Daftar Tindakan Informed Consent

Open reduction offracturewithoutinternalfixation

Open reduction ofseparatedepiphysis

Osteoclasis(correction ofbonedeformity)

Other

Other (peripheral) vascular shunt orbypass

Other amputationbelowknee

Other anastomosisofcranial or peripheralnerve

Other andunspecified repair oftheanulusfibrosus

Other arthrotomy

Other bunionectomy

Other bunionectomywithsofttissuecorrection

Other cervicalfusion oftheanterior column, anteriortechnique

Other cervicalfusion oftheposterior column,posterior technique

16

11Other changeinhandmuscleor tendonlengthOther changein muscleor tendonlengthOther destructionofintervertebral disc

NOKSM/INSTALASI/UNITTINDAKAN

231 Otherdiagnosticproceduresonjointstructures

Otherdiagnosticproceduresonmuscle, tendon, fascia, and232 bursa, including thatofhand

233 Otherdivisionofbone

234 Otherexcisionofjoint

235 Otherexcisionofsoft tissue

236 Otherexcisionofsoft tissueofhand

237 Otherexcisionor avulsionofcranial andperipheral nerves

238 Otherexcision, fusionand repair oftoes

Otherexplorationanddecompressionofspinal canal,239 Decompression

240Other fasciectomy

241 Other fasciectomyofhand

242 Other fusionof foot

243 Otherhandmuscletransfer or transplantation

244 Otherhandmuscletransposition

245 Otherhandtendontransferor transplantation

246Otherhandtendontransposition

247 Otherincisionofbonewithout division

248 Otherincisionofsoft tissue

249 Otherincisionofsoft tissueofhand

Otherinjectionoflocally-acting therapeuticsubstanceinto250 soft tissueofhand

251 Otherlocal excisionor destructionoflesionof joint

252 Other muscletransposition

253 Other myectomy

254 Other myectomyofhand

255 Otherneuroplasty

256 Otheroperationsonmuscle,tendon,fascia,andbursa

257 Otheroperationsonmuscle,tendon,fascia,andbursa,

Sutureof bursa

Otherpartial ostectomy(including:Bonecurretage,258 marginal resection/excision)

NOKSM/INSTALAS I/UNITTINDAKAN

259 Otherperipheral nerveor gangliondecompressionor lysisofadhesionsPeripheral nerveneurolysisNOS

260 Otherplasticoperationsonfascia

261 Otherplasticoperationsonhand

262 Otherplasticoperationson muscle

263Other repairofankle

264 Other repairofelbow

265 Other repairofhand,fingersandwrist

266 Other repairof joint

267 Other repairof knee

268 Other repairof shoulder

269 Other repairof thecollateral ligaments

270 Other repairof thecruciateligaments

271 Other repairorplasticoperationsonbone

272 Othersutureof flexor tendonofhand

273 Othersutureof muscleor fascia

274 Othersutureofother tendonofhand

275 Othersutureof tendon

276 Other tendontransposition

277 Other tenodesisofhand

278 Other tenonectomy

279 Other tenonectomyofhand

280 Other tenoplastyofhand

281 Other tenotomy

282 Other totalshoulder replacement

283 Partial hip replacement

284 Partial shoulder replacement

285 Patellarstabilization

286 Percutaneousdenervationof facet

287 Percutaneousvertebralaugmentation

288 Percutaneousvertebroplasty

289 Peripheral nerveinjection,nototherwisespecified

290 Plasticoperationonhandwithgraftof muscleor fascia

291 Plasticoperationonhandwithothergraft or implant

292 Pollicizationoperationcarryingover nervesandblood supply

293 Quadricepsplasty

294 Reattachment of muscle

295 Reattachment of muscleofhand

296 Reattachment oftendon

297 Reattachment oftendonofhand

18298Refusionofatlas-axisspine299 Refusionofdorsalanddorsolumbar spine, anterior column, anterior technique


