FORMULIR TINDAK LANJUT PEMBINAAN

MASALAH ETIK DAN DISIPLIN

PERAWAT/BIDAN
RS RUMAH SEHAT TERPADU DOMPET
DHUAFA

Hari / Tanggal :

Nama :

NIK :

Ruangan :

Masalah :

Uraian kegiatan :

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Kesimpulan: termasuk kategori pelanggaran : Ringan/ Sedang/ Berat

Dengan ini mengusulkan kepada Tim Komite etik dan disiplin profesi keperawatan /
kebidanan untuk menindaklanjuti masalah tersebut diatas.

Jakarta,..................................., ......

Nama Perawat

Mengetahui

Ka. Bidang Keperawatan Atasan Langsung

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 FORMULIR PEMBINAAN STAF INTERNAL
RS RUMAH SEHAT TERPADU DOMPET
DHUAFA

1. Hari / Tanggal :
2. Nama :
3. NIK :
4. Ruangan :
5. Masalah :
6. Uraian kegiatan :

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Bogor,..................................., ......

Atasan Langsung

( .................................................. ) ( ..................................................... )
Nama Perawat /Bidan
 LAPORAN KEJADIAN PELANGGARAN KODE ETIK DAN
DISIPLIN PROFESI PERAWAT DAN BIDAN
RS RUMAH SEHAT TERPADU DOMPET DHUAFA

Nama :
NIK :
Ruangan :
Masalah :

Uraian kejadian :.....................................................................................................

Hasil pembahasan tim Etik Keperawatan

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Berdasarkan buku pedoman etik dan disiplin profesi keperawatan / kebidanan RS

Rumah Sehat Terpadu Dompet Dhuafa, pelanggaran di atas termasuk kategori:
pelanggaran ringan / sedang / berat.
Saran Tim Etik Keperawatan
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Bogor,..........................
Dilaporkan oleh,

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Ketua Sub Komite Etik dan Disiplin profesi