PUSKESMAS DEMAK III No.

Dokumen : FM-MR-02-06

FORMULIR Halaman : Page 1 of 4

LOG STATUS AUDIT TglBerlaku : 01 April 2015

Tgl. Tgl. Unit Klau

Uraian Laporan Tgl.
No Tgl. Rencana Realisasi Tgl. sul
Ketidaksesuain Selesai Status
. LK Penyelesai Penyelesai Verifikasi
(Ditutup)
LK an an
1. 7 Nov petugas loket pendaftaran 14 Nov ‘16 14 Nov ‘16 Loket 16 Nov ‘16 16 Nov ‘16 6.2 In progres
‘16 belum mendapat pelatihan
rekam medis
2. 7 Nov Belum ada pengendalian 14 Nov ‘16 14 Nov ‘16 Loket 16 Nov ‘16 16 Nov ‘16 4.2.3 Closed
‘16 dokumen eksternal
3. 7 Nov Sasaran mutu baru 14 Nov ‘16 14 Nov ‘16 Kapuskes 16 Nov ‘16 16 Nov ‘16 5.4 Closed
‘16 terselesaikan 90%
4. 7 Nov proses bisnis belum dipampang 14 Nov ‘16 14 Nov ‘16 Kapuskes 16 Nov ‘16 16 Nov ‘16 Closed
‘16 di ruang Kapus
5. 7 Nov Ruangan belum bersih/ tertata 14 Nov ‘16 14 Nov ‘16 Gizi 16 Nov ‘16 16 Nov ‘16 6.4 Closed
‘16 dengan optimal karena masih
ada tumpukan stok MP ASI Ibu
Hamil
6. 7 Nov Pengendalian terhadap 14 Nov ‘16 14 Nov ‘16 R. 16 Nov ‘16 16 Nov ‘16 6.4 Closed
‘16 lingkungan, kebersihan, Tindakan
kerapihan, dan pengelolaan
limbah medis dan non edis
masih kurang optimal
7. 7 Nov Sterilisasi alat belum dilakukan 14 Nov ‘16 14 Nov ‘16 R. 16 Nov ‘16 16 Nov ‘16 Closed
‘16 sesuai jadwal Tindakan

8. 7 Nov Ada obat-obat yang sudah 14 Nov ‘16 14 Nov ‘16 R. 16 Nov ‘16 16 Nov ‘16 7.5.5 Closed
‘16 kadaluarsa masih tersimpan di Tindakan
ruang tindakan
 PUSKESMAS DEMAK III No. Dokumen : FM-MR-02-06

FORMULIR Halaman : Page 2 of 4

LOG STATUS AUDIT TglBerlaku : 01 April 2015

9. 7 Nov Stock obat-obat emergency 14 Nov ‘16 14 Nov ‘16 R. 16 Nov ‘16 16 Nov ‘16 7.5.5 Closed
‘16 belum terkendali Tindakan

10. 7 Nov Catatan medis belum terisi 14 Nov ‘16 14 Nov ‘16 R. 16 Nov ‘16 16 Nov ‘16 7.5.3 closed
‘16 lengkap Tindakan
11. 7 Nov Belum ada inform consent untuk 14 Nov ‘16 14 Nov ‘16 R. 16 Nov ‘16 16 Nov ‘16 7.5.1 closed
‘16 tindakan Tindakan
12. 7 Nov Register pasien belum terisi 14 Nov ‘16 14 Nov ‘16 R. 16 Nov ‘16 16 Nov ‘16 7.5.1 Closed
‘16 lengkap Tindakan
13. 7 Nov Kalibrasi alat sudah kadaluarsa 14 Nov ‘16 14 Nov ‘16 Imunisasi 16 Nov ‘16 16 Nov ‘16 7.5.3 In
‘16 Progress
14. 7 Nov CM belum dilengkapi dengan 14 Nov ‘16 14 Nov ‘16 Imunisasi 16 Nov ‘16 16 Nov ‘16 7.6 Closed
‘16 blanko MTBS
8 Nov Pengisian CM kurang lengkap 14 Nov ‘16 14 Nov ‘16 Poli 16 Nov ‘16 16 Nov ‘16 7.5.1 closed
15. ‘16 Umum
16. 8 Nov Peralatan belum dikalibrasi 14 Nov ‘16 14 Nov ‘16 Poli 16 Nov ‘16 16 Nov ‘16 7.6 In progress
‘16 Umum
17. 8 Nov Belum ada Tupoksi pegawai di 14 Nov ‘16 14 Nov ‘16 PKPR 16 Nov ‘16 16 Nov ‘16 5.5 Closed
‘16 ruangan
18. 8 Nov Tempat sampah masih ada 14 Nov ‘16 14 Nov ‘16 Sanitasi 16 Nov ‘16 16 Nov ‘16 7.5 Closed
‘16 yang belum diberi plastik sesuai
dengan jenis sampahnya
19. 9 Nov Inform consent belum konsisten 14 Nov ‘16 14 Nov ‘16 Poli Gigi 16 Nov ‘16 16 Nov ‘16 7.5.1 Closed
‘16 dilakukan untuk pasien
pencabutan gigi dewasa
20. 9 Nov Buku catatan BHP tahun 2016 14 Nov ‘16 14 Nov ‘16 Poli Gigi 16 Nov ‘16 16 Nov ‘16 7.5.5 Closed
‘16 belum terisi

