun 2012 tentang Tata
Kearsipan di Lingkungan Kementerian Dalam Negeri dan Pemerintah Daerah;
16. Peraturan Menteri Kesehatan Republik Indonesia, Nomor 14 tahun 2017 tentang Tata
Naskah Dinas di Lingkungan Kementerian Kesehatan
17. Peraturan Bupati Asahan Nomor 34 Tahun 2015 tentang Perubahan atas peraturan Bupati
Asahan Nomor 13 Tahun 2014 tentang Pembentukan Unit Pelaksana Teknis Dinas
Kesehatan Kabupaten Asahan;
18. Keputusan Kepala Dinas Kesehatan Kabupaten Asahan Nomor : ..........................................
tentang Pelimpahan wewenang kepada Kepala Puskesmas sebagai Penandatanganan Surat
Keputusan Kepala UPTD Puskesmas Se-Kabupaten Asahan;
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BAB II
DOKUMENTASI AKREDITASI UPTD PUSKESMAS

A. JENIS DOKUMEN BERDASARKAN SUMBER

1. Dokumen Internal
Sistem manajemen mutu, sistem penyelenggaraanpelayanan upaya kesehatan perorangan dan
sistem penyelenggaraan upaya kesehatan masyarakat yang berupa dokumen seperti surat
keputusan, pedoman/panduan, SOP (Standar Operasional Prosedur) serta Kerangka Acuan
Program maupun Kerangka Acuan Kegiatan perlu dibakukan berdasarkan sebagai dokumen
internalyang ditetapkan oleh Kepala UPTD Puskesmas . Dokumen internal tersebut disusun dan
ditetapkan dalam bentuk dokumen yang harus disediakan oleh UPTD Puskesmas untuk
memenuhi standar akreditasi.
2. Dokumen Eksternal
Dokumen eksternal yang berupa peraturan perundangan danpedoman-pedoman yang
diberlakukan oleh Kementerian Kesehatan, Pemerintah KabupatenAsahan, Dinas Kesehatan
Provinsi Sumatera Utara, Dinas Kesehatan Kabupaten Asahandan organisasi profesi, yang
merupakan acuan bagi UPTD Puskesmas dalam menyelenggarakan administrasi manajemen
dan upaya kesehatan perorangan serta khusus bagi Puskesmas untuk penyelenggaraan upaya
kesehatan masyarakat.
Dokumen-dokumen eksternal sebaiknya ada di Puskesmas tersebut, sebagai dokumen yang
dikendalikan, meskipundokumen eksternal tersebut tidak merupakan persyaratan dalam
penilaian akreditasi.

B. JENIS DOKUMEN AKREDITASI

1. Dokumen Induk
Dokumen asli dan telah disahkan oleh Kepala UPTD Puskesmas .
2. Dokumen terkendali
Dokumen yang didistribusikan kepada sekretariat/ tiapunit/ pelaksana, terdaftar dalam Daftar
Distribusi Dokumen Terkendali dan menjadi acuan dalam melaksanakan pekerjaan serta dapat
ditarik bila ada perubahan (revisi).
Dokumen ini harus ada tanda/stempel “TERKENDALI”.
3. Dokumen tidak terkendali
Dokumen yang didistribusikan untuk kebutuhan eksternalatau atas permintaan pihak di luar
UPTD Puskesmas digunakan untuk keperluan insidentil, tidak dapat digunakan sebagai
acuandalam melaksanakan pekerjaan dan memiliki tanda/stempel “TIDAK TERKENDALI”.
Yang berhak mengeluarkan dokumen ini adalah Tim Mutu dan tercatat pada Daftar Distribusi
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4. Dokumen Kadaluwarsa
Dokumen yang dinyatakan sudah tidak berlaku oleh karenatelah mengalami perubahan/revisi
sehingga tidak dapat lagimenjadi acuan dalam melaksanakan pekerjaan.
Dokumen ini harus ada tanda/stempel “KADALUWARSA”. Dokumeninduk diidentifikasi dan
dokumen sisanya dimusnahkan.

