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Puskesmas :

Kab./Kota :

Tanggal :

Surveior :

Kriteria.1.1.1. SKOR SKOR Maksimal

EP 1. 10 10

EP 2 0 10EP 3 5 10

EP 4 10 10

EP 5 0 10

Ep 5 10

!umla" 30 0 50.00#

Kriteria 1.1.2. SKOR SKOR Maksimal

EP 1. 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

Kriteria 1.1.3. SKOR SKOR Maksimal

EP 1 10EP 2 10

EP 3 10

!umla" 0 30 0.00#

Kriteria 1.1.4. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

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EP 5 10

!umla" 0 50 0.00#

Kriteria 1.1.5. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

Kriteria 1.2.1 SKOR SKOR Maksimal

EP 1 10

EP 2 10

!umla" 0 20 0.00#

Kriteria 1.2.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

!umla" 0 20 0.00#

1.2.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10EP 4 10

Ep 5 10

Ep 10

!umla" 0 0 0.00#

Kriteria 1.2.4. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

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!umla" 0 30 0.00#

Kriteria 1.2.5. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

EP $ 10

EP % 10

EP & 10

EP 10 10

EP 11 10

!umla" 0 110 0.00#

Kriteria 1.2.. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

Kriteria 1.3.1. SKOR SKOR MaksimalEP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

Kriteria 1.3.2. SKOR SKOR Maksimal

EP 1 10

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EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

!"tal Sk"r 3#

!"tal $P 5%#

&APAIA' 5.#

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BAB.I. Penyelenggaraan Pelayanan Pusk

*AK!A+A'A,ISIS

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mas (PPP)

APA -A' /AR0S IK$RAKA'

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Puskesmas :

Kabuaten/Kota :

Tanggal :

Surveior :

KRI!$RIA 2.1.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 2.1.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 2.1.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 2.1.4. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 2.1.5. SKOR SKOR MaksimalEP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

EP $ 10

!umla" 0 $0 0.00#

KRI!$RIA 2.2.1. SKOR SKOR MaksimalEP 1 10

EP 2 10

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EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 2.2.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 2.3.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 2.3.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 2.3.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

!umla" 0 20 0.00#

KRI!$RIA 2.3.4. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

!umla" 0 0 0.00#

KRI!$RIA 2.3.5. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 2.3.. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

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EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 2.3.6. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 2..3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 2.3.%. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 2.3.1#. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 2.3.11. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 2.3.12. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 2.3.13. SKOR SKOR Maksimal

EP 1 10

EP 2 10

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EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 2.3.14. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 2.3.15. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

!umla" 0 0 0.00#

KRI!$RIA 2.3.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 2.3.16. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 2.4.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 2.4.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

!umla" 0 20 0.00#

KRI!$RIA 2.5.1. SKOR SKOR Maksimal

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EP 1 5 10

EP 2 10 10

EP 3 0 10

!umla" 15 30 50.00#

KRI!$RIA 2.5.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30

KRI!$RIA 2..1. SKOR SKOR Maksimal

EP 1 0 10

EP 2 5 10

EP 3 10 10

EP 4 10

EP 5 10

EP 10

EP $ 10

EP % 10

EP & 10

EP 10 10

!umla" 15 100 15.00#

!"tal Sk"r 3#

!"tal $P 121#

&APAIA' 3.33

7/26/2019 14.2.a. FILE A.1. LAPORAN HASIL SELF ASSESSMENT.xlsx

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BAB.II. Keemiminan an Manaeme

*AK!A+A'A,ISIS

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uskesmas.(KMP).