300 Refusion of dorsalanddorsolumbar spine,posteriorcolumn,posterior technique

301 Refusion oflumbar andlumbosacral spine,anteriorcolumn,anterior technique

302 Refusion oflumbar andlumbosacral spine,anteriorcolumn,posterior technique

303 Refusion oflumbar andlumbosacral spine,posteriorcolumn,posterior technique

304 Refusion of other cervical spine, anterior column, anterior technique

305 Refusion of other cervical spine, posterior column,posterior technique

306 Refusion ofspine,notelsewhereclassified

307 Refusion ofspine,nototherwisespecified

308 Release ofcarpal tunnel

309 Release ofclubfoot,not elsewhereclassified

310 Release oftarsal tunnel

311 Removal of(cement) spacer

312 Removal of bonegrowthstimulator (invasive)

313 Removal offoreignbodyfromspinal canal

314 Removal ofimplanteddevicesfrom bone- carpalsandmetacarpals-Plate&screw

315 Removal ofimplanteddevicesfrom bone- carpalsandmetacarpals-simpleimplants(K-wire)

316 Removal ofimplanteddevicesfrom bone- Externalfixator device(invasive) (

317 Removal ofimplanteddevicesfrom bone-femur

318 Removal ofimplanteddevicesfrom bone- humerus

319 Removal ofimplanteddevicesfrom bone- radiusandulna

320 Removal ofimplanteddevicesfrom bone- scapula,clavicle, andthorax(ribs andsternum)

321 Removal ofimplanteddevicesfrom bone-unspecifiedsite(Phalanges(offoot) (of hand)) - Plate& Screw

322 Removal ofimplanteddevicesfrom bone-unspecifiedsite(Phalanges(offoot)(of hand)) - simpleimplants(K-wire)

323 Removal ofimplanteddevicesfrom bone-patella

324 Removal ofimplanteddevicesfrom bone- tarsals and metatarsals- simpleimplants(K-wire)

325 Removal ofimplanteddevicesfrom bone- tibiaandfibula

326 Removal ofimplanteddevicesfrom bone-other(Pelvic boneandVertebraae)


327 Removal ofimplanteddevicesfrom bone-tarsals and metatarsals-Plate&Screw

328 Removal ofinternal limblengtheningdevice

329 Removal of pediclescrew(s) usedinspinalfusion

330 Removal of peripheralneurostimulator lead(s)

331 Removal ofskeletal musclestimulator

332 Removal ofspinalneurostimulator lead(s)

333 Reopening oflaminectomysite

334 Repair ofclawtoe

335 Repair ofclefthand

336 Repair of hammer toe

337 Repair of hip,notelsewhereclassified

338 Repair ofmacrodactyly

339 Repair ofmalletfinger

340 Repair of oldtraumaticinjuryofcranial and peripheral nerves

341 Repair ofrecurrentdislocationofshoulder

342 Repair oftheanulusfibrosuswithgraftor prosthesis

343 Repair ofvertebralfracture, Elevationofspinal bonefragments,Reductionoffractureofvertebrae, Removal of bonyspiculesfrom spinal canal

344 Replacementofjoint offootandtoe

345 Resurfacinghip,partial, acetabulum, Hipresurfacingarthroplasty, partial, acetabulum

346 Resurfacinghip,partial,femoralhead

347 Revisionoftotal kneereplacement,tibial insert(liner),Replacementoftibial insert(liner)

348 Revisionor replacementof artificial spinal discprosthesis,cervical

349 Revisionor replacementof artificial spinal discprosthesis,lumbosacral

350 Revisionor replacementof artificial spinal discprosthesis,not otherwisespecified

351 Revisionor replacementof artificial spinal discprosthesis,thoracic

352 Rotator cuffrepair

353 Separation of equal conjoinedtwins

354 Separation of unequalconjoinedtwins

355 Sequestrectomy

356 Spinalfusion,nototherwisespecified

357 Subtalarfusion

358 Subtalar jointarthroereisis

20

359 Suture of Artery

360 Suture ofcapsuleor ligament ofankleandfoot


361 Suture ofcapsuleor ligament ofother lowerextremity

362 Suture ofcapsuleor ligament ofupper extremity

363 Suture ofcranial and peripheral nerves

364 Suture ofmuscleorfasciaof hand

365 Suture oftendonsheath

366 Suture oftendonsheathof hand

367 Suture of Vein

368 Synovectomy

369 Tarsometatarsalfusion

370 Tendongraft

371 Tendonpulleyreconstruction

372 Tendonpulleyreconstruction

373 Tendontransferor transplantation

374 Tenotomyof hand

375 Thighreattachment

376 Thumbreattachment

378 Toereattachment

379 Total anklereplacement

380 Total elbowreplacement

381 Total ostectomy

382 Total wristreplacement

383 Transplantfromcadaver

384 Transpositionofcranial andperipheral nerves -Nervetransplantation

389 Triadkneerepair

390 Triplearthrodesis

391 Unspecifiedoperationonboneinjury

392 Upper armreattachment

393 Upper limb amputation, nototherwisespecified

394 Wedgeosteotomy

21


5KSMBEDAH THORAKS DANKARDIOVASKULAR1 BiopsiTerbukaBronkhus

2 BiopsiTerbukaDiafragma

3 BiopsiTerbukaMediastinum

4 BiopsiTerbukaParu

5 BiopsiTerbukaPleura

6 BiopsiTerbukaPleuradenganVATS

7 BiopsiTerbukaTumor DindingThoraks

8 Debridement Mediastinum (Sternotomi)

9 Eksisi PadaBronkhus

10 Eksisi PadaParu (LungVolumeReduction)

11 Eksisi PadaParudenganVATS

12 Eksisi Tumor DindingDadadenganRekonstruksi DindingDada

13 Eksisi Tumor Mediastinum (Thymoma,Teratoma, Neurogenic dsb)

14 Ekstraksi CorpusAlienum di RegioToraks

15 Ekstraksi CorpusAlienum di RegioToraksdenganVATS

16 Evakuasi EfusiPleura/EmpyemasecaraTorakoskopik(VATS)

17 Fiksasi Costae(Clipp,Wire) (diluar Clipp)

18 Fiksasi Sternum(Wire,Plate) (diluar wire/plate)

19 Lobektomi Parsial (Reseksi Parusegmental)

20 Lobektomi Parsial (Reseksi Parusegmental)denganVATS

21 LumbalSimpatektomi

22 Mediastinostomy

23 Pemasanganthorakdrain/water sealeddrainage(WSD) (diluar alat)

24 Pleural window(Eloeser Flap)

25 Pleurektomi

26 Pleurodesis(Pleurosklerosis)

27 PlikaseBulae/BlebEmfisematous

28 Plikasi diafragma

29 Pneumonectomy

30 PneumonectomydenganVATS

31 PulmonaryDecortication

32 PulmonaryDecorticationdenganVATS

33 PulmonaryLobectomy/Bilobectomy

34 PulmonaryLobectomy/BilobectomydenganVATS

35 RedoTorakotomi

36 Rekonstruksi Sternum&DindingDada

37 repair deformitasPectus

2238 Repair FistulaBronkopleural39 Repair Laserasi Diafragma


40Revisi Thoraksdrain/watersealeddrainage(WSD)(diluar alat)