C. JENIS DOKUMEN YANG PERLU DISEDIAKAN

Dokumen-dokumen yang perlu disediakan di UPTD Puskesmas adalahsebagai berikut:
1. Penyelenggaraan manajemen UPTD Puskesmas :
a. Kebijakan Kepala UPTD Puskesmas ,
b. Pedoman (Manual)Mutu,
c. Pedoman/panduan teknis yang terkait denganmanajemen,
d. Standar Operasional Prosedur (SOP),
e. Perencanaan Tingkat Puskesmas (PTP)UPTD Puskesmas ,
f. Kerangka Acuan Kegiatan.

2. Penyelenggaraan Upaya Kesehatan Masyarakat (UKM):

a. Kebijakan Kepala UPTD Puskesmas ,
b. Pedoman untuk masing-masing UKM (esensial maupun pengembangan),
c. Standar Operasional Prosedur (SOP),
d. Rencana Tahunan untuk masing-masing UKM,
e. Kerangka Acuan Kegiatan pada tiap-tiap UKM.

3. Penyelenggaraan Upaya Kesehatan Perorangan (UKP)

a. Kebijakan tentang Pelayanan Klinis,
b. Pedoman Pelayanan Klinis,
c. Standar Operasional Prosedur (SOP) klinis,
d. Kerangka Acuan terkait dengan Program/KegiatanPelayanan Klinis dan Peningkatan
Mutu dan Keselamatan Pasien.

Sebagai bukti pelaksanaan kegiatan dan pelayanan, UPTD Puskesmas perlu menyiapkan rekam
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BAB III
PENYUSUNAN DOKUMEN AKREDITASI

A. TATA NASKAH
Untuk ketentuan tata naskah UPTD Puskesmas memberlakukan terhadap semua dokumen
yang akan disusun dalam akreditasi dengan mengacu pada Peraturan Menteri Dalam Negeri
Republik Indonesia Nomor 78 Tahun 2012 tentang Tata Kearsipan di Lingkungan Kementerian
Dalam Negeri dan Pemerintah Daerah; Pedoman penyusunan Dokumen akreditasi FKTP Direktorat
Jenderal Bina Upaya Kesehatan Direktorat Bina Upaya Kesehatan Dasar Tahun 2015; Keputusan
Kepala Dinas Kesehatan Kabupaten Asahan Nomor :/DINKES-AS/2016 tentang Pelimpahan
wewenang kepada Kepala Puskesmas sebagai Penandatanganan Surat Keputusan yang berkaitan
dengan Akreditasi Puskesmas Se-Kabupaten Asahan;
Adapun ketentuan yang dipergunakan oleh UPTD Puskesmas adalah sebagai berikut :
1. Pengertian
a. Tata Naskah dinas adalah pengelolaan informasi tertulis yang meliputi pengaturan jenis,
format, penyiapan, pengamanan, pengabsahan, distribusi dan penyimpanan naskah dinas
serta media yang digunakan dalam komunikasi kedinasan.
b. Naskah Dinas adalah Informasi tertulis sebagai alat komunikasi kedinasan yang dibuat dan
atau dikeluarkan oleh pejabat yang berwenang di UPTD Puskesmas .
c. Format adalah naskah dinas yang menggambarkan tata letak dan redaksional, serta
penggunaan lambang/logo dan cap dinas.
d. Stempel/cap dinas adalah tanda identitas dari suatu jabatan
e. Kop naskah dinas adalah kop surat yang menunjukan nama .
f. Kewenangan adalah kekuasaan yang melekat pada suatu jabatan.
g. Delegasi adalah pelimpahan wewenang dan tanggung jawab dari pejabat ke pejabat atau
pejabat dibawahnya.
h. Mandat adalah pelimpahan wewenang yang diberikan oleh atasan kepada bawahan untuk
melakukan suatu tugas tertentu atas nama yang memberi mandat.
i. Penandatanganan naskah dinas adalah hak, kewajiban dan tanggungjawab yang ada pada
seorang pejabat untuk menandatangani naskah dinas sesuai dengan tugas dan kewenangan
pada jabatannya.
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o. Surat perintah tugas adalah naskah dinas dari atasan yang ditujukan kepada bawahan yang
berisi perintah untuk melaksanakan pekerjaan sesuai tugas dan fungsinya.
p. Surat perintah perjalanan dinas adalah naskah dinas dari pejabat yang berwenang kepada
bawahan atau pejabat tertentu untuk melaksanakan perjalanan dinas.
q. Surat undangan adalah naskah dinas dari pejabat yang berwenang berisi undangan kepada
pejabat/pegawai yang tersebut pada alamat tujuan untuk menghadiri suatu acara kedinasan.
r. Nota dinas adalah naskah dinas yang bersifat internal berisi komunikasi kedinasan antar
pejabat atau dari atasan kepada bawahan dan dari bawahan kepada atasan.
s. Lembar disposisi adalah naskah dinas dari pejabat yang berwenang berisi petunjuk tertulis
kepada bawahan.
t. Surat pengantar adalah naskah dinas berisi jenis dan jumlah barang yang berfungsi sebagai
tanda terima.
u. Notulen adalah naskah dinas dari pejabat yang berwenang berisi catatan tertentu.
v. Daftar hadir adalah naskah dinas dari pejabat berwenang yang berisi keterangan atas
kehadiran seseorang.

