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8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
1/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
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STANDAR PELAYANAN MEDIS – GIZI
3.1. LAYANAN KLINIS YANG BERORIENTASI PASIEN (LKBP)
3.1.1. PROSES PENDAFTARAN PASIEN
STANDAR 3.1.1.a
PROSEDUR PENDAFTARAN DILAKSANAKAN DENGAN EFEKTIF DAN EFISIEN
DENGAN MEMPERHATIKAN KEBUTUHAN PELANGGAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADATIDAK
ADASKOR
KETE-
RANGAN
1 2 3 4 5 6
1. Terse!" #r$se%r #e&"'"r"&.
2. Terse!" "*"& "+%r #e&"'"r"&
3. Pe%*"s ,e&*e"%! "& ,e&*!%!
#r$se%r erse%
4. Pe+"&**"& ,e&*e"%! "& ,e&*!%! "+%r
/"&* !e"#"&
5. Ter"#" 0"r" ,e&*e"%! ""
#e+"&**"& #%"s er""# #r$ses
#e&"'"r"&
6. Ter"#" !&"+"&% !" #e+"&**"& !"
#%"s
. Kese+",""& #e+"&**"& er",!& ! e,#"
#e&"'"r"&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
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100
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
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STANDAR 3.1.1.*
INFORMASI TENTANG PENDAFTARAN TERSEDIA DAN TERDOKUMENTASI PADA
/AKTU PENDAFTARAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Terse!" ,e!" !&'$r,"s! e&"&* #e&"'"r"&
! e,#" #e&"'"r"&
2. Se,%" #!" /"&* ,e,%%"& !&'$r,"s!
#e&"'"r"& ,e,#er$+e !&'$r,"s! ses%"!
e&*"& /"&* !%%"&
3. Pe+"&**"& "#" ,e,#er$+e !&'$r,"s! +"!&
e&"&* s"r"&" #e+"/"&"&7 "&"r" +"!& "r!'7 e&!s
#e+"/"&"&7 r%%"&7 eerse!""& e,#" !%r
%&% P%ses,"s #er"""& r"" !&"# "&
!&'$r,"s! +"!& /"&* !%%"&
4. Pe+"&**"& ,e&"#" "&**"#"& ses%"! /"&*
!%%"& e!" ,e,!&" !&'$r,"s! e#""
#e%*"s
5. Terse!" !&'$r,"s! e&"&* er"s"," e&*"&'"s!+!"s r%%"& +"!&
6. Terse!" !&'$r,"s! e&"&* e&% er"s","
e&*"& '"s!+!"s r%%"& +"!&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
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101
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STANDAR 3.1.1.0
HAK DAN KE/AIBAN PASIEN2 KELUARGA2 DAN PETUGAS DIPERTIMBANGKANDAN DIINFORMASIKAN PADA SAAT PENDAFTARAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADATIDAK
ADASKOR
KETE-
RANGA
N
1. ;" "& e"!"& #"s!e&e+%"r*"
!!&'$r,"s!"& se+"," #r$ses #e&"'"r"&
e&*"& 0"r" "& ""s" /"&* !#"",! $+e
#"s!e& "&e+%"r*"
2. ;" "& e"!"& #"s!e&e+%"r*"
!#er"!"& $+e #e%*"s se+"," #r$ses#e&"'"r"&
3. Ter"#" %#"/" "*"r #"s!e&e+%"r*" "&
#e%*"s ,e,"",! " "& e"!"&
,"s!&*-,"s!&*
4. Pe&"'"r"& !+"%"& $+e #e%*"s /"&*
er+"! e&*"& ,e,#er"!"& "-"
#"s!e& e+%"r*" #"s!e&
5. Ter"#" r!er!" #e%*"s /"&* er%*"s !
r%"&* #e&"'"r"&
6. Pe%*"s erse% eer" e&*"& e'!s!e&7r","7 "& res#$&s!' er""# e%%"&
#e+"&**"&
. Ter"#" ,e"&!s,e $$r!&"s! #e%*"s !
r%"&* #e&"'"r"& e&*"& %&! +"!&%&! er"!
"*"r #"s!e&e+%"r*" #"s!e& ,e,#er$+e
#e+"/"&"&
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
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N","
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STANDAR 3.1.1.TAHAPAN PELAYANAN KLINIS DIINFORMASIKAN KEPADA PASIEN UNTUK
MENAMIN KESINAMBUNGAN PELAYANAN.
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADATIDAK
ADASKOR
KETE-
RANGA
N
1.Terse!" ""#"& "& #r$se%r
#e+"/"&"& +!&!s /"&* !#"",! $+e
#e%*"s2.
Se" ""+ #"s!e&e+%"r*" ,e,#er$+e
!&'$r,"s! "& #"", er""# ""#"&
"& #r$se%r #e+"/"&"& +!&!s
3.Terse!" "'"r e&!s #e+"/"&"& !
P%ses,"s erser" "%"+ #e+"/"&"&
4.Ter"#" er"s"," e&*"& s"r"&"
ese""& +"!& %&% ,e&",!&
e+"&*s%&*"& #e+"/"&"& +!&!s (r%%"&
+!&!s7 r%%"& !"*&$s!7 "& r%%"&
$&s%+"!')
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
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103
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
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N","
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STANDAR 3.1.1.e
KENDALA FISIK2 BAHASA2 BUDAYA DAN PENGHALANG LAIN
DALAM MEMBERIKAN PELAYANAN DIUSAHAKAN DIKURANGI.
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1.P!,#!&"& "& s"' P%ses,"s ,e&*!e&!'!"s!
",""& ""s"7 %"/"7 e!"s""&7 "&
#e&*"+"&* /"&* #"+!&* ser!&* er"! #""
,"s/"r"" /"&* !+"/"&!
2. A" %#"/" !&" +"&% %&% ,e&*""s! ""%
,e,""s! ",""& #"" "%
#"s!e& ,e,%%"& #e+"/"&"& ! P%ses,"s.
3.=#"/" erse% e+" !+"s"&""&.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
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104
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. T"&*"&
STANDAR PELAYANAN MEDIS – GIZI
3.1. LAYANAN KLINIS YANG BERORIENTASI PASIEN (LKBP)
3.1.2. PENGKA:IAN
STANDAR 3.1..a
PROSES KAIAN A/AL DILAKUKAN SE4ARA PARIPURNA2
MEN4AKUP BERBAGAI KEBUTUHAN DAN HARAPAN PASIEN-KELUARGA( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADATIDAK
ADASKOR
KETE-
RANGAN
1 2 3 4 5 6
1. Ter"#" #r$se%r #e&*"!"& ""+ /"&*
#"r!#%r&" (,e+!#%!
"&",es!s"++$"&",&es!s7 #e,er!s"& '!s!
"& #e,er!s""& #e&%&"&* ser" "!"&
s$s!"+) %&% ,e&*!e&!'!"s! er"*"!
e%%"& "& "r"#"& #"s!e& "&
e+%"r*" #"s!e& ,e&0"%# #e+"/"&"&
,e!s7 #e&%&"&* ,e!s "& e#er"""&
2. Pr$ses "!"& !+"%"& $+e e&"*" /"&*
$,#ee& %&% ,e+"%"& "!"&
3. Pe,er!s""& "& !"*&$s!s ,e&*"0% #""
s"&"r #r$'es! "& s"&"r "s%"&
4. Pr$se%r #e&*"!"& /"&* "" ,e&",!&
!" er"! #e&*%+"&*"& /"&* !" #er+%
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
105
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
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N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
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T"&*"& 88888
STANDAR 3.1..*
HASIL KAIAN DI4ATAT DALAM 4ATATAN MEDIS DAN MUDAH DIAKSES OLEHPETUGAS YANG BERTANGGUNG5A/AB TERHADAP PELAYANAN PASIEN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. D!+"%"& !e&!'!"s! !&'$r,"s! "#" s"" /"&*
!%%"& "+", #e&*"!"& "& "r%s !0""
"+", re", ,e!s
2. I&'$r,"s! erse% ,e+!#%! !&'$r,"s! /"&*
!%%"& %&% "!"& ,e!s7 "!"&
e#er"""&7 "& "!"& +"!& /"&* !#er+%"&
3. D!+"%"& $$r!&"s! e&*"& #e%*"s
ese""& /"&* +"!& %&% ,e&",!& #er$+e"&
"& #e,"&'"""& !&'$r,"s! erse% se0"r"
e#" "%
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N"," 888888888. :"""& 888888888 T"&" 88888
106
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
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. T"&*"&
N","
888888888.