41 Thoracal SymphatectomydenganVideoAssisstedThoracoscopicSurgery(VATS)

42 Thoracocentesis

43 Thymectomy

44 ThymectomydenganVATS

45 Torakoplasti(AirPlumbage/MusclePlumbage)

46 Torakotomi/sternotomiEksplorasi

47 Torakotomi Eksplorasi padaTraumajantung/RepairLaserasi Jantung

48 BedahKardio(Jantung)

49 AorticValveRepair(AVR)

50 AorticValveRepair(AVR)denganBioprosthesis Valve

51 AorticValveRepair(AVR)denganMechanical Valve

52 Atrial septalDefect (ASD)Closure

53 Bidirectional Cavo-Pulmonary Shunt (BCPS)

54 Biopsi Jantung

55 Biopsi Perikardium

56 Blalock-TaussingShunt (BTShunt)

57 Coronary Artery Bypass Graft (CABG)

58 Eksisi CardiacMyxoma

59 FontanOperation(Atrium-Pulmonary Artery Conduit)

60 Internal Resusitasi/CardiacMassage(OperasiTerbuka)

61 Ligasi PatentDuctus Arteriosus (PDA)

62 Mitral valve repair (MVr)

63 Mitral ValveRepair(MVR)denganBioprosthesis Valve

64 Mitral ValveReplacement (MVR)denganMechanicalValve

65 OperasiRedoOpenHeart (ValveReplacement)

66 OperasiReopenolehKarenasebab Perdarahan, TamponadeJantung

67 PemasanganIABP

68 PemasanganPaceMakerPermanen(diluaralat)

69 Pericardiocentesis

70 Perikardiektomi

71 Perikardiotomi/PericardialWindow

72 Pulmonal ValveRepair(PVR)

73 Pulmonal ValveRepair(PVR)denganBioprosthesisValve

74 Pulmonal ValveRepair(PVR)denganMechanical Valve

75 Pulmonary Artery Banding (PA)

23

NOKSM/INSTALASI/ UNITTINDAKAN

76Rastelli Procedure(right Ventricle-PulonaryArteryConduit)

77Repair (Eksisi) AneurismaJantung

78 Repair AortaTorakalis(38.34)

79 Repair AtrioventricularSeptal Defect(35.54)

80 RepairTotalAnomalous PulmoanryVenousConnection(TAPVC) (35.82)

81 RepairTransposition ofGreatArteries(TGA)(35.84)

82 RepairTrunkusArteriosus(35.83)

83 Revisi/AffPaceMaker Permanen(diluar alat)(37.89)

84 SeptostomiTerbukaSeptum Atrium (35.41)

85 Total KoreksiTetralogyofFallot (TOF) (35.81)

86 TricuspidValveRepair(TVR) (35.14)

87 TricuspidValveRepair(TVR) denganBioprosthesisValve(35.27)

88 TricuspidValveRepair(TVR) denganMechanical Valve(35.28)

89 VentricleSeptal Defect (VSD) Closure(35.5)

90 AmputasiAboveKnee(AK) (84.17)

91 AmputasiBelowKnee (BK) (84.14)

92 Arterial Pungsi,Kanulasi, Sectie(38.91)

93 ArteriovenousShuntt(AV Shunt)Brakiosefalika(39.42)

94 ArteriovenousShuntt(AV Shunt) Radiosefalika(39.27)

95BedahVarisesInsisi Babcock(38.5)

96 Biopsi PembuluhDarah(Perifer) (38.21)

97 Debriment-NekrotomiLukaGangren(86.22)

98 Disartikulasi Sendi Ekstremitas(84.13)

6EksisiBiopsiTumor Pembuluh Darah1 EksisiTumor PembuluhDarahPerifer (Hemangioma)

2 EksplorasiVaskular (Trauma/Non trauma)

3 Embolektomi/Trombektomi Aorta

4 Embolektomi/Trombektomi Pembuluh DarahArteri Abdominal

5 Embolektomi/Trombektomi Pembuluh DarahArteriEkstremitas Bawah

6 Embolektomi/Trombektomi Pembuluh DarahEkstremitasAtas(diluaralat)

7 Embolektomi/Trombektomi Pembuluh DarahEkstremitasBawah(diluaralat)

8 Embolektomi/Trombektomi Pembuluh DarahRegioservikal(Karotis,Jugular) (diluar alat)

9EvakuasiHematom di Ekstremitas(PascaPungsi HD/ Traumatik)

10 Fasciotomy

11 Ligasi Vaskular Ekstremitas

2412 Mutilasi Digiti Ekstermitas


13 PasangDoubleLumenHemodialisis(HD) (diluar alat)

14 PasangImplantableCentral Venous Access(diluar alat:porth-a-cath,celsite)

15 PemasanganCentralVenousCatheter (CVC) (diluar alat)

16 PemasanganIntraAortic BaloonPump(IABP) (diluar alat)

17 PemasanganPeritoneal Dyalisis(PD) Catheter(diluar alat)

18 PembedahanTeleangiectasis

19 Repair Aneurisma(True/false)EkstremitasSuperior(diluar graft)

20 Repair AneurismaAortaAbdominalis(DiluarProtesa)

21 Repair PembuluhDarahRegioServikal (Karotis, Jugular)

22 Repair Ruptur PembuluhArteri Abdominal

23 Revisi ArteriovenousShunt

24 Skleroterapi Vena(Varises,Hemangioma)

25 StrippingVarisesEkstremitasInferior

26 Vascular Shunting (Splenorenal Shunt,DePalmaShunt)

27 VenaPunctie,Kanulasi, Sectie

7KSM BEDAH

DIGESTIVE1 Abdominal pull through (sfingter savingprocedure)