21. 9 Nov Sasaran mutu belum tercapai 14 Nov ‘16 14 Nov ‘16 P2P 16 Nov ‘16 16 Nov ‘16 5.4 Closed
‘16
 PUSKESMAS DEMAK III No. Dokumen : FM-MR-02-06

FORMULIR Halaman : Page 3 of 4

LOG STATUS AUDIT TglBerlaku : 01 April 2015

22. 9 Nov Belum ada stock minimal dalam 16 Nov ‘16 16 Nov ‘16 Apotik 16 Nov ‘16 16 Nov ‘16 7.5.5 Closed
‘16 pengelolaan obat di apotik
23. 9 Nov Inventarisasi leaflat, maket 16 Nov ‘16 16 Nov ‘16 Promkes 16 Nov ‘16 16 Nov ‘16 7.5.5 Closed
‘16 konsultasi belum
terdokumentasikan dengan baik
24. 9 Nov Pengendalian lingkungan, 16 Nov ‘16 16 Nov ‘16 Promkes 16 Nov ‘16 16 Nov ‘16 6.4 Closed
‘16 kebersihan, kerapihan dan
penataan ruangan masih kurang

25. 10 Nov Belum ada 16 Nov ‘16 16 Nov ‘16 Laborator 16 Nov ‘16 16 Nov ‘16 7.5 Closed
‘16 pengendalian/pengelolaan stock ium
reagen di laboratorium
26. 10 Nov Belum ada buku catatan bahan 16 Nov ‘16 16 Nov ‘16 Laborator 16 Nov ‘16 16 Nov ‘16 7.5 Closed
‘16 medis habis pakai untuk ium
reagen/stick
27 10 Nov Belum ada data berupa hard 16 Nov ‘16 16 Nov ‘16 Surveilan 16 Nov ‘16 16 Nov ‘16 7.5 Closed
‘16 copy penyakit yang dapat s
mengakibatkan KLB per bulan
28 10 Nov Pencatatan dalam catatan 16 Nov ‘16 16 Nov ‘16 KIA-KB 16 Nov ‘16 16 Nov ‘16 7.5.3 Closed
‘16 medis kurang lengkap
29 10 Nov Belum adanya rencana tindak 16 Nov ‘16 16 Nov ‘16 KIA-KB 16 Nov ‘16 16 Nov ‘16 5.4 Closed
‘16 lanjut bila sasaran mutu belum
tercapai
30 10 Nov Peralatan belum dikalibrasi 16 Nov ‘16 16 Nov ‘16 KIA-KB 16 Nov ‘16 16 Nov ‘16 7.6 In progress
‘16
31. 10 Nov Belum ada ruang khusus untuk 16 Nov ‘16 16 Nov ‘16 Lansia 16 Nov ‘16 16 Nov ‘16 Closed
‘16 lansia
32. 10 Nov Belum ada CM khusus lansia 16 Nov ‘16 16 Nov ‘16 Lansia 16 Nov ‘16 16 Nov ‘16 7.5.5 Closed
‘16
 PUSKESMAS DEMAK III No. Dokumen : FM-MR-02-06

FORMULIR Halaman : Page 4 of 4

LOG STATUS AUDIT TglBerlaku : 01 April 2015

DibuatOleh Mengetahui

drg. DIAN WIDIYANTI dr. RETNO WIDHIASTUTI

Lead Auditor Management Representative