PEMERINTAH KABUPATEN NUNUKAN
RUMAH SAKIT UMUM DAERAH Jalan Ujang Fatimah RT.04 Desa Binusan Kecamatan Nunukan Telepon/fax manajemen 0556 – 2020755; UGD 0556-2020756 Website: rsud.nunukankab.go.id / e-mail:
[email protected]
Kode Pos 77482
DAFTAR TINDAKAN – TINDAKAN YANG PERLU INFORMED CONSENT
Sesuai Undang – Undang no 44 tahun 2009 tentang rumah sakit, terdapat beberapa tindakan kedokteran dan kedokteran gigi yang wajib diberikan informed consent. Tindakan tersebut yaitu: A. B. C. D.
Semua Tindakan Pembedahan dan Tindakan Invasive Semua Tindakan Anestesi & Sedasi ( Sedasi Sedang dan Sedasi Dalam ) Semua Tindakan Pemberian Produk Darah & Komponen Darah Semua Tindakan/PENGOBATAN Yang Berisiko Tinggi.
A.Tindakan Pembedahan dan Tindakan Invasive yang memerlukan informed consent antara lain: No
KSM/INSTALASI/UNIT
1
KSM Bedah Saraf
TINDAKAN 1. Amygdala Hypocampectomy (Epilepsi) 2. Anterior Temporomesial Lobectomi (Epilepsi) 3. Biopsi Saraf Tepi/Otot 4. Blok Saraf Perifer I 5. Cingulotomy (Psichiatric) 6. Corpus Callosotomi (Epilepsi) 7. Debrimen Rekonstruksi Vulnus Kulit Kepala 8. Dekompresi Saraf Tepi 9. Dekompresi Tulang Durameter 10. Dekortikasi Sinus Frontalis 11. Denervasi Facet 12. DREZ Lession (Pain) 13. Eksisi Ensefalokel/Mielokel 14. Eksisi Kista Jinak Kulit Kepala 15. Eksisi Osteoma/Osteositosis 16. Elevasi Kraniotomi Fraktur Impresi,Dengan Robekan 17. Dura 18. Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan 19. Dura 20. Extirpasi Tumor Jinak Saraf Kulit Kepala 21. Fusi Stabilisasi Corpus Vertebra 22. Graft/Transposisi Saraf Tepi 23. Hemisferektomi (Epilepsi) 24. Hemisferoktomi (Epilepsi) 25. Injeksi saraf perifer (dengan radiofrekuensi) 26. Injeksi spinal (Pain) 27. Insersi Elektrode Intradural (Epilepsi,movement,psikiatrik) 28. Kordotomi Perkutan 29. Kordotomi Servikal Open (Pain) 30. Kordotomi Servikal Perkutan (Pain) 31. Kranioplasti dua sisi 32. Kranioplasti satu sisi 33. Kraniotomi Biopsi otak
2
KSM Bedah
34. Laminektomi Eksisi Tumor Spinal 35. Laminoplasti 36. Laminotomi Biopsi Mielum 37. Laminotomi Diskektomi HNP/Stenosis>1 level 38. Laminotomi Diskektomi HNP/Stenosis 1 level 39. Lesionectomy (Epilepsi) 40. Lobektomi (Epilepsi) 41. Mesencephalectomy (Pain) 42. Mikrodisekktomi HNP 43. MVD (Microvascular Decompression) 44. Neurektomi/Neurolise 45. Neuroendoskopi (Otak,Spinal) 46. Neuroplasti 47. Omaya drain 48. Pallidotomi (movement Disorder) 49. Paravertebral Blok Perkutan 50. Pemasangan Traksi Servikal 51. Penjahitan Saraf Tepi 52. Punksi Cairan Otak 53. Reseksi Extra-Temporal (Epilepsi) 54. Revisi VP Shunt 55. Rhizotomi Selektif (Spastisitas) 56. Rhizotomy (Pain) 57. Selective Nerve Root Block 58. Selective Thalamotomi (Movement Disorder) 59. Simpatektomi Open (Pain) 60. Simpatektomi Perkutan 61. SLTH 62. Stereotactic Ablative Procedure (Psichiatric) 63. Subthalamotomy (Movement Disorder) 64. Suturektomi Kraniostenosis 65. Thalomotomy (Pain) 66. Transposisi kraniostenosis,dengan orbital advancement 67. Transposisi kraniostenosis,tanpa orbital advancement 68. Trepanasi Cedera Kepala (<4jam) 69. Trepanasi Cedera Kepala (>4jam) 70. Trepanasi CVA Bleeding 71. Trepanasi kelainan Saraf Kranial 72. Trepanasi Kelainan Vascular Otak 73. Trepanasi Tumor Otak 74. VA Shunt 75. VP Shunt Multiple 76. VP Shunt Satu Sisi 1. Aff Arch Barr Kepala Leher 2. Aff Arch Barr dan suspensi maksila 3. Biopsy Insisional dengan anastesi lokal 4. Deseksi submandibula 5. Diseksi leher radikal/radikal neck dissection 6. Eksisi gld submandibula 7. Eksisi higroma leher 8. Eksisi kista tiroglosus 9. Eksisi luas tumor ganas bibir dengan rekontruksi 10 flap lokal 11 Eksisi luas tumor ganas dengan rekontruksi flap jauh 12 Eksisi luas tumor ganas kulit dengan rekontruksi 13 flap lokal 14 Eksisi luas tumor ganas rongga mulut dengan 15 rekontruksi flap lokal 16 Eksisi parsial+marsupialisasi Ranula 17 Eksisi tumor ganas kulit dengan flap local atau graft 18 kulit 19 Eksisi tumor ganas kulit dengan flap local jauh 20 Eksisi tumor ganas kulit tanpa rekontruksi 21 Eksisi
tumor jinak dengan anastesi lokal 22 Ekskokleasi epulis 23 Ekskokleasi kista folikuler 24 Ekskokleasi kista radikuler 10. 25 11. Ekstirpasi/eksisi tumor jinak jaringan lunak ukuran <2cm 26 Ekstirpasi kista dermoid 27 Endoscopic thyroidectomy 28 Fiksasi interna fraktur maksilofasial 1-2 tempat patahan 12. 5 13. No 14. KSM/INSTALASI /UNIT TINDAKAN 29 Fiksasi interna fraktur nasal 30 Fiksasi interna pan-facial 31 Hemiglosektomi 32 Insisi abses dengan anastesi lokal 33 Insisi flegmon dasar mulut 34 Internal Fiksasi fraktur condylus mandibula 35 Internal Fiksasi fraktur maksilofasial 3-4 tempat 36 patahan 37 Internal fiksasi fraktur maksilofasial 5 tempat patahan 38 atau lebih 39 Laringectomi
3. KSM Bedah THT-KL 1 Adenotonsilektomi 2 Anthrostomi+Sinuskopi 3 BLM Simple (Kista,Polip,Nodul,Granulasi) 4 Biopsi Tumor 5 Bronkoskopi Rigid 6 BLM Advance (Stenosis, Subjektif/Trakea, Papiloma Laring/Trakea) 7 Cald Well Luc 8 Cochlear Implant/Implan Baha 9 Dekompresi Nervus Fasialis 10 DCR 11 Eksisi Ekstostosis 12 Ekstirpasi Kista Branchial 13 Ekstirpasi Kista Ductus Tiroglosus 14 Ekstraksi granulasi MAE/Kolesteatosis 15 Ekstraksi Polip 16 Esofagoskopi Rigid & Fleksibel 6 17 Ethmoidektomi (Intranasal) 18 Ekstraksi Korpus Alienum Kavum Nasi NO KSM/INSTALASI/ UNIT TINDAKAN 19 Ekstraksi Korpus Alienum Kavum Nasi Endoskopi 20 Ekstirpasi Fistel Pre Aurikuler 21 Ekstraksi Korpus Alienum MAE 22 Ekstirpasi Kelenjar Sub Mandibula 23 Ekstirpasi Angiofibroma Nasofaring 24 Eksplorasi Abses Parafaringeal 25 Ekstirpasi Tumor Jinak Kepala & Leher (Aterom Lipoma) 26 Faringotomi 27 FESS 28 FESS Advance 29 Frontal Sinusotomi 30 Fore Head Flap 31 Fronto Etmoidektomi (Ekstranasal) 32 FOL 33 Glosektomi Total/Parsial 34 Glosektomi Total/Hemiglosektomi+RND
35 Hemiglosektomi+SOHND 36 Insisi Abses Leher Dalam 37 Inversi Grommet 38 Insisi Perikondritis 39 Irigasi Sinus Maksila 40 Insisi Abses Peritonsil 41 Imunoterapi 42 Konka Reduksi 43 Kaustik Konka Inferior 44 Laringektomi 45 Laringektomi+ND 46 Laringo Fisur/Eksplorasi Laring 47 Ligasi A. Karotis Eksternal 7 48 Laringoskopi Rigid NO KSM/INSTALASI/ UNIT TINDAKAN 49 Laringoskopi Fleksible 50 Laringoskopi Direkta 51 Maksilektomi Total+Rekontruksi 52 Mastoidektomi Radikal 53 Mini FESS 54 Myocutaneus Flap (Pectoral Mayor) 55 Myringoplasty/Timpaniplasti 56 Mandibulekromi 57 Neurektomi Saraf Vidian 58 Osteotomi+Septum koreksi 68 Rekontruksi Fraktur Maksila Multiple 69 Rekontruksi Fraktur Maksila Sederhana 70 Rhinoplasti 71 Rinotomi Lateral+Maksilektomi Medial 72 Rekontruksi Laring Trakea 73 Reposisi Fraktur Os Nasal 74 Reposisi & Fiksasi Fraktur Mandibula 75 Septum Koreksi+Konkotomi 76 Stapedektomi 77 Skin Pricle Test 78 Tiroidektomi Sub-Total 79 Tonsilektomi/Adenoidektomi 80 Tracheostomi 81 Turbinektomi 82 Tiroidektomi Total+ND 83 Temporal Bone Resection 84 Terapi Wicara pada Anak-Anak dan dewasa 85 Terapi Wicara Tuna Laring 8 NO KSM/INSTALAS I/UNIT TINDAKAN 4 KSM Orthopedi 1 Abdominopelvic amputation Dan 2 Achillotenotomy Traumatologi 3 Adductor tenotomy of hip 4 Advancement of tendon 5 Advancement of tendon of hand 6 Amputation above knee 7 Amputation and disarticulation of finger- general anaesthesia 8 Amputation and disarticulation of finger -local anaesthesia
