Panduan Pelayanan Poli

BAB I PENDAHULUAN A. Latar Belakang

Pelayanan kesehatan adalah upaya yang diselenggarakan oleh suatu organisasi untuk memeliharan dan meningkatkan kesehatan, mencegah dan menyembuhkan penyakit serta memulihkan kesehatan individu, keluarga kelompok dan masyarakat. Pelayanan kesehatan yang bermutu adalah  pelayanan kesehatan yang dapat memuaskan setiap pemakai jasa pelayanan kesehatan sesuai dengan tingkat kepuasan rata-rata penduduk serta yang  penyelengganya s esuai dengan kode etik dan standar pelayanan profesi yang telah ditetapkan. Pelayanan

pasien

rawat

jalan

merupakan

pelayanan

yang

dapat

memberikan tindakan yang cepat, tepat dan professional sesuai dengan kebutuhan pasien. Upaya peningkatan pelayanan Unit Unit Poliklinik di tujukan untuk menunjang pelayanan sesuai kebutuhan pasien sehingga dapat memberikan pelayanan berkualitas dan professional untuk memenuhi kebutuhan pasien. Dengan semakin meningkatnya jumlah kunjungan pasien rawat jalan, maka diperlukan peningkatan pelayanan Unit Poliklinik. Berdasarkan hal tersebut, maka di Unit Poliklinik perlu dibuat standar pelayanan yang merupakan pedoman bagi semua pihak dalam pelaksanaan pelayanan yang diberikan ke pasien. Maka melakukan pelayanan Unit Poliklinik di harus  berdasarkan standar pelayanan Unit Poliklinik yang sudah sudah ditetapkan.

1

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B. Tujuan

1. Memberikan pedoman dalam pelaksanaan manajemen dan pelayanan Unit Poliklinik RS BaliMed Negara 2. Meningkatkan

mutu

dan

keselamatan

pasiendi

Unit

Poliklinik

Meningkatkan efektifitas pelayanan sehingga dapat memebrikan tindakan yang cepat, tepat dan professional sesuai dengan kebutuhan pasien C. Ruang Lingkup

Ruang lingkup pelayanan Unit Poliklinik RS BaliMed BaliMed Negara meliputi: 1. Pasien umum Yaitu pasien yang memerlukan penanganan oleh dokter umum 2. Pasien dengan kebutuhan khusus Yaitu pasien memerlukan pelayanan dengan dokter spesialis sesuai dengan kebutuhan atau penyakit yang mendasari D. Batasan Operasional

Unit Poliklinik adalah unit pelayanan yang memberikan pelayanan terhadap pasien non emergency yang memerlukan pelayanan dokter umum dan atau dokter spesialis E. Landasan Hukum

1. UU No. 36 tahun 2009 tentang Kesehatan 2. UU No. 44 tahun 2009 tentang Rumah Sakit 3. UU No. 29 tahun 2004 tentang Praktek Kedokteran

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BAB II STANDAR KETENAGAAN

A. Kualifikasi Sumber Daya Manusia

Pola ketenagaan dan sumber daya manusia Poliklinik  Nomor

Nama Jabatan

Kualifikasi

Keterangan

Formasi 1

Ka Unit Poliklinik

D III

Bersertifikat

Keperawatan

BHD dan Manajemen Bangsal

2

3

Perawat Primer

Perawat Asossiet

D III

Bersertifikat

Keperawatan

BHD

D III

Bersertifikat

Keperawatan

BHD

B. Distribusi Ketenagaan Ketenagaan

Pola pengaturan ketenagaan Unit Poliklinik yaitu: 1. Dines Pagi: dinas pagi dimulai dari pukul 07.30 sampai dengan pukul

14.00 2. Dines Sore: dinas sore dimulai dari pukul 14.00 sampai dengan pukul

21.00

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C. Pengaturan Pengaturan Shift Jaga Unit Poliklinik

