BAB PANDUAN ELEMEN KETERANGAN

Policies identify which screening and diagnostic tests are standard before Policy
Panduan Skrining Pasien admission.

Panduan TRIAGE
Panduan Identifikasi Pasien
Written policies and procedures support the processes for admitting inpatients Policy and Procedure
and registering outpatients. Includes:
Panduan Pendaftaran Pasien Rawat Outpatient registration
Jalan & Rawat Inap Admitting inpatients
Admitting emergency patients
Holding patients for observation
Panduan Praktik Kedokteran
Written policies and/or procedures support consistent practice [on the process Policy and Procedure
Panduan Penundaan Pelayanan Pasien
for managing inpatients and outpatients when there is a delay in treatment].
Panduan Informasi Pelayanan Pasien
AKSES KE PELAYANAN & Pedoman Pelayanan Unit Intensif
KONTINUITAS PELAYANAN Organization policy guides the process for patients being permitted to leave Policy
the organization during the planned course of treatment on an approved
pass for a defined period of time
Panduan Pemulangan Pasien
Policy and procedure define when the discharge summary must be Policy and Procedure
completed and in the record
Clinical records contain the completed summary list per organization policy Policy
The organization has established entry and/or transfer criteria for its Criteria
intensive and specialized services or units, including research and other
programs to meet special patient needs.
Established criteria or policies determine the appropriateness of transfers Criteria or Policies
Panduan Transfer (di dalam/ keluar RS)
within the organization
Pasien
The transfer of responsibility from individual to individual of the patients Policy
care is described in organization policy
The records of transferred patients contain documentation or other notes as Policy and Procedure
required by the policy of the transferring organization
Panduan Pelayanan Ambulance
 KELOMPOK PANDUAN
Panduan Kebutuhan Privasi dan
Perlindungan Harta
Panduan Perlindungan terhadap
Kekerasan Fisik
Panduan Penolakan Tindakan
(Resusitasi) dan Pengobatan
Panduan Menanggapi Keluhan
Panduan Pelayanan Kerohanian Pasien
Panduan Perlindungan Hak Pasien dan
Keluarga
HAK PASIEN & KELUARGA
Panduan Tantang Bantuan Hidup Dasar
Panduan Persetujuan Tindakan
Kedokteran
Panduan Informasi Pelayanan
Panduan Donor Organ
Panduan Transplantasi
ELEMEN KETERANGAN
Policies and procedures support consistent practice [on resuscitative Policy and Procedure
practices].
Policies and procedures support consistent practice [in the complaint process]. Policy and Procedure
Policies and procedures guide and support patient and family rights in the Policy and Procedure
organization.
Policies and procedures are developed to support and to promote patient and
family participation in care processes.
Policies and procedures address the patients right to seek a second opinion
without fear of compromise to their care within or outside the organization.
Policies and procedures support consistent practice [on resuscitative Policy and Procedure
practices].
The organization has a clearly defined informed consent process described in Policy and Procedure
policies and procedures.
The organization has listed those procedures and treatments that require Policy and Procedure
separate consent.
Policies and procedures guide the information and decision process [for Policy and Procedure
research].
Policies and procedures guide the procurement and donation process. Policy and Procedure
Policies and procedures guide the transplantation process. Policy and Procedure
 KELOMPOK PANDUAN ELEMEN KETERANGAN

