RUMAH SAKIT UMUM DAERAH

LINGGAJATI KUNINGAN

JENIS TINDAKAN / PEMERIKSAAN MEDIS YANG MEMERLUKAN PRSETUJUAN

(INFORMED CONSENT)

a. Semua tindakan pembedahan dan tindakan Invasive

b. Semua tindakan Anestesi & Sedasi (Sedasi sedang dan sedasi dalam)
c. Semua tindakan pemberian produk darah & komponen darah
d. Semua tindakan / pengobatan yang beriko tinggi

Bedah Orthopedi Keterangan

I

1 Achillotenomy
2 Adductor tenomy of hip
3 Advanvcement of tendon
4 Advanvcement of tendon of hand
5 Amputation above knee
6 Amputation and disarticulation of finger - general anaesthesia
7 Amputation and disarticulation of finger - local anaesthesia
8 Amputation and disarticulation of thumb anaesthesia
9 Amputation and disarticulation of finger - general anaesthesia
10 Amputation and disarticulation of thumb local anaesthesia
11 Amputation and disarticulation of thumb local anaesthesia
12 Amputation and disarticulation of thumb local anaesthesia
13 Amputation of ankle through malleoli of tibia and fibula
14 Amputation of toe-general anaesthesia
15 Amputation of toe-local anaesthesia
16 Amputsation through foot
17 Amputsation through foream
18 Amputation through hand, Amputation through carpals
19 Amputation, not otherwise specified
20 Application of external fixator device
21 Application of external fixator device, monoplanar system
22 Application of external fixator device, ring system
23 Application of external external device, ring system
24 Arthrocentesis
25 Arthrodesis of elbow
26 Arthrodesis of hip
27 Arthordesis of knee
28 Arthordesis of other spesified joints
29 Arthordesis of shoulder
30 Arthordesis of unspecified joint
31 Aspiration of bursa
32 Aspiration of bursa of hand
33 Aspiration of other soft tissue of hand
34 Biopsy of bone
35 Biopsy of joint structure
36 Bone Graft
37 Bone marrow or harnatopoietic stem cell tranplant (all procedurres included
in this class
38 Bunionectomy with soft tissue correction and osteotomy of the dirst
metatarsal
39 Bursectomy of hand
40 Bursotomy
41 Closed reducation of dislocation – general anaesthesia
42 Closed reducation of dislocation of ankle
43 Closed reducation of elbow
44 Closed reducationof dislocation of knee
45 Closed reducation of dislocation of other spesified sites-local anaesthesia
46 Closed reducation of dislocation shoulder
47 Closed reducation of dislocation of wrist
48 Closed reducation of fracture with internal fixation –carfal and metacarpal
49 Closed reducation of fracture with internal fixation-femur (Including : MIPO,
interlocking nail, TEN)
50 Closed reducation of fraacture with internal fication-humerus (including :
Interlocking nail, TEN, MIPO)
51 Closed reducation of fracture with internal fixation Intrarticular Maior Bone
52 Closed reducation of fracture with internal fixation of foot
53 Closed reducation of fracture with internal fixation phalang of hand
54 Closed reducation of fracture with internal fixation radius and ulna
(MIPO,TEN)
55 Closed reducation of fracture with internal fixation tarsal and metatarsal
56 Excision of bone for graft
57 Excision of intervertebral disc
58 Excision of lesion of muscle
59 Excision of lesion of muscle of hand
60 Excision of lesion of other soft tissue
61 Dorsal and dorsolumbar fusion o`f the anterior column, posterior technique
62 Excision of intervertebral disc
63 Excision of lesion of muscle
64 Excision of lesion muscle of hand
65 Excision of lesion of other soft tissue
66 Excision of
67 Ganglionectomy of tendon sheath (wrist)-local anaestesi
68 Excision of muscle or fascia for garft
69 Excision of muscle or fascia of hand of graft
70 Excision of intervertebral disc
71 Excision of lesion of muscle
72 Excision of lesion of muslce of hand
73 Excision of lesion of other soft tissue
74 Excision of lesion of tendon sheath
75 Excision of lesion of tendon sheath (wrist)-General anesthesia
76 Excision of muscle or fascia for graft
77 Excision of muscle or fascia of hand for graft
78 Excision of semilunar cartilage of knee
79 Excision of tendon for garft
80 Excision of correction of bunionette, that with osteotomy
81 Exploration of tendon sheath
82 Exploration of tendon sheath of hand
83 Exploration throracotomy
84 Fasciotomy
85 Fasciotomyof hand
86 Fusion or refusion of 2-3 vertebrae
87 Graft of muscle or fascia
88 Hip bearing surface, ceramic-on-ceramic
89 Hip bearing surface, oxidized zirconium-on-polyetthlene
90 Hip bearing surface, metal-on-metal
91 Hip bearing surface, metal-on polyetthlene
92 Hip bearing surface, metal-on polyetthlene
93 Implation or replaceement od spinal neurostimulation lead (s)
94 Incision and draeinage of paimar or thenar space
95 Injection of anesthetic into peripheral nerve for analgesia
96 Injection of therapeutik substance into bursa