:"""& 888888888
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T"&"
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STANDAR 3.1..0
PASIEN DENGAN KEBUTUHAN DARURAT2 MENDESAK2 ATAU SEGERA
DIBERIKAN PRIORITAS UNTUK ASESMEN DAN PENGOBATAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADATIDAK
ADASKOR
KETE-RANGA
N
1. Pe%*"s G"" D"r%r" P%ses,"s
,e+"s"&""& #r$ses r!"se
%&% ,e,#r!$r!"s"& #"s!e& e&*"&
e%%"& e,er*e&s!.
2. Pe%*"s erse% !+"!
,e&**%&""& r!er!" !&!.
3. P"s!e& !#r!$r!"s"& ""s "s"r %r*e&s!
e%%"&.
4. P"s!e& e,er*e&s! !#er!s" "& !%"
s"!+ er+e! "%+% ses%"!
e,",#%"& P%ses,"s see+%, !r%%
e #e+"/"&"& /"&* ,e,#%&/"!
e,",#%"& +e! !&**!
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
107
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8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
10/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
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N","
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STANDAR 3.1.3.*
TERDAPAT PERALATAN DAN TEMPAT YANG MEMADAI UNTUK MELAKUKAN KAIANA/AL PASIEN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1.Terse!" #er"+""& "& e,#" #e,er!s""&
/"&* ,e,""! %&% ,e+"%"& #e&*"!"&
""+ #"s!e& se0"r" #"r!#%r&"
2. A" ",!&"& %"+!"s er""# #er"+""& !
e,#" #e+"/"&"&
3. Per"+""& "& s"r"&" #e+"/"&"& /"&*!*%&""& ,e&",!& e","&"& #"s!e& "&
#e%*"s
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N"," 888888888.
:"""& 888888888.
T"&"T"&*"& 88888
109
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
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N","
888888888.
:"""& 888888888
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STANDAR PELAYANAN MEDIS – GIZI
3.1. LAYANAN KLINIS YANG BERORIENTASI PASIEN (LKBP)
3.1.4. RENANA LAYANAN KLINIS
STANDAR 3.1.'.a
TERDAPAT PROSEDUR YANG EFEKTIF UNTUK MENYUSUN REN4ANA LAYANANBAIK LAYANAN MEDIS MAUPUN LAYANAN TERPADU IKA PASIEN MEMBUTUHKAN
PENANGANAN OLEH TIM KESEHATAN YANG TERKOORDINASI
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADATIDAK
ADASKOR
KETE-
RANGA
N
1.Ter"#" e!""& "& #r$se%r /"&* e+"s %&% ,e&/%s%& re&0"&" +"/"&"&
,e!s "& re&0"&" +"/"&"& er#"% !"
!#er+%"& #e&"&*"&"& se0"r" !,.
2.Se!"# #e%*"s /"&* er"! "+",
#e+"/"&"& +!&!s ,e&*e"%! e!""&
"& #r$se%r erse% ser" ,e&er"#"&
"+", #e&/%s%&"& re&0"&" er"#!
"&""% re&0"&" +"/"&"& er#"%
3.D!+"%"& e>"+%"s! eses%"!"&
#e+"s"&""& re&0"&" er"#! "&""%
re&0"&" "s%"& e&*"& e!""& "&
#r$se%r
4.D!+"%"& !&" +"&% !" er"!
e!"ses%"!"& "&"r" re&0"&" +"/"&"&
e&*"& e!""& "& #r$se%r
5.D!+"%"& e>"+%"s! er""#
#e+"s"&""& "& "s!+ !&" +"&%.
T$"+ S$r
Kes!,#%+"& """&
110
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Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
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T"&"
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N","
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STANDAR 3.1.'.*
REN4ANA LAYANAN KLINIS DISUSUN BERSAMA PASIEN DENGAN MEMPERHATIKANKEBUTUHAN BIOLOGIS2 PSIKOLOGIS2 SOSIAL2 SPIRITUAL DAN TATA NILAI BUDAYA
PASIEN( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1.Pe%*"s ese""& "&""% !, ese""&
,e+!""& #"s!e& "+", ,e&/%s%& re&0"&"
+"/"&"&
2. Re&0"&" +"/"&"& !s%s%& %&% se!"# #"s!e&e&*"& ee+"s"& %%"& /"&* !&*!& !0"#"!
3.Pe&/%s%&"& re&0"&" +"/"&"& erse%
,e,#er!,"&*"& e%%"& !$+$*!s7
#s!$+$*!s7 s$s!"+7 s#!r!%"+ "& "" &!+"! %"/"
#"s!e&
4.B!+" ,e,%&*!&"& "& erse!"7
#"s!e&e+%"r*" #"s!e& !#er$+e"& %&%
,e,!+! e&"*" #r$'es! ese""&
T$"+ S$r Kes!,#%+"& """&
Be"s!7 88 Me! 2915
111
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
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PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
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STANDAR 3.1.'.0
REN4ANA LAYANAN TERPADU DISUSUN SE4ARA KOMPREHENSIF OLEH TIMKESEHATAN ANTAR PROFESI DENGAN KEELASAN TANGGUNG A/AB DARI
MASING5MASING ANGGOTANYA
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1.L"/"&"& !+"%"& se0"r" #"r!#%r&" %&%
,e&0"#"! "s!+ /"&* !!&*!&"& $+e e&"*"
ese""& "& #"s!e&e+%"r*" #"s!e&
2. Re&0"&" +"/"&"& erse% !s%s%& e&*"&
""#"& "% /"&* e+"s
3.Re&0"&" +"/"&"& erse% !+"s"&""&
e&*"& ,e,#er!,-"&*"& e'!s!e&s!
#e,"&'"""& s%,er "/" ,"&%s!"
4.R!s!$ /"&* ,%&*!& er"! #"" #"s!e&
!#er!,"&*"& se" ""+ "+", ,e&/%s%&
re&0"&" +"/"&"&
5.E'e s",#!&* "& r!s!$ #e&*$""&
!!&'$r,"s!"&6.
Re&0"&" +"/"&"& erse% !$%,e&"s!"&
"+", re", ,e!s
.Re&0"&" +"/"&"& /"&* !s%s%& %*" ,e,%"
#e&!!"& #e&/%+%"& #"s!e&.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
112
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PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
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STANDAR 3.1.'.
PERSETUUAN TINDAKAN MEDIK DIMINTA SEBELUM PELAKSANAAN TINDAKANBAGI YANG MEMBUTUHKAN PERSETUUAN TINDAKAN MEDIK
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. P"s!e&e+%"r*" #"s!e& ,e,#er$+e !&'$r,"s!
,e&*e&"! !&""& ,e!s#e&*$""& ere&%
/"&* er!s!$ /"&* ""& !+"%"&
2. Terse!" '$r,%+!r #erse%%"& !&""&
,e!s#e&*$""& ere&% /"&* er!s!$
3. Terse!" #r$se%r %&% ,e,#er$+e
#erse%%"& erse%
4. Pe+"s"&""& !&'$r,e 0$&se&
!$%,e&"s!"&.