2. Asas Naskah Dinas, terdiri atas :

a. Asas efisien dan efektif,
b. Asas pembakuan,
c. Asas akuntabilitas,
d. Asas keterkaitan,
e. Asas kecepatan dan ketepatan,
f. Asas keamanan.

3. Prinsip Naskah Dinas, terdiri dari :

a. ketelitian,
b. kejelasan,
c. singkat dan padat,
d. logis dan meyakinkan.

4. Penyelenggaraan naskah dinas :

a. Pengelolaan surat masuk dan keluar,
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d. Biasa (batas waktu maksmum 5 hari kerja setelah surat diterima).

6. Format Kepala Naskah

Format kepala naskah diperuntukkan terhadap dokumen surat keputusan saja, sedangkan
format kepala naskah Standar Operasional Prosedur (SOP) mengikuti aturan pedoman
penyusunan akreditasi UPTD Puskesmas .

CONTOH FORMAT KEPALA NASKAH YAITU KOP SURAT KEPUTUSAN KEPALA

UPTD PUSKESMAS BESERTA CARA PEMBUATAN ISINYA, SUSUNANNYA.

2,5 cm 3 cm
1,5 cm

PEMERINTAH KABUPATEN ASAHAN

DINAS KESEHATAN
3 cm
UPTD PUSKESMAS OPHA PADANG MAHONDANG 3 cm
KECAMATAN ...........................................
Jl. ........................................................ Kode Pos ......................
Hotline : ............................................. email : ......................
1,5 cm 1,5 cm

Keterangan :
1) Lambang Pemerintah Kabupaten Asahan (Rambate Rata Raya) diiletakan
di sebelah kiri dan logo Puskesmas di sebelah kanan.
2) Tulisan PEMERINTAH KABUPATEN ASAHAN ditulis pada baris
pertama, tulisan DINAS KESEHATAN ditulis pada baris kedua
menggunakan huruf Times New Roman ukuran 12 pt tebal, tulisan UPTD
PUSKESMAS......... menggunakan huruf Times New Roman ukuran 13 pt
tebal dan tulisan KECAMATAN....... menggunakan huruf Times New
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7. Metode Penomoran
a. Metode penomoran dokumen akreditasi Puskesmas dibuat terpisah dari surat menyurat
umum dengan tata aturan
b. ditetapkan sebagai berikut :
a) Dokumen Kebijakan / Keputusan
Sebagai contoh : 440/00/AB/AKR/KEP/II/YYYY
Keterangan :
440 : Menyatakan klasifikasi Surat Puskesmas
00 : Menyatakan nomor urut penyusunan
surat
AB : Menyatakan Air Batu (sesuaikan dengan inisial Puskesmas)
AKR : Menyatakan Akreditas
KEP : Menyatakan sebagai dokumen Surat Keputusan
I - IX : Menyatakan sebagai BAB
YYYY : Menyatakan tahun pembuatan SK

b) Dokumen Standar Operasional Prosedur (SOP)

