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KOLEGIUM ILMU ORTHOPAEDI & TRAUMATOLOGI INDONESIA

(THE INDONESIAN COLLEGE OF ORTHOPAEDIC & TRAUMATOLOGY)

Sekretariat : Dept. Medik Orthopaedi & Traumatologi


FKUI/RS Dr. Cipto Mangunkusumo
Jl. Diponegoro 71, Jakarta 10430 INDONESIA
Telp : (62-21) 392 9655 Fax : (62-21) 390 5894 Email : orthoui@dnet.net.id

FORMULIRPENDAFTARAN
NATIONALORTHOAPEDICBOARDEXAMINATION

KepadaYth.
:
KetuaKomisiUjianKompetensiNasional
KolegiumOrthopaedi&TraumatologiIndonesia
d/aDiv.Orthopaedi&TraumatologiFKUI/RSCM,
Jl.Diponegoro71,Jakarta10430,
Fax:(021)3905894

TEMPATUJIANTULIS/SESSIONI
KAMIS,23JUNI2011
Peserta:WilayahBarat
Peserta:WilayahTimur
(FKUI,FKUNPAD,FKUGM) (FKUNAIR,FKUNS,FKUNIBRAW,
FKUHANS,FKUNUD)
JAKARTA
Dept.MedikOrthopaedi&
Traumatologi,FKUI/RSCM
Jl.Diponegoro71,
Jakarta10430
T:(021)3929655
F:(021)3905894

SURABAYA
Bag.Orthopaedi&Traumatologi,
FKUNAIR/RSUDr.Soetomo,Jl.
MayjendProf.dr.MoestopoNo.68,
Surabaya,
T/F:(031)5020406

TEMPATUJIANORAL/SESSIONII
MINGGUDANSENIN,24&25JULI2011

JAKARTA
DeptMedikOrthopaedi&Traumatologi,FKUI/RSCM
Jl.Diponegoro71,
Jakarta10430
T:(021)3929655
F:(021)3905894

Yangbertandatangandibawah:

Nama

:
(namasesuaiIjasah)

Tempat/tglLahir

:..

NIP/NRP/NIP

:..

KesatuanInduk

:..

Institusi

:..

Karyaakhir

:..

AlamatRumah

:..

..

HP/Telp

:.

Menyatakan untuk mengikuti ujian nasional orthopaedi & traumatologi, pada bulan tersebut diatas dan
menyerahkanformulirkepadaKetuaKolegiumIlmuOrthopaedi&TraumatologidenganalamatDivisiOrthopaedi
& Traumatologi, FKUI/RS Dr. Cipto Mangunkusumo, Jl. Diponegoro 71, Jakarta 10430, Telp (021) 392 9655 Fax :
(021)3905894.

Mengetahui/menyetujui:

KetuaProgramStudi

PPDSIlmuOrthopaedi&Traumatologi

(..)
NIP.:

PesertaUjian:

Nama:

NIP/NRP:..

TandaTangan:..

RIWAYATPENDIDIKAN
KANDIDATUJIANNASIONAL
ORTHOPAEDIDANTRAUMATOLOGI

NAMA

:.................................................................................

TEMPAT&TANGGALLAHIR

:.................................................................................

JENISKELAMIN

:.................................................................................

MULAIPENDIDIKAN

:..................................................................................

NIM

:..................................................................................

ASALFK

:..................................................................................

PPDSORTHOPAEDI&TRAUMATOLOGI :...................................................................................
TAHAPSEMESTERIIV

:BedahDasar

KARYAILMIAH
No.
1.

2.

JUDUL

DIBACAKAN

LulusBedahDasar

:................................................

Nilai

:.................................................

IP

:................................................

KetuaProgramStudi
PPDSIlmuBedahFK...................

.............................................................
NIP.:..................................................

Foto
4x6


LOGBOOK

Foto
4x6

:..................................................................................

TEMPAT&TANGGALLAHIR

:..................................................................................

JENISKELAMIN

:................................................................................

MULAIPENDIDIKAN

:................................................................................

NIM

NAMA

:.................................................................................

ASALFK

PPDSORTHOPAEDI&TRAUMATOLOGI :.................................................................................
TAHAPSEMESTERIIV

:.................................................................................

KEGIATAN

JENISKASUS

SEMESTERIII

JUMLAHKASUS

Trauma

NonTrauma

SEMESTERIIIIV

Trauma

NonTrauma

Catatan:Harapdilampirkandaftarkasus

KetuaProgramStudi
PPDSIlmuBedahFK...........................

................................................
NIP.:..................................

