SURAT PERNYATAAN

PELANGGARAN KODE ETIK PROFESI KEPERAWATAN

Yang bertanda tangan dibawah ini :

Nama : ..............................................................................................................
NIK : ..............................................................................................................
Alamat : ..............................................................................................................
Jabatan : ..............................................................................................................
Unit Kerja : ..............................................................................................................
Pada Tanggal : ............................................................................., dihadapan :
Nama : Jabatan :
1. ...................................... ..............................
2. ...................................... ..............................
3. ...................................... ..............................
Menyatakan :
1. Saya mengaku telah melakukan kesalahan dalam menepati :
Peraturan/standar profesi/pekerjaan dinas yang berlaku di RS. Metta Medika Sibolga
Macam kesalahan/kealpaan, terlampir
2. Oleh karena kesalahan/kelpaan itu, saya bersedia menerima sanksi peraturan yang berlaku di
RS. Metta Medika berupa :
...............................................................................................................................................
...............................................................................................................................................
3. Setelah itu saya mohon maaf kepada semua pihak yang telah dirugikan akibat
kesalahan/kealpaan saya itu, serta saya akan lebih berhati-hati dalam melaksanakan tugas
pekerjaan saya selanjutnya ....................................................................................................

Sibolga, .........................
RS. Metta Medika

Saksi I Saksi II Yang Menyatakan

( .........................) ( .......................... ) ( ............................)

 LAPORAN PELANGGARAN
KODE ETIK PROFESI KEPERAWATAN

Yang bertanda tangan dibawah ini :

Nama : ..............................................................................................................
NIK : ..............................................................................................................
Alamat : ..............................................................................................................
Jabatan : ..............................................................................................................
Unit Kerja : ..............................................................................................................
Pada Tanggal : ............................................................................., Jam :

Melakukan kealpaan/kesalahan yang berupa :

........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
Telah merugikan :
Instansi/Institusi :
Pribadi : Nama : ........................ Umur : ............................... L/P
No. RM : ......................... Alamat : .................................
Pekerjaan :..........................
Yang ditangani : Dokter/Perawat : ..........................................................................
Urutan waktu kejadian :
........................................................................................................................................
........................................................................................................................................
Kesalahan/kealpaan yang saya buat adalah :
........................................................................................................................................
........................................................................................................................................
Kesalahan/kealpaan tersebut seharusnya saya hindari dengan jalan :
........................................................................................................................................
........................................................................................................................................

Saya yang melakukan

Kesalahan/kealpaan

( ............................... )
Tanda tangan & nama terang