Organization policy and procedure define the assessment information to be Policy and Procedure
obtained for inpatients.
Organization policy and procedure define the assessment information to be Policy and Procedure
obtained for outpatients.
Organization policy identifies the information to be documented for the Policy and Procedure
assessments.
The minimum content of assessments performed in inpatient settings is Policy and Procedure
defined in policies.
The minimum content of assessments performed in outpatient settings is Policy and Procedure
defined in policies.
All inpatients and outpatients have an initial assessment(s) that includes a Policy and Procedure
health history and physical examination consistent with the requirements
defined in hospital policy.
Policies and procedures support consistent practice in all areas [related to Policy and Procedure
Panduan Asesmen Pasien :
identifying patient medical and nursing needs].
a. Asesmen Medis
The initial medical assessment is conducted within the first 24 hours of Policy and Procedure
ASESMEN PASIEN b. Asesmen Keperawatan
admission as an inpatient or earlier as indicated by the patients condition or
c. Asesmen Nutrisi
hospital policy.
d. Asesmen Nyeri
The initial nursing assessment is conducted within the fist 24 hours of Policy and Procedure
admission as an inpatient or earlier as indicated by the patients condition or
hospital policy.
The organization defines criteria, in writing, that identify when additional, Criteria
specialized, or more in-depth special-needs assessments are performed.
Patients are reassessed at intervals based on their condition and when there Policy and Procedure
has been a significant change in their condition, plan of care, and individual
needs or according to organization policies and procedures.
For nonacute patients, the organization policy defines the circumstances in Policy and Procedure
which, and the types of patients or patient populations for which, a
physicians assessment may be less than daily and identifies the minimum
reassessment interval for these patients.
Those qualified to conduct patient assessments and reassessments have Policy and Procedure
their responsibilities defined in writing.
 KELOMPOK PANDUAN
Panduan Pengelolaan Bahan dan limbah
Berbahaya
Pedoman Pelayanan Laboratorium
Pedoman Pelayanan Radiologi
Panduan Pasien Risiko Jatuh
Panduan Manajemen Nyeri
Pedoman Pelayanan Laboratorium
Pedoman Pelayanan Radiologi
PELAYANAN PASIEN
Pedoman Pelayanan Transfusi Darah
Pedoman Pelayanan Gizi RS
Panduan pelayanan pasien tahap
terminal
ELEMEN KETERANGAN
Written policies and procedures address the handling and disposal of infectious Policy and Procedure
and hazardous materials.
There is a laboratory equipment management program and it is Program
implemented.
The laboratory has and follows written guidelines for evaluation of all Guideline
reagents to provide for accuracy and precision of results.
Procedures guide the ordering of tests. Procedure
Procedures guide the collection and identification of specimens. Procedure
Procedures guide the transport, storage, and preservation of specimens. Procedure
Procedures guide the receipt and tracking of specimens. Procedure
There is a quality control program for the clinical laboratory. Program
A radiation safety program is in place that addresses potential safety risks Program
and hazards encountered within or outside the department.
Written policies and procedures address compliance with applicable Policy and Procedure
standards, laws, and regulations.
Written policies and procedures address handling and disposal of Policy and Procedure
infectious and hazardous materials.
There is a radiology and diagnostic imaging equipment management Program
program, and it is implemented.
There is a quality control program for the radiology and diagnostic imaging Program
services, and it is implemented.
The use of restraint is guided by appropriate policies and procedures. Policy and Procedure
Patients in pain receive care according to pain management guidelines. Guideline
The handling, use, and administration of blood and blood products are guided Policy and Procedure
by appropriate policies and procedures.
 KELOMPOK PANDUAN ELEMEN KETERANGAN

The care of comatose patients is guided by appropriate policies and Policy and Procedure
procedures.
The care of patients who are on life support is guided by policies and Policy and Procedure
procedures.
The care of patients with communicable diseases is guided by appropriate Policy and Procedur
policies and procedures.
The care of immune-suppressed patients is guided by appropriate policies Policy and Procedure
and procedures.
Panduan Pelayanan Pasien Risiko Tinggi The care of patients on dialysis is guided by appropriate policies and Policy and Procedure
procedures.
The care of frail, dependent elderly patients is guided by appropriate Policy and Procedure
policies and procedures.
PELAYANAN PASIEN The care of young, dependent children is guided by appropriate policies Policy and Procedure
and procedures.
Patient populations at risk for abuse are identified, and their care is guided Policy and Procedure
by appropriate policies and procedures.
The care of patients receiving chemotherapy or other high-risk medications Policy and Procedure
is guided by appropriate policies and procedures.
Policies and procedures guide uniform care and reflect relevant laws and Policy and Procedure
Panduan Pelayanan Kedokteran dan
regulations.
keperawatan
Orders are written when required and follow organization policy. Policy
The care of emergency patients is guided by appropriate policies and Policy and Procedure
Panduan Pelayanan Kasus Emergensi
procedures.
The uniform use of resuscitation services throughout the organization is guided Policy and Procedure
Panduan Pelayanan Resusitasi
by appropriate policies and procedures.
 KELOMPOK PANDUAN ELEMEN KETERANGAN