9 Amputation and disarticulation of thumb-general anaesthesia 10 Amputation and disarticulation of finger- general anaesthesia 11 Amputation and disarticulation of finger -local anaesthesia 12 Amputation and disarticulation of thumb-general anaesthesia 13 Amputation and disarticulation of thumb-local anaesthesia 14 Amputation of ankle through malleoli of tibia and fibula 15 Amputation of toe-general anaesthesia 16 Amputation of toe-local anaesthesia 17 Amputation through foot 18 Amputation through forearm 19 Amputation through hand, Amputation through carpals 20 Amputation through humerus, Upper arm amputation 21 Amputation, not otherwise specified 22 Ankle fusion 23 Application of external fixator device 24 Application of external fixator device, monoplanar system 25 Application of external fixator device, ring system 9 26 Application of hybrid external fixator device 27 Arthrocentesis NO KSM/INSTALAS I/UNIT TINDAKAN 28 Arthrodesis of elbow 29 Arthrodesis of hip 30 Arthrodesis of knee 31 Arthrodesis of other specified joints 32 Arthrodesis of shoulder 33 Arthrodesis of unspecified joint 34 Arthroplasty of carpocarpal or carpometacarpal joint with implant 35 Arthroplasty of carpocarpal or carpometacarpal joint without implant 36 Arthroplasty of metacarpophalangeal and interphalangeal joint with implant
37 Arthroplasty of metacarpophalangeal and interphalangeal joint without implant 38 Arthroscopy 39 Arthrotomy for removal of prosthesis without replacement 40 Aspiration of bursa 41 Aspiration of bursa of hand 42 Aspiration of other soft tissue 43 Aspiration of other soft tissue of hand 44 Atlas-axis spinal fusion 45 Biopsy of bone 46 Biopsy of joint structure 47 Biopsy of spinal cord or spinal meninges 48 Bone graft 49 Bone marrow or hematopoietic stem cell transplant (all procedures included in this class 50 Bunionectomy with soft tissue correction and arthrodesis 51 Bunionectomy with soft tissue correction and osteotomy of the first metatarsal 52 Bursectomy 10 53 Bursectomy of hand 54 Bursotomy NO KSM/INSTALAS I/UNIT TINDAKAN 55 Bursotomy of hand 56 Carporadial fusion 57 Closed reduction of dislocation -General anaesthesia 58 Closed reduction of dislocation of ankle 59 Closed reduction of dislocation of elbow 60 Closed reduction of dislocation of foot and toe- general anaesthesia 61 Closed reduction of dislocation of foot and toe-local anaesthesia 62 Closed reduction of dislocation of hand and finger- general anaesthesia 63 Closed reduction of dislocation of hand and finger- local anaesthesia 64 Closed reduction of dislocation of hip 65 Closed reduction of dislocation of knee 66 Closed reduction of dislocation of other specified sites-general anaesthesia
67 Closed reduction of dislocation of other specified sites-local anaesthesia 68 Closed reduction of dislocation of other specified sites-local anaesthesia 69 Closed reduction of dislocation of shoulder 70 Closed reduction of dislocation of wrist 71 Closed reduction of dislocation-Local anaesthesia 72 Closed reduction of fracture with internal fixation - Carpal and metacarpal 11 73 Closed reduction of fracture with internal fixation - Femur (Including : MIPO, interlocking nail, TEN) 74 Closed reduction of fracture with internal fixation - Humerus (including : Interlocking nail, TEN, MIPO) NO KSM/INSTALAS I/UNIT TINDAKAN 75 Closed reduction of fracture with internal fixation - Intrarticular Major Bone 76 Closed reduction of fracture with internal fixation - Phalang of foot 77 Closed reduction of fracture with internal fixation - Phalang of hand 78 Closed reduction of fracture with internal fixation - Radius and ulna (MIPO, TEN) 79 Closed reduction of fracture with internal fixation - Tarsal and metatarsal 84 Excision of bone for graft 85 Excision of intervertebral disc 86 Excision of lesion of muscle 87 Excision of lesion of muscle of hand 88 Excision of lesion of other soft tissue
89 Dorsal and dorsolumbar fusion of the anterior column, anterior technique 90
Dorsal and dorsolumbar fusion of the posterior column, posterior technique 91 Excision of bone for graft 92 Excision of intervertebral disc 93 Excision of lesion of muscle 94 Excision of lesion of muscle of hand 95 Excision of lesion of other soft tissue 96 Excision of lesion of tendon sheath 97 Excision of lesion of tendon sheath of hand, Ganglionectomy of tendon sheath (wrist)-General anaesthesia 98 Excision of lesion of tendon sheath of hand, Ganglionectomy of tendon sheath (wrist)-Local Anaestesi 99 Excision of muscle or fascia for graft 100 Excision of muscle or fascia of hand for graft 12 101 Excision of other lesion of soft tissue of hand NO KSM/INSTALAS I/UNIT TINDAKAN 102 Excision of semilunar cartilage of knee 103 Excision of tendon for graft 104 Excision of tendon of hand for graft 105 Excision or correction of bunionette, That with osteotomy 106 Excision or destruction of intervertebral disc, unspecified 107 Exploration of tendon sheath 108 Exploration of tendon sheath of hand 109 Exploratory thoracotomy 110 Fasciotomy 111 Fasciotomy of hand 112 Finger reattachment 113 Five-in-one repair of knee 114 Foot reattachment 115 Forearm, wrist, or hand reattachment 116 Fusion or refusion of 2-3 vertebrae 117 Fusion or refusion of 4- 8 vertebrae 118 Fusion or refusion of 9 or more vertebrae 119 Graft of muscle or fascia 120 Hip bearing surface, ceramic-on-ceramic 121 Hip bearing surface, ceramic-on-polyethylene, Hip bearing surface, oxidized zirconium-onpolyethylene 122 Hip bearing surface, metal-on-metal 123 Hip bearing surface, metal-onpolyethylene 124 Implantation of internal limb lengthening device with kinetic distraction 125 Implantation of other internal limb lengthening device 126 Implantation or replacement of peripheral neurostimulator lead (s) 13 127
Implantation or replacement of spinal neurostimulator lead(s) 128 Incision and drainage of palmar or thenar space 129 Injection of anesthetic into peripheral nerve for analgesia NO KSM/INSTALASI /UNIT TINDAKAN 130 Injection of anesthetic into spinal canal for analgesia 131 Injection of destructive agent into spinal canal 132 Injection of locally-acting therapeutic substance into other soft tissue 133 Injection of other agent into spinal canal, Intrathecal injection of steroid, Subarachnoid perfusion of refrigerated saline 134 Injection of therapeutic substance into bursa 135 Injection of therapeutic substance into bursa of hand 136 Injection of therapeutic substance into joint or ligament 137 Injection of therapeutic substance into tendon 138 Injection of therapeutic substance into tendon of hand 139 Insertion of bone growth stimulator 140 Insertion of bone void filler 141 Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances, Insertion of catheter into epidural, subarachnoid, or subdural space of spine with intermittent or continuous infusion of drug (with creation of any reservoir) 142 Insertion of interbody spinal fusion device 143 Insertion of other spinal devices 144 Insertion of partial spinal disc prosthesis, cervical 145 Insertion of partial spinal disc prosthesis, lumbosacral 146 Insertion of recombinant bone morphogenetic protein 147 Insertion of spinal disc prosthesis, not otherwise specified, Replacement of spinal disc, NOS 148 Insertion of spinal disc prosthesis, thoracic 149 Insertion of sternal fixation device with rigid plates 150 Insertion of total spinal disc prosthesis, cervical 14 152 Insertion of total spinal disc prosthesis, lumbosacral 153 Insertion or replacement of (cement) spacer 154