1. Pengaturan jadwal jaga Unit Poliklinik menjadi tanggung jawab Ka Unit Rawat Jalam dan disetujui oleh Kepala Sub Divisi Asuhan Keperawatan 2. Pengaturan jadwal dinas perawat Unit Poliklinik dibuat dan dipertanggung  jawabkan oleh Kepala Unit Rawat Jalan dan disetujui oleh Kepala Bagian Keperawatan 3. Jadwal dinas dibuat untuk jangka waktu satu bulan dan direalisasikan setiap satu bulan 4. Untuk petugas yang memiliki keperluan penting pada hari tertentu, maka  petugas tersebut dapat mengajukan permintaan ijin/cuti kepada Kepala Ruangan Unit Poliklinik dan menulisnya pada form permintaan tukaran  jaga/cuti. Permintaan akan disesuaikan dengan kebutuhan tenaga yang ada (apabila tenaga cukup dan berimbang serta tidak menganggu pelayanan, maka permintaan tersebut disetujui) 5. Setiap petugas jaga/shift perawat harus ada perawat primer dengan syarat

 pendidikan minimal D III Keperawatan dan masa kerja minimal 2 tahun 6. Jadwal dinas terbagi atas dinas pagi dan dinas sore 7. Apabila ada petugas jaga karena sesuatu tidak dapat jaga sesuai dengan  jadwal yang telah ditetapkan (terencana), maka petugas bersangkutan harus membertahu Kepala Unit Rawat Jalan. Sebelum memberitahu Kepala Unit Rawat Jalan, diharapkan petugas yang bersangkutan sudah mencari

petugas

pengganti

yang

selevel,

apabila

petugas

yang

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 bersangkutan tidak mendapatkan petugas pengganti, maka Kepala Unit Rawat Jalan akan mencari petugas pengganti. 8. Apabila ada petugas yang tiba-tiba tidak dapat jaga jaga sesuai dengan  jadwal yang telah ditetapkan (tidak terencana), maka Kepala Unit Rawat Jalan akan mecari petugas pengganti. pengganti. Apabila petugas pengganti pengganti tidak didapatkan, maka petugas yang dinas pada shift sebelumnya wajib menggantikannya. D. Pengaturan Pengaturan Jadwal Praktek Dokter Umum Dan Dokter Spesialis

1. Pengaturan jaga praktek dokter umum di poliklinik umum mengikuti pola  jadwal dokter umum yang bertugas yang mengikuti shift jaga di UGD dan  poliklinik yang setiap bulan oleh kepala kepala SMF Umum 2. Pengaturan jaga praktek dokter spesialis disusun oleh kepala Sub Divisi Pelayanan Medic setelah berkoordinasi dengan masing-masing Kepala SMF 3. Jadwal praktek dokter spesialis sudah ditetapkan dan dijadwalkan dalam hari tertentu dan sudah diedarkan ke unit terkait 4. Apabila dokter spesialis karena sesuatu hal sehingga tidak dapat praktek sesuai dengan jadwal yang telah ditetapkan maka akan diberitahukan kepada pasien yang telah mendaftar secara langsung di registrasi ataupun via telepon bagi pasien yang reservasi via telepon, selanjutnya pasien dapat beralih ke dokter spesialis lain yang memiliki spesialisasi sama yang  praktek di hari tersebut t ersebut ataupun menunggu jadwal prakter dokter spesialis

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BAB III STANDAR FASILITAS

A. Denah Ruangan Poli Poli

Poli

Poli

Poli

Poli

Poli

Poli

Poli

estetika kulit

ortho

saraf

interna

gigi

bedah

THT

mata

Poli

Poli

obgyn

anak

RUANG TUNGGU 1. Ruangan Ruangan unit Poliklinik terdapat dilantai 1 untuk pelayanan rawat jalan  pasien umum dan dokter spesialis (spesialis interna, genekologi, anak, ortopedi, dll). Unit pelayanan rawat jalan berdekatan dengan bagian kasir dan farmasi untuk mempermudah dan mempercepat pelayanan terhadap  pasien. 2. Peralatan Peralatan yang tersedia di Unit Poliklinik meliputi alat medis untuk  pemeriksaan fisik umum dan alat khusus sesuai dengan bidang keahlian

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

 Nebulizer



Set rawat luka



Kasa steril yang sudah di pack



Alat BS stik

 b. Alat-alat di ruang poliklinik bedah 

Hecting set



WT set



Lampu sorot portable untuk tindakan



Kassa steril telah dipack dalam trombol



Troli tindakan bedah

c. Alat-alat di ruang poliklinik THT 

Set THT



Endoskopi THT



Sterilisator kering



Radiofrekuensi



Set irigasi sinus



Set myringotomi

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

Oxygen dan flowmeter



Alat BS stik

e. Alat-alat di ruang poliklinik obstetric dan genekologi

f.