5. D!+"%"& e>"+%"s! "& !&" +"&% er""#
#e+"s"&""& !&'$r,e 0$&se&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
113
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
15/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR PELAYANAN MEDIS – GIZI
3.1. LAYANAN KLINIS YANG BERORIENTASI PASIEN (LKBP)
3.1.5. RENANA R=:=KAN
STANDAR 3.1.6.a
TERDAPAT PROSEDUR RUUKAN YANG ELAS
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADATIDAK
ADASKOR
KETE-
RANGA
N
1. Terse!" #r$se%r r%%"& /"&* e+"sser" e"r!&* '"s!+!"s r%%"&
2. Pr$ses r%%"& !+"%"& er"s"r"&
e%%"& #"s!e& %&% ,e&",!&
e+"&*s%&*"& +"/"&"&
3. Terse!" #r$se%r ,e,#ers!"#"&
#"s!e& e+%"r*" #"s!e& %&% !r%%
4. D!+"%"& $,%&!"s! e&*"& '"s!+!"s
ese""& /"&* ,e&"! %%"& r%%"&
%&% ,e,"s!"& es!"#"& '"s!+!"s
erse% %&% ,e&er!," r%%"&.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
114
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
16/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.6.*
REN4ANA RUUKAN DAN KE/AIBAN MASING5MASING
DIPAHAMI OLEH TENAGA KESEHATAN DAN PASIEN-KELUARGA PASIEN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. I&'$r,"s! e&"&* r%%"& !s",#"!"& e&*"&
0"r" /"&* ,%" !#"",! $+e
#"s!e&e+%"r*" #"s!e&
2. I&'$r,"s! erse% ,e&0"%# "+"s"& r%%"&7
s"r"&" %%"& r%%"&7 "& "#"& r%%"& "r%s
!+"%"&
3. D!+"%"& er"s"," e&*"& '"s!+!"s
ese""& +"!& %&% ,e&",!& e+"&*s%&*"&
"s%"&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
115
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
17/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.6.0
FASILITAS RUUKAN PENERIMA DIBERI RESUME TERTULIS MENGENAI KONDISIKLINIS PASIEN DAN TINDAKAN YANG TELAH DILAKUKAN OLEH PUSKESMAS PADA
SAAT MENGIRIM PASIEN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. I&'$r,"s! +!&!s #"s!e& ""% res%,e +!&!s #"s!e&
!!r!, e '"s!+!"s ese""& #e&er!,"
r%%"& ers"," #"s!e&.
2. Res%,e +!&!s ,e,%" $&!s! #"s!e&.
3. Res%,e +!&!s ,e,%" #r$se%r "& !&""&-!&""& +"!& /"&* e+" !+"%"&
4. Res%,e +!&!s ,e,%" e%%"& #"s!e& ""&
#e+"/"&"& +e! +"&%
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N"," 888888888. :"""& 888888888 T"&" 88888
116
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
18/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
. T"&*"&
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.6.
SELAMA PROSES RUUKAN PASIEN SE4ARA LANGSUNG2 STAF YANG KOMPETENTERUS MEMONITOR KONDISI PASIEN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKOR
KETE-
RANGA
N
1 2 3 4 5 6
1. Se+"," #r$ses r%%"& se0"r" +"&*s%&* se,%"
#"s!e& se+"+% !,$&!$r $+e s"' /"&*
$,#ee&.
2. K$,#ee&s! s"' /"&* ,e+"%"& ,$&!$r
ses%"! e&*"& $&!s! #"s!e&.
T$"+ S$r Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
117
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
19/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR PELAYANAN MEDIS – GIZI
3.1. LAYANAN KLINIS YANG BERORIENTASI PASIEN (LKBP)
3.1.6. PELAKSANAAN LAYANAN
STANDAR 3.1.7.a
PEDOMAN PELAYANAN DIPAKAI SEBAGAI DASAR UNTUK MELAKSANAKAN
LAYANAN KLINIS
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADATIDAK
ADASKOR
KETE-
RANGA
N
1. Terse!" #e$,"& "& #r$se%r #e+"/"&"&
+!&!s
2. Pe&/%s%&"& "& #e&er"#"& re&0"&" +"/"&"&
,e&*"0% #"" #e$,"& "& #r$se%r /"&*
er+"%
3. L"/"&"& !+"s"&""& ses%"! e&*"&
#e$,"& "& #r$se%r /"&* er+"%
4. L"/"&"& !er!"& ses%"! e&*"& re&0"&"
+"/"&"&
5. L"/"&"& /"&* !er!"& e#"" #"s!e&
!$%,e&"s!"&
6. Per%""& re&0"&" +"/"&"& !+"%"&
er"s"r"& #ere,"&*"& #"s!e&.
. Per%""& erse% !0"" "+", re",,e!s
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
20/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.7.*
PELAKSANAAN LAYANAN BAGI PASIEN GA/AT DARURAT DAN-ATAU BERISIKOTINGGI DIPANDU OLEH KEBIAKAN DAN PROSEDUR YANG BERLAKU
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. K"s%s-"s%s *"" "r%r" "&""% er!s!$
!&**! /"&* !"s" er"! !!e&!'!"s!
2. Terse!" e!""& "& #r$se%r #e&"&*"&"&
#"s!e& *"" "r%r" (e,er*e&s!)
3. Terse!" e!""& "& #r$se%r #e&"&*"&"&
#"s!e& er!s!$ !&**!
4. Ter"#" er"s"," e&*"& s"r"&" ese""&
/"&* +"!&7 "#"!+" !" erse!" #e+"/"&"&
*"" "r%r" 24 ",
5. Terse!" #r$se%r #e&0e*""& (e"s#"""&
%&!>ers"+) er""# er"!&/" !&'es! /"&*
,%&*!& !#er$+e "!" #e+"/"&"& /"&*
!er!"& "! "*! #e%*"s ,"%#%& #"s!e&
"+", #e&"&*"&"& #"s!e& er!s!$ !&**!.
T$"+ S$r Kes!,#%+"& """&
Be"s!7 88 Me! 2915
119
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
21/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.7.0
PENANGANAN2 PENGGUNAAN2 DAN PEMBERIAN DARAH DAN PRODUK DARAHDIPANDU DENGAN KEBIAKAN DAN PROSEDUR YANG ELAS
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Pe&"&*"&"&7 #e&**%&""& "& #e,er!"&
"r" "& #r$% "r" !"r""& $+e
e!""& "& #r$se%r /"&* "%
2. D"r" "& #r$% "r" !er!"& ses%"!
e!""& "& #r$se%r
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
120
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
22/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.7.
HASIL PEMANTAUAN PELAKSANAAN LAYANAN DIGUNAKAN UNTUKMENYESUAIKAN REN4ANA LAYANAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. D!e"#"& I&!"$r %&% ,e,"&"% "&
,e&!+"! #e+"s"&""& +"/"&"& +!&!s.
2. Pe,"&"%"& "& #e&!+"!"& er""# +"/"&"&
+!&!s !+"%"& se0"r" %"&!"!' ,"%#%&
%"+!"!'
3. Terse!" "" /"&* !%%"& %&%,e&*e"%! #e&0"#"!"& %%"& "& "s!+
#e+"s"&""& +"/"&"& +!&!s
4. D!+"%"& "&"+!s!s er""# !&!"$r /"&*
!%,#%+"&
5. D!+"%"& !&" +"&% er""# "s!+ "&"+!s!s
erse% %&% #er"!"& +"/"&"& +!&!s.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
121
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
23/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.7.e
SELURUH PETUGAS KESEHATAN MEMPERHATIKAN DAN MENGHARGAIKEBUTUHAN DAN HAK PASIEN SELAMA PELAKSANAAN LAYANAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Terse!" #r$se%r %&% ,e&*!e&!'!"s!
e+%"& #"s!e&e+%"r*" #"s!e& ses%"!
e&*"& e%%"& "& " #"s!e& se+","
#e+"s"&""& "s%"&
2. Terse!" #r$se%r %&% ,e&"&*"&! "&
,e&!&"+"&%! e+%"& erse%3. Ke+%"& #"s!e&e+%"r*" #"s!e& !!&" +"&%!