Pedoman Pelayanan Kamar Operasi

Policy and procedure address the minimum frequency and type of Policy
monitoring during anesthesia and are uniform for similar patients receiving
similar anesthesia wherever anesthesia is provided.
Panduan Pelayanan anestesi Physiological status is monitored according to policy and procedure during Policy and Procedure
anesthesia administration.
Patients are monitored according to policy during the postanesthesia Policy
recovery period.
PELAYANAN ANESTESI & Panduan Pelayanan Bedah
BEDAH Panduan Pembuatan Laporan Operasi
Appropriate policies and procedures, addressing at least elements a) through f) Policy and Procedure
found in the intent statement, guide the care of patients undergoing moderate
and deep sedation.
Policy
There is a pre-sedation assessment performed that is consistent with
Panduan Sedasi
organization policy to evaluate risk andappropriateness of the sedation for the
patient.
Estab lished criteria are developed and documented for the recovery and Criteria
discharge from sedation.
 KELOMPOK PANDUAN ELEMEN KETERANGAN

There is a plan or policy or other document that identifies how medication Plan or Policy
use is organized and managed throughout the organization.
There is a list of medications stocked in the organization or readily available List
from outside sources.
Organization policy defines how medications brought in by the patient are Policy
identified and stored.
Organization policy defines how appropriate nutrition products are stored.
Policy
Organization policy defines how radioactive, investigational, and similar
Policy
medications are stored.
Organization policy defines how sample medications are stored and Policy
MANAJEMEN controlled.
PENGGUNAAN OBAT Policies and procedures address any use of medications known to be Policy and Procedure
Pedoman Pelayanan Farmasi
expired or outdated.
Policies and procedures address the destruction of medications known to Policy and Procedure
be expired or outdated.
Policies and procedures guide the safe prescribing, ordering, and
Policy and Procedure
transcribing of medications in the organization.
Policies and procedures address actions related to illegible prescriptions Policy and Procedure
and orders.
The organization has a policy that identifies those adverse effects that are Policy
to be recorded in the patients record and those that must be reported to
the organization.
A medication error and near miss are defined through a collaborative
process. Document

Pedoman Pelayanan PKRS

Bahan Materi Edukasi
PENDIDIKAN PASIEN &
Formulir Pemberian Edukasi
KELUARGA
Panduan Komunikasi Yang Efektif
Panduan Rekam Medis
 KELOMPOK PANDUAN ELEMEN KETERANGAN

Panduan Upaya Peningkatan Mutu
Pelayanan RS
PENINGKATAN MUTU &
KESELAMATAN PASIEN
Panduan Keselamatan Pasien
The organizations leadership participates in developing the plan for the Plan/Program
quality improvement and patient safety program.
On an annual basis, clinical leaders determine at least five priority areas on Priority Areas
which to focus the use of guidelines, clinical pathways, and/or clinical
protocols.
Process
The organization has an internal data validation process that includes a)
through f) in the intent statement.
The hospital leaders have established a definition of a sentinel event that at Policy Definition
least includes a) through d) found in the intent statement.
The organization establishes a definition of a near miss. Policy Definition
The organizations leaders adopt a risk management framework to include Framework
a) through f) in the intent.