USG 2 dimensi dan 4 dimensi



Alat Kolposkopi



Alat Cryoterapi



Meja Ginekologi



Set pemeriksaan ginekologi



Sterilisator kering

Alat-alat di ruang poliklinik anak 

Otoskop



Alat untuk tindik telinga

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BAB IV TATALAKSANA PELAYANAN UNIT POLIKLINIK

A. Tata Laksana Pendaftaran Pasien

1. Petugas penanggung jawab Petugas admission 2. Perangkat kerja Status medis 3. Tata laksana pendaftaran di poliklinik a. Pendaftaran pasien untuk poliklinik umum Dilakukan di registrasi lantai 1, selanjutnya pasien tracer yang  berwarna merah dan tancapkan di antrian pasien yang ditempatkan di depan poliklinik umum. Apabila pasien memerlukan rujukan ke spesialis akan dibuatkan lembar konsul dan pasien di antar untuk  pendaftran ke poliklinik spesialis yang di tuju.  b. Pendaftran pasien ke poliklinik spesialis Pasien yang akan mendaftar ke polklinik spesialis dapat melakukan

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 b. Perawat Unit Poliklinik 2. Perangkat kerja a. Pesawat Telepon  b. Hand phone 3. Tata laksana pendaftaran di poliklinik a. Antara Unit Poliklinik dengan unit lain dalam adalah dengan nomor extension masing-masing unit  b. Antara Unit Poliklinik dengan dokter spesialis menggunakan pesawat telephone langsung dari Unit Poliklinik atau melalui bagian operator c. Antara pasien dari luar dapat langsung melalui operator atau nomor telepon poliklinik C. Tata Laksana Pelayanan di Unit Poliklinik

1. Petugas penanggung jawab Dokter umum di poliklinik umum dan dokter spesialis di poliklinik spesialis 2. Perangkat kerja a. Stetoskop

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3. Tata laksana pendaftaran di poliklinik a. Pasien/keluarga pasien mendaftar ke bagian admission  b. Pasien dipanggil ke ruang periksa sesuai dengan nomor antrian c. Apabila diperlukan pemeriksaan penunjang seperti laboratorium atau radiologi, dokter akan memberikan surat pengantar pemeriksaan  penunjang dan perawat akan mengantarkan pasien ke unit pemeriksaan  penunjang tersebut. d. Setelah ada hasil pemeriksaan penunjang, pasien akan dipanggil kembali

keruang

periksa

untuk

dijelaskan

hasil

pemeriksaan

 penunjang, diagnostic, dan rencana rencana terapi e. Jika diperlukan tindakan yang dapat dilakukan di polklinik dokter umum atau dokter spesialis maka pasien dan keluarga diminta untuk mengisi form persetujuan tindakan sebagai bukti pasien dan keluarga

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i.

Jika pasien direncanakan untuk rawat inap atau tindakan bedah hari itu,  pasien akan diberikan surat pengantar atau instruksi dalam catatan medis terintergrasi oleh dokter umum atau dokter spesialis, selanjutnya  pasien di antar oleh perawat menuju UGD untuk prosedur lebih le bih lanjut. Perawat poliklinik wajib memberikan operan kepada perawat UGD dan atau dokter jaga UGD mengenai instruksi yang diberikan dokter spesialis. Jika pasien ada tindakan khusus seperti pasien obstetric dan ginekologi maka pasien akan diantar oleh perawat poliklinik ke ruang VK

 j.

Bagi pasien yang membutuhkan tindakan diagnostic khusus seperti endoskopi, bronkoskopi dan tindakan ESWL akan dijadwalkan sesuai kesepakatan pasien dengan dokter spesialis. Pada saat sebelum rencana tindakan, pasien disarankan ke bagian regristrasi dan front office (FO)

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dihadapannya sesudah mendapatkan informasi cukup tentang tindakan kedokteran yang dimaksud. 1. Petugas penanggung jawab Dokter yang akan melakukan tindakan medis mempunyai tanggung jawab utama memberikan informasi dan penjelasan yang diperlukan. Perawat hanya bertindak sebagai saksi dalam imformed consent. 4. Perangkat kerja Formulir persetujuan tindakan 5. Tata laksana pendaftaran di poliklinik a. Dokter umum atau dokter spesialis menjelaskan tujuan dari pengisian informed consent pada pasien/keluarga pasien di saksikan oleh perawat  b. Bila pasien menyetujui, jnformed consent diisi dengan lengkap di saksikan oleh perawat

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

Persetujuan atau penolakan tindakan medis diberikan setelah diberikan cukup adekuat informasi dan penjelasan yang diperlukan

e. Isi informasi meliputi 

Diagnosis



Informasi dan penjelasan tentang tujuan dan prospek keberhasilan tindakan medik yang akan dilakukan



Cara yang akan dilakukan



Resiko dan komplikasi yang akan terjadi



Alternatif tindakan medis yang tersedia dan serta resiko masing masing



Prognosis kasus bila tindakan medis dilakukan

Informasi diberikan secara lisan.