4. D!+"%"& $%,e&"s! e&"&* e+%"& "&
!&" +"&% e+%"& #"s!e&e+%"r*" #"s!e&.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
122
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
24/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.7.8
PELAKSANAAN LAYANAN DILAKUKAN UNTUK MENAMIN KELANGSUNGAN DANMENGHINDARI PENGULANGAN YANG TIDAK PERLU
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Terse!" e!""& "& #r$se%r %&%
,e&*!&"r! #e&*%+"&*"& /"&* !" #er+%
"+", #e+"s"&""& +"/"&"&
2. Terse!" e!""& "& #r$se%r %&%
,e&",!& es!&",%&*"& #e+"/"&"&
3. L"/"&"& +!&!s "& #e+"/"&"& #e&%&"&* /"&*
!%%"& !#"%"& e&*"& "!7 se!&**"
!" er"! #e&*%+"&*"& /"&* !" #er+%.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
123
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
25/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.7.9
PASIEN DAN KELUARGA PASIEN MEMPEROLEH PENELASAN TENTANG HAK DANTANGGUNG A/AB MEREKA BERHUBUNGAN DENGAN PENOLAKAN ATAU TIDAK
MELANUTKAN PENGOBATAN2 TERMASUK PENOLAKAN UNTUK DIRUUK KEFASILITAS KESEHATAN YANG LEBIH MEMADAI
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA TIDAK
ADA
SKOR
KETE-RANGA
N
1 2 3 4 5 6
1. Pe%*"s #e,er! #e+"/"&"& ,e,er!"%"&
#"s!e& "& e+%"r*"&/" e&"&* " ,ere"
%&% ,e&$+" ""% !" ,e+"&%"&
#e&*$""&.
2. Pe%*"s #e,er! #e+"/"&"& ,e,er!"%"&
#"s!e& "& e+%"r*"&/" e&"&* $&se%e&s!
"r! e#%%s"& ,ere".
3. Pe%*"s #e,er! #e+"/"&"& ,e,er!"%"&
#"s!e& "& e+%"r*"&/" e&"&* "&**%&*
"" ,ere" er"!"& e&*"& e#%%s"&
erse%.
4. Pe%*"s #e,er! #e+"/"&"& ,e,er!"%"&
#"s!e& "& e+%"r*"&/" e&"&* erse!"&/"
"+er&"!' #e+"/"&"& "& #e&*$""&.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N"," 888888888. :"""& 888888888 T"&" 88888
124
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
26/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
. T"&*"&
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR PELAYANAN MEDIS – GIZI
3.1. LAYANAN KLINIS YANG BERORIENTASI PASIEN (LKBP)
3.1.. PELAYANAN ANESTESI LOKAL7 SEDASI DAN PEMBEDA;AN
STANDAR 3.1.:.aPELAYANAN ANESTESI LOKAL DAN SEDASI DI PUSKESMAS DILAKSANAKAN
MEMENUHI STANDAR DI PUSKESMAS2 STANDAR NASIONAL2 UNDANG5UNDANG2DAN PERATURAN SERTA STANDAR PROFESI SESUAI DENGAN KEBUTUHAN PASIEN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADATIDAK
ADASKOR
KETE-
RANGA
N
1. Terse!" #e+"/"&"& "&eses! +$"+ "&
se"s! ses%"! e%%"& ! P%ses,"s
2. Pe+"/"&"& "&eses! +$"+ "& se"s!
!+"%"& $+e e&"*" ese""& /"&*
$,#ee&
3. Pe+"s"&""& "&eses! +$"+ "& se"s!
!#"&% e&*"& e!""& "& #r$se%r
/"&* e+"s
4. Se+"," #e,er!"& "&eses! +$"+ "&
se"s! #e%*"s ,e+"%"& ,$&!$r!&*
s"%s '!s!$+$*! #"s!e&5. A&eses! +$"+ "& se"s!7 e&!
"&eses! +$"+ "& se"s! !%+!s "+",
re", ,e!s #"s!e&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
125
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
27/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N"," 888888888.
:"""& 888888888.
T"&"T"&*"& 88888
STANDAR 3.1.:.*
PELAYANAN BEDAH DI PUSKESMAS DIREN4ANAKAN DAN DILAKSANAKANMEMENUHI STANDAR DI PUSKESMAS2 STANDAR NASIONAL2 UNDANG5UNDANG2
DAN PERATURAN SERTA STANDAR PROFESI SESUAI DENGAN KEBUTUHAN PASIEN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. D$er ""% $er *!*! /"&* ""& ,e+"%"&
#e,e""& ,!&$r ,e+"%"& "!"& see+%,
,e+"s"&""& #e,e""&
2. D$er ""% $er *!*! /"&* ""& ,e+"%"&
#e,e""& ,!&$r ,ere&0"&""& "s%"&
#e,e""& er"s"r "s!+ "!"&.
3. D$er ""% $er *!*! /"&* ""& ,e+"%"&
#e,e""& ,!&$r ,e&e+"s"& r!s!$7 ,"&'""7
$,#+!"s! #$e&s!"+7 "& "+er&"!' e#""
#"s!e&e+%"r*" #"s!e&
4. See+%, ,e+"%"& !&""& "r%s ,e&"#""&
#erse%%"& "r! #"s!e&e+%"r*" #"s!e&
5. Pe,e""& !+"%"& er"s"r"& #r$se%r /"&*
!e"#"&
6. L"#$r"&0"""& $#er"s! !%+!s"& "+", re",
,e!s
. S"%s '!s!$+$*! #"s!e& !,$&!$r er%s ,e&er%s
se+"," "& se*er" see+" #e,e""& "&
!%+!s"& "+", re", ,e!s
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N"," 888888888. :"""& 888888888 T"&" 88888
126
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. T"&*"&
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR PELAYANAN MEDIS – GIZI
3.1. LAYANAN KLINIS YANG BERORIENTASI PASIEN (LKBP)
3.1.!"s#e&/",#"!"& !&'$r,"s! e#"" #"s!e&e+%"r*"
#"s!e& "*"r ,ere" "#" er#er"& "!' "+",
#r$ses +"/"&"& "& ,e,"",! $&se%e&s!
+"/"&"& /"&* !er!"&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR127
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N"," 888888888.
:"""& 888888888.
T"&"T"&*"& 88888
STANDAR PELAYANAN MEDIS – GIZI
3.1. LAYANAN KLINIS YANG BERORIENTASI PASIEN (LKBP)
3.1.?. MAKANAN DAN TERAPI N=TRISI @)
STANDAR 3.1.
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N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
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N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.>,
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. P"s!e& /"&* #"" "ses,e& er"" #"" r!s!$
&%r!s!7 ,e&"#" er"#! *!!.
2. S%"% #r$ses er"s"," !#""! %&%
,ere&0"&""&7 ,e,er!"& "& ,e,$&!$r
er"#! *!!
3. Res#$& #"s!e& er""# er"#! *!! !,$&!$r
4. Res#$& #"s!e& er""# er"#! *!! !0""
"+", re", ,e!s&/"
T$"+ S$r
**) kriteria ini juga berlaku untuk Puskesmas yang menjalankan home-care pada pasien
yang memerlukan terapi gizi.
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N"," 888888888. :"""& 888888888 T"&" 88888
130
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. T"&*"&
STANDAR PELAYANAN MEDIS – GIZI
3.1. LAYANAN KLINIS YANG BERORIENTASI PASIEN (LKBP)
3.1.19. PEM=LANGAN DAN TINDAK LAN:=T @)
STANDAR 3.1.1?.a
PEMULANGAN DAN-TINDAK LANUT PASIEN2 BAIK YANG BERTUUAN UNTUKKELANGSUNGAN LAYANAN2 RUUKAN MAUPUN PULANG DIPANDU OLEH
PROSEDUR YANG STANDAR
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKOR
KETE-
RANGA
N
1 2 3 4 5 6
1. Terse!" #r$se%r #e,%+"&*"& "&!&" +"&%
#"s!e&
2. A" #e&"&**%&*"" "+", #e+"s"&""&
#r$ses #e,%+"&*"& "&!&" +"&% erse%
3. Terse!" r!er!" /"&* !*%&""& %&%
,e&e"#"& s"" #e,%+"&*"& "&!&"
+"&% #"s!e&
4. Terse!" %,#"& "+! "r! s"r"&" ese""&
+"!& /"&* ,e&er!," #"s!e&7 "#"!+" !+"%"&
#e,%+"&*"& "&!&" +"&% #"s!e& "&"r
s"r"&" ese""&.