Insertion or replacement of facet replacement device(s) NO KSM/INSTALAS I/UNIT TINDAKAN 155 Insertion or replacement of interspinous process device(s) 156 Insertion or replacement of pedicle-based dynamic stabilization device(s) 157 Insertion or replacement of skeletal muscle stimulator 158 Internal fixation of bone without fracture reduction 159 Interphalangeal fusion 160 Interthoracoscapular amputation, Forequarter amputation 161 Intra-operative neurophysiologic monitoring - Neuromonitoring 162 Intervertebral chemonucleolysis 163 Limb lengthening procedures 164 Limb shortening procedures 165 Local excision of lesion or tissue of bone 166 Lower leg or ankle reattachment 167 Lower limb amputation, not otherwise specified 168 Lumbar and lumbosacral fusion of the anterior column, anterior technique 169 Lumbar and lumbosacral fusion of the anterior column, posterior technique 170 Lumbar and lumbosacral fusion of the posterior column, posterior technique 171 Lysis of adhesions of hand 172 Lysis of adhesions of muscle, tendon, fascia, and bursa 173 Lysis of adhesions of spinal cord and nerve roots 174 Metacarpocarpal fusion 175 Metacarpophalangeal fusion 176 Metatarsophalangeal fusion 177 Midtarsal fusion 178 Muscle transfer or transplantation 15 179 Myotomy 180 Myotomy of hand 181 Neurectasis NO KSM/INSTALASI/ UNIT TINDAKAN 182 Open biopsy of cranial or peripheral nerve or ganglion 183 Open biopsy of soft tissue 184 Open reduction of dislocation of ankle - Neglected dislocation 185 Open reduction of dislocation of elbow -Fresh dislocation 186 Open reduction of dislocation of hand and finger -Fresh dislocation 187 Open reduction of dislocation of hip - Fresh dislocation 188 Open reduction of dislocation of hip - Neglected dislocation 189
Open reduction of dislocation of knee - Neglected dislocation 190 Open reduction of dislocation of knee -Fresh dislocation 191 Open reduction of dislocation of other specified sites 192 Open reduction of dislocation of shoulder -Fresh dislocation 193 Open reduction of dislocation of shoulder -Neglected dislocation 194 Open reduction of dislocation of unspecified site-Fresh dislocation 195 Open reduction of dislocation of unspecified site- Neglected dislocation 196 Open reduction of dislocation of wrist -Fresh dislocation 197 Open reduction of fracture with internal fixation- radius and ulna-Simple fracture 198 Open reduction of fracture with internal fixation- unspecified site (Periarticular Major Bone ) 199 Open reduction of fracture with internal fixation-carpals and metacarpals - plate & screws Hand NOS -Plate & Screw 200 Open reduction of fracture with internal fixation-carpals and metacarpals - plate & screws Hand NOS -Plate & Screw 201 Open reduction of fracture with internal fixation-carpals and metacarpals - simple implants (Kwire) Hand NOS -implant sederhana (K-wire) 202 Open reduction of fracture with internal fixation-femur- Comminutive or Segmental 203 Open reduction of fracture with internal fixation-femur- Simple fracture 16 NO KSM/INSTALAS I/UNIT TINDAKAN 204 Open reduction of fracture with internal fixation- humerus - Simple fracture 205 Open reduction of fracture with internal fixation- humerus - Comminutive or Segmental 206 Open reduction of
fracture with internal fixation- other specified bone (Intraartikular Major Bone ) 207 Open reduction of fracture with internal fixation- phalanges of foot - simple implants (K-wire) 208 Open reduction of fracture with internal fixation- phalanges of foot-Plate & Screws 209 Open reduction of fracture with internal fixation- phalanges of hand- Plate & Screws 210 Open reduction of fracture with internal fixation- phalanges of hand- simple implants 211 Open reduction of fracture with internal fixation- tarsals and metatarsals- Plate & Screws 212 Open reduction of fracture with internal fixation- tarsals and metatarsals- simple implants 213 Open reduction of fracture with internal fixation-tibia and fibula -Simple fracture 214 Open reduction of fracture with internal fixation-tibia and fibula-Comminutive or Segmental 215 Open reduction of fracture without internal fixation 216 Open reduction of separated epiphysis 217 Osteoclasis (correction of bone deformity) 218 Other 219 Other (peripheral) vascular shunt or bypass 220 Other amputation below knee 221 Other anastomosis of cranial or peripheral nerve 222 Other and unspecified repair of the anulus fibrosus 223 Other arthrotomy 224 Other bunionectomy 225 Other bunionectomy with soft tissue correction 226 Other cervical fusion of the anterior column, anterior technique 227 Other cervical fusion of the posterior column, posterior technique 17 228 Other change in hand muscle or tendon length 229 Other change in muscle or tendon length 230 Other destruction of intervertebral disc NO KSM/INSTALAS I/UNIT TINDAKAN 231 Other diagnostic procedures on joint structures 232 Other diagnostic procedures on muscle, tendon, fascia, and bursa, including that of hand 233 Other division of bone 234 Other excision of joint 235 Other excision of soft tissue 236 Other excision of soft tissue of hand 237 Other excision or avulsion of cranial and peripheral nerves 238 Other excision, fusion and repair of toes 239 Other exploration and decompression of spinal canal, Decompression 240 Other fasciectomy 241 Other fasciectomy of hand 242 Other fusion of foot 243 Other hand muscle transfer or transplantation 244 Other hand muscle transposition 245 Other hand tendon transfer or transplantation 246 Other hand tendon transposition 247 Other incision of bone without division 248 Other incision of soft tissue 249 Other incision of soft tissue of hand 250 Other injection of locally-acting therapeutic substance into soft tissue of hand 251 Other local excision or destruction of lesion of joint 252 Other muscle transposition 253 Other myectomy 254 Other myectomy of hand 255 Other neuroplasty 256 Other operations on muscle, tendon, fascia, and bursa 257 Other operations on muscle, tendon, fascia, and bursa, 18