The program is guided by appropriate policies and procedures [to reduce risks Policy and Procedure
of health careassociated infections].

The organization assesses these risks [of the infection prevention and Risk Assessment
reduction program] at least annually, and the assessment is documented.
The organization has identified those processes associated with infection risk.
The organization identifies which risks require policies and/or procedures, staff Processes
education, practice changes, and other Policy and Procedure
PENCEGAHAN & activities to support risk reduction.
Pedoman pelayanan PPI
PENGENDALIAN INFEKSI There is a policy and procedure consistent with national laws and regulations
and professional standards in place that identifies the process for managing Policy and Procedure
expired supplies.
When single-use devices and materials are reused, the policy includes items a)
through e) in the intent statement. Policy
The disposal of sharps and needles is consistent with infection prevention and
control polices of the organization. Policy
The organization develops an infection prevention and control program that
includes all staff and other professionals and patients and families. Program
 KELOMPOK PANDUAN ELEMEN KETERANGAN

Panduan Sterilisasi
Panduan Manajemen Linen & Laundry
Patients with known or suspected contagious diseases are isolated in Policy
accordance with organization policy and recommended guidelines.
Policies and procedures address the separation of patients with Policy and Procedure
PENCEGAHAN & communicable diseases from patients and staff who are at greater risk due
Panduan Kamar Isolasi
to immunosuppression or other reasons.
PENGENDALIAN INFEKSI
Policies and procedures address how to manage patients with airborne Policy and Procedure
infections for short periods of time when negative pressure rooms are not
available.
Panduan APD
The organization has adopted hand-hygiene guidelines from an authoritative Guideline
Panduan hand hygiene
source.

Panduan Standar Fasilitas

Pedoman manajemen SDM :
a. Panduan Penilaian Kinerja Profesional
b. Panduan Penerimaan Staf
c. Panduan Persyaratan Jabatan
KUALIFIKASI & PENDIDIKAN d. Panduan Uraian Jabatan
STAF e. Panduan Ketenagaan
Panduan Pemberian Vaksinasi dan
Imunisasi bagi staf
Panduan evaluasi, konseling, dan tindak
lanjut terhadap staf yang terpapar
penyakit infeksius
There is a written plan for staffing the organization. Plans
There is a process described in policy for the review of each medical staff Policy
members credential file at uniform intervals at least once every three
years.
The organization uses a standardized process that is documented in official Policy
organization policy for granting privileges to each medical staff member to
provide services on initial appointment and on reappointment.
The ongoing professional practice evaluation and annual review of each Policy
medical staff member are accomplished by a uniform process that is
defined by organization policy.
The organization has a standardized procedure to gather the credentials of Procedure
each nursing staff member.
The organization has a standardized procedure to gather the credentials of Procedure
each health professional staff member.
There is a policy on the provision of staff vaccinations and immunizations. Policy
There is a policy on the evaluation, counseling, and follow-up of staff exposed Policy
to infectious diseases that is coordinated with the infection prevention and
control program.
 KELOMPOK PANDUAN
Pedoman pelayanan K3
MANAJEMEN FASILITAS &
KESELAMATAN Panduan K3 Konstruksi
Panduan Pengelolaan Bahan & Limbah
Berbahaya
Panduan Penanggulangan Kebakaran,
Kewaspadaan Bencana & Evakuasi
Panduan Pembelian Alat Medis
Panduan Pemeliharaan Alat Medis
Panduan Larangan Merokok
Panduan Penarikan Produk dan
Peralatan
ELEMEN KETERANGAN
There are written plans that address the risk areas a) though f) in the intent Plans
statement.
a) Safety and security (Also see FMS.4 ME 1 through ME 4)
b) Hazardous materials (Also see FMS.5 ME 2 through ME 7)
c) Emergencies (Also see FMS.6, ME 1)
d) Fire Safety (Also see FMS.7.1 ME 1 through ME 5)
e) Medical equipment (Also see FMS.8 MEs 1 through ME 3 and FMS.8.1 ME 1
and ME 2)
f ) Utility systems (Also see FMS.9.1, ME 3)
The organization has a documented, current, accurate inspection of its Document
physical facilities.
The organization has a plan to reduce evident risks based on the inspection. Plan
The organization identifies hazardous materials and waste and has a current List
list of all such materials within the organization.
Inspection, testing, and maintenance of equipment and systems are Documented Inspections
documented.
The organization has developed a policy and/or procedure to eliminate or to Policy and Procedure
limit smoking.
Policy or procedure addresses any use of any product or equipment under Policy
recall.
 KELOMPOK PANDUAN ELEMEN KETERANGAN