5. Terse!" #r$se%r "& "+er&"!' #e&"&*"&"&
"*! #"s!e& /"&* ,e,er+%"& !&" +"&%
r%%"& ""& e"#! !" ,%&*!& !+"%"&
T$"+ S$r
*) untuk Puskesmas dengan rawat inap
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
131
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N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.1?.*PASIEN- KELUARGA PASIEN MEMPEROLEH PENELASAN YANG MEMADAI
TENTANG TINDAK LANUT LAYANAN SAAT PEMULANGAN ATAU SAAT DIRUUK KESARANA KESEHATAN YANG LAIN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. I&'$r,"s! /"&* !%%"& ,e&*e&"! !&"+"&% +"/"&"& !er!"& $+e #e%*"s e#""
#"s!e&e+%"r*" #"s!e& #"" s"" #e,%+"&*"&
""% !" !+"%"& r%%"& e s"r"&" ese""&
/"&* +"!&
2. Pe%*"s ,e&*e"%! "" !&'$r,"s! /"&*
!s",#"!"& !#"",! $+e #"s!e&e+%"r*"
#"s!e&
3. D!+"%"& e>"+%"s! #er!$! er""# #r$se%r
#e+"s"&""& #e&/",#"!"& !&'$r,"s! erse%
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N"," 888888888. :"""& 888888888. T"&"T"&*"& 88888
132
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N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3.1.1?.0PELAKSANAAN RUUKAN DILAKUKAN
ATAS DASAR KEBUTUHAN DAN PILIHAN PASIEN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. D!+"%"& !e&!'!"s! e%%"& "& #!+!"&
#"s!e& (,!s"+&/" e%%"& r"&s#$r"s!7
#e%*"s $,#ee& /"&* ,e&",#!&*!7 s"r"&"
,e!s "& e+%"r*" /"&* ,e&e,"&!) se+","
#r$ses r%%"&
2. A#"!+" erse!" +e! "r! s"% s"r"&" /"&*
"#" ,e&/e!""& #e+"/"&"& r%%"& erse%7
#"s!e&e+%"r*" #"s!e& !er! !&'$r,"s! /"&*
,e,""! "& !er! ese,#""& %&% ,e,!+!
s"r"&" #e+"/"&"& /"&* !!&*!&"&3. Kr!er!" r%%"& !+"%"& ses%"! e&*"& SPO
r%%"&7
4. D!+"%"& #erse%%"& r%%"& "r!
#"s!e&e+%"r*" #"s!e&.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
133
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N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR PELAYANAN MEDIS – GIZI
3.2. MANA:EMEN PEN=N:ANG LAYANAN KLINIS (MPLK)
3.2.1. PELAYANAN LABORATORI=M
STANDAR 3..1.a
PEMERIKSAAN LABORATORIUM DILAKUKAN OLEH PETUGAS YANG KOMPETEN
DAN BERPENGALAMAN UNTUK MELAKUKAN DAN-ATAU MENGINTERPRETASIKANHASIL PEMERIKSAAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. D!e"#"& e&!s-e&!s #e,er!s""& +"$r"$r!%,
/"&* "#" !+"%"& !P%ses,"s
2. Terse!" e&!s "& %,+" #e%*"s ese""&/"&* $,#ee& ses%"! e%%"& "& ", %"
#e+"/"&"&
3. Pe,er!s""& +"$r"$r!%, !+"%"& $+e
"&"+!s#e%*"s /"&* er+"! "& er#e&*"+","&
4. I&er#er"s! "s!+ #e,er!s""& +"$r"$r!%,
!+"%"& $+e #e%*"s /"&* er+"! "&
er#e&*"+","&.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N"," 888888888. :"""& 888888888 T"&" 88888
134
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
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. T"&*"&
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3..1.*
TERDAPAT KEBIAKAN DAN PROSEDUR SPESIFIK UNTUK SETIAP ENISPEMERIKSAAN LABORATORIUM
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K ADA
SKO
R
KETE-
RANGAN
1 2 3 4 5 6
1. Terse!" e!""& "& #r$se%r %&% #er,!&""&
#e,er!s""&7 #e&er!,""& s#es!,e&7 #e&*",!+"&
"& #e&/!,#"& s#es!,e&
2. Terse!" #r$se%r #e,er!s""& +"$r"$r!%,
3. D!+"%"& #e,"&"%"& se0"r" er"+" er""#
#e+"s"&""& #r$se%r erse%
4. D!+"%"& e>"+%"s! er""# ee#""& "%
#e&/er""& "s!+ #e,er!s""& +"$r"$r!%,
5. Terse!" e!""& "& #r$se%r #e,er!s""& ! +%"r
", er" (#"" P%ses,"s r"" !&"# ""% #""
P%ses,"s /"&* ,e&/e!""& #e+"/"&"& ! +%"r
", er")
6. A" e!""& "& #r$se%r %&% #e,er!s""&
/"&* er!s!$ !&**! (,!s"+&/" s#e0!,e& s#%%,7
"r" "& +"!&&/")
. Terse!" #r$se%r ese""& "& ese+",""& er"7
"& "+" #e+!&%&* !r! "*! #e%*"s +"$r"$r!%,
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Check List
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3..1.0
HASIL PEMERIKSAAN LABORATORIUM SELESAI DAN TERSEDIA DALAM /AKTUSESUAI DENGAN KETENTUAN YANG DITETAPKAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K ADA
SKO
R
KETE-
RANGAN
1 2 3 4 5 6
1. P!,#!&"& P%ses,"s ,e&e"#"& "% /"&*
!"r"#"& %&% +"#$r"& "s!+ #e,er!s""&.
2. Kee#""& "% ,e+"#$r"& "s!+ #e,er!s""&
/"&* %r*e&*"" "r%r" !%%r.
3. ;"s!+ +"$r"$r!%, !+"#$r"& "+", er"&*"
"% *%&" ,e,e&%! e%%"& #"s!e&
T$"+ S$r Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N"," 888888888. :"""& 888888888 T"&" 88888
136
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Check List
. T"&*"&
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3..1.
ADA PROSEDUR MELAPORKAN HASIL TES DIAGNOSTIK YANG KRITIS
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 61. Me$e $+"$r"!' !*%&""& %&%
,e&*e,"&*"& #r$se%r %&% #e+"#$r"&
"s!+ /"&* r!!s "& #e,er!s""& !"*&$s!
2. Pr$se%r erse% ,e&e"#"& &!+"! ","&*
r!!s %&% se!"# es
3. Pr$se%r erse% ,e&e"#"& $+e s!"#" "&
e#"" s!"#" "s!+ /"&* r!!s "r! #e,er!s""&
!"*&$s! "r%s !+"#$r"&
4. Pr$se%r erse% ,e&e"#"& "#" /"&* !0""!"+", re", ,e!s #"s!e&
5. Pr$ses !,$&!$r %&% ,e,e&%! ee&%"&
"& !,$!'!"s! er"s"r"& "s!+ ,$&!$r!&*
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
137
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
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N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3..1.e
REAGENSIA ESENSIAL DAN BAHAN LAIN YANG DIPERLUKAN SEHARI5HARI SELALUTERSEDIA DAN DIE=ALUASI UNTUK MEMASTIKAN AKURASI DAN PRESISI HASIL
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. D!e"#"& re"*e&s!" ese&s!"+ "& ""&+"!& /"&* "r%s erse!"
2. Re"*e&s!" ese&s!"+ "& ""& +"!& erse!"7
"& "" #r$ses %&% ,e&/"""& !" re"*e&
!" erse!".
3. Se,%" re"*e&s!" !s!,#"& "& !!sr!%s!
ses%"! #e$,"& "r! #r$%se& ""%
!&sr%s! #e&/!,#"&"& "& !sr!%s! /"&*
"" #"" e,"s"&
4. Terse!" #e$,"& er%+!s /"&* !+"s"&""&
%&% ,e&*e>"+%"s! se,%" re"*e&s!" "*"r
,e,er!"& "s!+ /"&* "%r" "& #res!s!.
5. Se,%" re"*e&s!" "& +"r%"& !er! +"e+
se0"r" +e&*"# "& "%r".
6. D!e"#"& re"*e&s!" ese&s!"+ "& ""&
+"!& /"&* "r%s erse!"
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
138
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
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N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3..1.8
DITETAPKAN NILAI NORMAL DAN RENTANG NILAI YANG DIGUNAKAN UNTUKINTERPERTASI DAN PELAPORAN HASIL LABORATORIUM
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Ke#"+" P%ses,"s ,e&e"#"& &!+"!
re&"&* &!+"! r%%"& %&% se!"# #e,er!s""&
/"&* !+"s"&""&.