Suture of bursa 258 Other partial ostectomy (including : Bone curretage, marginal resection/excision) NO KSM/INSTALAS I/UNIT TINDAKAN 259 Other peripheral nerve or ganglion decompression or lysis of adhesions Peripheral nerve neurolysis NOS 260 Other plastic operations on fascia 261 Other plastic operations on hand 262 Other plastic operations on muscle 263 Other repair of ankle 264 Other repair of elbow 265 Other repair of hand, fingers and wrist 266 Other repair of joint 267 Other repair of knee 268 Other repair of shoulder 269 Other repair of the collateral ligaments 270 Other repair of the cruciate ligaments 271 Other repair or plastic operations on bone 272 Other suture of flexor tendon of hand 273 Other suture of muscle or fascia 274 Other suture of other tendon of hand 275 Other suture of tendon 276 Other tendon transposition 277 Other tenodesis of hand 278 Other tenonectomy 279 Other tenonectomy of hand 280 Other tenoplasty of hand 281 Other tenotomy 282 Other total shoulder replacement 283 Partial hip replacement 284 Partial shoulder replacement 285 Patellar stabilization 286 Percutaneous denervation of facet 287 Percutaneous vertebral augmentation 288 Percutaneous vertebroplasty 289 Peripheral nerve injection, not otherwise specified 290 Plastic operation on hand with graft of muscle or fascia 291 Plastic operation on hand with other graft or implant 292 Pollicization operation carrying over nerves and blood supply 293 Quadricepsplasty 294 Reattachment of muscle 295 Reattachment of muscle of hand 296 Reattachment of tendon 297 Reattachment of tendon of hand 19 298 Refusion of atlas-axis spine 299 Refusion of dorsal and dorsolumbar spine, anterior column, anterior technique NO KSM/INSTALAS I/UNIT TINDAKAN 300 Refusion of dorsal and dorsolumbar spine, posterior column, posterior technique 301 Refusion of lumbar and lumbosacral spine, anterior column, anterior technique 302 Refusion of lumbar and lumbosacral spine, anterior column, posterior technique 303 Refusion of lumbar and lumbosacral spine, posterior column, posterior technique 304 Refusion of other cervical spine, anterior column, anterior technique 305 Refusion of other cervical spine, posterior column, posterior technique 306 Refusion of spine, not elsewhere classified 307 Refusion of spine, not otherwise specified 308 Release of carpal tunnel 309 Release of clubfoot, not elsewhere classified 310 Release of tarsal tunnel 311 Removal of (cement) spacer 312 Removal of bone growth stimulator (invasive) 313 Removal of foreign body from spinal canal 314 Removal of implanted devices from bone - carpals and metacarpals-Plate & screw 315 Removal of implanted devices from bone - carpals and metacarpals-simple implants (K-wire) 316 Removal of implanted devices from bone - External fixator device (invasive) ( 317 Removal of implanted devices from bone - femur 318 Removal of implanted devices from bone - humerus 319 Removal of implanted devices from bone - radius and ulna 320 Removal of implanted devices from bone - scapula, clavicle, and thorax (ribs and sternum) 321 Removal of implanted devices from bone - unspecified site (Phalanges (of foot) (of hand)) - Plate & Screw 322 Removal of implanted devices from bone - unspecified site (Phalanges (of foot) (of hand)) - simple implants
(K-wire) 323 Removal of implanted devices from bone -patella 324 Removal of implanted devices from bone- tarsals and metatarsals- simple implants (K-wire) 325 Removal of implanted devices from bone- tibia and fibula 20 326 Removal of implanted devices from bone-other (Pelvic bone and Vertebraae) NO KSM/INSTAL ASI/UNIT TINDAKAN 327 Removal of implanted devices from bone-tarsals and metatarsals - Plate & Screw 328 Removal of internal limb lengthening device 329 Removal of pedicle screw(s) used in spinal fusion 330 Removal of peripheral neurostimulator lead(s) 331 Removal of skeletal muscle stimulator 332 Removal of spinal neurostimulator lead(s) 333 Reopening of laminectomy site 334 Repair of claw toe 335 Repair of cleft hand 336 Repair of hammer toe 337 Repair of hip, not elsewhere classified 338 Repair of macrodactyly 339 Repair of mallet finger 340 Repair of old traumatic injury of cranial and peripheral nerves 341 Repair of recurrent dislocation of shoulder 342 Repair of the anulus fibrosus with graft or prosthesis 343 Repair of vertebral fracture, Elevation of spinal bone fragments, Reduction of fracture of vertebrae, Removal of bony spicules from spinal canal 344 Replacement of joint of foot and toe 345 Resurfacing hip, partial, acetabulum, Hip resurfacing arthroplasty, partial, acetabulum 346 Resurfacing hip, partial, femoral head 347 Revision of total knee replacement, tibial insert (liner), Replacement of tibial insert(liner) 348 Revision or replacement of artificial spinal disc prosthesis, cervical 349 Revision or replacement of artificial spinal disc prosthesis, lumbosacral 350 Revision or replacement of artificial spinal disc prosthesis, not otherwise specified 351 Revision or replacement of artificial spinal disc prosthesis, thoracic 352 Rotator cuff repair 353 Separation of equal conjoined twins 354 Separation of unequal conjoined twins 355 Sequestrectomy 356 Spinal fusion, not otherwise specified 357 Subtalar fusion 358 Subtalar joint arthroereisis 21 359 Suture of Artery 360 Suture of capsule or ligament of ankle and foot NO KSM/INSTALASI /UNIT TINDAKAN 361 Suture of capsule or ligament of other lower extremity 362 Suture of capsule or ligament of upper extremity 363 Suture of cranial and peripheral nerves 364 Suture of muscle or fascia of hand 365 Suture of tendon sheath 366 Suture of tendon sheath of hand 367 Suture of Vein 368 Synovectomy 369 Tarsometatarsal fusion 370 Tendon graft 371 Tendon pulley reconstruction 372 Tendon pulley reconstruction 373 Tendon transfer or transplantation 374 Tenotomy of hand 375 Thigh reattachment 376 Thumb reattachment 378 Toe reattachment 379 Total ankle replacement 380 Total elbow replacement 381 Total ostectomy 382 Total wrist replacement 383 Transplant from cadaver 384 Transposition of cranial and peripheral nerves - Nerve transplantation 389 Triad knee repair 390 Triple arthrodesis 391 Unspecified operation on bone injury 392 Upper arm reattachment 393 Upper limb amputation, not otherwise specified 394 Wedge osteotomy 22 NO KSM/INSTALASI /UNIT
TINDAKAN 5 KSM BEDAH 1 Biopsi Terbuka Bronkhus THORAKS 2 Biopsi Terbuka Diafragma DAN 3 Biopsi Terbuka Mediastinum KARDIOVASKULAR 4 Biopsi Terbuka Paru 5 Biopsi Terbuka Pleura 6 Biopsi Terbuka Pleura dengan VATS 7 Biopsi Terbuka Tumor Dinding Thoraks 8 Debridement Mediastinum (Sternotomi) 9 Eksisi Pada Bronkhus 10 Eksisi Pada Paru (Lung Volume Reduction) 11 Eksisi Pada Paru dengan VATS 12 Eksisi Tumor Dinding Dada dengan Rekonstruksi Dinding Dada 13 Eksisi Tumor Mediastinum (Thymoma, Teratoma, Neurogenic dsb) 14 Ekstraksi Corpus Alienum di Regio Toraks 15 Ekstraksi Corpus Alienum di Regio Toraks dengan VATS 16 Evakuasi Efusi Pleura/Empyema secara Torakoskopik (VATS) 17 Fiksasi Costae (Clipp, Wire) (diluar Clipp) 18 Fiksasi Sternum (Wire, Plate) (diluar wire/plate) 19 Lobektomi Parsial (Reseksi Paru segmental) 20 Lobektomi Parsial (Reseksi Paru segmental) dengan VATS 21 Lumbal Simpatektomi 22 Mediastinostomy 23 Pemasangan thorak drain/water sealed drainage (WSD) (diluar alat) 24 Pleural window (Eloeser Flap) 25 Pleurektomi 26 Pleurodesis (Pleurosklerosis) 27 Plikase Bulae / Bleb Emfisematous 28 Plikasi diafragma 29 Pneumonectomy 30 Pneumonectomy dengan VATS 31 Pulmonary Decortication 32 Pulmonary Decortication dengan VATS 33 Pulmonary Lobectomy/Bilobectomy 34 Pulmonary Lobectomy/Bilobectomy dengan VATS 35 Redo Torakotomi 36 Rekonstruksi