2Abdominoperineal resection(miles) denganpenyulit mayor

3Abdominoperineal resection(miles) denganpenyulit minor

4 Abdominoperineal resection(miles) tanpapenyulit

5 Abdominoplasty

6 Apendektomi

7 Apendektomidgnpenyulitmajor

8 Apendektomidgnpenyulitminor

9 Apendektomi laparoskopik

10 Bilio-difgestif anastomosistanpapenyulit

11 Biliodigestif denganpenyulitmayor

12 Biliodigestif denganpenyulitminor

13 Biopsi insisional,localanastesi

14 Biopsi rectum

15 Eksisi hemoroideksterna

16 Eksplorasi duktusbilier &cholangiografi intraoperatif

17 Esofagotomi

18 Fistulotomi

25


19 Fistulotomi dgnpenyulitmayor

20 Fistulotomi dgnpenyulitminor

21 Gastrostomi

22 Hemikolektomidenganpenyulitmayor

23 Hemikolektomidenganpenyulitminor

24 Hemikolektomitanpa penyulit

25 Hemoroidstapling (diluar alat)

26 Hemoroidektomi

27 Herniotomi

28 Herniotomi dgnpenyulitmayor

29 Herniotomi dgnpenyulitminor

30 Herniotomi laparoskopik

31 Jejunostomi /ileostomi

32 Laparotomi denganpenyulitminor

33 Laparotomi tanpapenyulit

34 Ligasi hemoroid(diluar alat)

35 Pankreatiko-duodenektomi cephalis(Whipple)denganpenyulitmayor

36 Peritoneal dreanse (CAPD)

37 Peritoneal lavase

38 Polipektomi

39 Potongkolostomi

40 Prosedur Heller

41 Rektopexy

42 Repairfistelusus

43 Repairfistel vesicorectal

44 Repair herniacicatricalis

45 Repair herniacicatricalis dgnpenyulitmayor (diluar alat)

46 Repair herniacicatricalis dgnpenyulitminor (diluar alat)

47 Repair HerniaDiafragmatika (diluar alat)

48 Reseksi anterior denganpenyulitmayor

49 Reseksi anterior denganpenyulitminor

50 Reseksi anterior tanpapenyulit

51 Reseksi esofagus-colon/ileumtransposisi

52 Reseksi esofagus-endtoend

53 Reseksi esofagus-esofago-gastrectomy

54 Reseksi hati

55 Secondlooklaparoscopy

56 Splenektomi /splenoraphytraumatika

57 Splenektomi nontrauma

58 Terminalesofagus proksimal gastrektomi (TEPG)

26

59 Total gastrektomi


60 Total pantreaktomi

61 Total prokto-kolektomi

62 Tutupburstabdomen (tanpaalat)

63 Tutupburstabdomendenganpenyulitmayor

64 Tutupburstabdomendenganpenyulitminor

65 Tutupkolostomi/ileostomi

66 Tutupkolostomi/ileostomi denganpenyulitmayor

67 Tutupkolostomi/ileostomi denganpenyulitminor

68 Repair AortaTorakalis(38.34)

69 Repair AtrioventricularSeptal Defect(35.54)

8KSM BEDAHUROLOGI1 Adrenalektomi

2 Adrenalektomi (Abdominotorakal)

3 Anastomosis endtoendUreter

4 Augmentasi Buli

5 Biopsi Ginjalperkutan

6 Biopsi GinjalTerbuka

7 Biopsi Penis

8 Biopsi Prostat

9 BiopsiTestis

10 Bladder NeckRekonstruksi

11 BuriedPenis

12 Businasi/Dilatasi Uretra

13 CabutDJStent

14 DefooringKistaGinjalper Laparoskopi

15 Deroofing/UnroofingKista

16 Diseksi Kelenjar GetahBeningInguinal

17 Diseksi Kelenjar GetahBening pelvis

18 Diseksi Kelenjar GetahBeningPelvis perLaparoskopi

19 Divertikulektomi Buli

20 DivertikulumUretra

21 Dorsumsisi

22 DrainasePeriureter

23 Eksisi Chordae/Chordektomi

24 Eksisi Fibroma/Rekonstruksi Penis

25 Eksisi Plaque(PeyronieDisease)

26 EksisiWebbedPenis

27 Eksplorasi testis(Microsurgery)

28 Ekstraksi Batu

29 Ekstrofi Buli Rekonstruksi

30 Epispadia

31 Evakuasi BekuanDarah(Clot)

32 ExtendedPyelolithotomy

2733 Fistulektomi/Repair Fistel Uretra


34 Funikokelektomi

35 Ganti Nefrostomy

36 Hidrokel per Inguinal/Ligasi Tinggi

37 Hidrokel per Skrotal

38 HipospadiaSubkoronal

39 Holmium YaGLaser (Sewa)

40 Ileal Conduit(Bricker)

41 Insersi DJ Stent

42 Insisi AbsesPerineum

43 Insisi AbsesSkrotum

44 Insisi Posterior Urethral Valve

45 Johanson

46 JohansonI

47 JohansonII

48 Kalibrasi Uretra

49 Kauterisasi

50 Koreksi HorseshoeKidney

51 Koreksi Priapismus

52 LaparoskopiAdrenalektomi

53 Laparotomi Eksplorasi

54 Ligasi V.SpermatikaInterna(Microsurgery)

55 Limfadenektomi Ilioinguinal

56 Limfadenektomi Retroperitoneal/RPLND

57 Litholapaksi

58 Lithotripsi

59 MasaseProstat

60 Meatoplasti

61 Meatotomi

62 MMK/SlingUretra

63 Nefrektomi

64 Nefrektomi Donor Transplant

65 Nefrektomi Parsial

66 Nefrektomi perLaparoskopi