2. Re&"&*-&!+"! r%%"& !&! "r%s !ser""& "+",
0"""& +!&!s #"" "% "s!+ #e,er!s""&
!+"#$r"&.
3. Pe,er!s""& /"&* !+"%"& $+e +"$r"$r!%,
+%"r "r%s ,e&0"&-%,"& re&"&* &!+"!.
4. Re&"&*-&!+"! !e>"+%"s! "& !re>!s! er"+"
se#er+%&/".
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N"," 888888888. :"""& 888888888 T"&" 88888
139
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. T"&*"&
STANDAR 3..1.9
PENGENDALIAN MUTU DILAKUKAN2 DITINDAKLANUTI DAN DIDOKUMENTASIUNTUK SETIAP PEMERIKSAAN LABORATORIUM
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Terse!" e!""& "& #r$se%r #e&*e&"+!"&
,%% #e+"/"&"& +"$r"$r!%,
2. D!+"%"& "+!r"s! ""% >"+!"s! !&sr%,e&"+"%%r e#" "% "& $+e #!" /"&* $,#ee&
ses%"! #r$se%r
3. Ter"#" %! $%,e&"s! !+"%"&&/"
"+!r"s! ""% >"+!"s!7 "& ,"s! er+"%
4. A#"!+" !e,%"& #e&/!,#"&*"& !+"%"&
!&""& #er"!"&
5. D!+"%"& #e,"&"#"& ,%% eser&"+ er""#
#e+"/"&"& +"$r"$r!%, $+e #!" /"&*
$,#ee&.
6. Ter"#" ,e"&!s,e r%%"& s#es!,e& "&
#"s!e& !+" #e,er!s""& +"$r"$r!%, !"
!+"%"& ! P%ses,"s7 "& P%ses,"s
,e,"s!"& "" #e+"/"&"& erse%
!er!"& ses%"! e&*"& e%%"& #"s!e&.
. Ter"#" %! $%,e&"s! !+"%"&&/"
#e,"&"#"& ,%% !&er&"+ "& eser&"+
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
140
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42/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3..1.@
UPAYA KESELAMATAN (SAFETY, DIREN4ANAKAN2 DILAKSANAKAN2 DANDIDOKUMENTASIKAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Ter"#" %#"/" ese+",""& e","&"&
+"$r"$r!%, /"&* ,e&*"%r r!s!$ ese+",""&/"&* #$e&s!"+ ! +"$r"$r!%, "& ! "re" +"!&
/"&* ,e&"#" #e+"/"&"& +"$r"$r!%,.
2. =#"/" !&! ""+" "*!"& "r! %#"/"
ese+",""& ! P%ses,"s
3. Pe%*"s +"$r"$r!%, ,e+"#$r"& e*!""&
#e+"s"&""& %#"/" ese+",""& e#""
#e&*e+$+" %#"/" ese+",""& ! P%ses,"s
se%r"&*-%r"&*&/" se"%& se"+! "& !+"
er"! !&s!e&s ese+",""&.
4. Ter"#" e!""& "& #r$se%r er%+!s
e&"&* #e&"&*"&"& "& #e,%"&*"& ""&
er""/"
5. D!+"%"& !e&!'!"s!7 "&"+!s!s "& !&"
+"&% r!s!$ ese+",""& ! +"$r"$r!%,
6. S"' +"$r"$r!%, !er!"& $r!e&"s! %&%
#r$se%r "& #r"e ese+",""&e","&"&
er"
. S"' +"$r"$r!%, ,e&"#" #e+"!"&
#e&!!"& %&% #r$se%r "r% "&
#e&**%&""& ""& er""/" /"&* "r%7
,"%#%& #er"+""& /"&* "r%.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
141
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
43/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR PELAYANAN MEDIS – GIZI
3.2. MANA:EMEN PEN=N:ANG LAYANAN KLINIS (MPLK)
3.2.2. PELAYANAN OBAT
STANDAR 3...a
BERBAGAI ENIS OBAT YANG SESUAI DENGAN KEBUTUHAN TERSEDIA DALAMUMLAH YANG MEMADAI
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Ter"#" ,e$e /"&* !*%&""& %&% ,e&!+"! "&
,e&*e&"+!"& #e&/e!""& "& #e&**%&""& $"
2. Ter"#" ee+"s"& #r$se%r #e&/e!""& "&
#e&**%&""& $"
3. A" ee+"s"& s!"#" /"&* er"&**%&*""4. A" e!""& "& #r$se%r /"&* ,e&",!&
eerse!""& $"-$" /"&* se"r%s&/" ""
5. Terse!" #e+"/"&"& $"-$""& se+"," %% "r!
"+", se,!&**% "& 24 ", #"" P%ses,"s /"&*
,e,er!"& #e+"/"&"& *"" "r%r"
6. Terse!" "'"r '$r,%+"r!%, $" P%ses,"s
. D!+"%"& e>"+%"s! "& !&" +"&% eerse!""&
$" !"&!&*"& e&*"& '$r,%+"r!%,
"+%"s! "& !&" +"&% eses%"!"&
#erese#"& e&*"& '$r,%+"r!%,.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N"," 888888888.
:"""& 888888888.
T"&"T"&*"& 88888
142
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3...*
PERESEPAN2 PEMESANAN DAN PENGELOLAAN OBAT DIPANDU KEBIAKAN DANPROSEDUR YANG EFEKTIF
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 61. Ter"#" ee&%"& #e%*"s /"&* er"
,e,er!"& rese#
2. Ter"#" ee&%"& #e%*"s /"&* ,e&/e!""&
$" e&*"& #ers/"r""& /"&* e+"s
3. A#"!+" #ers/"r""& #e%*"s /"&* !er!
ee&"&*"& "+", #e&/e!""& $" !"
"#" !#e&%!7 #e%*"s erse% ,e&"#"
#e+"!"& %s%s.
4. Terse!" e!""& "& #r$ses #erese#"&7
#e,es"&"&7 "& #e&*e+$+""& $"
5. Ter"#" #r$se%r %&% ,e&"*" !"
er"!&/" #e,er!"& $" /"&* e"+%"rs"
e#"" #"s!e&
6. D!+"%"& #e&*""s"& er""# #e&**%&""&
"& #e&*e+$+""& $" $+e D!&"s Kese""&
K"%#"e&K$" se0"r" er"%r
. Ter"#" ee&%"& s!"#" /"&* er"
,e&%+!s"& rese# %&% $"-$" ere&%
(,!s"+ #s!$r$#!" "& &"r$!")
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3...0
ADA AMINAN KEBERSIHAN DAN KEAMANAN DALAM PENYIMPANAN2 PENYIAPAN2DAN PENYAMPAIAN OBAT KEPADA PASIEN SERTA PENATALAKSANAAN OBAT
KEDALU/ARSA-RUSAK
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADATIDA
K
ADA
SKO
R
KETE-RANGA
N
1 2 3 4 5 6
1. Ter"#" #ers/"r""& #e&/!,#"&"& $"
2. Pe&/!,#"&"& !+"%"& ses%"! e&*"&
#ers/"r""&
3. Pe,er!"& $" e#"" #"s!e& !ser"! e&*"&
+"e+ $" /"&* e+"s (,e&0"%# &","7 $s!s7
0"r" #e,""!"& $" "& 're%e&s!
#e&**%&""&&/")
4. Pe,er!"& $" !ser"! e&*"& !&'$r,"s!#e&**%&""& $" /"&* ,e,""! e&*"&
""s" /"&* "#" !,e&*er! $+e
#"s!e&e+%"r*" #"s!e&
5. Pe%*"s ,e,er!"& #e&e+"s"& e&"&*
e,%&*!&"& er"! e'e s",#!&* $" ""%
e'e /"&* !" !"r"#"&
6. Pe%*"s ,e&e+"s"& #e%&% e&"&*
#e&/!,#"&"& $" ! r%,"
. Terse!" e!""& "& #r$se%r #e&"&*"&"&
$" /"&* e"+%"rs"r%s"
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3...