Sebagai contoh : 440/00/AL/AKR/SOP/II/YYYY
Keterangan :
440 : Menyatakan klasifikasi surat Puskesmas
00 : Menyatakan nomor urut Penyusunan
Surat
AB : Menyatakan Air Batu (sesuaikan dengan inisial Puskesmas)
AKR : Menyatakan
Akreditas SOP : Menyatakan
SOP
I - IX : Menyatakan
BAB YYYY : Menyatakan
Tahun
8) Penulisan
a. Memakai kertas dengan menggunakan ukuran F4 (21,5cm x 33cm) dengan penulisan
SK menggunakan margin atas 1,5 cm, margin kiri 2cm, margin kanan 2cm dan
margin bawah 2cm.
b. Penulisan SOP menggunakan margin atas 1,5 cm, margin kiri 2 cm, margin kanan 2 cm
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B. KEBIJAKAN
Kebijakan adalah Peraturan/ Surat Keputusan yang ditetapkan oleh Kepala UPTD
Puskesmas yang merupakan garis besar yang bersifat mengikat dan wajib dilaksanakan oleh
penanggung jawab maupun pelaksana. Berdasarkan kebijakan tersebut, disusunpedoman/ panduan
dan standar operasional prosedur (SOP) yang memberikan kejelasan langkah-langkah dalam
pelaksanaan kegiatan di UPTD Puskesmas .
Penyusunan Peraturan/Surat Keputusan tersebut harus didasarkan pada peraturan perundangan, baik
Undang-undang, Peraturan Pemerintah, Peraturan Presiden, Peraturan Daerah, Peraturan Kepala
Daerah, Peraturan Menteri dan pedoman- pedoman teknis yang berlaku seperti yang ditetapkan oleh
Kementerian Kesehatan, Kementerian Dalam Negeri, Dinas Kesehatan Provinsi, dan Dinas
Kesehatan Kabupaten.
Peraturan/ Surat Keputusan Kepala UPTD Puskesmas dapat dituangkan dalam lampiran dari
peraturan/ keputusan tersebut.

Format Surat Keputusan disesuaikan dengan Peraturan Daerah yang berlaku atau dapat disusun
sebagai berikut:
1. Pembukaan ditulis dengan huruf kapital:
a. Kebijakan : Keputusan Kepala UPTD Puskesmas
b. Nomor : ditulis sesuai sistem penomoran di FKTP,
c. Judul : ditulis judul Peraturan/Keputusan tentang
d. Dengan Rahmat Tuhan Yang Maha Esa
e. Jabatan pembuat keputusan ditulis simetris, diletakkan di tengah margin.

2. Konsideran, meliputi :
a. Menimbang:
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3. Diktum:
a. Diktum “MEMUTUSKAN” ditulis simetris di tengah,seluruhnya dengan huruf kapital;
b. Diktum Menetapkan dicantumkan setelah katamemutuskan sejajar dengan kata menimbang
dan mengingat, huruf awal kata menetapkan ditulis dengan huruf kapital, dan diakhiri
dengan tanda baca titik dua ( : );
c. Nama keputusan sesuai dengan judul keputusan(kepala), seluruhnya ditulis dengan huruf
kapital dan diakhiri dengan tanda baca titik ( . ).

4. Batang Tubuh.
a. Batang tubuh memuat semua substansi Peraturan/Surat Keputusan yang dirumuskan dalam
diktum-diktum,
b. Dicantumkan saat berlakunya Peraturan/SuratKeputusan, perubahan, pembatalan,
pencabutanketentuan, dan peraturan lainnya, dan
c. Materi kebijakan dapat dibuat sebagai lampiranPeraturan/ Surat Keputusan, dan pada
halaman terakhir ditandatangani oleh pejabat yang menetapkanPeraturan/Surat Keputusan.

5. Kaki :
Kaki Peraturan/Surat Keputusan merupakan bagian akhirsubstansi yang memuat penanda
tangan penerapan Peraturan/Surat Keputusan, pengundangan peraturan/keputusan yang terdiri
dari:
a. tempat dan tanggal penetapan,
b. nama jabatan diakhiri dengan tanda koma (,),
c. tanda tangan pejabat, dan
d. nama lengkap pejabat yang menanda tangani.
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CONTOH FORMAT SURAT KEPUTUSAN

PEMERINTAH KABUPATEN ASAHAN

DINAS KESEHATAN
Menetapkan :
UPTD PUSKESMAS ............................................... KEPUTUSAN
KECAMATAN ........................................... KEPALA UPTD
Jl. ........................................................ Kode Pos ...................... PUSKESMAS …………
TENTANG….….....
Hotline : ............................................. email : ......................

KEPUTUSAN

KEPALA UPTD PUSKESMAS ........................................

NOMOR : ....../....../AB/AKR/KEP/II/YYYY

TENTANG
………………………………………………………….

