KATA PENGANTAR

Dengan mengucapkan Puji syukur kehadirat Allah SWT ,serta atas limpahan
taufik rahmat dan hidayahNya akhirnya kami dapat menyusun dan menyelesaikan
penyusunan Standart Pelayanan Minimal Puskesmas Kendal tahun 2017 sampai
dengan tahun 2021 tepat pada waktunya.
Tujuan penyusunan Standart Pelayanan Minimal Puskesmas Kendal adalah
untuk Mempersiapkan Puskesmas Kendal menjadi Puskesmas BLUD/ Badan
LayananUmum Daerah yang senantiasa mampu memberikan kualitas pelayanan
yang diharapkan masyarakat serta
dapat dijadikan acuan untuk melaksanakan Program kegiatan Puskesmas Kendal
BLUD tahun 2017 sampai dengan tahun 2021.
Dalam penyusunan Standart Pelayanan Minimal ini tentunya masih jauh dari
kesempurnaan maka dari itu kami mengucapkan terimakasih atas semua pihak baik
dari programer maupun bapak kepala puskesmas yang senantiasa memberikan
dukungan berupa support moral dan material sehingga penyusunan buku ini sesuai
waktu yang telah ditentukan.
Dan akhirnya besar harapan kami agar buku ini bisa membawa banyak
manfaat terhadap peningkatan kualitas pelayanan puskesmas meliputi upaya
kesehatan prioritas maupun pengembangan berbasis pemberdayaan
masyarakat.Akhir kata wassalamualaikum warahmatullohi wabarokhatu.

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 DAFTAR ISI

Kata Pengantar ............................................................................................ i

Daftar Isi ....................................................................................................... ii
.....................................................................................................................
Indikator Standar Pelayanan Minimal Bidang Kesehatan Di Kab/Kota .........
Profil Dan Target SPM Bidang Kesehatan Kabupaten/Kota .........................
BAB 1 ........................................................................................................... 1
.....................................................................................................................
USULAN STANDAR PELAYANAN MINIMAL PUSKESMAS
BLUD KABUPATEN NGAWI ........................................................................ 1
UPAYA KESEHATAN MASYARAKAT (UKM) PUSKESMAS KENDAL
BLUD TAHUN 2017-2021 ............................................................................ 1
I. Upaya Kesehatan Dasar ........................................................................ 1
II. Meningkatnya Kesehatan Rujukan ........................................................ 2
III. Meningkatnya Penyelidikan Epidemiologi dan Penanggulangan KLB ... 2
IV. Meningkatnya Promosi Kesehatan dan Pemberdayaan Masyarakat ..... 2
Standart Pelayanan Minimal Inovatif ............................................................ 3
UPAYA KESEHATAN PERORANGAN (UKP) KENDAL BLUD TAHUN
2017-2021 .................................................................................................... 4
A. Pelayanan Dalam Gedung ..................................................................... 4
I. Pelayanan Loket ................................................................................ 4
II. Pengobatan Umum ............................................................................ 4
III. Pengobatan Gigi ................................................................................ 4
..........................................................................................................
IV. Gawat Darurat ................................................................................... 4
V. Pelayanan KIA/KB ............................................................................. 5
VI. Pelayanan Imunisasi.......................................................................... 5
VII. Rawat Inap ........................................................................................ 6
VIII. Laboratorium ..................................................................................... 7
IX. Kefarmasian ...................................................................................... 8
X. Pelayanan Gizi .................................................................................. 8

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 XI. Pelayanan Keluarga Miskin ( Gakin )................................................. 8
XII. Aspek Rekam Medis .......................................................................... 8
XIII. Pengelolaan Limbah .......................................................................... 9
XIV. Ambulans........................................................................................... 9
XV. Pelayanan Laundry ............................................................................ 9
XVI. Pencegahan Pengendalian Infeksi .................................................... 9
XVII. Pemeliharaan sarana......................................................................... 9
XVIII. Administrasi dan manajemen ............................................................ 10

