RSUD KOTA LANGSA Jln. Jend. A. Yani No.1 KOTA LANGSA
PERSETUJUAN / PENOLAKAN TINDAKAN MEDIS (INFORMED CONSENT
NO DOKUMEN :
NO REVISI :
HALAMAN : 1/7
DITETAPKAN OLEH : PROSEDUR TETAP
PENGERTIAN
TANGGAL TANGGAL TERBIT: TERB IT: dr. HERMAN I PEMBINA TINGKAT 1 (IV/) NIP : 196222 196222 19!9" 1 1 In!o"#ed $on%en& #d#$#% : 1. P&r'&*#+ P&r'&*#+ ,#+- d&r0#+ d&r0#+ $&% #'&+/ #'&+/ 0&$#r0&$#r-#+,# #+,# ($'#+ ## $'#+) 0&#d# d0&r +0 3&$#00#+ &3&r0'##+4 &+-##+ d#+ +d#0#+ 3&d' ##+4 ##+4 '&&$#% 3&+d## +5r3#' ,#+- *&$#' d#r d0&r+,#. '. P&r'&*#+ ## + &r$' d#r #'&+/ 0&$#r-#+,#
0&#d# d0&r &r%#d# +d#0#+ &r#5/ ## +#'& $#++,# ,#+- 3&3+,# r&'0. . P&r'&*#+ / P&+$#0#+ &r%#d# +d#0#+ 3&d' ,#+-
#0#+ d&r0#+ 0&#d# #'&+ $&% &3&r &$#,#+#+ 3&r#0#+ %#0 #'&+ ,#+- d0&30#0#++,# '&8#r# &#'4 r#'+#$4 #+# #0'##+ (voluntary (voluntary)) '&&$#% 3&+d##0#+ +5r3#' d#+ &+*&$#'#+ ,#+- #d&0# &+#+- +d#0#+ 3&d' d3#0'd. ). I3$&d 8+'&+ &r'&*#+ &r'r# ## d#+--# &$#%
d&r0#+ (d#0 &r$ &r$') #d# 0&#d##+ +r3#$ ## #'# ## d#$#3 0&#d##+ d#rr# d3#+# #'&+ d#0 &rd#,# ## d#0 #d# 0&$#r-#+,# (Pr&'3&d +'&+).
RSUD KOTA LANGSA Jln. Jend. A. Yani No.1 KOTA LANGSA
PERSETUJUAN / PENOLAKAN TINDAKAN MEDIS (INFORMED CONSENT
NO DOKUMEN :
NO REVISI :
HALAMAN : 2/7
1. T&r8##+,# &r #d3+'r#' d#$#3 r#+-0#
TUJUAN
3&++-0#+,# 3 &$#,#+#+ 0&#d# #'&+. '. T&r'&d#+,# &d3#+ #- '&$r% &-#' ,#+- &r0#
d#$#3 3&$#0'#+#0#+ $#+-0#%$#+-0#% +d#0#+ 3&d0 &r%#d# #'&+. . M&3&r0#+ &r$+d+-#+ &r%#d# #'&+ 3&$#$
&3&+%#+ %#0%#0 #'&+ 3&+d##0#+ +5r3#' ,#+- #d&0# ##' +d#0#+ 3&d' ,#+- #0#+ d&r0#+ KE*IJAKAN
&3&r &$#,#+#+ 3&d' 0&#d#+,# 1. P&r#r#+ M&+&r K&'&%##+ R&$0 I+d+&'# N3r 1691 /M&+0&'/ P&r/ VIII/ 211 T&+#+- K&'&$#3##+ P#'&+ R3#% '#0. '. 269/ M&+0&'/ P&r/ III/ 2! T&+#+- R&0#3 M&d'. . K&'#+ Dr&0r ;&+dr#$ P&$#,#+#+ M&d0 +.HK..6.".<.1!66 &+#+- P&d3#+ P&r'&*#+ T+d#0#+ M&d0 (I+5r3&d +'&+). ). PP N "2 TH 1996 T&+#+- TENAGA KESEHATAN +. P&r#r#+ M&+&r K&'&%##+ N3r 29/MENKES/PER/ VI/ 211 T&+#+- P&r'&*#+