DENGAN RAHMAT TUHAN YANG MAHA ESA

KEPALA UPTD PUSKESMAS.......................................,

Menimbang : a. bahwa ………………..............................................................…..…................

….................................................................................................................................
;
b. bahwa ………………..............................................................…..…................
….................................................................................................................................
;

Mengingat : 1. ……………………………………………………….………………………….
2. ……………………………………………………….…………………………;

MEMUTUSKAN:
Logo Instansi dan Nama Instansi yang telah dicetak

Penomoran mengacu pada Pola Klasifikasi Arsip

Judul Keputusan ditulis dengan huruf kapital

Memuat alasan tentang perlu ditetapkan Keputusan

Memuat Ketentuan perundang-undangan yang menjadi dasar ditetapkannya Peraturan

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CONTOH FORMAT LAMPIRAN KEPUTUSAN

Huruf pertama
setiap Kata Judul
Lampiran
Keputusan ditulis
dengan huruf
Lampiran : Keputusan .......................................... Kapital

...........................................................
Nomor : ........................................................ Penomoran
mengacu pada
Tanggal : .......................................................
Pola Klasifikasi
Arsip
(isi lampiran menyesuaikan kebutuhan berdasarkan uraian maksud dari Surat Keputusan, baik
dalam bentuk narasi maupun dalam bentuk uraian tabel..)

CONTOH I :
URAIAN POKOK DAN FUNGSI TIM MANAJEMEN MUTU
UPTD PUSKESMAS .......................................

KETUA
1. TugasPokok : ...........................................................................................
2. Fungsi : ...........................................................................................
3. Uraian Tugas : a. ........................................................................................
b. ........................................................................................
dst ...

CONTOH II :
JADWAL DAN JENIS PELAYANAN UPAYA KESEHATAN PERORANGAN
DI UPTD PUSKESMAS ............................................
Memuat
subtansi tentang
JADWAL LAYANAN UKP isi kebijakan
yang ditetapkan

Waktu
No Jenis Layanan Ket.
Hari Jam
 Senin – Kamis 08.00 – 12.30
1. Pendaftaran Jumat 08.00 – 10.30
Sabtu 08.00 – 12.30
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C. PEDOMAN (MANUAL) MUTU

Pedoman (Manual) mutu adalah dokumen yang memberi informasi yangkonsisten ke dalam
maupun ke luar tentang sistem manajemenmutu. Pedoman (Manual)Mutu disusun, ditetapkan dan
dipelihara olehorganisasi. Pedoman (Manual) Mutu tersebut meliputi :

Kata Pengantar
BAB I. Pendahuluan
A. Latar belakang
1. Gambaran Umum UPTD Puskesmas
2. Visi UPTD Puskesmas
3. Misi UPTD Pukesmas AekLoba
4. Struktur UPTD Puskesmas
5. Motto UPTD Puskesmas
6. Tata NIlai UPTD Puskesmas
B. Tujuan
C. Pengertian / Istilah
D. Ruang Lingkup
E. Landasan Hukum
F. Kebijakan
BAB II. PENGORGANISASIAN
A. Struktur Tim Mutu
B. Uraian Tugas Tim Mutu
a. Ketua Tim Manajemen Mutu
b. Sekretaris Manajemen Mutu
c. Auditor Internal
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Rencana lima tahunan tersebut harus sesuai dengan visi, misi,tugas pokok dan fungsi Puskesmas
bedasarkan pada analisiskebutuhan masyarakat akan pelayanan kesehatan sebagai upaya untuk
meningkatkan derajat kesehatan masyarakat secara optimal.
Dalam menyusun rencana lima tahunan, Kepala Puskesmas bersama seluruh jajaran karyawan yang
bertugas di Puskesmas melakukan analisis situasi yang meliputi analisis pencapaian kinerja,
mencari faktor-faktor yang menjadi pendorong maupun penghambat kinerja, sehingga dapat
menyusun program kerja lima tahunan yang dijabatkan dalam kegiatan dan rencana anggaran.