97 Injection of therapeutik substance into joint or ligament
98 Injection of therapeutik substance into tendon of hand
99 Insertion of bone growth stimulator
100 Insertion of bone void filler
101 Limb lengthening procedures
102 Limb shortening procedures
103 Lower limb amputation, not otherwise specified
104 Lysis of adhesions of hand
105 Metacarpocarfal fusion
106 Metacarpophalangeal fusion
107 Metacarpophalangeal fusion
108 Midtarsal fusion
109 Muscle transfer or transplantation
110 Myotomy
111 Mytomy of hand
112 Open biopsy of soft tissue
113 Open reducation of dislocation of ankle-Neglected dislocation
114 Open reducation of dislocation of hip-fresh dislocation
115 Open reducation of dislocation of knee-fresh dislocation
116 Open reducation of dislocation of shoulder – Neglected dislocation
117 Open reducation of dislocation of unspecified site-fresh dislocation
118 Open reducation reducation of dislocation of wrist-Fresh dislocation
119 Open reducation of practure with internal fixation-radius and ulna-simple
facture
120 Open reducation of fracture with internal fixation-unspecified site
(Periaticular maior Bone)
121 Open reducation of fracture with internal fixation-carpals and metarcarpals-
plate & screws hand NOS-Plate & Screw
122 Open reducation of fracture with internal fixation-carpals and metecarpals-
simple implants (K-wire) Hand NOS-implant sederhana (K-wire)
123 Open reducation of fracture with internal fixation-femur comminutive or
segmental
124 Open reducation of fracture with internal fixation-femur simple fracture
125 Open reducation of fracture with internal fixation-humerus-simple fracture
126 Open reducation of fracture with internal fixation-humerus-communitve or
sgemnetal
127 Open reducation of fracture with internal fixation-other specified bone
(intraartikular major bone)
128 Open reducation of fracture with internal fixation-phalangaes of foot-plate &
screws
129 Open reducation of fracture with internal fixation-phalangaes of hand simple
implants
130 Open reducation of fracture with internal fixation-tibia and fibula simple
fracture
131 Open reducation of fracture with internal fixation
132 Open reducation of separated epiphysis
133 Osteoclosis (correction of bone deformoty)
134 Other
135 Other amputation below knee
136 Other bunionectomy with soft tissue correction
137 Other change in hand muscle or tendon length
138 Other change in musle or tendon length
139 Other destruction of intervertebral disc
140 Other diagnostic procedures on joint sctructures
141 Other diagnostic procedures on muscle, tendon, fascia, and bursa including
that of hand
142 Other division of bone
143 Other excision of joint
144 Other excision or avulsion of cranial and pheriperal nervers
145 Other exploration and decommpression of spinal scanal
146 Other fascioectomy
147 Other fasciotomy of hand
148 Othermyectomy
149 Other operations on muscle, tendon,fascia, and bursa
150 Otherr operations on muscle, tendon,fascia, and bursa
151 Other partial ostectomy (including : Bone currectage, marginal
resection/excision)
152 Other plastik operation of adhesion peripheral nerve neurolysis NOS
153 Other plastic operation on fascia
154 Other plastic operation on hand
155 Other plastic operation on muscle
156 Other repair of ankle
157 Other repair elbow
158 Other reapir of knee
159 Other repair of the collacteral ligaments
160 Other repair or plastic operations on bone
161 Other suture of flexor tendon of hand
162 Other suture of muscle or fascia
163 Other suture of other tendon of hand
164 Other tendon transposition
165 Other tenodesis of hand
166 Partial hip replacement
167 Refusion `of dorsal and dorsolumbar spine, psterior
168 Refusioposterior column, of lumbar and lumbosacral spine, posterior
column, posterior technique
169 Refusion of lumbar and lumbosacral spine, anterior column, anterior
technique
170 Refusion of lumbar and lumbosacral spine, posterior column, posterior
technique
171 Release of carpal tunnel
172 Removal of (cement) spacer
173 Removal of bone growth stimulator (invasive)
174 Removal of implanted devices from bone-carpals and metacarpals-plate &
screw
175 Removal of implanted devices from bone-carpals and metacarpals-simple
implants (K-wire)
176 Removal of implanted devices from bone- External fixator device (invasive)
177 Removal of implanted devices from bone – femur
178 Removal of implanted devices from bone – humerus
179 Removal of implanted devices from bone – radius and ulna
180 Removal of implanted devices from bone – scapula, clavicle and throrax (ribs
and strenum)
181 Removal of implanted devices from bone – unspecified site (phalanges of
foot of hand) plate & screw
182 Removal of implanted devices from bone - unspecified site (phalanges of foot
of hand) simple implants (K-wire)