67 Nefrektomi Radial

68 Nefropeksi/Renopeksi

69 Nefrostomi Perkutan/Temporer

70 NefrostomiTerbuka/Permanen

71 Nefroureterektomi

72 Neobladder

73 Operasi Priapismus(prosedurWinter)

74 Operasi Repair BuliTrauma

75 Operasi Sistokel

28


76 OperasiTraumaGinjal

77 Operasi Urakhus/Reseksi urakhus

78 Orkhidektomi

79 Orkhidektomi extended

80 Orkhidektomi LigasiTinggi

81 Orkhidektomi Subkapsuler

82 Orkhidopeksi (TorsioTestis)

83 Orkhidopeksi (UDT)

84 Orkhidopeksi perLaparoskopi

85 PasangKateter

86 PasangKateter denganMandrain

87 PasangKateterTenckhoff untukCAPD

88 PCNL/PNL

89 Penektomi Parsial

90 PenektomiTotal/Amputasi Penis

91 PER (PrimaryEndoscopicRealignment)

92 Pielokalikotomi

93 Pielolitotomi

94 Pieloplasti

95 Pieloplastiper Laparoskopi

96 Prostatektomi Radikal

97 Prostatektomi Retropubik

98 ProstatektomiTerbuka

99 ProstatektomiTerbukadanSectioAlta

100 PsoasHitch/Boari Flap

101 Punksi dansklerosingKistaGinjal

102 Railroading RuptureUretra

103 Reimplantasi Ureter Bilateral

104 Reimplantasi UreterUnilateral/Ureteroneosistostomi

105 Rekontruksi Renovaskuler

106 Repair Fistel Enterovesika

107 Repair Fistel Vesikokutan

108 Repair Fistel Vesikorektal

109 Repair Fistel Vesikovagina

110 Repair Fistel VesikovaginaKompleks

111 Reparasi Penis

112 Reseksi-anastomosisUretra

113 RPG

114 SectioAlta/Vesikolithotomi

115 Sirkumsisi

115 Sistektomi Parsial/Sistoplasti Reduksi

116 Sistektomi Per Laparoskopi

117 SistektomiTotal/Radikal

29118 Sistoskopi119 SistoskopiODS


120 Sistostomi perkutan

121 SistostomiTerbuka

122 Skrotoplasti

123 Spermatokelektomi

124TailoringUreter

125 TransplanResipien

126 Transuretero-ureterostomi

127 TUR Prostat/TUIP/BNI

128 TURTumor Buli

129 TVP/TMP

130 Ureterokutaneostomi

131 Ureterolisis

132 Ureterolithotomi

133 Ureterolithotomi Distal

134 UreterolithotomiProksimal

135 Ureterosigmoidostomi(Caffey)

136 Ureterostomi

137 Ureterouretostomi

138 Uretroplasti Hipospadia

139 Uretroskopi/Uretrosistoskopi

140 UretrotomiInterna(Sachse)

141 URS/Lithotripsi

142 Varikokelektomi (Palomo)

143 Vasektomi (anestesi lokal)

144 Vasektomi (narkose)

145 Vasoepididimostomi

146 Vasografi

147 Vasovasostomi

9KSM ILMUKESEHATAN MATA1 AngkatJahitan

2AngkatJahitandenganGA

3 Anterior ChamberTap/Parasintesis

4 Aspirasi MassaLensa

5 Blefaroplasty(2KelopakMata)

6 ClawLens

7 CryopexyKornea

8 CycloCryo

9 Dacryocystorinostomi (Without SiliconTube)

10 Dekompresi Orbital/Lateral Orbitotomi

11 Disisi Aspirasi &IOL

12 ECCE

13 ECCE&IOL

14 Eksenterasi

15 Eksisi Hordeolum/Chalazion

30

3737

16 Ekstirpasi CorpusAlienum di Kornea17 Ekstirpasi Pterygium+ GraftKonjungtiva


18 Ekstripasi CorpusAlienum di BilikMataDepan

19 Enukleasi/Eviscerasi (DFG/Bonegraft)

20 Evakuasi SilikonOil

21 FornixRepair

22 ICCE

23 ICCE&IOL

24 Injeksi IntraVitreal

25 Injeksi PeriokulerTerapetik

26 IOLExplant

27 Iridectomi

28 JahitKelopakMataFull Thickness&LidMargin

29 JahitKornea

30 Keratoplasti (CornealTransplantation)

31 Konjungtival Flap/AmnionGraft

32 PiggyBackIOL

33 Pneumoretinopexy

34 Repair Canalis Lacrimalis(Without SiliconTube)

35 Repair ColobomaPalpebra(Skin/Mucosal Graft)

36 Reposisi IOL

37 Reposisi Iris

38 Resesi &Reseksi 2Otot



41 Resesi/Reseksi 1Otot

42 Sekunder Implant(Posterior Chamber)

43 Sekunder ImplantClawLens/Fiksasi Sulcus

44 SICS

45 SICS&IOL

46 Simpel Vitrektomi

47 Skleral Buckle

48 SocketRepair (ContractedSocket)

49 Trabekulektomi

50 Trabekuletomi &Ollogen

51 Trabulektomi &Goniotomi padaPediatricGlaucoma

52 TubeShunt(Express)

53 Viscocanulostomy

54 Vitrektomi +++

55 Vitrektomi Lengkap&Skleral Buckle

56 WideEksisi Tumor KelopakMata

57 WideEksisi Tumor KelopakMata+ Flap+ graft


10DivisiOnkologi1 Aspirasi KistaMammaSingledan Multiple

2 Biopsi CoreLokalAnestesi

3 Biopsi Eksisi Lokal

4 Biopsi Eksisi Narkose

5 Biopsi InsisiLokal

6 Biopsi Narkose

7 BreastConservingSurgery(BCS)

8 BreastConservingSurgery+ LD Flap

9 DebrimentMamma

10 Diseksi Axilla