Pemberian informasi secara tertulis hanya

sebagai pelengkap penjelasan. Cara menyatakan persetujuan persetujuan dapat lisan maupun

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BAB V LOGISTIK

A. Perencanaan Menentukan macam, mutu dan jumlah alat yang dibutuhkan dalan pelayanan Unit Poliklinik 1. Peralatan kesehatan Alat kesehatan yang yang digunakan untuk mendiagnosa,

menangani dan

monitor, serta alat medis pendukung pendukung untuk pelayanan rawat jalan 2. Obat-obatan di troli emergency diperiksa oleh petugas farmasi setiap sebulan sekali B. Pengadaan

Pengadaan peralatan, obat, bahan medis habis pakai pakai sesuai. Kebutuhan:

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D. Distribusi

Peralatan dapat dikeluarkan untuk digunakan bila diperlukan. Terdapat tiga  prosedur administrasi yang berkaitan dengan pengeluaran peralatan, antara lain: 1. Catatan buku besar (menuliskan pengeluaran barang tersebut dalam buku  besar persediaan) 2. Surat/kupon pengeluaran barang harus ditanda tangani 3. Catatan inventaris dari bagian yang menerima dan menggunakan peralatan

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BAB VI KESELAMATAN PASIEN

A. Pengertian

Keselamatan pasien (pasien safety) adalah suatu sistem dimana rumah sakit membuat asuhan pasien lebih aman. Sistem tersebut meliputi: 1. Assesmen resiko 2. Identifikasi dan pengelolaan hal yang berhubungan dengan resiko pasien

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suatu KTD yang terjadi akibat komplikasi yang tidak dapat dicegah dengan pengetahuan mutakhir 3. Kejadian Nyaris Cidera (KNC) / Near Miss adalah suatu kesalahan akibat melaksanakan suatu tindakan (commission) atau tidak mengambil mengambil tindakan yang yang seharusnya diambil (omission), yang dapat mencederai pasien, tetapi cedera serius tidak terjadi: a. Karena "keberuntungan"  b. Karena "pencegahan"

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1. Tercipta nya budaya keselamatan pasien di rumah sakit 2. Meningkatkan akuntabilitas rumah sakit terhadap pasien dan masyarakat 3. Menurunkan Kejadian Tidak Diharapkan (KTD) di rumah sakit Terlaksananya

program

program

pencegahan

sehingga

 pengulangan Kejadian Tidak Diharapkan Diharapkan (KTD)

C. Standar Keselamatan Pasien

Standar keselamatan pasien harus mencangkup beberapa hal:

tidak

terjadi

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3. Memberikan tindakan sesuai dengan instruksi dokter jaga MOD atau dokter praktek 4. Mengobservasi keadaan umum pasien 5. Mendokumentasikan kejadian tersebut pada formulir "Pelaporan Insiden Keselamatan"

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BAB VII KESELAMATAN KERJA

A. Pendahuluan

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Dengan munculnya penyebaran penyakit tersebut diatas memperkuat keinginan untuk mengembangkan dan menjalankan prosedur yang bisa melindungi semua pihak dari penyebaran infeksi.

Upaya pencegahan

 penyebaran infeksi dikenal melalui "Kewaspadaan Umum" atau "Universal

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6. Praktek kebersihan ruangan yang belum memadai D. Prinsip keselamatan kerja

 prinsip utama prosedur universal precaution dalam kaitan keselamatan kerja adalah menjaga higiene sanitasi indivisu, higiene sanitasi ruangan dan

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BAB VIII PENGENDALIAN PENGENDALIAN MUTU

Ada beberapa indikator mutu dalam pelayanan unit Poliklinik seperti dalam table

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BAB IX PENUTUP

Demikian panduan pelayanan unit poliklinik ini dibuat untuk mendukung