EFEK SAMPING YANG TERADI AKIBAT PEMBERIAN OBAT5OBAT YANGDIRESEPKAN ATAU RI/AYAT ALERGI TERHADAP OBAT5OBATAN TERTENTU HARUS
DIDOKUMENTASIKAN DALAM REKAM MEDIS PASIEN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Terse!" #r$se%r #e+"#$r"& e'e s",#!&* $"
2. E'e s",#!&* $" !$%,e&"s!"& "+",
re", ,e!s
3. Terse!" e!""& "& #r$se%r %&%
,e&0""7 ,e,"&"%7 "& ,e+"#$r"& !+"
er"! e'e s",#!&* #e&**%&""& $" "&
KTD7 er,"s% es"+""& #e,er!"& $"
4. Ke"!"& e'e s",#!&* $" "& KTD
!!&"+"&%! "& !$%,e&"s!"&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N"," 888888888. :"""& 888888888 T"&" 88888
145
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47/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
. T"&*"&
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3...e
KESALAHAN OBAT (MEDIKATION ERRORS, DILAPORKAN MELALUI PROSES DANDALAM KERANGKA /AKTU YANG DITETAPKAN OLEH PUSKESMAS
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Ter"#" #r$se%r %&% ,e&*!e&!'!"s! "&
,e+"#$r"& es"+""& #e,er!"& $" "&
KN
2. Kes"+""& #e,er!"& $" "& KN !+"#$r"&
e#" "% ,e&**%&""& #r$se%r "%
3. D!e"#"& #e%*"s ese""& /"&*
er"&**%&*"" ,e&*",!+ !&""& %&%
#e+"#$r"& !!e&!'!"s!
4. I&'$r,"s! #e+"#$r"& es"+""& #e,er!"& $"
"& KN !*%&""& %&% ,e,#er"!! #r$ses
#e&*e+$+""& "& #e+"/"&"& $".
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N"," 888888888.
:"""& 888888888.
T"&"T"&*"& 88888
146
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3...8
OBAT5OBATAN EMERGENSI TERSEDIA2 DIMONITOR DAN AMAN BILAMANADISIMPAN DI LUAR FARMASI
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N1 2 3 4 5 6
1. O" e,er*e&s! erse!" #"" %&!-%&! !,"&"
""& !#er+%"& ""% "#" er"ses se*er"
%&% ,e,e&%! e%%"& /"&* ers!'"
e,er*e&s!
2. A" e!""& /"&* ,e&e"#"& "*"!,"&"
$" e,er*e&s! !s!,#"&7 !"*" "& !+!&%&*!
"r! e!+"&*"& ""% #e&0%r!"&
3. O" e,er*e&s! !,$&!$r "& !*"&! se0"r"
e#" "% ses%"! e!""& P%ses,"s
see+" !*%&""& ""% !+" ""+%"rs" ""%
r%s"
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N"," 888888888.
:"""& 888888888.
T"&"T"&*"& 88888
147
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
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Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR PELAYANAN MEDIS – GIZI
3.2. MANA:EMEN PEN=N:ANG LAYANAN KLINIS (MPLK)
3.2.3. PELAYANAN RADIODIAGNOSTIK (:IKA TERSEDIA)
STANDAR 3..3.a
PELAYANAN RADIODIAGNOSTIK DISEDIAKAN UNTUK MEMENUHI KEBUTUHAN
PASIEN2 DAN MEMENUHI STANDAR NASIONAL2 PERUNDANG5UNDANGAN DANPERATURAN YANG BERLAKU
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Pe+"/"&"& r"!$!"*&$s! ,e,e&%! s"&"r
&"s!$&"+
2. Pe+"/"&"& r"!$!"*&$s! !+"%"& se0"r"
"e%"
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
148
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
50/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3..3.*
ADA UPAYA PENGAMANAN RADIASI2 DILAKSANAKAN DAN DIDOKUMENTASI
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Ter"#" %#"/" e","&"& r"!"s! /"&*
,e&*"%r r!s!$ e","&"& "& "&!s!#"s!
""/" /"&* !s" er"! ! "+", ""% ! +%"r
%&! er"
2. =#"/" e","&"& ,er%#""& "*!"& "r! %#"/"
ese+",""& ! P%ses,"s7 "& "!
!+"#$r"& se%r"&*-%r"&*&/" se"+! se"%&
""% !+" "" e"!"&
3. Ke!""& "& #r$se%r er%+!s /"&* ,e&*"%r
"& ,e,e&%! s"&"r er"!7 %&"&*-%&"&*
"& #er"%r"& /"&* er+"%.4. Ke!""& "& #r$se%r er%+!s /"&* ,e&*"%r
#e&"&*"&"& "& #e,%"&*"& ""& !&'es!%s
"& er""/".
5. R!s!$ e","&"& r"!"s! /"&* !!e&!'!"s!
!!,"&*! e&*"& #r$se%r ""% #er"+""&
%s%s %&% ,e&*%r"&*! r!s!$ (se#er! "#r$&
!,"7 "*e r"!"s! "& /"&* see&!s)
6. Pe%*"s #e,er! #e+"/"&"& r"!$!"*&$s-
! !er! $r!e&"s! e&"&* #r$se%r "& #r"e
ese+",""&
. Pe%*"s #e,er! #e+"/"&"& r"!$!"*&$s-
! ,e&"#" #e&!!"& %&% #r$se%r "r%
"& ""& er""/"
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N"," 888888888. :"""& 888888888 T"&" 88888
149
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
51/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
. T"&*"&
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3..3.0
STAF YANG KOMPETEN DENGAN PENGALAMAN MEMADAI2 MELAKSANAKANPEMERIKSAAN RADIO DIAGNOSTIK MENGINTERPRETASI HASIL2 DAN
MELAPORKAN HASIL PEMERIKSAAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. D!e"#"& #e%*"s /"&* ,e+"%"&
#e,er!s""& !"*&$s!
2. Terse!" #e%*"s /"&* $,#ee& "&
#e&*"+","& /"&* ,e,""! ,e+"s"&""&
#e,er!s""& r"!$!"*&$s!.
3. Pe%*"s /"&* $,#ee& "& #e&*"+","& /"&*
,e,""! ,e&*!&er#re"s! "s!+ #e,er!s""&.4. Pe%*"s /"&* $,#ee& /"&* ,e,""!7
,e,>er!'!"s! "& ,e,%" +"#$r"& "s!+
#e,er!s""&
5. Terse!" s"' "+", %,+" /"&* "e%" %&%
,e,e&%! e%%"& #"s!e&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N"," 888888888. :"""& 888888888 T"&" 88888
150
8/16/2019 Instrumen 3 Standar Pelayanan Medis-gizi
52/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
. T"&*"&
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3..3.
HASIL PEMERIKSAAN RADIOLOGI TERSEDIA TEPAT /AKTU SESUAIKETENTUAN YANG DITETAPKAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Ke#"+" P%ses,"s ,e&e"#"& e&"&*"r"#"& "% #e+"#$r"& "s!+ #e,er!s""&.
2. Kee#""& "% #e+"#$r"& "s!+ #e,er!s""&
!%%r7 !,$&!$r7 "& !!&"+"&%!
3. ;"s!+ #e,er!s""& r"!$+$*! !+"#$r"& "+",
er"&*" "% %&% ,e,e&%! e%%"&
#"s!e&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
151
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53/82
Instrumen / Lembar Kerja: Diklat Sosialisasi Akreditasi Puskesmas
Check List
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
STANDAR 3..3.eSEMUA PERALATAN YANG DIGUNAKAN UNTUK PEMERIKSAAN RADIOLOGI DAN
DIAGNOSTIK IMAING DIPERIKSA2 DIRA/AT DAN DI KALIBRASI SE4ARA TERATUR2DAN DISERTAI 4ATATAN MEMADAI YANG DIPELIHARA DENGAN BAIK
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. A" %#"/" #e,e+!"r""&
#er"+""& r"!$+$*! "& !+"s"&"-"&
2. =#"/" er,"s% !&>e&"r!s"s! #er"+""&
3. =#"/" er,"s% !&s#es! "& es!&* #er"+""&
4. =#"/" er,"s% "+!r"s! "& #er"""&
#er"+""&
5. =#"/" er,"s% ,$&!$r!&* "& !&" +"&%
6. A" $%,e&"s! /"&* "e%" %&% se,%"
es!&*7 #er"""& "& "+!r"s! #er"+""&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N"," 888888888. :"""& 888888888 T"&" 88888
152
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. T"&*"&
STANDAR 3..3.8
FILM 5RAY DAN PERBEKALAN LAIN TERSEDIA SE4ARA TERATUR
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. -r"/ '!+,7 re"*e&s!" "& se,%" #ere"+"&
#e&!&* !e"#-"&.
