Formulir Pembinaan Etik [PDF]

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FORMULIR TINDAK LANJUT PEMBINAAN MASALAH ETIK DAN DISIPLIN PERAWAT/BIDAN RS RUMAH SEHAT TERPADU DOMPET DHUAFA Hari / Tanggal



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Nama



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NIK



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Ruangan



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Masalah



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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



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



FORMULIR PEMBINAAN STAF INTERNAL RS RUMAH SEHAT TERPADU DOMPET DHUAFA



1. Hari / Tanggal



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2. Nama



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3. NIK



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4. Ruangan



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5. Masalah



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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



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NIK



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Ruangan



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Masalah



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Uraian kejadian



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Hasil pembahasan tim Etik Keperawatan ....................................................................................................................................... ....................................................................................................................................... .......................................................................................................................................



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 ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... .......................................................................................................................................



Bogor,.......................... Dilaporkan oleh,



(..........................) Ketua Sub Komite Etik dan Disiplin profesi