PROSEDUR
T+d#0#+ K&d0&r#+. 1. D0&r ,#+- &r=&+#+- 3&$#00#+ +d#0#+ 3&d' &r#+--+-*#=# 3&3&r0#+ +5r3#' d#+ &+*&$#'#+ ,#+- #d&0# &r$&% d#%$ &+#+-: #. T*#+ d#+ r'&0 0&&r%#'$#+ +d#0#+ 3&d' ,#+- #0#+ d$#00#+ ( purpose of medical procedure) . T## 8#r# +d#0#+ 3&d' ,#+- #0#+ d$#00#+
RSUD KOTA LANGSA Jln. Jend. A. Yani No.1 KOTA LANGSA
PERSETUJUAN / PENOLAKAN TINDAKAN MEDIS (INFORMED CONSENT
NO DOKUMEN :
NO REVISI :
HALAMAN : "/7
( contemplated medical procedures) 8. R&'0 (risk inherent in such medical procedure) d#+ 03$0#' ,#+- 3+-0+ &r*#d. d. A$&r+#5 +d#0#+ 3&d' $#+ ,#+- &r'&d# '&r# r&'0+,# 3#'+-3#'+- (alternative medical procedure and risk ) &. Pr-+'' &+,#0 ##$# +d#0#+ 3&d' &r'& d$#00#+ 3#+ d#0 d$#00#+ ( prognosis with and without medical procedure). 5.
D#-+''.
2. A#$# d0&r ,#+- #0#+ 3&$#00#+ +d#0#+ 3&d0 &r%#$#+-#+4 3#0# &+,#3##+ +5r3#' d#+ &+*&$#'#+ d3#0'd d## d=#0$0#+ 0&#d# d0&r $#+ d&+-#+ '&&+-&#%#+ d0&r ,#+- &r'#+-0#+. D0&r ,#+- 3&=#0$ d3#0'd %&+d#0+,# 3&+8## +5r3#' d#+ &+*&$#'#+ ,#+- &$#% d&r0#++,# d#$#3 $&3#r#+ &$&+-0# +5r3#' d#+ &+*&$#'#+ $'#+4 '&#-# #'#+ #- d0&r ,#+- #0#+ 3&$#00#+ +d#0#+ 3&d'. ". I+5r3#' d#+ &+*&$#'#+ d&r0#+ '&8#r# $'#+> +5r3#' d#+ &+*&$#'#+ '&8#r# &r$' d$#00#+ %#+,# '&#-# &$&+-0# &+*&$#'#+ ,#+- &$#% d'#3#0#+ '&8#r# $'#+. ?. P&r'&*#+ ## &+$#0#+ +d#0#+ 3&d' d&r0#+ '&'&r#+- ,#+- '&%# 3&+#$ (#'&+ 3#+ r#+$#+ ,#+- 3&3#+- &r%#0 3&3&r0#++,# d#r '&- %03):
RSUD KOTA LANGSA Jln. Jend. A. Yani No.1 KOTA LANGSA
PERSETUJUAN / PENOLAKAN TINDAKAN MEDIS (INFORMED CONSENT
NO DOKUMEN :
NO REVISI :
HALAMAN : ?/7