1. Sistematika Rencana Kinerja Lima Tahunan Puskesmas (Rencana Strategi Bisnis)

Sistematika Rencana Kinerja Lima Tahunan Puskesmas dapat disusun dengan sistematika
sebagai berikut:
Kata Pengantar
BAB I. Pendahuluan
A. Keadaan Umum Puskesmas
B. Tujuan penyusunan rencana lima tahunan
BAB II. Kendala dan Masalah
A. Identifikasi keadaan dan masalah
a. Tim mempelajari kebijakan, RPJMN, rencanastrategis Kementerian Kesehatan,
DinasKesehatan Provinsi/Kabupaten/Kota, target kinerja lima tahunan yang
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BAB III.Indikator dan standar kinerja untuk tiap jenis pelayanan dan upaya Puskesmas
BAB IV. Analisis Kinerja
A. Pencapaian Kinerja untuk tiap jenis pelayanan dan upaya Puskesmas
B. Analisis Kinerja: menganalisis faktor pendukung dan penghambat pencapaian
kinerja
BAB V. Rencana Pencapaian Kinerja Lima Tahun
A. Program Kerja dan kegiatan: berisi program-programkerja yang akan dilakukan
yang meliputi antara lain:
1) Program Kerja Pengembangan SDM,yang dijabarkan dalam kegiatan-
kegiatan,misalnya: pelatihan, pengusulan penambahan SDM, seminar,
workshop, dsb.
2) Program Kerja Pengembangan sarana,yang dijabarkan dalam kegiatan-
kegiatan,misalnya: pemeliharaan sarana, pengadaan alat-alat kesehatan, dsb.
3) Program Kerja Pengembangan Manajemen,dan seterusnya.
B. Rencana anggaran: yang merupakan rencanabiaya untuk tiap-tiap program kerja
dan kegiatankegiatanyang direncanakan secara garis besar.
BAB VI. Pemantauan dan Penilaian
BAB VII. Penutup
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b. Pelayanan/Upaya Puskesmas: diisi dengan Pelayanan Klinis (Upaya Kesehatan

Perseorangan), dan Upaya Kesehatan Masyarakat yang dilaksanakan di UPTD
Puskesmas , misalnya Upaya KIA, Upaya KB, Upaya PKM, dan seterusnya.
c. Indikator: diisi dengan indikator-indikator yang menjadi tolok ukur kinerja
Upaya/Pelayanan.
d. Standar: diisi dengan standar kinerja untuk tiap indikator.
e. Pencapaian: diisi dengan pencapaian kinerja tahun terakhir.
f. Target pencapaian: diisi dengan target-target yang akan dicapai pada tiap tahap tahunan.
g. Program Kerja: diisi dengan Program Kerja yang akan dilakukan untuk mencapai target
pada tiap tahunberdasarkan hasil analisis kinerja, misalnya program kerja
pengembangan SDM, program kerja peningkatan mutu, program kerja pengembangan
SDM, program kerja pengembangan sarana, dsb.
h. Kegiatan: merupakan rincian kegiatan untuk tiap program yang direncanakan, misalnya
untuk program pengembangan SDM, kegiatan Pelatihan Perawat, Pelatihan Tenaga
PKM, dan sebagainya.
i. Volume: diisi dengan volume kegiatan yang direncanakan untuk tiap tahapan tahunan.
j. Harga Satuan: harga satuan untuk tiap kegiatan.
 k. Perkiraan Biaya: diisi dengan perkalian antara volumedengan harga satuan.
4. Penutup
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Penyusunan Rencana Usulan Kegiatan (RUK) memperhatikan berbagai kebijakan yang

berlaku, baiksecara global, nasional maupun daerah sesuai dengan hasil kajian data dan
informasi yang tersedia di Puskesmas. Puskesmas perlu mempertimbangkan masukan dari
masyarakat melalui kajian maupun asupan dari lintas sektoral Puskesmas.
Rencana Usulan Kegiatan harus dilengkapi usulan pembiayaan untuk kebutuhan rutin, sarana,
prasarana dan operasional Puskesmas. RUK yang disusun merupakan RUK tahun mendatang
(H+1). Penyusunan RUK tersebut dilakukan pada bulan Januari tahun berjalan (H) berdasarkan
hasil kajian pencapaian kegiatan tahun sebelumnya (H-1) dan diharapkan proses penyusunan
RUK telah selesai dilaksanakan di Puskesmas pada akhir bulan Januari tahun berjalan (H).
RUK kemudian dibahas di Dinas Kesehatan Kabupaten/ Kota selanjutnya terangkum dalam
usulan Dinas Kesehatan Kabupaten/ Kota akan diajukan ke DPRD untuk memperoleh
persetujuan pembiayaan dan dukungan politis.
Setelah mendapatkan persetujuan, selanjutnya diserahkanke Puskesmas melalui Dinas
Kesehatan Kabupaten/Kota. Berdasarkan alokasi biaya yang telah disetujui tersebut,secara rinci
RUK dijabarkan ke dalam rencana pelaksanaan kegiatan (RPK). Penyusunan RPK
dilaksanakan pada bulan Januari tahun berjalan dalam forum Lokakarya Mini yangpertama.
2. Tahap Penyusunan Perencanaan Tingkat Puskesmas (PTP).
a. Tahap persiapan.
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2) Menetapkan urutan prioritas masalah,