LOGBOOKSEMESTERIIV

I.SemesterI
%Trauma:
No.
1
2
3
4
5
6
7
8
9
10

Tindakan
ReposisitertutupLLP/LAC/SAP
Cystostomi
DebridementRepairTendon
Laparotomi
Craniotomi
DebridementORIF
DebridementOREF
Tracheostomi
ThoracostomiWSD
IOIDW

Assistensi

Bimbingan

Mandiri

%NonTrauma:
No.
1
2
3
4
5
6

Tindakan

Assistensi

Bimbingan

Appendiktomi
Herniotomi
Laparotomi
Debridement
Thoracostomy
Kolostomi

Mandiri

II.SemesterII
%Trauma
No.
1
2
3
4
5
6
7

Tindakan
ReposisitertutupLLP/LAC/SAP
Cystostomi
DebridementRepairTendon
Laparotomi
Craniotomi
DebridementORIF
DebridementOREF

Assistensi

Bimbingan

Mandiri

%NonTrauma:
No.
1
2
3
4

Tindakan

Assistensi

Bimbingan

Appendiktomi
Herniotomi
Laparotomi
Debridement

Mandiri

III.SemesterIII
%Trauma
No.
1
2
3
4
5
6
7

Tindakan
ReposisitertutupLLP/LAC/SAP
Cystostomi
DebridementRepairTendon
Laparotomi
Craniotomi
DebridementORIF
DebridementOREF

Assistensi

Bimbingan

Mandiri

%NonTrauma:
No.
1
2
3
4

Tindakan

Assistensi

Bimbingan

Appendiktomi
Herniotomi
Laparotomi
Debridement

Mandiri

IV.SemesterIV
%Trauma
No.
1
2
3
4
5
6
7

Tindakan
ReposisitertutupLLP/LAC/SAP
Cystostomi
DebridementRepairTendon
Laparotomi
Craniotomi
DebridementORIF
DebridementOREF

Assistensi

Bimbingan

Mandiri

%NonTrauma:
No.
1
2
3
4

Tindakan
Appendiktomi
Herniotomi
Laparotomi
Debridement

Assistensi

Bimbingan

Mandiri

RIWAYATPENDIDIKAN
KANDIDATUJIANNASIONAL
ORTHOPAEDIDANTRAUMATOLOGI

NAMA

:.................................................................................

TEMPAT&TANGGALLAHIR

:.................................................................................

JENISKELAMIN

:.................................................................................

MULAIPENDIDIKAN

:..................................................................................

NIM

:..................................................................................

ASALFK

:..................................................................................

PPDSORTHOPAEDI&TRAUMATOLOGI :...................................................................................
TAHAPSEMESTERVIX

:...................................................................................

KARYAILMIAH

No.
JUDUL
DIBACAKAN

1.

2.

No.
JUDULPENELITIANAKHIR
DIBACAKAN

1.

UjianInstitusi :.................................................
DiInstitusi:.........................
Nilai
:.................................................
IPK

:.................................................

KetuaProgramStudi
PPDSIlmuOrthoapedi&Traumatologi.......................

.............................................................
NIP.:..................................................

Foto
4x6


LOGBOOK

Foto
4x6

:..................................................................................

TEMPAT&TANGGALLAHIR

:..................................................................................

JENISKELAMIN

:................................................................................

MULAIPENDIDIKAN

:................................................................................

NIM

NAMA

:.................................................................................

ASALFK

PPDSORTHOPAEDI&TRAUMATOLOGI :.................................................................................
TAHAPSEMESTERVIX

:................................................................................

KEGIATAN

SEMESTERVIX

JENISKASUS

JUMLAHKASUS

Trauma

Spine

Onkologi

Pediatric

Hand

Sport&Arthroscopy

Lainlain

JUMLAHKESELURUHANJENISKASUS

Catatan:Harapdilampirkandaftarkasus

KetuaProgramStudi
PPDSIlmuOrthopaedi&Traumatologi.......................

................................................
NIP.:..................................

LOGBOOKSEMESTERVIX

NAMA

:.........................................................................................

TEMPAT&TANGGALLAHIR

:.........................................................................................

JENISKELAMIN

:........................................................................................

MULAIPENDIDIKAN

:.........................................................................................

NIM

:.........................................................................................

ASALFK

:.........................................................................................

PPDSORTHOPAEDI&TRAUMATOLOGI :.........................................................................................
TAHAPSEMESTERVIX

:.........................................................................................