11 Eksisi Fibroadenoma Lokal AnestesiSingleSatuSisi

12 Eksisi Fibroadenoma MultipleNarkose

13 Eksisi Tumor MetastaseLoco-regional

14 Eksplorasi DuktusMama

15 Eksplorasi DuktusMama+VC

16 Insisi AbscesMastitisLokal

17 LD Flap+ EksisiTumor

18 Mastectomy+ TramFlap

19 ModifiedRadical Mastectomy+ Flap/SingleGrafting

20 ModifiedRadical MastectomySingle

21 Quadrantectomy/ Partial Mastectomy

22 Simple Mastektomy+ Flap/SkinGrafting

23 Simple MastektomySingle

24 TramFlap+ Eksisi Tumor

25 OperasiTumorKulit

26 Biopsi InsisiTumor Kulit Lokal

27 Biopsi EksisiTumor KulitNarcose

28 Eksisi Tumor Jinak 3cm

29 Eksisi Tumor Jinak+ Flap/SkinGraft

30 Eksisi Tumor JinakKulit>3cm

31 WideEksisi + Diseksi KGB

32 WideEksisi Tumor GanasKulit

33 WideEksisi Tumor GanasKulit+Flap/ SkinGraft

34 Operasi SoftTissueTumor

35 Amputasi + Diseksi KGB

36 Amputasi Jari + Flap/SkinGraft

37 AmputasiTungkai /Lengan

38 Biopsi CoresoftTissue

39 Biopsi InsisiTumor SofTissuedenganNarcose

40 Biopsi InsisiTumor SoftTissueLokalAnestesi

41 Eksisi Tumor Jinak>3cm

42 Eksisi Tumor Jinak1

8 Amputasi jari single

9 Augmentasimamae

10 Blefaroplasty(2kelopakmata)

11 Blefaroplastypadakasussulit

3612 Blefaroptosis


13 Bone rekonstruksifacial cleft

14 Bone rekonstruksifacial cleft

15 Cheilonasoraphy

16 Chordectomy

17 Chordectomy+urethroplasty

18 ClosedReductionFr.Nasal

19 Comisuroplasty

20 Eksmammaaberanbilateral

21 Eksisi neoplasmajinak(lipoma, atheromadll)

22 Eksisi luas+ Deltopectoralflap

23 Eksisi luas+ Foreheadflap

24 Eksisi luas+ Muskulocutanflap

25 Eksisi luas+ rekonstruksi dengan bedah mikrovaskular

26 Eksisi malformasi lymphatik/vaskuler

27 Ekstraksi ateroma/keloid

28 Ekstraksi korpusalienum

29 Elevasi ear rimcartilago

30Excisehemangioma+rekonstruksi

31 Exciseintrakeloid

32 Excisepolydactyly

33 Excisereduksi lymedema

34 Facial slingdenganallograft

35 Fasciotomyburninjury

36 Fasciotomywithcomplication

37 Flaplokal sederhana

38 Fr.Condylusmandibulaopenred

39 Fr.Maksilasuspensi (IOID)

40 Fr.Nasal openreduction

41 Fraktur Prosesus alveolaris denganinterdental wiring (IDW) (per rahang)

42 Fraktur Prosesus alveolarisluasdenganIDW(per rahang)

43 Fraktur rahang reduksiterbuka&inter oseuswiring(IOW)

37


44 LDflap

45 LefortIosteotomy

46 Liposuction

47 Lobuloplasti

48 Malarplasty

49 Mammaaberanunilateral

50 Mandibular distraksi

51 Mandibular rekonstruksi dengancostochondral graft

52 Mastopexi

53 Mentoplasty

54 Microsurgery

55 Multiplefacialfraktur +implant

56 Muskulokutaneusflap

57 Myokutaneusflap/pectoralismayorflap

58 Nasal repair danrekonstruksi

59 Neovagina

60 Operasi bedahmikro

61 Oriffraktur zygoma

62 Oriffraktur hand

63 Oriffrakturmandibula

64 Oriffrakturmaxilla

65 Orifmaksilaplating

66 Orifmandibulaplating

67 Orifmandibulawiring

68 Oriforbital wall

69 Oriforbital wall

70 Orifzygomawiring

71 Osteotomycraniosynostosisreconstruction

72 Osteotomyfacial rekonstruksi

73 Osteotomygenioplastitanpatarif bahan

74 OsteotomymaksilaLefortI

75 OsteotomymaksilaLefortII

76 Palatoplastibilateral komplit

77 Palatoplastibilateral takkomplit

78 Palatoplastiunilateralkomplit

79 Palatoplastiunilateral takkomplit

80 Palatoraphy

81 Pasangarchbar

82 Pasang backslab/foreslab

83 Pasangcast/gipstanpareposisi

84 Recheiloraphy

85 Rekonstruksidengan alloplasticmaterial

38

4444

86 Rekonstruksifacial cleft87 Rekonstruksinasal


88 Rekonstruksipalpebra

89 Releasedburiedpenis

90 Releasedsyndactylykompleks

91 Repair canalislacrimalis(withoutsilicontube)

92 Repair colobomapalpebra(skin/mucosal graft)

93 Repair ductusnasolacrimalis

94 Repairfingertipinjury

95 Repairfistelurethra

96 Replantation

97 Reposisifraktur nasalsederhana

98 Reposisifraktur osnasalis(complicated)

99 Reseksi mandibula+ bonegraft

100 Rhinoplasty

101 Rotationflap

102 Sagital Split osteotomimandibula

103 Simplebonegrafting

104 Simpleskingrafting

105 Skinflap

106 Skingraft>5cm

107 Skingraftsedang5cm

108 Skingraftingkecil