Sternum&Dinding Dada 37 repair deformitas Pectus 23 38 Repair Fistula Bronkopleural 39 Repair Laserasi Diafragma NO KSM/INSTALASI /UNIT TINDAKAN 40 Revisi Thoraks drain/water sealed drainage (WSD) (diluar alat) 41 Thoracal Symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) 42 Thoracocentesis 43 Thymectomy 44 Thymectomy dengan VATS 45 Torakoplasti (Air Plumbage/Muscle Plumbage) 46 Torakotomi / sternotomi Eksplorasi 47 Torakotomi Eksplorasi pada Trauma jantung/Repair Laserasi Jantung 48 Bedah Kardio (Jantung) 49 Aortic Valve Repair (AVR) 50 Aortic Valve Repair (AVR) dengan Bioprosthesis Valve 51 Aortic Valve Repair (AVR) dengan Mechanical Valve 52 Atrial septal Defect (ASD) Closure 53 Bidirectional CavoPulmonary Shunt (BCPS) 54 Biopsi Jantung 55 Biopsi Perikardium 56 Blalock-Taussing Shunt (BT Shunt) 57 Coronary Artery Bypass Graft (CABG) 58 Eksisi Cardiac Myxoma 59 Fontan Operation (Atrium-Pulmonary Artery Conduit) 60 Internal Resusitasi/Cardiac Massage (Operasi Terbuka) 61 Ligasi Patent Ductus Arteriosus (PDA) 62 Mitral valve repair (MVr) 63 Mitral Valve Repair (MVR) dengan Bioprosthesis Valve 64 Mitral Valve Replacement (MVR) dengan Mechanical Valve 65 Operasi Redo Open Heart (Valve Replacement) 66 Operasi Reopen oleh Karena sebab Perdarahan, Tamponade Jantung 67 Pemasangan IABP 68 Pemasangan Pace Maker Permanen (diluar alat) 69 Pericardiocentesis 70 Perikardiektomi 71 Perikardiotomi/Pericardial Window 72 Pulmonal Valve Repair (PVR) 73 Pulmonal Valve Repair (PVR) dengan Bioprosthesis Valve 74 Pulmonal Valve Repair (PVR) dengan Mechanical Valve 75 Pulmonary Artery Banding (PA) 24 NO KSM/INSTALASI/ UNIT
TINDAKAN 76 Rastelli Procedure (right Ventricle-Pulonary Artery Conduit) 77 Repair (Eksisi) Aneurisma Jantung 78 Repair Aorta Torakalis (38.34) 79 Repair Atrioventricular Septal Defect (35.54) 80 Repair Total Anomalous Pulmoanry Venous Connection (TAPVC) (35.82) 81 Repair Transposition of Great Arteries (TGA) (35.84) 82 Repair Trunkus Arteriosus (35.83) 83 Revisi/Aff Pace Maker Permanen (diluar alat) (37.89) 84 Septostomi Terbuka Septum Atrium (35.41) 85 Total Koreksi Tetralogy of Fallot (TOF) (35.81) 86 Tricuspid Valve Repair (TVR) (35.14) 87 Tricuspid Valve Repair (TVR) dengan Bioprosthesis Valve (35.27) 88 Tricuspid Valve Repair (TVR) dengan Mechanical Valve (35.28) 89 Ventricle Septal Defect (VSD) Closure (35.5) 90 Amputasi Above Knee (AK) (84.17) 91 Amputasi Below Knee (BK) (84.14) 92 Arterial Pungsi, Kanulasi, Sectie (38.91) 93 Arteriovenous Shuntt (AV Shunt) Brakiosefalika (39.42) 94 Arteriovenous Shuntt (AV Shunt) Radiosefalika (39.27) 95 Bedah Varises Insisi Babcock (38.5) 96 Biopsi Pembuluh Darah (Perifer) (38.21) 97 Debriment-Nekrotomi Luka Gangren (86.22) 98 Disartikulasi Sendi Ekstremitas (84.13) 6 Eksisi Biopsi 1 Eksisi Tumor Pembuluh Darah Perifer (Hemangioma) Tumor Pembuluh 2 Eksplorasi Vaskular (Trauma/Non trauma) Darah 3 Embolektomi/Trombektomi Aorta 4 Embolektomi/Trombektomi Pembuluh Darah Arteri Abdominal 5 Embolektomi/Trombektomi Pembuluh Darah Arteri Ekstremitas Bawah 6 Embolektomi/Trombektomi Pembuluh Darah Ekstremitas Atas (diluar alat) 7 Embolektomi/Trombektomi Pembuluh Darah Ekstremitas Bawah(diluar alat) 8 Embolektomi/Trombektomi Pembuluh Darah Regio servikal (Karotis, Jugular) (diluar alat) 9 Evakuasi Hematom di Ekstremitas (Pasca Pungsi HD/ Traumatik) 10 Fasciotomy 11 Ligasi Vaskular Ekstremitas 25 12 Mutilasi Digiti Ekstermitas NO KSM/INSTALASI /UNIT TINDAKAN 13 Pasang Double Lumen Hemodialisis (HD) (diluar alat) 14 Pasang Implantable Central Venous Access (diluar alat: porth-a-cath, celsite) 15 Pemasangan Central Venous Catheter (CVC) (diluar alat) 16 Pemasangan Intra Aortic Baloon Pump (IABP) (diluar alat) 17 Pemasangan Peritoneal Dyalisis (PD) Catheter (diluar alat) 18 Pembedahan Teleangiectasis 19 Repair Aneurisma (True/false) Ekstremitas Superior (diluar graft) 20 Repair Aneurisma Aorta Abdominalis (Diluar Protesa) 21 Repair Pembuluh Darah Regio Servikal (Karotis, Jugular) 22 Repair Ruptur Pembuluh Arteri Abdominal 23 Revisi Arteriovenous Shunt 24 Skleroterapi Vena (Varises, Hemangioma) 25 Stripping Varises Ekstremitas Inferior 26 Vascular Shunting (Splenorenal Shunt, De Palma Shunt) 27 Vena Punctie, Kanulasi, Sectie 7 KSM BEDAH 1 Abdominal pull through (sfingter saving procedure) DIGESTIVE 2 Abdominoperineal resection (miles) dengan penyulit mayor 3 Abdominoperineal resection (miles) dengan penyulit minor 4
Abdominoperineal resection (miles) tanpa penyulit 5 Abdominoplasty 6 Apendektomi 7 Apendektomi dgn penyulit major 8 Apendektomi dgn penyulit minor 9 Apendektomi laparoskopik 10 Bilio-difgestif anastomosis tanpa penyulit 11 Biliodigestif dengan penyulit mayor 12 Biliodigestif dengan penyulit minor 13 Biopsi insisional, local anastesi 14 Biopsi rectum 15 Eksisi hemoroid eksterna 16 Eksplorasi duktus bilier & cholangiografi intra operatif 17 Esofagotomi 18 Fistulotomi 26 NO KSM/INSTALASI /UNIT TINDAKAN 19 Fistulotomi dgn penyulit mayor 20 Fistulotomi dgn penyulit minor 21 Gastrostomi 22 Hemikolektomi dengan penyulit mayor 23 Hemikolektomi dengan penyulit minor 24 Hemikolektomi tanpa penyulit 25 Hemoroid stapling (diluar alat) 26 Hemoroidektomi 27 Herniotomi 28 Herniotomi dgn penyulit mayor 29 Herniotomi dgn penyulit minor 30 Herniotomi laparoskopik 31 Jejunostomi / ileostomi 32 Laparotomi dengan penyulit minor 33 Laparotomi tanpa penyulit 34 Ligasi hemoroid (diluar alat) 35 Pankreatiko-duodenektomi cephalis (Whipple) dengan penyulit mayor 36 Peritoneal dreanse (CAPD) 37 Peritoneal lavase 38 Polipektomi 39 Potong kolostomi 40 Prosedur Heller 41 Rektopexy 42 Repair fistel usus 43 Repair fistel vesicorectal 44 Repair hernia cicatricalis 45 Repair hernia cicatricalis dgn penyulit mayor (diluar alat) 46 Repair hernia cicatricalis dgn penyulit minor (diluar alat) 47 Repair Hernia Diafragmatika (diluar alat) 48 Reseksi anterior dengan penyulit mayor 49 Reseksi anterior dengan penyulit minor 50 Reseksi anterior tanpa penyulit 51 Reseksi esofagus-colon / ileum transposisi 52 Reseksi esofagus-end to end 53 Reseksi esofagus-esofago-gastrectomy 54 Reseksi hati 55 Second look laparoscopy 56 Splenektomi / splenoraphy traumatika 57 Splenektomi non trauma 58 Terminal esofagus proksimal gastrektomi (TEPG) 27 59 Total gastrektomi NO KSM/INSTALASI /UNIT TINDAKAN 60 Total pantreaktomi 61 Total prokto-kolektomi 62 Tutup burst abdomen (tanpa alat) 63 Tutup burst abdomen dengan penyulit mayor 64 Tutup burst abdomen dengan penyulit minor 65 Tutup kolostomi / ileostomi 66 Tutup kolostomi / ileostomi dengan penyulit mayor 67 Tutup kolostomi / ileostomi dengan penyulit minor 68 Repair Aorta Torakalis (38.34) 69 Repair Atrioventricular Septal Defect (35.54) 8 KSM BEDAH 1 Adrenalektomi UROLOGI 2 Adrenalektomi (Abdominotorakal) 3 Anastomosis end to end Ureter 4 Augmentasi Buli 5 Biopsi Ginjal perkutan 6 Biopsi Ginjal Terbuka 7 Biopsi Penis 8 Biopsi Prostat 9 Biopsi Testis 10 Bladder Neck Rekonstruksi 11 Buried Penis 12 Businasi/Dilatasi Uretra 13 Cabut DJ Stent 14 Defooring Kista Ginjal per Laparoskopi 15 Deroofing/Unroofing Kista 16 Diseksi Kelenjar Getah Bening Inguinal 17 Diseksi Kelenjar Getah Bening pelvis 18 Diseksi Kelenjar Getah Bening Pelvis per Laparoskopi 19 Divertikulektomi Buli 20 Divertikulum Uretra 21 Dorsumsisi 22 Drainase Periureter 23 Eksisi Chordae/Chordektomi 24 Eksisi Fibroma/Rekonstruksi Penis 25 Eksisi Plaque (Peyronie Disease) 26 Eksisi Webbed Penis 27 Eksplorasi testis (Microsurgery) 28 Ekstraksi Batu 29 Ekstrofi Buli Rekonstruksi 30 Epispadia 31 Evakuasi Bekuan Darah (Clot) 32 Extended Pyelolithotomy 28 33 Fistulektomi/Repair Fistel Uretra