183 Removal of implanted devices from bone – pateiia

184 Removal of implanted devices from bone – tarsals and metatarsal – simple
implants (K-wire)
185 Removal of implanted devices from bone – tibia and fibula
186 Removal of implanted devices from bone – other (Pelvic boe and vetebratae)
187 Removal of implanted devices from bone – tarsals and metatasals plate &
screw
188 Removal of internal limb lengthening device
189 Removal of pedicle screw (s) used inspinal flusion
190 Repair of claw toe
191 Repair of cleft hand
192 Repair of hammer toe
193 Repair of hip, not elsewhere classified
194 Repair of macrodactyly
195 Repair of mallet finger
196 Repair of old traumatic injury of cranial and peripheral nerves
197 Repair of reccurent dislocation of shoulder
198 Resurfacing hip, partial, femoral head
199 Revision of total knee replacement of artificial spinal disc prosthesis, cervical
200 Rotator cuff refair
201 Sequestrectomy
202 Subtalar fusion
203 Subtalar joint arthroereisis
204 Suture of capsule or ligament of other lower extreminity
205 Suture of muscle or fascia of hand
206 Suture of tendon sheath of hand
207 Suture of vein
208 Synovectomy
209 Tarsometatarsal fusion
210 Tendon graft
211 Tendon pulley reconstruction
212 Tendon pulley reconstruction
213 Tendon transfer or transplantation
214 Tenotomy of hand
215 Total ankle replacement
216 Total elbow replacement
217 Total ostectomy
218 Triple arthrodesis
219 Upper limb amputation, not otherwise specified
220 Wedge osteotomy
II OBGYN
1 Kuratase
2 Hecting
3 laserasi grade
4 Vakum ekstrasi
5 Cauter serviks
6 Ekplorasi vagina
7 Extirpasi + polip+kenet+endoserviks
8 Ekstiirpasi miom geburg + kenetore
9 Histerroctomy pada mola
10 Kistektomi
11 Kuret abortus inkomplit
12 Myomektomi
13 Overectomi
14 Persalinan normal
15 Persalinan normal dengan penyulit
16 Forcep ekstrasi, Indukasi
17 Persalinan sungsang
18 Salfingektomi
19 Salvingoovarectomi
20 Seksio sesara
21 Seksio sesara dengan penyulit
22 Supra vaginal hyterectomy
23 TAH + BSO
24 TAH + BSO dengan penyulit
25 Tubektomi
27 Reposisi inversito uteri
28 Manual Placenta
29 Pasang up Iud Sudarman, AM.Kep.
30 Pasang up implant

III ANAK
1 Pemasangan pentilator
2 Intubasi endotrakea
3 Pemasangan Laryngeal mask
4 Infus intraosseus
5 Kanulasi vena perifer
6 Pengambilan darah intra vena dan intra arteri
7 Fungsi lumbal
8 Fungsi pleura
9 Pemasangan kateter urine
10 Pemasangan kateter recial
11 Pemasangan orograstik tube
12 Pemasangan nasogastrik tube
IV Bedah Umum
1 Apendiktomi
2 Biopsi
3 Circumsisi
4 Debridement
5 Extervasi Lipom
6 Extervasi TU Mamae Abaran
7 Extervasi Hemangiom
8 Extervasi Ganglion
9 Extervasi Kuku
10 Extervasi Naenis
11 Extervasi Veruca
12 Extervasi Clavus
13 Extervasi Mucocel
14 Extervasi Granuloma
15 Extervasi Bursitis
16 Extervasi Kista Atherom
17 Insisi abses
18 Herniotomi
19 Hemoroidektomi
20 Laparotomi
21 FAM
22 Strukmetomi
23 Extervasi tumor kepala
24 Extervasi Tumor lidah
25 Extervasi Tumor submandibula
26 Extervasi Tumor parotis
27 Extervasi Kista dermoid
28 Explorasi luka invasif
29 Amputasi jari invasif
30 Mastektomi
31 Fistolektomi
32 Coloctomig
33 Repair Tendon
34 Hidrocelectomi
35 Tersiotestis
36 Limpadenektomi
37 Repair Fraktur Nasal
38 Nektromi Debridement Luka Bakar
39 Nektromi Debridement Ulkus DM