KEGIATANSEMESTERVIX

KASUS

JENISKASUS

TRAUMA

PlatingFrakturClavicle
PlatingFrakturSkapula
TBWACJointDisruption
PlatingFrakturCaputHumerus
PlatingFrakturHumerusShaft
ExternalFiksasiHumerus
NailingFrakturHumerusShaft
Plating/PinningFrakturSupracondiler
PlatingFrakturIntercondilerHumerus
TBWFrakturOlecranon
PlatingFrakturOlecranon
PlatingFrakturAntebrachii
EksternalFiksasiAntebrahii
PlatingFrakturMontegia
PlatingFrakturGaleazi
Plating/PinningFrakturRadiusDistal
ExternalFiksasiWrist
Plating/PinningFrakturMetacarpal/Phalang
Screwing/PinningFrakturScaphoid
Tendorapi/Neurorapi/RepairVasculerExtremitasAtas
FasiotomiExtremitasAtas
Amputasi/DisartikulasiExtremitasAtas
ScrewingCaputFemur
DHS/ABPFractureofPertrochanterFemur
PlatingofFemurTrochanter
PlatingofFrakturFemurShaft
NailingofFrakturFemurShaft
ExternalFiksasiofFemur
Plating/ABPDistalofFrakturSupracondilerFemur
ABP/DCS/CondilerButtersPlateofFrakturIntercondilerFemur
TBW/ScrewingofFrakturPatela
PlatingofFrakturTibialPlatau
PlatingofFrakturTibiaShaft
NailingofFrakturTibiaShaft
ExternalFiksasiofCruris
Plating&SrewingofFrakturAnkle
ExternalFiksasiofAnkle
PlatingofFrakturTibialPilon
PinningofFrakturMetatarsal/PhalangPedis
ScrewingofTalus
Plating/screwingofCalcaneus
Tendoraphy,Neuroraphy,andRepairVasculerofLowerExtremity
FasciotomyofLowerExtremity
Amputation/DisartikulationofLowerExtremity
PosteriorStabilizationofthoracolumbar
PosteriorStabilizationofCervical
JUMLAHTOTALTRAUMA

SPINE

JUMLAHKASUS

ThoracophrenocolombotomyDebridement
ThoracotomyDebridement
LombotomyDebridement
AnteriorStabilizationCervical
DiscectomyofLumbarSpine
DecompresionofLumbarCannalStenosis

JULMAHTOTALSPINE


KASUS

ONCOLOGY

PEDIATRIC

HAND

Sport&
Arthroscopy

OTHERS

JENISKASUS
OpenBiopsy
WideExcision
Amputation
CurettageBonegraft
CurettageBoneCement
WideExcisionFemurProximal&Prosthesis
CurettageFemurProximal/Distal&ABP/DHS+BoneCement
BoneResection+BoneAllograft
JULMAHTOTALONCOLOGY

AchillesTendonLengthening
PosteriorMedialRelease
Siskhebab
ArthrotomyofSepticArthritis
ReleaseofContracture
ReleaseofConstrictionBand
DerotationofHeadFemur
ShalterOsteotomy
ValgusOsteotomyofTheKnee
JULMAHTOTALPEDIATRIC

PlexusBrachialExploration
NerveGraftingofUpperExtremity
NeurolisysofUpperExtremity
TendonTransferUpperExtremity
ReconstructionofShoulderJoint
ArthroplastyofShoulder
ReconstructionofElbowJoint
ArthroplastyofElbow
RecontructionofWristJoint
ArthroplastyofMP/PIPJoint
Replantation
ReleaseofDequarvain,TriggerFinger
ReleaseofTendonContracture
ReleaseofDupuytrenContracture
ReductionofMacrodactily
SeparationofSindactily
ReconstructionofPolydactily
ExcisionofHaemengioma
JULMAHTOTALHAND

ArthroscopyofShoulder
ArthroscopyofKnee
Acromioplasty&RepairRotatorCuff
KneeLigamentReconstruction
Mozaicplasty
JULMAHTOTALSPORT&ARTHROSCOPY

TotalHipArthroplasty
TotalKneeArthroplasty
ElevationandMedializationofPatelarTendon
TibialPosteriorTendonTransfer
ArthrodesisofHip
ArthrodesisofKnee
ArthrodesisofWrist
ArthrodesisofAnkle
HighTibialOsteotomy
SupracondilerFemurOsteotomy
SequesterectomyonOsteomielytis
PapinaouProcedure
JULMAHTOTALTOTAL

JUMLAHKESELURUHAN

KetuaProgramStudi
PPDSIlmuOrthopaedi&Traumatologi.....................

..................................................................................
NIP.:

JUMLAHKASUS

JADWALROTASIKESENTERSENTER
(JAKARTABANDUNGSOLOSURABAYA)
UJIANSESSIONI:22DESEMBER2011
UJIANSESSIONII:2829JANUARI2012
ROTASI:26DESEMBER201121JANUARI2012

KOTA

JAKARTA

BANDUNG

SOLO

SURABAYA

GroupA

GroupB

GroupC

GroupD

GroupB

GroupC

GroupD

GroupA

GroupC

GraupD

GroupA

GroupB

GroupD

GroupA

GroupB

GroupC

TANGGAL

2631Des2011

2s/d7Jan2012

9s/d14Jan2012

16s/d21Jan2012