Panduan Komunikasi Yang Efektif

Policy establishes those health care practitioners who have access to the Policy
patients record(s).
There is a written policy for addressing the privacy and confidentiality of Policy
information that is based on and consistent with laws and regulations.
The policy defines the extent to which patients have access to their health Policy
information and the process to gain access whenpermitted.
The organization has a written policy for addressing information security, Policy
including data integrity, that is based on or consistent with law or
regulation.
Policy
The policy includes levels of security for each category of data and
information identified.
Policy
The organization has a policy on retaining patient clinical records and other
data and information.
There is a written policy or protocol that defines the requirements for Policy
developing and maintaining policies and procedures including at least items
MANAJEMEN KOMUNIKASI & a) through h) in the intent, and it is implemented.
INFORMASI Pedoman Pelayanan Rekam Medis There is a written protocol that outlines how policies and procedures that Protocol
originated outside the organization will be controlled, and it is
implemented. Policy or Protocol
There is a written policy or protocol that defines retention of obsolete
policies and procedures for at least the time required by laws and
regulations, while ensuring that they will not be mistakenly used, and it is
implemented.
There is a written policy or protocol that outlines how all policies and Policy or Protocol
procedures in circulation will be identified and tracked, and it is
implemented.
Those authorized to make entries in the patient clinical record are Policy
identified in organization policy.
The format and location of entries are determined by organization policy. Policy
Those authorized to have access to the patient clinical record are identified Policy
in organization policy.
There is a process to ensure that only authorized individuals have access to Policy
the patient clinical record.
 KELOMPOK PANDUAN ELEMEN KETERANGAN

Panduan Identifikasi Pasien
Panduan Komunikasi Yang Efektif
Panduan obat high alert, NORUM
SASARAN KESELAMATAN
PASIEN
Surgical Safety Checklist
Panduan Hand Hygiene
Panduan pencegahan pasien jatuh
Policies and procedures support consistent practice in all situations and Policy and Procedure
locations. (See ME 1 through ME 4 for policy inclusions.)
Policies and procedures support consistent practice in verifying the accuracy of Policy and Procedure
verbal and telephone communications. (See ME 1 through ME 3 for policy
inclusions.)
Policies and/or procedures are developed to address the identification, Policy and Procedure
location, labeling, and storage of high-alert medications
Policies and procedures are developed that will support uniform processes to Policy and Procedure
ensure the correct site, correct procedure, and correct patient, including
medical and dental procedures done in settings other than the operating
theatre.
Policies and/or procedures are developed that support continued reduction of Policy and Procedure
health careassociated infections.
Policies and/or procedures support continued reduction of risk of patient harm Policy and Procedure
resulting from falls in the organization.

Panduan penyelenggaraan PONEK 24

jam di RS
Pedoman pelaksanaan program RS
sayang ibu dan bayi
Panduan pelayanan kesehatan BBLR
MDGs dengan perawatan metode kanguru
Panduan rawat gabung ibu dan bayi
Panduan pelayanan orang dengan
HIV/AIDS (ODHA)
Panduan pelayanan TBC dengan strategi
DOTS