#. P#'&+ '&+dr $# #'&+ &$#% &r3r 21 #%+ ## &$#% 3&+0#% . P#'&+ &r'# 0r#+- d#r 21 #%+4 3#0# r#+ %#0: A,#% / I 0#+d+-4 S#d#r#'#d#r# 0#+d+-. 8. P#'&+ &r'# 0r#+- d#r 21 #%+ d#+ d#0 3&3+,# r#+-# ## r#+-#+,# &r%#$#+-#+ %#dr4 3#0# r#+ %#0: A,#% / I #d'4 S#d#r#'#d#r# 0#+d+-4 I+d0 '&3#+-. d. P#'&+ d&=#'# d&+-#+ -#+--#+ 3&+#$4 3#0# r#+ %#0: A,#% / I 0#+d+-4 @#$ ,#+- '#%4 S#d#r#'#d#r# 0#+d+-. &. P#'&+ d&=#'# ,#+- &r#d# d #=#% &+-#3#+ (curratelle)4 3#0# r#+ %#0: @#$4 curator . 5. P#'&+ d&=#'# ,#+- &$#% 3&+0#% / r#+- #4 3#0# r#+ %#0: S#3 / I'&r4 A,#% / I 0#+d+-4 A+#0 0#+d+-4 S#d#r# 0#+d+-. <. P&$#0'#+##+ informed consent ,#+- &+#r $# &r'&*#+ ## &+$#0#+ +d#0#+ 3&d' d&r0#+: #. U+0 +d#0#+ 3&d' ,#+- d+,##0#+ '&8#r# '&'50 (the consent must be for what will be actually performed ). P&r$#'#+ +d#0#+ 3&d' '&$#+ +d#0#+ 3&d' ,#+- &$#% d'&* d#0 d&+#r0#+ d$#00#+4 0&8#$ ##$# &r$#'#+ +d#0#+ 3&d' &r'& &r#0'# d$#00#+ +0 3&+,&$#3#0#+ *=# #'&+.
RSUD KOTA LANGSA Jln. Jend. A. Yani No.1 KOTA LANGSA
PERSETUJUAN / PENOLAKAN TINDAKAN MEDIS (INFORMED CONSENT
NO DOKUMEN :
NO REVISI :
HALAMAN :
. T#+# #0'##+ (voluntary). 8. O$&% '&'&r#+- ,#+- '&%# 3&+#$ (#0 #'&+ 3#+ r#+- $#+ ,#+- 3&3#+- &r%#0 3&3&r0#++,# d#r '&- %03. S&&$#% d&r0#+ 80 (adekuat ) +5r3#' d#+ &+*&$#'#+ ,#+d&r$0#+. 6. P&r'&*#+ ## &+$#0#+ &e"&,li% 3$#0 d&r$0#+ d#r #'&+ (3#+ r#+- $#+ ,#+- &r%#0 3&3&r0#++,# d#r '&- %03) #d# +d#0#+ 3&d' ,#+- -e"i%io &ini4 '&d#+-0#+ +0 +d#0#+ 3&d' ,#+- d#0 &r'0 +-- 80 &r'&*#+ ## &+$#0#+ $'#+. S&3# *&+' +d#0#+ 3&d' ,#+3&+-#+d+- r'0 +-- %#r' d'&r# informed consent . 7. B#- #'&+ -#=# d#rr#4 d#$#3 0&#d##+ d#0 '#d#r d#+ d#0 dd#3+- $&% 0&$#r-# #'&+ ,#+- &r%#0 3&3&r0#+ &r'&*#+ ## &+$#0#+ +d#0#+ 3&d'4 d#0 d&r$0#+ informed consent !. r3# '#+ &r'&*#+ / &+$#0#+ +d#0#+ 3&d' d' '&8#r# $&+-0#4 &+#r d#+ *&$#' (3&+--+#0#+ %r5 #$0) $&% &r#=# ,#+- &r#+--+-*#=# +0 . 9. B$#3#+# #'&+ (r#+- $#+ ,#+- 3&3#+- &r%#0 3&3&r0#++,# d#r '&- %03) &$#% '# +0 3&3&r0#+ 0&'#+4 3#0# &r'&*#+ / &+$#0#+ +d#0#+ 3&d' ,#+- &$#% d' d&+-#+ $&+-0#4 &+#r
