Vous êtes sur la page 1sur 13

KELOMPOK PANDUAN ELEMEN KETERANGAN

AKSES KE PELAYANAN &


KONTINUITAS
PELAYANAN
Panduan Skrining Pasien
Policies identify which screening and diagnostic tests are standard
before admission.
Policy
Panduan TRIAGE
Panduan Identifikasi Pasien
Panduan Pendaftaran Pasien Rawat
a!an & Rawat Ina"
Written policies and procedures support the processes for admitting
inpatients and registering outpatients. Includes:
Outpatient registration
Admitting inpatients
Admitting emergency patients
Holding patients for observation
Policy and Procedure
Panduan Praktik Ked#kteran
Panduan Penundaan Pe!a$anan
Pasien
Written policies and/or procedures support consistent practice on the
process for managing inpatients and outpatients when there is a delay in
treatment!.
Policy and Procedure
Panduan Inf#r%asi Pe!a$anan
Pasien
Ped#%an Pe!a$anan Unit Intensif
Panduan Pe%u!angan Pasien
Organi"ation policy guides the process for patients being permitted to
leave the organi"ation during the planned course of treatment on an
approved pass for a defined period of time
Policy and procedure define when the discharge summary must be
completed and in the record
#linical records contain the completed summary list per organi"ation
policy
Policy
Policy and Procedure
Policy
Panduan Transfer &di da!a%' ke!uar
RS( Pasien
$he organi"ation has established entry and/or transfer criteria for its
intensive and speciali"ed services or units% including research and
other programs to meet special patient needs.
&stablished criteria or policies determine the appropriateness of
transfers within the organi"ation
$he transfer of responsibility from individual to individual of the
patient's care is described in organi"ation policy
$he records of transferred patients contain documentation or other
notes as re(uired by the policy of the transferring organi"ation
#riteria
#riteria or Policies
Policy
Policy and Procedure
Panduan Pe!a$anan A%)u!an*e
KELOMPOK PANDUAN ELEMEN KETERANGAN
+AK PASIEN & KELUARGA
Panduan Ke)utu,an Pri-asi dan
Per!indungan +arta
Panduan Per!indungan ter,ada"
Kekerasan .isik
Panduan Pen#!akan Tindakan
&Resusitasi( dan Peng#)atan
Policies and procedures support consistent practice on resuscitative
practices!.
Policy and Procedure
Panduan Menangga"i Ke!u,an
Policies and procedures support consistent practice in the complaint
process!.
Policy and Procedure
Panduan Pe!a$anan Ker#,anian
Pasien
Panduan Per!indungan +ak Pasien
dan Ke!uarga
Policies and procedures guide and support patient and family rights in
the organi"ation.
Policies and procedures are developed to support and to promote
patient and family participation in care processes.
Policies and procedures address the patient's right to see) a second
opinion without fear of compromise to their care within or outside the
organi"ation.
Policy and Procedure
Panduan Tantang /antuan +idu"
Dasar
Policies and procedures support consistent practice on resuscitative
practices!.
Policy and Procedure
Panduan Persetu0uan Tindakan
Ked#kteran
$he organi"ation has a clearly defined informed consent process
described in policies and procedures.
$he organi"ation has listed those procedures and treatments that re(uire
separate consent.
Policy and Procedure
Policy and Procedure
Panduan Inf#r%asi Pe!a$anan
Policies and procedures guide the information and decision process for
research!.
Policy and Procedure
Panduan D#n#r Organ
Policies and procedures guide the procurement and donation process. Policy and Procedure
Panduan Trans"!antasi
Policies and procedures guide the transplantation process. Policy and Procedure
KELOMPOK PANDUAN ELEMEN KETERANGAN
ASESMEN PASIEN
Panduan Ases%en Pasien 1
a2 Ases%en Medis
)2 Ases%en Ke"erawatan
*2 Ases%en Nutrisi
d2 Ases%en N$eri
Organi"ation policy and procedure define the assessment information
to be obtained for inpatients.
Organi"ation policy and procedure define the assessment information
to be obtained for outpatients.
Organi"ation policy identifies the information to be documented for the
assessments.
$he minimum content of assessments performed in inpatient settings
is defined in policies.
$he minimum content of assessments performed in outpatient settings
is defined in policies.
All inpatients and outpatients have an initial assessment*s+ that
includes a health history and physical e,amination consistent with the
re(uirements defined in hospital policy.
Policies and procedures support consistent practice in all areas
related to identifying patient medical and nursing needs!.
$he initial medical assessment is conducted within the first -. hours of
admission as an inpatient or earlier as indicated by the patient's
condition or hospital policy.
$he initial nursing assessment is conducted within the fist -. hours of
admission as an inpatient or earlier as indicated by the patient's
condition or hospital policy.
$he organi"ation defines criteria% in writing% that identify when
additional% speciali"ed% or more in/depth special/needs assessments
are performed.
Patients are reassessed at intervals based on their condition and when
there has been a significant change in their condition% plan of care% and
individual needs or according to organi"ation policies and procedures.
0or nonacute patients% the organi"ation policy defines the
circumstances in which% and the types of patients or patient
populations for which% a physician's assessment may be less than
daily and identifies the minimum reassessment interval for these
patients.
$hose (ualified to conduct patient assessments and reassessments
have their responsibilities defined in writing.
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy and Procedure
#riteria
Policy and Procedure
Policy and Procedure
Policy and Procedure
KELOMPOK PANDUAN ELEMEN KETERANGAN
Panduan Penge!#!aan /a,an dan
!i%)a, /er)a,a$a
Written policies and procedures address the handling and disposal of
infectious and ha"ardous materials.
Policy and Procedure
Ped#%an Pe!a$anan La)#rat#riu% $here is a laboratory e(uipment management program and it is
implemented.
$he laboratory has and follows written guidelines for evaluation of all
reagents to provide for accuracy and precision of results.
Procedures guide the ordering of tests.
Procedures guide the collection and identification of specimens.
Procedures guide the transport% storage% and preservation of
specimens.
Procedures guide the receipt and trac)ing of specimens.
$here is a (uality control program for the clinical laboratory.
Program
1uideline
Procedure
Procedure
Procedure
Procedure
Program
Ped#%an Pe!a$anan Radi#!#gi A radiation safety program is in place that addresses potential safety risks
and hazards encountered within or outside thedepartment.
Written policies and procedures address compliance with applicable
standards, laws, and regulations.
Written policies and procedures address handling and disposal of
infectious and hazardous materials.
There is a radiology and diagnostic imaging equipment management
program, and it is implemented.
There is a quality control program for the radiology and diagnostic imaging
services, and it is implemented.
Program
Policy and Procedure
Policy and Procedure
Program
Program