3) Merumuskan masalah,
4) Mencari akar penyeBAB, dapat mempergunakan diagram seBAB akibat, pohon
masalah, curah pendapat, dan alat lain yang dapat digunakan.
b. Penyusunan RUK.
Penyusunan RUK meliputi Upaya Kesehatan Masyarakat (UKM) dan Upaya Kesehatan
Perseorangan (UKP) tingkat pertama, UKM esensial dan pengembanganyang meliputi :
1) Kegiatan tahun yang akan datang,
2) Kebutuhan sumber daya,
3) Rekapitulasi rencana usulan kegiatan.

4. Penyusunan Rencana Pelaksanaan Kegiatan.

Rencana Pelaksanaan Kegiatan baik Upaya Kesehatan Masyarakat (UKM) dan Upaya
Kesehatan Perseorangan (UKP) tingkat pertama, UKM esensial dan pengembangan secara
bersama-sama, terpadu dan terintegrasi, dengan langkah-langkah:
a. Mempelajari alokasi kegiatan,
b. Membandingkan alokasi kegiatan yang disutujui dengan RUK,
c. Menyusun rancangan awal secara rinci,
d. Mengadakan lokakarya mini,
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•
Data Fasilitas pelayanan kesehatan yang ada di Puskesmas (Di Dalam dan Luar
Gedung)
B. Data Sumber Daya
1) Ketenagaan Puskesmas (Format 2a)
2) Keadaan Obat dan Bahan Habis Pakai (Format 2b)
3) Keadaan Alat Kesehatan Format 2c)
4) Pembiayaan Kesehatan (Format 2d)
5) Keadaan Sarana dan Prasarana (Format 2e)
C. Data Peran Serta Masyarakat (Format 3)
D. Data Penduduk dan sasaran Program (Format 4)
E. Data Sekolah (Format 5)
F. Data Kesehatan Lingkungan (Format 6)
2. Data Khusus
A. Status Kesehatan
1) Data Kematian (Format 7)
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4. Bila Kementerian Kesehatan telah menerbitkan Pedoman/Panduan untuk suatu kegiatan/

pelayanan tertentu, maka UPTD Puskesmas dalam membuat pedoman/ panduan wajib
mengacu pada pedoman/ panduan yang diterbitkan oleh Kementerian Kesehatan.
5. Format baku sistematika pedoman panduan yang lazim digunakan sebagai berikut:
a. Format Pedoman Pengorganisasian Unit Kerja
Kata pengantar
BAB I Pendahuluan
BAB II Gambaran Umum
BAB III Visi, Misi, Falsafah, Nilai dan Tujuan
BAB IV Struktur Organisasi
BAB V Struktur Organisasi Unit Kerja
BAB VI Uraian Jabatan
BAB VII Tata Hubungan Kerja
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BAB VI KESELAMATAN SASARAN KEGIATAN/PROGRAM

BAB VII KESELAMATAN KERJA
BAB VIII PENGENDALIAN MUTU
BAB IX PENUTUP

c. Format Pedoman Penyusunan Akreditasi

HALAMAN JUDUL
KATA PENGANTAR
DAFTAR ISI
BAB I. Pendahuluan
A. Latar Belakang
B. Maksud dan Tujuan
C. Sasaran
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BAB IV. Penutup

Daftar Pustaka

d. Format Panduan Pelayanan

BAB I DEFINISI
BAB II RUANG LINGKUP
BAB III TATA LAKSANA
BAB V DOKUMENTASI
e. Format Pedoman Pengendalian dokumen
Halaman Judul
Kata Pengantar
Daftar Isi
BAB I . Pendahuluan
A. Latar Belakang
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Sistematika pedoman/panduan UPTD Puskesmas , dapat dibuat sesuai dengan materi atau isi
pedoman/panduan. Pedoman/ panduan yang harus dibuat adalah pedoman/panduan minimal yang
harus ada di UPTD Puskesmas yang dipersyaratkan sebagai regulasi yang diminta dalam elemen
penilaian.