109 Skingraftingluas

110 Skingraftingsedang

111 Skingraftingwithcomplication

112 Tendonreconstruction

113 Tendontransfer

114 Tendontransfer withcomplication

115 Tennoraphy

116 Tennoraphywithcomplication

117 TMJ arthroplasty

118 TMJ arthrostomy

119 Tram flap

120 WoundDressing

121 WoundRepair


13KSM OBGYN1 Cauter serviks

2 Cordosentesis

3 Debulkingtumor ovarium

4 Eksplorasi vagina

5 Embryotomi

6 Extirpasi + kuret polipendoserviks

7 Extirpasi geborenmioma

8 Extirpasi geborenmioma+kuiretasi

9 Histeroctomypada mola/chorioCa

10 Histeroctomyradikal

11 Kistektomi

12 Konisasi serviks

13 Kuretabortusincompletes

14 Lapop:myomektomi

15 Laparoskopi (Kistektomi Ovarium,Salphingektomi, Adhesiolisis)

16 Laparoskopi Histerektomi

17 Laparoskopi steril

18 LaparoskopikDiagnostik

19 Laparotomi denganpenyulitmayor

20 Laparotomi denganpenyulitminor

21 Laparotomi tanpapenyulit

22 LEEP

23 MicrokuretaseDUB

24 Mikrokuret

25 Miomectomy

26 Neovagina

27 Operasi Cavagina

28 Operasi kanker corpusuteri

29 Operasi tumor ganasovarium

4030 Operativehisteroscopy/Ablasi endometrium

31 Overectomi


32 Painlesslabor

33 Persalinannormal

34 Persalinannormaldenganpenyulit

35 Persalinanpervaginam tindakanoperatif

36 Persalinansungsang

37 Rekanalisasi

38 Rekanalisasituba

39 Salfingektomi unilateral

40 Salvingoovarectomi unilateral

41 SecoundlooksurgeryCaovarium

42 Seksiosesaria

43 Seksiosesariadenganpenyulit penyulit

44 Sirklaseserviks

45 Seksiosesariadenganpenyulit penyulit

46 Sirklaseserviks

47 Supravaginal hyterectomy

48 Surgical staging

49 TAH+BSOdenganPenyulit

50 TAH+BSOdenganPenyulit PemasanganTamponAbdomen

51 Total abdominal hysterectomy+bilateral salfingektomi

52 Tubektomi klinik

53 Tutupburstabdomen

4343


14KSM GIGIdanMULUT1 AugmentasiTulangPer Regio(Belum TermasukBahan)2 DebrimentMukosadanPengelolaanLukaSayat3 Dislokasi Sendi Mandibula4 Eksisi EpulisPer Rahang

5 Eksisi KelenjarLudahSubmandibula

6 Eksisi KistaOdontogenik Keratosis+ Ostektomi

7 Eksisi NeoplasmaJinak ExtraOral UkuranKecil

8 Eksisi Parsial + Marsupialisasi Ranula

9 Eksisi PlungingRanula

10 Eksisional Biopsi NeoplasmaJinak

11 Enukleasi KistaDentigerous+ Extraksi Gigi Impaksi12 Enukleasi Kistaradikuler Per Rahang+ Extraksi GigiPenyebab13 Extirpasi KistaDermoid

14Extirpasi Sialolith

15 Extraksi Corpus AlienumdenganTeknik Lindorf16 Extraksi Gigi Anak denganKelainanJantungPerRahang17 Extraksi Gigi Anak PerRahang

18 Extraksi Gigi DewasaPer Rahang

19 FissureSealantpadaAutis

20 Fraktur DentoalveolarDenganarchBar

21 Fraktur DentoalveolarDenganBracket(belum termasukbahan)22 fraktur DentoAlveolardenganEyelet

23 Fraktur MaksiladenganSuspensiWiring

24 Fraktur Nasal closeReduksi

25 Fraktur Nasal OpenReduksi26 Fraktur RahangReduksi TertutupdenganIntermaksilaFiksasi27 Frenektomi Per Rahang

28 Genioplasty

29 Gingivektomi Per Rahang

42


30 Hemi MaksilektomiTanpaRekonstruksi

31 Insisi Abses/Phlegmon

32 InsisionalBiopsi NeoplasmaJinak

33 Mandibular Distraksi

34 OdontektomiPer Gigi

35 ORIF Maksila+ Zygoma+ Mandibula (belum termasukimplant)

36 ORIF MaksilaPlating(belumtermasukimplant)

37 ORIF MandibulaPlating (belumtermasukimplant)

38 ORIF ZygomaPlating (belumtermasukimplant)

39 Osteotomi MaksilaleFortI

40 Osteotomi MaksilaleFortII

41 PelepasanArchBar (IntermaksilaFiksasi)

15DIVISIPEDIATRI GAWAT DARURAT ILMU KESEHATAN ANAK1 Intubasi Endotrakea

2 Krikotirotomi

3 Kanulasi venaperifer

4 Venasectie

5 Pungsi lumbal

6 PungsivPleura

16KSM PENYAKIT JANTUNG&PEMBULUH DARAH1 Diagnostik KateterisasiJantung

2 PTMC

3 PTCA/Stenting

4 Pacemaker Temporer&Permanen

5 IABP

6 Perikardiosintesis

7 PemasanganSwanGanzKateter

8 PemasanganAmplatzer/ADO/Coilling

9 CVC

10 PelepasanArchBar (IntermaksilaFiksasi)

17KSM PENYAKIT DALAMEndoscopy

43

B.TindakanAnestesi&Sedasi ( Sedang danDalam),tindakan yang memerlukan informed consenttersebut antaralain:a. Semuatindakananestesi dansedasi didalamkamaroperasi b. Semuatindakananestesi dansedasi di ICU