PELAYANAN PASIEN
Panduan Pasien Risik# atu,
$he use of restraint is guided by appropriate policies and procedures. Policy and Procedure
Panduan Mana0e%en N$eri
Patients in pain receive care according to pain management guidelines. uideline
Ped#%an Pe!a$anan La)#rat#riu%
Ped#%an Pe!a$anan Radi#!#gi
Ped#%an Pe!a$anan Transfusi
Dara,
$he handling% use% and administration of blood and blood products are
guided by appropriate policies and procedures.
Policy and Procedure
Ped#%an Pe!a$anan Gi3i RS
Panduan "e!a$anan "asien ta,a"
ter%ina!
KELOMPOK PANDUAN ELEMEN KETERANGAN
PELAYANAN PASIEN
Panduan Pe!a$anan Pasien Risik#
Tinggi
$he care of comatose patients is guided by appropriate policies and
procedures.
$he care of patients who are on life support is guided by policies and
procedures.
The care of patients with communicable diseases is guided by appropriate
policies and procedures.
The care of immune!suppressed patients is guided by appropriate policies
and procedures.
The care of patients on dialysis is guided by appropriate policies and
procedures.
The care of frail, dependent elderly patients is guided by appropriate
policies and procedures.
The care of young, dependent children is guided by appropriate policies
and procedures.
Patient populations at risk for abuse are identified, and their care is guided
by appropriate policies and procedures.
The care of patients receiving chemotherapy or other high!risk medications
is guided by appropriate policies andprocedures.
Policy and Procedure
Policy and Procedure
Policy and Procedur
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy and Procedure
Panduan Pe!a$anan Ked#kteran
dan ke"erawatan
Policies and procedures guide uniform care and reflect relevant laws
and regulations.
Orders are written when re(uired and follow organi"ation policy.
Policy and Procedure
Policy
Panduan Pe!a$anan Kasus
E%ergensi
$he care of emergency patients is guided by appropriate policies and
procedures.
Policy and Procedure
Panduan Pe!a$anan Resusitasi
$he uniform use of resuscitation services throughout the organi"ation is
guided by appropriate policies and procedures.
Policy and Procedure
KELOMPOK PANDUAN ELEMEN KETERANGAN
PELAYANAN ANESTESI
& /EDA+
Ped#%an Pe!a$anan Ka%ar
O"erasi
Panduan Pe!a$anan anestesi
Policy and procedure address the minimum fre(uency and type of
monitoring during anesthesia and are uniform for similar patients
receiving similar anesthesia wherever anesthesia is provided.
Physiological status is monitored according to policy and procedure
during anesthesia administration.
Patients are monitored according to policy during the postanesthesia
recovery period.
Policy
Policy and Procedure
Policy
Panduan Pe!a$anan /eda,
Panduan Pe%)uatan La"#ran
O"erasi
Panduan Sedasi
Appropriate policies and procedures% addressing at least elements a+
through f+ found in the intent statement% guide the care of patients
undergoing moderate and deep sedation.
$here is a pre/sedation assessment performed that is consistent with
organi"ation policy to evaluate ris) andappropriateness of the sedation
for the patient.
&stab lished criteria are developed and documented for the recovery and
discharge from sedation.
Policy and Procedure
Policy
"riteria
KELOMPOK PANDUAN ELEMEN KETERANGAN
MANAEMEN
PENGGUNAAN O/AT
Ped#%an Pe!a$anan .ar%asi
$here is a plan or policy or other document that identifies how
medication use is organi"ed and managed throughout the
organi"ation.
$here is a list of medications stoc)ed in the organi"ation or readily
available from outside sources.
Organi"ation policy defines how medications brought in by the patient
are identified and stored.
Organi"ation policy defines how appropriate nutrition products are
stored.
Organi"ation policy defines how radioactive% investigational% and
similar medications are stored.
Organi"ation policy defines how sample medications are stored and
controlled.
Policies and procedures address any use of medications )nown to be
e,pired or outdated.
Policies and procedures address the destruction of medications
)nown to be e,pired or outdated.
Policies and procedures guide the safe prescribing% ordering% and
transcribing of medications in the organi"ation.
Policies and procedures address actions related to illegible
prescriptions and orders.
$he organi"ation has a policy that identifies those adverse effects
that are to be recorded in the patient's record and those that must be
reported to the organi"ation.
A medication error and near miss are defined through a collaborative
process.
Plan or Policy
2ist
Policy
Policy
Policy
Policy
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy and Procedure
Policy
#ocument