G. PENYUSUNAN KERANGKA ACUAN PROGRAM/KEGIATAN

Kerangka acuan disusun untuk program atau kegiatan yang akan dilakukan oleh UPTD Puskesmas .
Program/kegiatan yang dibuat kerangka acuan adalah sesuai dengan Standar Akreditasi.
Dalam menyusun kerangka acuan harus jelas tujuan dankegiatan-kegiatan yang akan dilakukan
dalam mencapai tujuan. Tujuan dibedakan atas tujuan umum yang merupakan tujuan secara garis
besar dari keseluruhan program/kegiatan, dan tujuan khusus yang merupakan tujuan dari tiap-tiap
kegiatan yang akan dilakukan. Dalam kerangka acuan harus dijelaskan bagaimana cara
melaksanakan kegiatan agar tujuan tercapai, dengan penjadwalan yang jelas dan evaluasi serta
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Jadwal adalah merupakan perencanaan waktu untuk tiap-tiap rincian kegiatan yang akan
dilaksanakan, yang digambarkan dalam bentuk bagan.
VIII. Monitoring Evaluasi pelaksanaan kegiatan dan pelaporan
Yang dimaksud dengan evaluasi pelaksanaan kegiatanadalah evaluasi pelaksanaan kegiatan
terhadap jadwalyang direncanakan. Jadwal tersebut akan dievaluasi setiap berapa bulan
sekali (kurun waktu tertentu), sehingga apabila dari evaluasi diketahui ada pergeseran
jadwal atau penyimpangan jadwal, maka dapat segera diperbaiki sehingga tidak
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4. Istilah Standar Prosedur Operasional (SOP) digunakan di UU Nomor 29 Tahun 2004 tentang
Praktik Kedokteran dan UU Nomor 36 tahun 2009 tentang Kesehatan dan UU Nomor 44 Tahun
2009, tentang Rumah Sakit.
5. Beberapa Istilah Prosedur yang sering digunakan yaitu:
a. Prosedur yang telah ditetapkan disingkat Protap,
b. Prosedur untuk panduan kerja (prosedur kerja, disingkat PK),
c. Prosedur untuk melakukan tindakan,
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e. Format merupakan format minimal, oleh karena itu format ini dapat diberi tambahan
materi/kolom misalnya, nama penyusun SOP, unit yang memeriksa SOP. Untuk SOP
tindakan agar memudahkan di dalam melihat langkah – langkahnya dengan bagan alir,
persiapan alat dan bahan dan lain – lain , namun tidak boleh mengurangi item-item yang
ada di SOP.
Format SOP sebagai berikut:
Contoh Kop/heading SOP Puskesmas:

JUDUL SOP
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• Penjelasan :
a) Penulisan SOP harus tetap di dalam kotak adalah : nama puskesmas dan logo, judul
SOP, nomor dokumen, tanggal terbit dan tanda tangan kepala puskesmas
b) Logo Kabupaten dan lambang puskesmas
c) Tulisan judul SOP
d) Kotak logo kabupaten dan logo puskesmas
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d) Referensi : berisi dokumen eksternal sebagai acuan penyusunan SOP, bisa

berbentuk buku, peraturan perundang-undangan, ataupun bentuk lain sebagai bahan
pustaka.
e) Prosedur: bagian ini merupakan bagian utama yang menguraikan langkah-langkah
kegiatan untuk menyelesaikan proses kerja tertentu.
f) Diagram Alir/ bagan alir (Flow Chart):Di dalam penyusunan prosedur maupun
instruksi kerja sebaiknya dalam langkah – langkah kegiatan dilengkapi dengan
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Langkah awal menyusun daftar tilik dengan melakukan Identifikasi prosedur yang
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Instruksi adalah naskah dinas yang memuat perintah atau arahan untuk melakukan
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b) Wewenang penetapan dan penandatanganan instruksi tidak dapat dilimpahkan

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