BAB II ........................................................................................................... 11
DEFINISI OPERASIONAL STANDAR PELAYANAN MINIMAL
PUSKESMAS BLUDUPAYA KESEHATAN MASYARAKAT (UKM) ............. 11
I. PELAYANAN KESEHATAN DASAR ......................................................... 11
.....................................................................................................................
1. Cakupan kunjungan ibu hamil K4 ....................................................... 11
2. Cakupan komplikasi kebidanan yang ditangani .................................. 13
3. Cakupan pertolongan persalinan oleh tenaga kesehatan yang memiliki
Kompetensi kebidanan ...................................................................... 16
4. Cakupan pelayanan nifas ................................................................... 18
5. Cakupan Neonatus dengan komplikasi yang ditangani ...................... 21
6. Cakupan kunjungan bayi .................................................................... 23
7. Cakupan Desa/Kelurahan universal Child Immunization ( UCI ) ......... 26
8. Cakupan pelayanan anak balita.......................................................... 28
9. Cakupan pemberian makanan pendamping ASI pada anak usia 6-24 bulan
Keluarga miskin ................................................................................. 30
10. Cakupan balita gizi buruk mendapat perawatan ................................. 32
11. Cakupan penjaringan kesehatan siswa SD dan setingkat .................. 34
12. Cakupan peserta KB aktif ................................................................... 36
13. Cakupan penemuan dan penanganan penderita penyakit ................. 38
a. Cakupan penemuan penderita AFP .............................................. 38
b. Cakupan penemuan dan penanganan penderita peneumoni balita
...................................................................................................... 40

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 c. Cakupan penemuan dan penanganan pasien baru TB BTA positif
...................................................................................................... 43
d. Cakupan penemuan dan penanganan DBD .................................. 45
e. Cakupan penanganan penderita diare .......................................... 48
f. Cakupan penemuan kasus HIV/AIDS ............................................ 50
g. Cakupan penemuan kasus malaria ............................................... 50
14. Cakupan Pelayanan Kesehatan Dasar Pasien Masysrakat Miskin ..... 51
II. PELAYANAN KESEHATAN RUJUKAN ................................................... 53
15. Cakupan pelayanan kesehatan rujukan pasien masyarakat miskin .... 53
III. PENYELIDIKAN EPIDEMIOLOGI DAN PENANGGULANGAN KLB ....... 55
16. Cakupan Desa/Kelurahan Mengalami KLB yang dilakukan penyelidikan
Epidemiologi <24 jam ................................................................................... 55
.....................................................................................................................
IV. PROMOSI KESEHATAN DAN PEMBERDAYAAN
MASYARAKAT ....................................................................................... 58
...............................................................................................................
17. Cakupan desa siaga aktif.................................................................... 58

BAB III .......................................................................................................... 62

DEFINISI OPERASIONAL STANDAR PELAYANAN MINIMAL
PUSKESMAS BLUD UPAYA KESEHATAN MASYARAKAT
(UKM) INOVATIF ......................................................................................... 62
1. Cakupan K1 ....................................................................................... 62
2. KN Lengkap ....................................................................................... 63
3. Pelayanan Anak Pra Sekolah ............................................................ 64
4. Cakupan Bumil Mendapat Tablet fe ................................................... 65
5. Cakupan Pemberian Vitamin A Usia 6-11 bulan ................................ 66
6. Cakupan Pemberian Vitamin A Usia 12-59 bulan .............................. 68
7. Cakupan Pelayanan Kesehatan Remaja ........................................... 69
8. Skrining Kesehatan dan pelayanan Kesehatan Reproduksi Pada
Penduduk Dewasa (20-59 tahun )di Puskesmas dan Jaringannya .... 71
9. Cakupan Lansia dan Pralansia yang Dilayani .................................... 74
10. Penemuan Kasus Filariasis ............................................................... 75

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 11. Penemuan Kasus Malaria .................................................................. 76
12. Cakupan Kesembuhan Penderita Kusta (PB/MB) ............................. 78
13. Cakupan Posyandu PURI .................................................................. 79
14. Cakupan Rumah Tangga Sehat ........................................................ 82
15. Perawatan Kesehatan Masyarakat (Comunity Health Nursing/CHN) 84
16. Rumah Sehat ..................................................................................... 85
17. Inspeksi Sanitasi di Sekolah Pendidikan Dasar, Pasar Tradisional,
Hotel NonBintang, dan Rumah Makan/Restoran ....................................... 86
18. Upaya Kesehatan Kerja ..................................................................... 88