V Tindakan Diagnostik dan Penunjang

1 Kolonoskopi
2 Pap Smear
 3 Biopsi dan FNAB
4 Pemeriksaaan BMP (Bone Marrow Punction)
5 Semua pemeriksaan penunjang menggunakan kontras (MRI, CT Scan,
Hysterosalphingography, Intra Pyolography, Anterograde/Retrograde
Pyolographhy, Uretrography, Myelography, Pistulography, Arteriography,
Colangiography, dll)
6 Penggunahan Bahan Kontras
- Barium Sulfat
- Lopamiro
- Lohexol
- Gadodiamide

7 Semua pemeriksaan penunjang menggunakan Choral hidrat pada ank

VI Pemberian Darah dan Produk Darah

1 Whole Blode
2 Wash Erytrocite
3 Pack Red Cell
4 Fresh Frozen Plasma
5 Liquid plasma
6 Trombosit
7 Trombopheresis
8 Human albumin:
- Plasbumin
- Octalbin
- Albuminar

VII Tindakan Anastesi dan Sedasi

1 Tindakan Anestesi
 Anestesi Umum
 Anestesi Regional
 Anestesi Infiltrasi
 Anestesi Blok
 Anestesi spinal
 Blok epinoral
 blok Transakral (Kaudal)
 Anestesi Rigional Intrevera
2 Tindakan Sedasi
 Sedasi sedang
 Menggunakan Midazolam 0,1 mg/kbgg
 Menggunakan Ketamin 0,5 mg/kgbb
 Menggunakan Propofol 0,5 mg/kgbb
 Sedasi Dalam
 Menggunakan Ketamin 3-8 mg/kgbbintramuskular
  Menggunakan Ketamin 1 mg/kgbbintravena
 Menggunakan Midazolam oral 10 mg/kgbb
 Menggunakan Flunitrazepam 0,1-1 mg/kgbb
 Mengunakan Remifentanil 0,1 mg/kg/min

VIII Gigi (Perdisipln ilmu bidang kedokteran gigi)

1 Kontras gigi
a. Penambalan Sementara
 Trepanasi
 Preparasi saluran akar dan sterlisasi
 Pulp capping
b. Penambalan Tetap
 Tambalan Silikat (GI)
 Tambalan Composite

2 Periodontri
- Scalling
- Rootplan
3 Pedodonti
- Extraksi gigi sulung dengan anestesi topikal
- Penambalan sementara pada gigi sulung (sda)
- Penabalan tetap pada gigi sulung

4 Ezodonti / Oral Surgensi

- Extraksi gigi dewasa
- Extraksi gigi dewasa dengan sparasi akar / dengan komplikasi
- Extraksi gigi dewasa dengan plap dan hecting
- Injeksi dengan anestesi lokal
5 Prostodonti
- Gigi tiruan lepasan
- Gigi tiruan penuh

IX Bedah Mulut dan Mmaksilofusial

1 Apex reseksi akar
2 Aff plate dan screw
3 Alveolar bone graft / gnatoplasty
4 Alveolektomi
5 Aff arch bar
6 Reposisi TMS dislocation
7 Debridement nektomi
8 Biopsi eksisi
9 Biopsi ekstisposi
10 Enukleasi kista
11 Insisi abses / flegman
12 Operkulektomi
13 ORIF
14 Labioplasty
15 Palatoplasty
16 Osteotomi eksisi tulang makslofasial
17 Interdental wiring / arch bar
18 Release tongse tie / frenektomi
19 Reposisi tertutup Fraktur kondilus
20 Injeksi skleroterapi agent
21 Sialolitektomi
22 Reseksi segmental rhy
23 Caldwell Iva
24 Odontektomi
25 Pengambilan torus dan eksotosis
26 Bone window
27 Sinus lifting
28 Sekuesterektomi
29 Penutupan oro antrhal fistula
30 Implant dental
31 Marsvpiallisasi
32 Vestibulopaty
33 Augmentasi alveolar
34 Cetak feeding plate
35 Multiple extraksi
30 Ekstrasi dengan penyulit

X Tindakan Kedokteran Lainnya

1 Pemasangan Endotracheal Tube (ETT)
2 Needle Cricothyoridectomy
3 Tracheostomy
4 Pemasangan Ches Tube dengan WSD
5 Venaseksi
6 Pemasangan Cateter sentral dan double lumen
7 Penggunaaan Ventolator
8 Pemasangan Cimio
9 Pemasangan WSD
10 Hemodialisa
11 Imunisasi
12 Explorasi luka invasif
13 Amputasi Jari Invasif
14 Pemasangan Restrain
15 Pemeriksaan HIV