RSUD KOTA LANGSA Jln. Jend. A. Yani No.1 KOTA LANGSA
PERSETUJUAN / PENOLAKAN TINDAKAN MEDIS (INFORMED CONSENT
NO DOKUMEN :
NO REVISI :
HALAMAN : 6/7
d#+ *&$#' $&% &r#=# ,#+- &r#+--+-*#=# +0 d#8# $&% / d#8#0#+ 0&#d# #'&+ (r#+- $#+ ,#+- 3&3#+- &r%#0 d#r '&- %03) d#+ #0%r+,# d#+d#+-#+ $&% ,#+- &r'#+-0#+4 d0&r ,#+- #0#+ 3&$#00#+ +d#0#+ 3&d'4 d#+ 2 r#+- '#0' ('&r#+ &r#=# d#+ '&r#+- $#- '# d#r %#0 0&$#r-# #'&+) '&8#r# &r%#d#%#d##+. B$#3#+# d#0 3&3+-0+0#+ 3&+d##0#+ #+d# #+-#+ d#r #'&+ 3#+ 0&$#r-#+,# (# %r5)4 3#0# ,#+ &r'#+-0#+ %#r' 3&3%0#+ 8# *&3$ *#r #+-#+ 0#+#++,# . 1. P&+,#3##+ +5r3#' d#+ &+*&$#'#+4 &r+,###+ &r'&*#+ / &+$#0#+ &r%#d# +d#0#+ 3&d' d$#00#+ d r#+-#+ / &3# ,#+- 3&+*#3+ &r'&$&+--#r#+,# &+,#3##+ d&+-#+ #0 d#+ &r*#3++,# 0&r#%#'##+ #'&+ d#r %#0%#0 ,#+d#0 &r=&+#+-> #0 d P$0$+04 R#+- &r#=# #+ 3#+ d I+'#$#' G#=# D#rr#. 11. r3$r &r'&*#+ +d#0#+ 3&d' %#r' 'd#% d' '&8#r# $&+-0#4 &+#r4 *&$#' d#+ d#+d##+-#+ '&$#3#+,# 2? *#3 '&&$3 +d#0#+ 3&d' d$#00#+> #+# 3&&r#. 12. r3$r #'$ %#r' d'3#+ d#$#3 &r0#' r&0#3 3&d' d#$#3 r#+ '&&$3 $&3#r $#r#+ +d#0#+ 3&d' ,#+- d&r0#+. 1". Ad#+ I+5r3&d +'&+ ,#+- d-+#0#+ d RSUD K# L#+-'# #d#$#% :
RSUD KOTA LANGSA Jln. Jend. A. Yani No.1 KOTA LANGSA
PERSETUJUAN / PENOLAKAN TINDAKAN MEDIS (INFORMED CONSENT
NO DOKUMEN :
NO REVISI :
HALAMAN : 7/7
#. I+5r3&d +'&+ &+#+- T+d#0#+ #+&'&' d#+ '&d#' . I+5r3&d +'&+ &+#+- &r'&*#+ d#+ &+$#0#+ T+d#0#+ 0&d0&r#+. 8. I+5r3&d +'&+ &+#+- &r'&*#+ d#+ &+$#0#+ +d#0#+ 0&d0&r#+ 0&3%&r# d. I+5r3&d +'&+ &+#+- &r'&*#+ d#+ &+$#0#+ &3&r#+ d#r#% d#+ rd0 d#r#% &. I+5r3&d +'&+ &+#+- &r'&*#+ d#+ &+$#0#+ r'&dr d#-+'0 r#d$-. UNIT TERKAIT
1. 2. ". ?. <. 6.
I+'#$#' R&0#3 M&d' I+'#$#' G#=# D#rr# I+'#$#' R#=# I+# I+'#$#' R#=# ;#$#+ I+'#$#' R#d$- I+'#$#' B&d#% S&+r#$