2. -r"/ '!+,7 re"*e&s!" "& #ere"+"& #e&!&*
+"!& erse!".
3. Se,%" #ere"+"& ! s!,#"& "& !!sr!%s!
ses%"! e&*"& #e$,"&
4. Se,%" #ere"+"& !e>"+%"s! se0"r" #er!$!
%&% "%r"s! "& "s!+&/".
5. Se,%" #ere"+"& !er! +"e+ se0"r" +e&*"#
"& "%r"T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
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N","
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:"""& 888888888
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153
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STANDAR 3..3.9
PELAYANAN RADIOLOGI DIKELOLA2 DIPIMPIN2 DAN DILAKSANAKAN OLEHPETUGAS YANG KOMPETEN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Pe+"/"&"& r"!$+$*! !"" #!,#!&"& se$r"&*
/"&* $,#ee&
2. Pe+"/"&"& r"!$+$*! !+"s"&""& $+e #e%*"s
/"&* $,#ee&
3. Pe&"&**%&*"" #e+"/"&"& r"!$+$*!,e&*e,"&*"&7 ,e+"s"&""&7
,e,#er""&"& e!""& "& #r$se%r
!e"#"& "& !+"s"&""&.
4. Pe&"&**%&*"" #e+"/"&"& r"!$+$*!
,e+"%"& #e&*""s"& ",!&!sr"s! !e"#"&
"& !+"s"&""&.
5. Pe&"&**%&*"" #e+"/"&"& r"!$+$*!
,e,#er""&"& %#"/" $&r$+ ,%%
!e"#"& "& !+"s"&""&.
6. Pe&"&**%&*"" #e+"/"&"& ,e,"&"% "&
,ere>!e #e+"/"&"& r"!$+$*! /"&* !se!""&
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
154
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STANDAR 3..3.@
ADA PROSEDUR KONTROL MUTU2 DILAKSANAKAN DAN DIDOKUMENTASIKAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. A" %#"/" $&r$+ ,%% %&% #e+"/"&"&
r"!$!"*&$s!7 "& !+"s"&""&
2. =#"/" $&r$+ ,%% er,"s% >"+!"s! ,e$e
es.
3. =#"/" $&r$+ ,%% er,"s% #e&*""s"&"r!"& "s!+ #e,er!s""&.
4. =#"/" $&r$+ ,%% er,"s% #er"!"& 0e#"
!+" !e,%"& e%r"&*"&.
5. =#"/" $&r$+ ,%% er,"s% #e&$%,e&-
"s!"& "s!+ "& +"&*"-+"&*" #er"!"&.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
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T"&"
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STANDAR PELAYANAN MEDIS – GIZI
155
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3.2. MANA:EMEN PEN=N:ANG LAYANAN KLINIS (MPLK)
3.2.4. MANA:EMEN INFORMASI C REKAM MEDIS
STANDAR 3..'.a
ADA PEMBAKUAN KODE KLASIFIKASI DIAGNOSIS2 KODE PROSEDUR2
SIMBOL2 DAN ISTILAH YANG DIPAKAI
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. Ter"#" s"&"r!s"s! $e +"s!'!"s!
!"*&$s!s "& er,!&$+$*! +"!& /"&* $&s!se&"& s!se,"!s
2. Ter"#" s"&"r!s"s! $e +"s!'!"s! !"*&$s!s
"& er,!&$+$*/ /"&* !s%s%& $+e P%ses,"s
(,!&!,"+ 19 es"r #e&/"!)
3. D!+"%"& #e,"%"& s!&*""&-s!&*""& /"&*
!*%&""& "+", #e+"/"&"& ses%"! e&*"&
s"&"r &"s!$&"+ ""% +$"+.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
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T"&"
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N","
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:"""& 888888888
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STANDAR 3..'.*
156
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PETUGAS MEMILIKI AKSES INFORMASI SESUAI DENGAN KEBUTUHAN
DAN TANGGUNGA/AB PEKERAAN
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K ADA
SKO
R
KETE-
RANGAN
1 2 3 4 5 6
1. D!e"#"& e!""& "& #r$se%r "ses
#e%*"s er""# !&'$r,"s! ,e!s
2. Ases #e%*"s er""# !&'$r,"s! /"&*
!%%"& !+"s"&""& ses%"! e&*"& %*"s
"& "&**%&* ""
3. Ases #e%*"s er""# !&'$r,"s! !+"s"&""&ses%"! e&*"& e!""& "& #r$se%r
4. ;" %&% ,e&*"ses !&'$r,"s! erse%
,e,#er!,"&*"& !&*" er""s!""& "&
e","&"& !&'$r,"s!
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
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:"""& 888888888
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STANDAR 3..'.0
ADANYA SISTEM YANG MEMANDU PENYIMPANAN DAN PEMROSESAN
157
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REKAM MEDIS
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N1 2 3 4 5 6
1. P%ses,"s ,e,#%&/"! re", ,e!s "*!
se!"# #"s!e& e&*"& ,e$" !e&!'!"s! /"&*
"%
2. S!se, #e&*$e"&7 #e&/!,#"&"&7 "&
$%,e&"s! ,e,%""& #e%*"s %&%
,e&e,%"& re", #"s!e& e#" "% ,"%#%&
%&% ,e&0"" #e+"/"&"& /"&* !er!"&
e#"" #"s!e&
3. A" e!""& "& #r$se%r #e&/!,#"&"&
er"s re", ,e!s e&*"& ee+"s"& ,"s"
ree&s! ses%"! #er"%r"& #er%&"&*"& /"&*
er+"%.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
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888888888.
:"""& 888888888
.
T"&"
T"&*"& 88888
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:"""& 888888888
.
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STANDAR 3..'.
REKAM BERISI INFORMASI YANG MEMADAI DAN DIAGA KERAHASIAANNYA
158
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3.2.5. MANA:EMEN KEAMANAN LINGK=NGAN
STANDAR 3..6.a
LINGKUNGAN FISIK PUSKESMAS2 INSTALASI LISTRIK2 AIR2 =ENTILASI2 GAS DANSISTIM LAIN YANG DIPERSYARATKAN DIPERIKSA SE4ARA RUTIN2 DIPELIHARA2
DAN DIPERBAIKI BILA PERLU
( Beri Tana ! Paa K"#"$ 3 a%a& K"#"$ ' e&ai )eaaan e*enarn+a ,
NO ELEMEN PENILAIAN ADA
TIDA
K
ADA
SKO
R
KETE-
RANGA
N
1 2 3 4 5 6
1. K$&!s! '!s! +!&*%&*"& P%ses,"s !#"&"%
se0"r" r%!&.
2. I&s"+"s! +!sr!7 %"+!"s "!r7 >e&!+"s!7 *"s "&
s!se, +"!& /"&* !*%&""& !#"&"% se0"r"
#er!$! $+e #e%*"s /"&* !er! "&**%&*
""
3. Terse!" s"r"&" %&% ,e&"&*"&! ,"s"+"
+!sr!"#! "#"!+" er"! e""r"&
4. Terse!" e!""& "& #r$se%r !&s#es!7
#e,"&"%"&7 #e,e+!"r""& "& #er"!"&
5. I&s#es!7 #e,"&"%"&7 #e,e+!"r""&7 "&
#er"!"& "+" !+"%"& ses%"! e&*"&
#r$se%r "& "%"+ /"&* !e"#"&
6. D!+"%"& $%,e&"s! #e+"s"&""&7 "s!+ "&
!&" +"&% !&s#es!7 #e,"&"%"&7
#e,e+!"r""& "& #er"!"& /"&* e+"
!+"%"&.
T$"+ S$r
Kes!,#%+"& """&
Be"s!7 88 Me! 2915
PENILAI - ASSESSOR
N","
888888888.
:"""& 888888888
.
T"&"
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