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Pada hari ini, hari……………………………..tanggal…………..… hari……………………………..tanggal…………..…..….bulan…………………...…….tahun………………………. yang bertandatangan dibawah ini : Nama :…………………………………………………………………………………………………………………………… :…………………………………………………………………………………………………………………………… Umur & Jenis kelamin :…………………….….tahun, laki-laki laki-laki / Perempuan Jabatan :…………………………………………………………………………………………………………………………… :…………………………………………………………………………………………………………………………… Unit Kerja :…………………………………………………………………………………………………………………………… Melaporkan telah terjadi pelanggaran: Disiplin ( ) Peraturan & Kebijakan ( ) Kelalaian ( )Kurang Terampil/Human Error ( ) Karyawan Yang mengalami kejadian: Nama :…………………………………………………………………………………………………………………………… Umur & Jenis kelamin :…………………….….tahun, laki-laki laki-laki / Perempuan Jabatan :…………………………………………………………………………………………………………………………… Unit Kerja :…………………………………………………………………………………………………………………………… Lokasi Kejadian :.................... :............................... ...................... ..................... .................... .......... Tanggal Kejadian :........../........... :........../.........../........... /.................. ....... Jam kejadian kej adian : .................... ............................. ......... Kronologis Kejadian : ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ................................................................. Tindakan Yang Segera dilakukan:............... dilakukan:......................... ...................... ...................... ..................... ...................... ....................... ...................... ............... ..... ........................................................................................................................................................................ ........................................................................................................................................................................ ..................................................................................................................... Dilaporkankepada :Nama:............... :Nama:......................... ...................... .............. .. Jabatan..................... Jabatan............................... ...................... ...................... .......... Tgl dan Waktu:........../......... Waktu:........../............../..... ...../....... .. Jam : …………………. AM/PM Tindak lanjut yang diberikan: ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ................................................................................... Demikian laporan kejadian pelanggaran kode etik keperawatan ini saya sampaikan. Karyawan
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