PENDIDIKAN PASIEN &
KELUARGA
Ped#%an Pe!a$anan PKRS
/a,an Materi Edukasi
.#r%u!ir Pe%)erian Edukasi
Panduan K#%unikasi Yang Efektif
Panduan Reka% Medis
KELOMPOK PANDUAN ELEMEN KETERANGAN
PENINGKATAN MUTU &
KESELAMATAN PASIEN
Panduan U"a$a Peningkatan Mutu
Pe!a$anan RS
$he organi"ation's leadership participates in developing the plan for
the (uality improvement and patient safety program.
On an annual basis% clinical leaders determine at least five priority
areas on which to focus the use of guidelines% clinicalpathways%
and/or clinical protocols.
$he organi"ation has an internal data validation process that includes
a+ through f+ in the intent statement.
Plan$Program
Priority Areas
Process
Panduan Kese!a%atan Pasien
$he hospital leaders have established a definition of a sentinel event
that at least includes a+ through d+ found in the intent statement.
$he organi"ation establishes a definition of a near miss.
$he organi"ation's leaders adopt a ris) management framewor) to
include a+ through f+ in the intent.
Policy 3efinition
Policy 3efinition
0ramewor)

PEN4EGA+AN &
PENGENDALIAN IN.EKSI
Ped#%an "e!a$anan PPI
$he program is guided by appropriate policies and procedures to reduce
ris)s of health care4associated infections!.
$he organi"ation assesses these ris)s of the infection prevention and
reduction program! at least annually% and theassessment is documented.
$he organi"ation has identified those processes associated with
infection ris).
$he organi"ation identifies which ris)s re(uire policies and/or
procedures% staff education% practice changes% and other
activities to support ris) reduction.
$here is a policy and procedure consistent with national laws and
regulations and professional standards in place thatidentifies the process
for managing e,pired supplies.
When single/use devices and materials are reused% the policy includes
items a+ through e+ in the intent statement.
$he disposal of sharps and needles is consistent with infection
prevention and control polices of the organi"ation.
$he organi"ation develops an infection prevention and control program
that includes all staff and other professionals and patients and families.
Policy and Procedure
5is) Assessment
Processes
Policy and Procedure
Policy and Procedure
Policy
Policy
Program
KELOMPOK PANDUAN ELEMEN KETERANGAN
PEN4EGA+AN &
PENGENDALIAN IN.EKSI
Panduan Steri!isasi
Panduan Mana0e%en Linen &
Laundr$
Panduan Ka%ar Is#!asi
Patients with )nown or suspected contagious diseases are isolated in
accordance with organi"ation policy and recommended guidelines.
Policies and procedures address the separation of patients with
communicable diseases from patients and staff who are at greater
ris) due to immunosuppression or other reasons.
Policies and procedures address how to manage patients with
airborne infections for short periods of time when negativepressure
rooms are not available.
Policy
Policy and Procedure
Policy and Procedure
Panduan APD
Panduan hand hygiene
$he organi"ation has adopted hand/hygiene guidelines from an
authoritative source.
1uideline

KUALI.IKASI &
PENDIDIKAN STA.
Panduan Standar .asi!itas
Ped#%an %ana0e%en SDM 1
a2 Panduan Peni!aian Kiner0a
Pr#fesi#na!
)2 Panduan Peneri%aan Staf
*2 Panduan Pers$aratan a)atan
d2 Panduan Uraian a)atan
e2 Panduan Ketenagaan
$here is a written plan for staffing the organi"ation.
$here is a process described in policy for the review of each medical
staff member's credential file at uniform intervals at least once every
three years.
$he organi"ation uses a standardi"ed process that is documented in
official organi"ation policy for granting privileges to each medical staff
member to provide services on initial appointment and on
reappointment.
$he ongoing professional practice evaluation and annual review of
each medical staff member are accomplished by a uniform process
that is defined by organi"ation policy.
$he organi"ation has a standardi"ed procedure to gather the
credentials of each nursing staff member.
$he organi"ation has a standardi"ed procedure to gather the