BAB IV .......................................................................................................... 90
DEFINISI OPERASIONAL STANDART PELAYANAN MINIMAL
PUSKESMAS BLUD UPAYA KESEHATAN PERORANGAN (UKP) ............ 90
I. PUSKESMAS SECARA KESELURUHAN ............................................... 90
1.1 Visite rate ........................................................................................... 90
1.2 Contact rate........................................................................................ 90
II. PELAYANAN GAWAT DARURAT ........................................................... 91
II.1 Kemampuan menangani life saving ................................................... 91
II.2 Pasien yang tertangani di UGD .......................................................... 92
II.3 Waktu tanggap pelayanan gawat darurat ........................................... 92
II.4 Jam buka pelayanan gawat darurat ...................................................
II.5 Pemberi pelayanan kegawatdaruratan bersertifikat Advanced Trauma Life
II.6 Support/Basic Trauma Life Support/Advanced Cardiac Life Support/
Penanggulangan penderita gawat darurat yang masih berlaku ............... 93
II.7 Kepuasan pelanggan ......................................................................... 93
II.8 Kematian pasien ≤ 24 jam .................................................................. 94
III. PELAYANAN RAWAT JALAN ............................................................... 94
III.1 Dokter pemberi pelayanan di poli umum ........................................... 94
III.2 Dokter pemberi pelayanan di poli gigi ............................................... 95
III.3 Ketersediaan pelayanan.................................................................... 95
III.4 Jam buka pelayanan sesuai ketentuan ............................................. 96
III.5 Waktu tunggu di rawat jalan .............................................................. 96
III.6 Kepuasan pelanggan ........................................................................ 97

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IV. PELAYANAN RAWAT INAP .................................................................. 97
IV.1 Pemberi pelayanan di rawat inap ...................................................... 97
IV.2 Dokter penanggung jawab pasien rawat inap ................................... 98
IV.3 Ketersediaan pelayanan rawat inap .................................................. 98
IV.4 Jam visite dokter ............................................................................... 99
IV.5 Kejadian infeksi nosokomial.............................................................. 99
IV.6 Tidak adanya kejadian pasien jatuh yang berakibat
kecacatan/kematian .................................................................................
..................................................................................................................... 100
IV.7 Kematian pasien > 48 jam ................................................................
..................................................................................................................... 100
IV.8 Kejadian pulang paksa......................................................................
..................................................................................................................... 101
IV.9 Kepuasan pelanggan ........................................................................
..................................................................................................................... 101
IV.10 BOR ( Bed Occupation Rate ).........................................................
..................................................................................................................... 102
IV.11 ALOS ( Average Length of Stay ) ...................................................
..................................................................................................................... 102
V. PELAYANAN PERSALINAN ..................................................................
............................................................................................................... 103
V.1 Kejadian kematian ibu karena persalinan ..........................................
..................................................................................................................... 103
V.2 Pemberi pelayanan persalinan normal ..............................................
..................................................................................................................... 103
V.3 Pemberi persalinan dengan penyulit oleh Tim Pelayanan Obstetri neonatal
Emergency Dasar ( PONED ) ..................................................................
..................................................................................................................... 104
V.5 Kemampuan menangani berat badan lahir rendah ( BBLR )
1500 gr-2500 gr........................................................................................
..................................................................................................................... 105
V.6 Kepuasan pelanggan .........................................................................
..................................................................................................................... 105

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VI. PELAYANAN LABORATURIUM .............................................................
..................................................................................................................... 106
VI.1 Waktu tunggu hasil pelayanan laboraturium .....................................
..................................................................................................................... 106
VI.2 Pelaksanaan ekspertisi hasil pemeriksaan laboraturium ..................
..................................................................................................................... 106
VI.3 Tidak adanya kesalahan pemberian hasil pemeriksaan laboraturium
..................................................................................................................... 107
VI.4 Kepuasan pelanggan ........................................................................
..................................................................................................................... 107
VII. PELAYANAN FARMASI.........................................................................
............................................................................................................... 108
VII.1 Waktu tunggu pelayanan obat jadi ...................................................
..................................................................................................................... 108
VII.2 Waktu tunggu pelayanan obat racikan .............................................
..................................................................................................................... 108
VII.3 Tidak adanya kejadian kesalahan pemberian obat ..........................
..................................................................................................................... 109
VII.4 Kepuasan pelanggan .......................................................................
..................................................................................................................... 109
VII.5 Penulisan resep sesuai formularium ................................................
..................................................................................................................... 110
VIII. PELAYANAN GIZI ...............................................................................
............................................................................................................. 110
VIII.1 Ketepatan waktu pemberian makanan kepada pasien ...................
..................................................................................................................... 110
VIII.2 Ketersediaan konseling gizi oleh tenaga gizi ..................................
..................................................................................................................... 111
VIII.3 Kesesuaian pemberian diet ............................................................
..................................................................................................................... 111
IX. PELAYANAN KELUARGA MISKIN ( GAKIN ) .......................................
............................................................................................................... 112
IX.1 Pelayanan terhadap pasien keluarga miskin ( gakin ) yang datang ke