NO KSM/INSTALASI /UNIT TINDAKAN 34 Funikokelektomi 35 Ganti Nefrostomy 36 Hidrokel per Inguinal/Ligasi Tinggi 37 Hidrokel per Skrotal 38 Hipospadia Subkoronal 39 Holmium YaG Laser (Sewa) 40 Ileal Conduit (Bricker) 41 Insersi DJ Stent 42 Insisi Abses Perineum 43 Insisi Abses Skrotum 44 Insisi Posterior Urethral Valve 45 Johanson 46 Johanson I 47 Johanson II 48 Kalibrasi Uretra 49 Kauterisasi 50 Koreksi Horseshoe Kidney 51 Koreksi Priapismus 52 Laparoskopi Adrenalektomi 53 Laparotomi Eksplorasi 54 Ligasi V.Spermatika Interna (Microsurgery) 55 Limfadenektomi Ilioinguinal 56 Limfadenektomi Retroperitoneal/RPLND 57 Litholapaksi 58 Lithotripsi 59 Masase Prostat 60 Meatoplasti 61 Meatotomi 62 MMK/Sling Uretra 63 Nefrektomi 64 Nefrektomi Donor Transplant 65 Nefrektomi Parsial 66 Nefrektomi per Laparoskopi 67 Nefrektomi Radial 68 Nefropeksi/Renopeksi 69 Nefrostomi Perkutan/Temporer 70 Nefrostomi Terbuka/Permanen 71 Nefroureterektomi 72 Neobladder 73 Operasi Priapismus (prosedur Winter) 74 Operasi Repair Buli Trauma 75 Operasi Sistokel 29 NO KSM/INSTALASI /UNIT TINDAKAN 76 Operasi Trauma Ginjal 77 Operasi Urakhus/Reseksi urakhus 78 Orkhidektomi 79 Orkhidektomi extended 80 Orkhidektomi Ligasi Tinggi 81 Orkhidektomi Subkapsuler 82 Orkhidopeksi (Torsio Testis) 83 Orkhidopeksi (UDT) 84 Orkhidopeksi per Laparoskopi 85 Pasang Kateter 86 Pasang Kateter dengan Mandrain 87 Pasang Kateter Tenckhoff untuk CAPD 88 PCNL/PNL 89 Penektomi Parsial 90 Penektomi Total/Amputasi Penis 91 PER (Primary Endoscopic Realignment) 92 Pielokalikotomi 93 Pielolitotomi 94 Pieloplasti 95 Pieloplasti per Laparoskopi 96 Prostatektomi Radikal 97 Prostatektomi Retropubik 98 Prostatektomi Terbuka 99 Prostatektomi Terbuka dan Sectio Alta 100 Psoas Hitch/Boari Flap 101 Punksi dan sklerosing Kista Ginjal 102 Railroading Rupture Uretra 103 Reimplantasi Ureter Bilateral 104 Reimplantasi Ureter Unilateral/Ureteroneosistostomi 105 Rekontruksi Renovaskuler 106 Repair Fistel Enterovesika 107 Repair Fistel Vesikokutan 108 Repair Fistel Vesikorektal 109 Repair Fistel Vesikovagina 110 Repair Fistel Vesikovagina Kompleks 111 Reparasi Penis 112 Reseksianastomosis Uretra 113 RPG 114 Sectio Alta/Vesikolithotomi 115 Sirkumsisi 115 Sistektomi Parsial/Sistoplasti Reduksi 116 Sistektomi Per Laparoskopi 117 Sistektomi Total/Radikal 30 118 Sistoskopi 119 Sistoskopi ODS NO KSM/INSTALASI /UNIT TINDAKAN 120 Sistostomi perkutan 121 Sistostomi Terbuka 122 Skrotoplasti 123 Spermatokelektomi 124 Tailoring Ureter 125 Transplan Resipien 126 Transuretero-ureterostomi 127 TUR Prostat/TUIP/BNI 128 TUR Tumor Buli 129 TVP/TMP 130 Ureterokutaneostomi 131 Ureterolisis 132 Ureterolithotomi 133 Ureterolithotomi Distal 134 Ureterolithotomi Proksimal 135 Ureterosigmoidostomi (Caffey) 136 Ureterostomi 137 Ureterouretostomi 138 Uretroplasti Hipospadia 139 Uretroskopi/Uretrosistoskopi 140 Uretrotomi Interna (Sachse) 141 URS/Lithotripsi 142 Varikokelektomi (Palomo) 143 Vasektomi (anestesi lokal) 144 Vasektomi
(narkose) 145 Vasoepididimostomi 146 Vasografi 147 Vasovasostomi 9 KSM ILMU 1 Angkat Jahitan KESEHATAN 2 Angkat Jahitan dengan GA MATA 3 Anterior Chamber Tap/Parasintesis 4 Aspirasi Massa Lensa 5 Blefaroplasty (2 Kelopak Mata) 6 Claw Lens 7 Cryopexy Kornea 8 Cyclo Cryo 9 Dacryocystorinostomi (Without Silicon Tube) 10 Dekompresi Orbital/Lateral Orbitotomi 11 Disisi Aspirasi & IOL 12 ECCE 13 ECCE & IOL 14 Eksenterasi 15 Eksisi Hordeolum / Chalazion 31 16 Ekstirpasi Corpus Alienum di Kornea 17 Ekstirpasi Pterygium + Graft Konjungtiva NO KSM/INSTALASI /UNIT TINDAKAN 18 Ekstripasi Corpus Alienum di Bilik Mata Depan 19 Enukleasi/Eviscerasi (DFG/Bonegraft) 20 Evakuasi Silikon Oil 21 Fornix Repair 22 ICCE 23 ICCE & IOL 24 Injeksi Intra Vitreal 25 Injeksi Periokuler Terapetik 26 IOL Explant 27 Iridectomi 28 Jahit Kelopak Mata Full Thickness & Lid Margin 29 Jahit Kornea 30 Keratoplasti (Corneal Transplantation) 31 Konjungtival Flap/Amnion Graft 32 Piggy Back IOL 33 Pneumoretinopexy 34 Repair Canalis Lacrimalis (Without Silicon Tube) 35 Repair Coloboma Palpebra (Skin/Mucosal Graft) 36 Reposisi IOL 37 Reposisi Iris 38 Resesi & Reseksi 2 Otot 39 Resesi & Reseksi 3 Otot 40 Resesi & Reseksi 4 Otot 41 Resesi/Reseksi 1 Otot 42 Sekunder Implant (Posterior Chamber) 43 Sekunder Implant Claw Lens / Fiksasi Sulcus 44 SICS 45 SICS & IOL 46 Simpel Vitrektomi 47 Skleral Buckle 48 Socket Repair (Contracted Socket) 49 Trabekulektomi 50 Trabekuletomi & Ollogen 51 Trabulektomi & Goniotomi pada Pediatric Glaucoma 52 Tube Shunt (Express) 53 Viscocanulostomy 54 Vitrektomi +++ 55 Vitrektomi Lengkap & Skleral Buckle 56 Wide Eksisi Tumor Kelopak Mata 57 Wide Eksisi Tumor Kelopak Mata + Flap + graft 32 NO KSM/INSTALASI /UNIT TINDAKAN 10 Divisi Onkologi 1 Aspirasi Kista Mamma Single dan Multiple 2 Biopsi Core Lokal Anestesi 3 Biopsi Eksisi Lokal 4 Biopsi Eksisi Narkose 5 Biopsi Insisi Lokal 6 Biopsi Narkose 7 Breast Conserving Surgery (BCS) 8 Breast Conserving Surgery + LD Flap 9 Debriment Mamma 10 Diseksi Axilla 11 Eksisi Fibroadenoma Lokal Anestesi Single Satu Sisi 12 Eksisi Fibroadenoma Multiple Narkose 13 Eksisi Tumor Metastase Loco-regional 14 Eksplorasi Duktus Mama 15 Eksplorasi Duktus Mama+VC 16 Insisi Absces Mastitis Lokal 17 LD Flap + Eksisi Tumor 18 Mastectomy + Tram Flap 19 Modified Radical Mastectomy + Flap/Single Grafting 20 Modified Radical Mastectomy Single 21 Quadrantectomy / Partial Mastectomy 22 Simple Mastektomy + Flap/Skin Grafting 23 Simple Mastektomy Single 24 Tram Flap + Eksisi Tumor 25 Operasi Tumor Kulit 26 Biopsi Insisi Tumor Kulit Lokal 27 Biopsi Eksisi Tumor Kulit Narcose 28 Eksisi Tumor Jinak ≤ 3cm 29 Eksisi Tumor Jinak + Flap/Skin Graft 30 Eksisi Tumor Jinak Kulit >3cm 31 Wide Eksisi + Diseksi KGB 32 Wide Eksisi Tumor Ganas Kulit 33 Wide Eksisi Tumor Ganas Kulit+Flap / Skin Graft 34 Operasi Soft Tissue Tumor 35 Amputasi + Diseksi KGB 36 Amputasi Jari + Flap / Skin Graft 37 Amputasi Tungkai / Lengan 38 Biopsi Core soft Tissue 39 Biopsi Insisi Tumor Sof Tissue dengan Narcose 40 Biopsi Insisi Tumor Soft Tissue Lokal Anestesi 41 Eksisi Tumor Jinak > 3cm 42 Eksisi Tumor Jinak Ø<3cm 43 Wide Eksisi + Compartement Procedure 44 Wide Eksisi + Diseksi KGB 33
