FORM 4

PENILAIAN KINERJA STAF MEDIS

NAMA LENGKAP
(dengan gelar)

DIAJUKAN UNTUK

Proses Pengangkatan Kembali Staf Medis

Proses Penambahan Kewenangan Klinis
Rekredensial

baik sekali
kurang
1. Patient Care
(praktisi menyediakan perawatan pasien yang tepat dan efektif
untuk promosi kesehatan, pencegahan penyakit,pengobatan penyakit,
dan perawatan di akhir hidup)

2. Medical/Clinical Knowledge *
(menerapkan dan mengembangkan ilmu medis, ilmu klinis dan sosial,
dan penerapan pengetahuan untuk perawatan pasien dan
pendidikan)

3. Technical Skills & Application *

(demonstrated knowledge and application of the skills required,

Includes knowledge and understanding of appropriate equipment,
policies and procedures)

4. Practice-Based Learning & Improvement

(using scientific evidence and methods to investigate, evaluate,
and improve patient care practices)

5. Interpersonal & Communication Skills

(enable them to establish and maintain professional relationships
with patients, families, and other members of health care teams)

6. Professionalism
(reflected in a commitment t continuous professional
development, ethical practice, an understanding and sensitivity
to diversity and a responsible attitude toward patients, their
profession, and society)

7. Personal & Professional Development

(demonstrated experience and understanding of the need for
continuation of both personal and professional development)

8. Teamwork
(demonstrated ability to participate as an active member of the
team, consistent with the philosophy and policies of the
organization)

9. System-Based Practices
(the understanding of the contexts and systems in which health
care is provided)

10.

Administration & Documentation

(through the use of organizational processes ensure that all

Administration and documentation requirements are initiated and
Completed in a professional and timely manner)

*) Dilakukan oleh Komite Medik

11.

Number of Services

baik

cukup

(see attachment)
12.
Clinical Outcomes Review
(see attachment)

HASIL PENILAIAN
DIREKOMENDASI (UNTUK DILAKUKAN PENGANGKATAN KEMBALI)
TIDAK DIREKOMENDASI

KOMENTAR

TIM
PENILAI
Tanda
tangan

Dr. Mulyadi Muchtiar MARS

Dr. Juniwati Gunawan

Medical & Ancillaries

Manager

Chief Executive Officer

FORM 4 (lampiran)

PENILAIAN KINERJA STAF MEDIS

NAMA LENGKAP
(dengan gelar)

NUMBER OF SERVICES

Previous Year

Current Year
1. Number of Out-Patient
2. Number of In-Patient
3. Number of Surgery
Complex
Major
Minor
Simple
4. Number of Procedure
5. Average length of stay

CLINICAL OUTCOME REVIEW

This is particularly to review the clinical outcome performed by medical staf
based on clinical indicator/clinical pathway/etc :
1.
2.
3.
4.

Unplanned Re-admission (72 hours)

Unplanned Return to OT
Unexpected Admit to Intensive Care
Nasocomial infection
Pressure Ulcer

ILO (surgical side infection)

5. Mortality Rate