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 Puskesmas pada setiap unit pelayanan ............................................
..................................................................................................................... 112
X. ASPEK REKAM MEDIS .........................................................................
............................................................................................................... 113
X.1 Kelengkapan pengisian rekam medis 24 jam setelah pelayanan ......
..................................................................................................................... 113
X.2 Kelengkapan Informal Consent setelah mendapatkan informasi
yang jelas .................................................................................................
..................................................................................................................... 113
X.3 Waktu penyediaan dokumen rekam medis pelayanan rawat jalan ....
..................................................................................................................... 114
X.4 Waktu penyediaan dokumen rekam medis pelayanan rawat inap .....
..................................................................................................................... 114
XI. PENGELOLAAN LIMBAH .......................................................................
..................................................................................................................... 115
XI.1 Baku mutu limbah cair ......................................................................
..................................................................................................................... 115
XI.2 Pengelolaan limbah padat infeksius sesuai dengan aturan ..............
..................................................................................................................... 116
XII. PELAYANAN AMBULANS .....................................................................
............................................................................................................... 116
XII.1 Waktu pelayanan ambulans.............................................................
..................................................................................................................... 116
XII.2 Kecepatan memberikan pelayanan ambulans .................................
..................................................................................................................... 117
XII.3Response time pelayanan ambulans oleh masyarakat
yang membutuhkan ..................................................................................
..................................................................................................................... 117
XIII. PELAYANAN LAUNDRY .....................................................................
............................................................................................................. 118
XIII.1 Tidak adanya kejadian linen yang hilang ........................................
..................................................................................................................... 118

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 XIII.2 Ketepatan waktu penyediaan linen untuk ruang rawat inap ............
..................................................................................................................... 118
XIV. PENCEGAHAN PENGENDALIAN INFEKSI ........................................
............................................................................................................. 119
XIV.1 Tersedianya alat pelindung diri (ADP ) di setiap instalasi ...............
..................................................................................................................... 119
XV. PELAYANAN PEMELIHARAAN SARANA ...........................................
............................................................................................................. 119
XV.1 Kecepatan waktu menanggapi kerusakan alat ................................
..................................................................................................................... 119
XV.2 Ketepatan waktu pemeliharaan alat ................................................
..................................................................................................................... 120
XV.3 Peralatan laboraturium dan alat ukur yang digunakan dalam
pelayanan terkalibrasi tepat waktu sesua dengan ketentuan kalibrasi .........
..................................................................................................................... 121
XVI. PELAYANAN ADMINISTRASI MANAJEMEN......................................
............................................................................................................. 121
XVI.1 Minilokarya puskesmas ..................................................................
..................................................................................................................... 121
XVI.2 Kelengkapan laporan akuntabilitas kinerja .....................................
..................................................................................................................... 122
XVI.3 Ketepatan waktu pengusulan kenaikan pangkat ............................
..................................................................................................................... 122
XVI.4 Ketepatan waktu pengurusan gaji berkala ......................................
..................................................................................................................... 123
XVI.5 Ketepatan waktu penyusunan laporan keuangan ...........................
..................................................................................................................... 123
XVI.6 Ketepatan waktu pemberian informasi tentang tagihan pasien
rawat inap.................................................................................................
..................................................................................................................... 124

LAMPIRAN-LAMPIRAN ...............................................................................
Rekap Program Kegiatan Standar Pelayanan Minimal Puskesmas Kendal
Tahun 2017
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Biaya Standar Pelayanan Minimal Wajib Puskesmas Kendal Tahun 2017
Biaya Standar Pelayanan Minimal Pengembangan Puskesmas Kendal Tahun 2017