Criterion 1.2.2 Policies, guidelines/guidelines, procedures and terms of reference

 b. Criterion 1.2.2

Policies, guidelines/guidelines, procedures and terms of reference related to the implementation of activities are prepared, documented and controlled and are based on the provisions of laws and regulations, including control of documents proving the implementation of activities.

1) Main Thoughts:

a) In preparing policies, guidelines/guidelines, procedures and terms of reference, they are based on the provisions of applicable laws and regulations and/or based on the latest scientific evidence.

b) Based on the latest scientific evidence, it can be proven by referring to updated references.

c) To compile, document and control all documents in the Puskesmas, it is necessary to prepare guidelines for the Puskesmas manuscript system.

d) The Puskesmas text management guidelines function as a reference in preparing documents, including:

(1) regulatory documents (policies, guidelines/guidelines, procedures and terms of reference);

(2) external documents; And

(3) documentary evidence of recording the implementation of activities.

e) The Puskesmas script management guidelines regulate, among other things:

(1) preparation, review and approval of internal regulatory documents by the head of the Community Health Center;

(2) the process of reviewing internal regulatory documents is carried out periodically and then ratified by the head of the Community Health Center;

(3) document control is carried out to ensure the latest internal regulatory documents are available in service units;

(4) document changes must be identified, one of which is through the history of changes in internal regulatory documents;

(5) document maintenance includes arrangement and storage in accordance with coding in the provisions of statutory regulations to ensure the identity and readability of documents;

(6) management of external documents including recording, structuring and storing in accordance with coding in the provisions of statutory regulations;

(7) setting the storage period (retention) for expired documents in accordance with the provisions of laws and regulations, while ensuring that these documents are not misused; And

(8) providing a flow for document preparation and distribution in accordance with statutory provisions.

f) The preparation of guidelines for community health center scripts can refer to the policies of each region and/or in accordance with the provisions of laws and regulations related to service scripts.

g) All employees must use the policies, guidelines/guidance, terms of reference and procedures that have been established for implementing activities including KMP, UKM, UKP, laboratory and pharmacy.

h) Preparation of policies, guidelines/guidelines, terms of reference and procedures for each service referring to the provisions of statutory regulations and/or guidelines issued by the relevant professional organizations.

i) Each individual health service must develop individual health service procedures that refer to the Medical Service Guidelines and Clinical Practice Guidelines.

2) Assessment Elements:

a) Established guidelines for Puskesmas (R) script management.

b) Determine policies, guidelines/guidelines, procedures and terms of reference for KMP, UKM implementation and UKP, laboratory and pharmacy management which are based on the provisions of statutory regulations and/or based on the latest scientific evidence (R,W).

c) Controlling, structuring and distributing documents is carried out in accordance with established procedures (R,D,O,W).