'pa (ang "arus )iker*akan

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Puskesmas :

Kab/ Kota

Tanggal :

Surveior :

KRI!$RIA 3.1.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 3.1.2. SKOR SKOR Maksimal

EP 1 10 10EP 2 10 10

EP 3 0 10

EP 4 5 10

!umla" 25 40 2.50#

KRI!$RIA 3.1.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 3.1.4. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 3.1.5. SKOR SKOR MaksimalEP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 3.1.. SKOR SKOR Maksimal

EP 1 10

EP 2 10

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EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 3.1.6. SKOR SKOR Maksimal

EP 1 10EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

EP $ 10

!umla" 0 $0 0.00#

!"tal Sk"r 25!"tal $P 32#

&APAIA' 6.1

7/26/2019 14.2.a. FILE A.1. LAPORAN HASIL SELF ASSESSMENT.xlsx

30/107

BAB.III. Peningkatan Mutu Puskesmas (PMP)

*AK!A+A'A,ISIS

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APA -A' /AR0S IK$RAKA'

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Puskesmas :

Kab./Kota :

Tanggal :

Surveior :

KRI!$RIA 4.1.1. SKOR SKOR Maksimal

EP 1 5 10

EP 2 10 10

EP 3 10

EP 4 10

EP 5 10

EP 10

EP $ 10

!umla" 15 $0 21.43#

KRI!$RIA 4.1.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 4.1.3. SKOR SKOR MaksimalEP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 4.2.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 4.2.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10EP 5 10

!umla" 0 50 0 00#

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KRI!$RIA 4.2.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

!umla" 0 0 0.00#

KRI!$RIA 4.2.4. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 4.2.5. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 4.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 4.3.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

!"tal Sk"r 15

!"tal $P 53#

&APAIA' 2.3

7/26/2019 14.2.a. FILE A.1. LAPORAN HASIL SELF ASSESSMENT.xlsx

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BAB.I7. 0KM Puskesmas yang Ber"ri

*AK!A+A'A,ISIS

Kurang S+P

7/26/2019 14.2.a. FILE A.1. LAPORAN HASIL SELF ASSESSMENT.xlsx

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7/26/2019 14.2.a. FILE A.1. LAPORAN HASIL SELF ASSESSMENT.xlsx

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ntasi Sasaran (0KMBS)

APA -A' /AR0S IK$RAKA'

,engkapi S+P

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BAB.

Puskesmas :

Kab./Kota :

Tanggal :

Surveior :

KRI!$RIA 5.1.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 5.1.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 5.1.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 5.1.4 SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

EP $ 10

!umla" 0 $0 0.00#

KRI!$RIA 5.1.5 SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

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!umla" 0 0 0.00#

KRI!$RIA 5.1.. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 5.2.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 5.2.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 5.2.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

EP $ 10

!umla" 0 $0 0.00#

KRI!$RIA 5.3.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

EP $ 10

!umla" 0 $0 0.00#

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KRI!$RIA 5.3.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 5.3.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 5.4.1. SKOR SKOR Maksimal

EP 1 10EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 5.4.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 5.5.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 5.5.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

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KRI!$RIA 5.5.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 5..1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 5..2. SKOR SKOR Maksimal

EP 1 10

EP 2 10EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA 5..3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 5.6.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

!umla" 0 20 0.00#

KRI!$RIA 5.6.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

!"tal Sk"r #

!"tal $P 1#1#

&APAIA' #.##

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. Keemiminan an M

*AK!A+A'A,ISIS

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47/107

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naemen 0aya Kese8atan Masyarakat (KM0KM).

APA -A' /AR0S IK$RAKA'

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Puskesmas :

Kab./Kota :

Tanggal :

Surveior :

KRI!$RIA .1.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

!umla" 0 0 0.00#

KRI!$RIA .1.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA .1.3. SKOR SKOR Maksimal

EP 1 10EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA .1.4. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10!umla" 0 40 0.00#

KRI!$RIA .1.5. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

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KRI!$RIA .1.. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10EP $ 10

!umla" 0 $0 0.00#

!"tal Sk"r #

!"tal $P 2%#

&APAIA' #.##

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BAB. 7I. Sasaran Kinera an M

*AK!A+A'A,ISIS

7/26/2019 14.2.a. FILE A.1. LAPORAN HASIL SELF ASSESSMENT.xlsx

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s. (SKM).