credentials of each health professional staff member.
Plans
Policy
Policy
Policy
Procedure
Procedure
Panduan Pe%)erian 5aksinasi dan
I%unisasi )agi staf
$here is a policy on the provision of staff vaccinations and
immuni"ations.
Policy
Panduan e-a!uasi6 k#nse!ing6 dan $here is a policy on the evaluation% counseling% and follow/up of staff Policy
tindak !an0ut ter,ada" staf $ang
ter"a"ar "en$akit infeksius
e,posed to infectious diseases that is coordinated with the infection
prevention and control program.
KELOMPOK PANDUAN ELEMEN KETERANGAN
MANAEMEN .ASILITAS &
KESELAMATAN
Ped#%an "e!a$anan K7
$here are written plans that address the ris) areas a+ though f+ in the
intent statement.
a+ 6afety and security *Also see 076.. 7& 8 through 7& .+
b+ Ha"ardous materials *Also see 076.9 7& - through 7& :+
c+ &mergencies *Also see 076.;% 7& 8+
d+ 0ire 6afety *Also see 076.:.8 7& 8 through 7& 9+
e+ 7edical e(uipment *Also see 076.< 7&s 8 through 7& = and
076.<.8 7& 8 and 7& -+
f + >tility systems *Also see 076.?.8% 7& =+
Plans
Panduan K7 K#nstruksi
$he organi"ation has a documented% current% accurate inspection of
its physical facilities.
$he organi"ation has a plan to reduce evident ris)s based on the
inspection.
3ocument
Plan
Panduan Penge!#!aan /a,an &
Li%)a, /er)a,a$a
$he organi"ation identifies ha"ardous materials and waste and has a
current list of all such materials within the organi"ation.
2ist
Panduan Penanggu!angan
Ke)akaran6 Kewas"adaan /en*ana
& E-akuasi
Panduan Pe%)e!ian A!at Medis
Panduan Pe%e!i,araan A!at Medis
Inspection% testing% and maintenance of e(uipment and systems are
documented.
3ocumented Inspections
Panduan Larangan Mer#k#k
$he organi"ation has developed a policy and/or procedure to eliminate
or to limit smo)ing.
Policy and Procedure
Panduan Penarikan Pr#duk dan
Pera!atan
Policy or procedure addresses any use of any product or e(uipment
under recall.
Policy
KELOMPOK PANDUAN ELEMEN KETERANGAN
MANAEMEN
KOMUNIKASI &
IN.ORMASI
Panduan K#%unikasi Yang Efektif
Ped#%an Pe!a$anan Reka% Medis Policy establishes those health care practitioners who have access to
the patient's record*s+.
$here is a written policy for addressing the privacy and confidentiality
of information that is based on and consistent withlaws and
regulations.
$he policy defines the e,tent to which patients have access to their
health information and the process to gain access whenpermitted.
$he organi"ation has a written policy for addressing information
security% including data integrity% that is based on or consistent with
law or regulation.
$he policy includes levels of security for each category of data and
information identified.
$he organi"ation has a policy on retaining patient clinical records and
other data and information.
$here is a written policy or protocol that defines the re(uirements for
developing and maintaining policies and procedures including at least
items a+ through h+ in the intent% and it is implemented.
$here is a written protocol that outlines how policies and procedures
that originated outside the organi"ation will be controlled% and it is
implemented.
$here is a written policy or protocol that defines retention of obsolete
policies and procedures for at least the time re(uired by laws and
regulations% while ensuring that they will not be mista)enly used% and
it is implemented.
$here is a written policy or protocol that outlines how all policies and
procedures in circulation will be identified and trac)ed% and it is
implemented.
$hose authori"ed to ma)e entries in the patient clinical record are
identified in organi"ation policy.
$he format and location of entries are determined by organi"ation
policy.
$hose authori"ed to have access to the patient clinical record are
identified in organi"ation policy.
$here is a process to ensure that only authori"ed individuals have
Policy
Policy
Policy
Policy
Policy
Policy
Policy
Protocol
Policy or Protocol
Policy or Protocol
Policy
Policy
Policy
Policy
access to the patient clinical record.
KELOMPOK PANDUAN ELEMEN KETERANGAN

