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Nomor
:
Revisi ke : Berlaku Tgl. :
011./FM TINDAKAN PERBAIKAN DAN PENCEGAHAN JANUARI 2017 No. Dokumen
FORMULIR FM/................./WMM/2017
Revisi Ke Tanggal berlaku KABUPATEN BOJONEGORO
No. Permohonan Bagian/Urusan/Unit Tgl.
TINDAKAN PERBAIKAN & PENCEGAHAN : : : Temuan oleh Karyawan / Unit
UPTD PUSKESMAS SEKAR
Keluhan Pelanggan
Audit Internal Lain-lain Uraian Keluhan/ Pengaduan; ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. (disi oleh pelapor) Pelapor Penerima Tanggal .....................................
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Analisa Penyebab Masalah; ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. (Diisi oleh Pengelola Unit/Auditor)
Tindakan Perbaikan & Pencegahan; ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. (Diisi oleh Manajemen Mutu)
Batas Tanggal Penyelesaian Tindakan Perbaikan & Pencegahan
Penanggung jawab Tindakan Perbaikan & Pencegahan
PJ Unit
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Verifikasi Tindakan Perbaikan & Pencegahan :
Tanggal Verifikasi ....................................... Wakil Manajemen Mutu
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