45 Wide Eksisi Tumor Ganas 46 Wide Eksisi Tumor Jinak + Flap/Skin Graft NO KSM/INSTALASI /UNIT TINDAKAN 47 Operasi Tindakan Tertentu 48 Advancement Flap 49 Aspirasi Effusi Pleura 50 Aspirasi Paru + Pleurodhesis 51 Delto Pectoral Flap (DP Flap) 52 Diseksi Axilla 53 Diseksi Inguinal 54 Diseksi Para Aorta 55 Eksisi Tumor Lidah 56 Eksisi Tumor Sub Mandibula/Sub Mental 57 Insersi Chest Tube 58 Ismulobectomy 59 Kemoterapi Perinfus 60 Latissimus Dorsi Flap (LD Flap) 61 Maksilektomi Total 62 Mastopexy 63 Modifikasi RND 64 Operasi Compartement Otot 65 Ovariectomy Bilateral 66 Reseksi Mandibula 67 Rotation Flap 68 Skin Grafting 69 Sub Total Thyroidectomy 70 Superficial Parotidectomy 71 Thoraco Abdominal Flap (TA-Flap) 72 Total Parotidectomy 73 Total Thyyroidectomy 74 Transversus-Rectus Abdominis Flap (Tram Flap) 34 NO KSM/INSTALASI /UNIT TINDAKAN 11 DIVISI BEDAH 1 Abdominal pull through (sfingter saving procedure) ANAK 2 Adhesiolisis 3 Appendektomi dgn penyulit 4 Appendektomi laparoskopik 5 Appendektomi tanpa penyulit 6 Biliodigesif dengan penyulit mayor 7 Biliodigestif anastomosis tanpa penyulit atau penyulit minor 8 Biopsi rectum 9 By pass usus dengan penyulit mayor / minor 10 Divertikulektomy 11 Drainase abses dengan general anasthesia 12 Drainase abses local anasthesia 13 Eksisi hygroma colli 14 Eksisi kista brachialis 15 Eksisi kista duktus tiroglossus 16 Eksisi neoplasma Jinak ( lipoma, atheroma dll ) 17 Eksisi sinus/granuloma umbilikalis 18 Eksisi soft tissue tumor dengan penyulit 19 Eksisi soft tissue tumor tanpa penyulit 20 Eksisi teratoma dengan penyulit dan rekonstruksi 21 Eksisi teratoma tanpa penyulit 22 Eksisi tumor jinak wajah 23 Eksisi urachus 24 Ekstirpasi fistel pre aurikulae 25 Ekstirpasiranula 26 Endoskopik diagnostik 27 Endoskopik terapeutik 28 Gastrostomi 29 Hemikolektomi 35 30 Herniotomi elektif tanpa penyulit 31 Herniotomi laparoskopik NO KSM/INSTALASI /UNIT TINDAKAN 32 Hernitomi dgn penyulit / komplikasi 33 Hidrokolektomi 34 Intraoperatif kolangiografi 35 Intraoperatif kolangiografi laparoskopik 36 Jejenostomi / ileostomi dengan penyulit mayor 37 Jejenostomi / ileostomi dengan penyulit minor 38 Jejenostomi / ileostomi tanpa penyulit 39 Koledokotomi dengan penyulit mayor 40 Kolesistektomi 41 Kolesistektomi laparoskopik 42 Kolostomi / sigmoidostomi (46.11) 43 LADD Operation (54.95) 44 Laparoskopik diagnostik (61.6) 45 Ligasihemoroid (49.4) 46 Operasi kelainan umbilikal lain (54.3) 47 Orchidopexy (62.5) 48 Orchidopexy laparoskopik (62.5 + 61.6) 49
Other Repair of Abdominal Wall (Repair Omphacele) (954.72) 50 Polipektomi (48.36) 51 Posterosagital anorectoplasty (49.79) 52 Posterosagital anorectoplasty urethro vaginoplasty (70.79) 53 Potong kolostomi (46.14) 54 Potong Stump (84.3) 55 Prosedur Heller (44.6) 56 Prosedur Kasai (51.37) 57 Repair atresia esofagus (42.5) 58 Repair defek diafragma (53.8) 36 59 Repair ekstrofia buli (57.8) 60 Repair hernia diafragma (53.7/53.8) NO KSM/INSTALASI /UNIT TINDAKAN 61 Repair of Gastrochisis (54.71) 62 RPLND (40.59) 63 Separasi conjoined twin (84.9) 64 Sirkumsisi dengan general anesthesia (64.0) 65 Sirkumsisi dengan local anesthesia (64.0) 66 Splenektomi (41.5) 67 Splenorenal shunt (39.1) 68 Transnasal endorectal pullthrough laparascopic assisted (48.42) 69 Transplantasi organ 70 Tutup burst abdomen dengan penyulit (54.61) 71 Tutup burst abdomen tanpa penyulit (54.61) 72 Tutup ileostomi dengan penyulit (46.5) 73 Tutup kolostomi / ileostomi (46.5) 74 Tutup Stoma (46.5) 75 Urethroplasty / chordectomy (64.42) 76 Vena Sectie Aksilaris (38.94) 77 Vena sectie Femoralis / saphena magna (38.94) 78 Wound repair (86.8) 12 KSM BEDAH 1 Abdominoplasty PLASTIK 2 Aff archbar, Lokal Anastesi 3 Aff Suspensi, Lokal Anastesi 4 Amputasi above elbow 5 Amputasi bellow elbow 6 Amputasi digital 7 Amputasi jari >1 8 Amputasi jari single 9 Augmentasi mamae 10 Blefaroplasty (2 kelopak mata) 11 Blefaroplasty pada kasus sulit 37 12 Blefaroptosis NO KSM/INSTALASI /UNIT TINDAKAN 13 Bone rekonstruksi facial cleft 14 Bone rekonstruksi facial cleft 15 Cheilonasoraphy 16 Chordectomy 17 Chordectomy+urethroplasty 18 Closed Reduction Fr. Nasal 19 Comisuroplasty 20 Eks mamma aberan bilateral 21 Eksisi neoplasma jinak (lipoma, atheroma dll) 22 Eksisi luas + Deltopectoral flap 23 Eksisi luas + Fore head flap 24 Eksisi luas + Muskulocutan flap 25 Eksisi luas + rekonstruksi dengan bedah mikrovaskular 26 Eksisi malformasi lymphatik / vaskuler 27 Ekstraksi ateroma / keloid 28 Ekstraksi korpus alienum 29 Elevasi ear rim cartilago 30 Excise hemangioma + rekonstruksi 31 Excise intra keloid 32 Excise polydactyly 33 Excise reduksi lymedema 34 Facial sling dengan allograft 35 Fasciotomy burn injury 36 Fasciotomy with complication 37 Flap lokal sederhana 38 Fr. Condylus mandibula open red 39 Fr. Maksila suspensi (IOID) 40 Fr. Nasal open reduction 41 Fraktur Prosesus alveolaris dengan inter dental wiring (IDW) (per rahang) 42 Fraktur Prosesus alveolaris luas dengan IDW (per rahang) 43 Fraktur rahang reduksi terbuka & inter oseus wiring (IOW) 38
NO KSM/INSTALASI /UNIT TINDAKAN 44 LD flap 45 Le fort I osteotomy 46 Liposuction 47 Lobuloplasti 48 Malarplasty 49 Mamma aberan unilateral 50 Mandibular distraksi 51 Mandibular rekonstruksi dengan costochondral graft 52 Mastopexi 53 Mentoplasty 54 Microsurgery 55 Multiple facial fraktur + implant 56 Muskulokutaneus flap 57 Myokutaneus flap/pectoralis mayor flap 58 Nasal repair dan rekonstruksi 59 Neo vagina 60 Operasi bedah mikro 61 Orif fraktur zygoma 62 Orif fraktur hand 63 Orif fraktur mandibula 64 Orif fraktur maxilla 65 Orif maksila plating 66 Orif mandibula plating 67 Orif mandibula wiring 68 Orif orbital wall 69 Orif orbital wall 70 Orif zygoma wiring 71 Osteotomy craniosynostosis reconstruction 72 Osteotomy facial rekonstruksi 73 Osteotomy genioplasti tanpa tarif bahan 74 Osteotomy maksila Le fort I 75 Osteotomy maksila Le fort II 76 Palatoplasti bilateral komplit 77 Palatoplasti bilateral tak komplit 78 Palatoplasti unilateral komplit 79 Palatoplasti unilateral tak komplit 80 Palatoraphy 81 Pasang archbar 82 Pasang back slab/fore slab 83 Pasang cast/gips tanpa reposisi 84 Recheiloraphy 85 Rekonstruksi dengan alloplastic material 39 86 Rekonstruksi facial cleft 87 Rekonstruksi nasal NO KSM/INSTALASI /UNIT TINDAKAN 88 Rekonstruksi palpebra 89 Released buried penis 90 Released syndactyly kompleks 91 Repair canalis lacrimalis (without silicon tube) 92 Repair coloboma palpebra (skin/mucosal graft) 93 Repair ductus nasolacrimalis 94 Repair fingertip injury 95 Repair fistel urethra 96 Replantation 97 Reposisi fraktur nasal sederhana 98 Reposisi fraktur os nasalis (complicated) 99 Reseksi mandibula + bone graft 100 Rhinoplasty 101 Rotation flap 102 Sagital Split osteotomi mandibula 103 Simple bone grafting 104 Simple skin grafting 105 Skin flap 106 Skin graft >5 cm 107 Skin graft sedang 5 cm 108 Skin grafting kecil 109 Skin grafting luas 110 Skin grafting sedang 111 Skin grafting with complication 112 Tendon reconstruction 113 Tendon transfer 114 Tendon transfer with complication 115 Tennoraphy 116 Tennoraphy with complication 117 TMJ arthroplasty 118 TMJ arthrostomy 119 Tram flap 120 Wound Dressing 121 Wound Repair 40 NO KSM/INSTALASI/ UNIT TINDAKAN 13 KSM 1 Cauter serviks OBGYN 2 Cordosentesis 3 Debulking tumor ovarium 4 Eksplorasi vagina 5 Embryotomi 6 Extirpasi + kuret polip endoserviks 7 Extirpasi geboren mioma 8 Extirpasi geboren mioma+kuiretasi 9 Histeroctomy pada mola / chorio Ca 10 Histeroctomy radikal 11 Kistektomi 12 Konisasi serviks 13 Kuret abortus incompletes 14 Lap op: myomektomi 15 Laparoskopi (Kistektomi Ovarium, Salphingektomi, Adhesiolisis) 16 Laparoskopi Histerektomi 17 Laparoskopi steril 18 Laparoskopik Diagnostik 19 Laparotomi dengan penyulit mayor 20 Laparotomi dengan penyulit minor 21 Laparotomi tanpa penyulit 22 LEEP 23 Micro kuretase