SASARAN KESELAMATAN
PASIEN
Panduan Identifikasi Pasien
Policies and procedures support consistent practice in all situations and
locations. *6ee 7& 8 through 7& . for policy inclusions.+
Policy and Procedure
Panduan K#%unikasi Yang Efektif
Policies and procedures support consistent practice in verifying the
accuracy of verbal and telephone communications. *6ee 7& 8 through
7& = for policy inclusions.+
Policy and Procedure
Panduan #)at ,ig, a!ert6 NORUM
Policies and/or procedures are developed to address the identification%
location% labeling% and storage of high/alert medications
Policy and Procedure
Surgi*a! Safet$ 4,e*k!ist
Policies and procedures are developed that will support uniform
processes to ensure the correct site% correct procedure% and correct
patient% including medical and dental procedures done in settings other
than the operating theatre.
Policy and Procedure
Panduan +and +$giene
Policies and/or procedures are developed that support continued
reduction of health care4associated infections.
Policy and Procedure
Panduan "en*ega,an "asien 0atu,
Policies and/or procedures support continued reduction of ris) of patient
harm resulting from falls in the organi"ation.
Policy and Procedure

MDGs
Panduan "en$e!enggaraan PONEK
89 0a% di RS
Ped#%an "e!aksanaan "r#gra% RS
sa$ang i)u dan )a$i
Panduan "e!a$anan kese,atan
//LR dengan "erawatan %et#de
kanguru
Panduan rawat ga)ung i)u dan
)a$i
Panduan "e!a$anan #rang dengan
+I5'AIDS &OD+A(
Panduan "e!a$anan T/4 dengan
strategi DOTS