TindakanAnestesidiICU

Pemasanganintubasiventilator

Pemasanganvenacentral

PemasanganCRRT

PemasanganSwanGanz(KateterArteriPulmonal)

PemasanganIntraArterialCatheher(KateterIntraArterial)

PemasanganPercutaneousDilatationalTracheostomy

PemasanganDrainIntraThorakal/PunksiThorax

PemasanganIABP

PemasanganDrainIntraAbdominal

PemasanganGemo

Cardioversi

Bronchoskopi-FOB

TEE

C.TindakanPemberianProdukDarah dan Komponen Darah,tindakanyang memerlukan informed consenttersebut antaralain:Transfusi darah: a. Plasma sel b. PRCc. WholeBloodCell d. Trombositee. Albumin

f. lainlain

44

D.SemuaTindakan Yang Berisiko Tinggi:

NoKSM /INSTALASINAMATINDAKAN

1

KSMAnak1Chesttube

2Tindakan kemotherapi

3PemasanganVentilator

4Intubasi Endotrakea

5PemasanganLaryngeal mask

6Krikotirotomi

7Infusintraosseus

8Kanulasi venaperifer

9Venasectie

10Pengambilandarahintravenadanintraarteri

11Pungsi lumbal

12PungsivPleura

13Pemasangankateterurine

14Pemasanganketeter rectal

15Pemasanganorogastriktube

16Pemasangannasogastriktube

2

THT-KL1PemeriksaanAudiometri

2PemeriksaanTimpanometri

3PemeriksaanAudiometri Tutur

4PemeriksaanSisi&ToreDecay

5PemeriksaanPendengaranPadaAnak

6PemeriksaanBrainstemEvokedResponseAudiometry

3KSM Patologi

AnatomiFNAB(FineNeedleAspirationBiopsy)

4Inst.

RadiotherapiTindakanRadiotherapi

5

KSM Neurologi1Cerebral Angiografi

2AVM&Embolisasi

3AneurismaCoiling

4Embolisasi preoperasi

5DiagnosisDSA

6LumbalPunksi

7PainIntervention

8InjeksiTriger point

9InjeksiTriger Fringer

10Injeksi CTS

11SubOptical Functional

12Injeksi botox

13EMG

6KSM PatologiPhlebotomi

45

Klinik

7

KSM Gigidan

Mulut1Scaling

2Curettage/root planning(jikadiperlukananestesi)

3Gingivektomi

4Frenektomi

5Flapoperasi(bonegraft/membrance/GTR/interseptif)

6Implant

7Vital pulpektomi dan Partial Nekrose

8Cauter

9RetraksiGingivapadaprep.crown

8PoliAndrologiSuntikIntraCavernosal Penis

9KSM Kardiologi dan Kedokteran Vaskular1DobutaminStressEkhokardiografi

2Transophegal Ekhokardiografi

3TreadmillTes

4ExerciseStress Ekhokardiografi

10

KSM Pulmonologi dan Ilmu Kedokteran Respirasi1Bronchoscopy/FOB

2Tindakan kemotherapi

3Thoracoscopy

4ContraVentil/WSD

5PunctiePleura

6FNAB

7ScaleneBiopsy

8Reposisi

9Pleurodesis

10AFFWSD

11PerawatanLukaWSD

12USGThoraxMarker

11

KSM Radiologi1TindakanRadiologi Injecteecontrast

2TindakanRadiologi padapasiendengankelainancardiovaskuler

3TindakanRadiologi padapasiendenganalergiberat

4TindakanRadiologi padapasiendenganKU yang menurun

5TindakanRadiologi yangmemerlukanFNABGuiding MSCT pada pasiendengankelainanyang berdekatandenganorganvital

6TindakanRadiologi padaIbuhamil yangmemerlukanfoto

12KSM Neurologi1Cerebral Angiografi

2AVM&Embolisasi

3AneurismaCoiling

4Embolisasi preoperasi

5DiagnosisDSA

46

6LumbalPunksi

7PainIntervention

8InjeksiTriger point

9InjeksiTriger Fringer

10Injeksi CTS

11SubOptical Functional

12Injeksi botox

13EMG

14Neuroendovaskuler:Coiling,Embolisasi,DSA

13InstalasiHemodialisisSetiapkalimelakukantindakanHemodialisis

14KSM Rehabilitasi Medik

ElektromiografidanKecepatanHantarSaraf

16

IRNAJiwa1 PsychoAnalisa

2 PsychoTherapyDalam

3 PemeriksaanCalonPimpinanPublik

4 Aborsi ProvocatusMedicinalis

5 Tindakanterapi elektroconfusi

6 Pemeriksaankandunganzatnarkotika

7 Restraint/Fiksasi :mekanikdanpsikotropika

8 Pemeriksaansengketa/konflikdalamkeluarga

15Semuainjeksi denganobat risikotinggi

47

Daftar Tindakan Informed Consent

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