APA -A' /AR0S IK$RAKA'

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Puskesmas :

Kab./Kota :

Tanggal :

Surveior :

KRI!$RIA 6.1.1. SKOR SKOR Maksimal

EP 1 10 10

EP 2 10 10

EP 3 0 10

EP 4 5 10

EP 5 0 10

EP 0 10

EP $ 10 10

!umla" 35 $0 50.00#

KRI!$RIA 6.1.2. SKOR SKOR Maksimal

EP 1 10 10

EP 2 0 10

EP 3 10 10

EP 4 0 10

EP 5 0 10

EP 0 10

!umla" 20 0 33.33#

KRI!$RIA 6.1.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

EP $ 10

EP % 10

!umla" 0 %0 0.00#

KRI!$RIA 6.1.4. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 6.1.5. SKOR SKOR Maksimal

EP 1 10EP 2 10

EP 3 10

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!umla" 0 30 0.00#

KRI!$RIA 6.2.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 6.2.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

KRI!$RIA 6.2.3. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

EP 4 10

!umla" 0 40 0.00#

KRI!$RIA 6.3.1. SKOR SKOR Maksimal

EP 1 10

EP 2 10

EP 3 10

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!umla" 0 40 0.00#

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EP 3 10

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EP 1 10

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EP 1 10

EP 2 10

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KRI!$RIA 6..5. SKOR SKOR Maksimal

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EP 1 10

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KRI!$RIA 6.6.1. SKOR SKOR Maksimal

EP 1 10

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EP 1 10

EP 2 10

EP 3 10

EP 4 10

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KRI!$RIA 6.1#.2. SKOR SKOR Maksimal

EP 1 10

EP 2 10

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!"tal Sk"r 55

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BAB.7II. ,ayanan Klinis ya

*AK!A+A'A,ISIS

SK - S+P a)a

agan alur a)a

elum perna" sos - monev

alur a)a sos belum

survei belum

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S+P i)enti pasien a)a

e)ia ino a)a

evaluasi blm

S+P a)a

Evaluasi tanggapan blm

o blm

no ker*asama blm

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g Ber"rientasi Pasien (,KPP).

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,akukan Evaluasi

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uat o u*ukan

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Puskesmas :

Kab./Kota :

Tanggal :

Surveior :

KRI!$RIA .1.1. SKOR SKOR Maksimal

EP 1 10

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EP 1 10

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EP 2 10

EP 3 10

EP 4 10

EP 5 10

!umla" 0 50 0.00#

KRI!$RIA .1.. SKOR SKOR MaksimalEP 1 10

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EP 4 10

!umla" 0 40 0.00#

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EP 2 10

EP 3 10EP 4 10

EP 5 10

EP 10

EP $ 10

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EP 1 10

EP 2 10

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EP 5 10

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EP $ 10

EP % 10

!umla" 0 %0 0.00#

KRI!$RIA .2.2. SKOR SKOR Maksimal

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EP 1 10

EP 2 10

EP 3 10

EP 4 10

EP 5 10

EP 10

EP $ 10EP % 10

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EP 1 10

EP 2 10

EP 3 10

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EP 1 10

EP 2 10

EP 3 10

!umla" 0 30 0.00#

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EP 1 10

EP 2 10

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!umla" 0 20 0.00#

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EP 1 10

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EP 2 10

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EP 5 10

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KRI!$RIA .6.3. SKOR SKOR Maksimal

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&APAIA' 1.1

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BAB.7III. Manae

*AK!A+A'A,ISIS

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en Penunang ,ayanan Klinis (MP,K).

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Puskesmas :

Kab./Kota :

Tanggal :Surveior :

KRI!$RIA %.1.1. SKOR SKOR Maksimal

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EP 5 10

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EP 1 10

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BAB.I9.Peningkatan Mutu Klinis an

*AK!A+A'A,ISIS

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eselamantan Pasien (PMPK).

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