DUB 24 Mikrokuret 25 Miomectomy 26 Neovagina 27 Operasi Ca vagina 28 Operasi kanker corpus uteri 29 Operasi tumor ganas ovarium 41 30 Operative histeroscopy/Ablasi endometrium 31 Overectomi NO KSM/INSTALASI /UNIT TINDAKAN 32 Painless labor 33 Persalinan normal 34 Persalinan normal dengan penyulit 35 Persalinan pervaginam tindakan operatif 36 Persalinan sungsang 37 Rekanalisasi 38 Rekanalisasi tuba 39 Salfingektomi unilateral 40 Salvingoovarectomi unilateral 41 Secound look surgery Ca ovarium 42 Seksio sesaria 43 Seksio sesaria dengan penyulit penyulit 44 Sirklase serviks 45 Seksio sesaria dengan penyulit penyulit 46 Sirklase serviks 47 Supra vaginal hyterectomy 48 Surgical staging 49 TAH+BSO dengan Penyulit 50 TAH+BSO dengan Penyulit Pemasangan Tampon Abdomen 51 Total hysterectomy+bilateral salfingektomi 52 Tubektomi klinik 53 Tutup burst abdomen
abdominal
42 NO KSM/INSTALASI /UNIT TINDAKAN 14 KSM 1 Augmentasi Tulang Per Regio (Belum Termasuk Bahan) GIGI dan 2 Debriment Mukosa dan Pengelolaan Luka Sayat MULUT 3 Dislokasi Sendi Mandibula 4 Eksisi Epulis Per Rahang 5 Eksisi Kelenjar Ludah Submandibula 6 Eksisi Kista Odontogenik Keratosis + Ostektomi 7 Eksisi Neoplasma Jinak Extra Oral Ukuran Kecil 8 Eksisi Parsial + Marsupialisasi Ranula 9 Eksisi Plunging Ranula 10 Eksisional Biopsi Neoplasma Jinak 11 Enukleasi Kista Dentigerous + Extraksi Gigi Impaksi 12 Enukleasi Kista radikuler Per Rahang + Extraksi Gigi Penyebab 13 Extirpasi Kista Dermoid 14 Extirpasi Sialolith 15 Extraksi Corpus Alienum dengan Teknik Lindorf 16 Extraksi Gigi Anak dengan Kelainan Jantung Per Rahang 17 Extraksi Gigi Anak Per Rahang 18 Extraksi Gigi Dewasa Per Rahang 19 Fissure Sealant pada Autis 20 Fraktur Dento alveolar Dengan arch Bar 21 Fraktur Dento alveolar Dengan Bracket (belum termasuk bahan) 22 fraktur Dento Alveolar dengan Eyelet 23 Fraktur Maksila dengan Suspensi Wiring 24 Fraktur Nasal close Reduksi 25 Fraktur Nasal Open Reduksi 26
Fraktur Rahang Reduksi Tertutup dengan Intermaksila Fiksasi 27 Frenektomi Per Rahang 28 Genioplasty 29 Gingivektomi Per Rahang 43 NO KSM/INSTALASI /UNIT TINDAKAN 30 Hemi Maksilektomi Tanpa Rekonstruksi 31 Insisi Abses / Phlegmon 32 Insisional Biopsi Neoplasma Jinak 33 Mandibular Distraksi 34 Odontektomi Per Gigi 35 ORIF Maksila + Zygoma + Mandibula (belum termasuk implant) 36 ORIF Maksila Plating (belum termasuk implant) 37 ORIF Mandibula Plating (belum termasuk implant) 38 ORIF Zygoma Plating (belum termasuk implant) 39 Osteotomi Maksila le Fort I 40 Osteotomi Maksila le Fort II 41 Pelepasan Arch Bar (Intermaksila Fiksasi) 15 DIVISI PEDIATRI 1 Intubasi Endotrakea GAWAT 2 Krikotirotomi DARURAT 3 Kanulasi vena perifer ILMU 4 Vena sectie KESEHATAN 5 Pungsi lumbal ANAK 6 Pungsiv Pleura 16 KSM PENYAKIT 1 Diagnostik Kateterisasi Jantung JANTUNG & 2 PTMC PEMBULUH 3 PTCA/Stenting DARAH 4 Pacemaker Temporer&Permanen 5 IABP 6 Perikardiosintesis 7 Pemasangan Swan Ganz Kateter 8 Pemasangan Amplatzer/ADO/Coilling 9 CVC 10 Pelepasan Arch Bar (Intermaksila Fiksasi) 17 KSM PENYAKIT DALAM Endoscopy 44 B. Tindakan Anestesi &Sedasi ( Sedang dan Dalam), tindakan yang memerlukan informed consenttersebut antara lain: a. Semua tindakan anestesi dan sedasi di dalam kamar operasi b. Semua tindakan anestesi dan sedasi di ICU Tindakan Anestesi di ICU Pemasangan intubasi ventilator Pemasangan vena central Pemasangan CRRT Pemasangan Swan Ganz (Kateter Arteri Pulmonal) Pemasangan Intra Arterial Catheher (Kateter Intra Arterial) Pemasangan Percutaneous Dilatational Tracheostomy Pemasangan Drain Intra Thorakal/Punksi Thorax Pemasangan IABP Pemasangan Drain Intra Abdominal Pemasangan Gemo Cardioversi Bronchoskopi-FOB TEE C. Tindakan Pemberian Produk Darah dan Komponen Darah,tindakan yang memerlukan informed consenttersebut antara lain: Transfusi darah: a. Plasma sel b. PRC c. Whole Blood Cell d. Trombosite e. Albumin f. lain – lain 45 D. Semua Tindakan Yang Berisiko Tinggi : No KSM / INSTALASI NAMA TINDAKAN 1 KSM Anak
1 Chest tube 2 Tindakan kemotherapi 3 Pemasangan Ventilator 4 Intubasi Endotrakea 5 Pemasangan Laryngeal mask 6 Krikotirotomi 7 Infus intraosseus 8 Kanulasi vena perifer 9 Vena sectie 10 Pengambilan darah intra vena dan intra arteri 11 Pungsi lumbal 12 Pungsiv Pleura 13 Pemasangan kateter urine 14 Pemasangan keteter rectal 15 Pemasangan orogastrik tube 16 Pemasangan nasogastrik tube 2 THT-KL 1 Pemeriksaan Audiometri 2 Pemeriksaan Timpanometri 3 Pemeriksaan Audiometri Tutur 4 Pemeriksaan Sisi&Tore Decay 5 Pemeriksaan Pendengaran Pada Anak 6 Pemeriksaan Brainstem Evoked Response Audiometry 3 KSM Patologi Anatomi FNAB (Fine Needle Aspiration Biopsy) 4 Inst. Radiotherapi Tindakan Radiotherapi 5 KSM Neurologi 1 Cerebral Angiografi 2 AVM&Embolisasi 3 Aneurisma Coiling 4 Embolisasi pre operasi 5 Diagnosis DSA 6 Lumbal Punksi 7 Pain Intervention 8 Injeksi Triger point 9 Injeksi Triger Fringer 10 Injeksi CTS 11 Sub Optical Functional 12 Injeksi botox 13 EMG 6 KSM Patologi Phlebotomi 46 Klinik 7 KSM Gigi dan Mulut 1 Scaling 2 Curettage/root planning (jika diperlukan anestesi) 3 Gingivektomi 4 Frenektomi 5 Flap operasi (bone graft/membrance/GTR/interseptif) 6 Implant 7 Vital pulpektomi dan Partial Nekrose 8 Cauter 9 Retraksi Gingiva pada prep.crown 8 Poli Andrologi Suntik Intra Cavernosal Penis 9 KSM Kardiologi dan Kedokteran Vaskular 1 Dobutamin Stress Ekhokardiografi 2 Transophegal Ekhokardiografi 3 Treadmill Tes 4 Exercise Stress Ekhokardiografi 10 KSM Pulmonologi dan Ilmu Kedokteran Respirasi
1 Bronchoscopy/FOB 2 Tindakan kemotherapi 3 Thoracoscopy 4 Contra Ventil/WSD 5 Punctie Pleura 6 FNAB 7 Scalene Biopsy 8 Reposisi 9 Pleurodesis 10 AFF WSD 11 Perawatan Luka WSD 12 USG Thorax Marker 11 KSM Radiologi 1 Tindakan Radiologi Injectee contrast 2 Tindakan Radiologi pada pasien dengan kelainan cardiovaskuler 3 Tindakan Radiologi pada pasien dengan alergi berat 4 Tindakan Radiologi pada pasien dengan KU yang menurun 5 Tindakan Radiologi yang memerlukan FNAB Guiding MSCT pada pasien dengan kelainan yang berdekatan dengan organ vital 6 Tindakan Radiologi pada Ibu hamil yang memerlukan foto 12 KSM Neurologi 1 Cerebral Angiografi 2 AVM&Embolisasi 3 Aneurisma Coiling 4 Embolisasi pre operasi 5 Diagnosis DSA 47 6 Lumbal Punksi 7 Pain Intervention 8 Injeksi Triger point 9 Injeksi Triger Fringer 10 Injeksi CTS 11 Sub Optical Functional 12 Injeksi botox 13 EMG 14 Neuro endovaskuler: Coiling,Embolisasi,DSA 13 Instalasi Hemodialisis Setiap kali melakukan tindakan Hemodialisis 14 KSM Rehabilitasi Medik Elektromiografi dan Kecepatan Hantar Saraf 16 IRNA Jiwa 1 Psycho Analisa 2 Psycho Therapy Dalam 3 Pemeriksaan Calon Pimpinan Publik 4 Aborsi Provocatus Medicinalis 5 Tindakan terapi elektroconfusi 6 Pemeriksaan kandungan zat narkotika 7 Restraint / Fiksasi : mekanik dan psikotropika 8 Pemeriksaan sengketa/ konflik dalam keluarga 15 Semua injeksi dengan obat risiko tinggi
