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: Permohonan Kewenangan Klinik Dokter Umum


: 1 Berkas

Kepada Yth:
Direktur Rumah Sakit Umum Daerah Majalengka
Di tempat
Dengan hormat,
Dengan ini kami mengajukan permohonan kewenangan klinik dokter umum sebagai staf medis
Rumah Sakit Umum Daerah Majalengka (Paruh waktu/ Purna waktu*).
Demikianlah permohonan ini kami sampaikan. Atas perhatiannya diucapkan terima kasih.
Majalengka, ..
Pemohon,

Dr. Dewi Nurmalasari

Keterangan:
* Coret yang dianggap tidak perlu
* Berkas yang dilampirkan: fotocopy STR, fotocopy Surat Pindah/ SK Pensiun, fotocopy ijazah
dan CV

KEWENANGAN KLINIK DOKTER UMUM


DOKTER YANG MENGAJUKAN : dr. DEWI NURMALASARI
LULUSAN
:
TAHUN LULUS :
No
Kewenangan Klinik
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44

Angina pectoris
Unstable angina
Myocardial Infarction
Imminent Myocardial
Infarction
Cardiac aneurysm
Heart failure
Cardiorespiratory arrest
Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation
Other valvular heart
diseases
VSD
ASD
Sinus tachycardia
Supraventricular
tachycardia
Atrial fibrillation
Atrial flutter
Supraventricular
extrasystole
Ventricular extrasystole
BBB
Other arrhythmias
Endocarditis
Pericarditis
Myocarditis
Cardiomyopathy
Essential hypertension
Secondary hypertension
Pulmonary hypertension
Raynaud's disease
Arterial thrombosis
Coarctation of the aorta
Burger's disease
Arterial embolism
Atherosclerosis
Subclavian steal syndrome
Aortic aneurysm
Dissecting aneurysm
Claudicatio
Cardiogenic shock
Septic shock
Hypovolemic shock
Varices (primary,secondary)
Obstructed venous return

Permohonan
Kemampuan Klinik
1
2
3
4

Disetujui Kemampuan
Klinik
1
2
3
4

45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94

Deep vein thrombosis


Thrombophlebitis
Lymphangitis
Lymphadenitis
Lymphedema, primary and
secondary
Uncomplicated Pulmonary
Tuberculosis
TBC with HIV
TBC with pneumothorax
Acute Bronchitis
Bronchiolitis
Bronchial asthma
Status asmaticus
Lung emphysema
Atelectasis
Bronchiectasis
COPD
SARS
Pneumonia
Avian influenzae
Lung abscess
Pulmonary embolism
Lung infarction
Pleurisy TBC
Pleurisy Cancer
Pleurisy Lupus
Pneumothorax
Cystic fibrosis
Aspiration pneumonia
Cleft lip and palate
Micrognatia and
macrognatia
Leukoplakia
Candidiasis
Mouth ulcers (aphthous,
herpes)
Glossitis
Esophageal atresia
Achalasia
Corrosive lesions of
esophageus
Esophageal varices
Esophageal rupture
Reflux esophaghitis
Diaphramatic hernia
Hiatus hernia
Inguinal hernia, direct and
indirect
Femoral hernia Bedah
Epigastric hernia
Incisional hernia
Umbilical hernia
Peritonitis
Abscess in pouch of Douglas
Ileus

95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146

Perforation
Salphingitis
Acute appendicitis
Appendicular abscess
Mesenteric lymphadenitis
Gastritis
Gastric/duodenal ulcer
Gastrointestinal bleeding
Zollinger-ellison syndrome
Mallory-weiss syndrome
Gastroenteritis
Fatty liver
Hepatitis A
Uncomplicated Hepatitis B
Active Hepatitis C
Cirrhosis hepatis
Amoebic liver abscess
Liver failure
Chole(docho)lithiasis
Acute cholecystitis
Hydrops of gall bladder
Empyema of gall bladder
Pancreatitis
Intestinal atresia
Meckel's diverticulum
Umbilical fistula,
omphalocoele-gastroschisis
Malrotation
Enteritis
Irritable bowel syndrome
Necrotizing enterocolitis
Diverticulosis/diverticulitis
Colitis
Rectal, anal prolapse
Proctitis
Hemorrhoids
(peri)anal abscess
Fistula
Anal fissure
Esophageal atresia
Intestinal atresia
Anal atresia
Diapragmatic hernia
(congenital)
Pyloric stenosis
Gastro-esophageal reflux
Gastro-enteritis
Gastro-enteritis dengan
dehidrasi
Worms
Dehydration
Malabsorbsion
Food intolerance
Acute abdomen
Ileus

147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168

169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196

Peritonitis tuberculosis
Peritonitis pancreatitis
Intussussception
Malrotation
Umbilical hernia
Meckell's diverticulum
Crohn's disease
Ulcerative colitis
Hirschsprung's disease
Biliary atresia
Hepatitis
Reye's syndrome
Cirrhosis of the liver
Food allergy
Acute renal failure
Chronic renal failure
Nephrotic syndrome
Acute glomerulonephritis
Chronic glomerulonephritis
Interstitial nephritis
Renal colic
Urinary stone diseases
or urinary calculi
without colic
Polycystic kidneys
symptomatic
Urinary tract infection
Acute tubular necrosis
Horse shoe kidney
Uncomplicated
Pyelonephritis
Urinary incontinence
Nocturnal and diurnal
enuresis
Prostatitis
Hypospadia
Epispadia
Undescended
testes/cryptorchidism
Retractile testes
Torsion of testis
Epididymitis
Spermatocele
Varicocele
Hydrocele
Phimosis
Paraphimosis
Ruptur uretra
Ruptur kandung kencing
Ruptur ginjal
Striktura uretra
Priapismus
Penyakit peironi
Ekstrophia vesicae
Infertility
Erection disorders

197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
240
241
242
243

Ejaculation disorders
Vulvitis
Dystrophy of vulva
Cyst of bartholin, abscess of
bartholin's gland
Abscess of hair follicle or
sebaceous gland
Condylomata acuminata
Congenital malformations
Vaginitis
Bacterial vaginosis
Cyst of gartner
Cystocoele
Rectocoele
Enterocoele
Fistula (vesico-vaginal,
uretero-vaginal, rectovaginal fistula)
Foreign body
Cervicitis
Polyps
Nabothian cyst
Congenital malformations
Uterine prolaps
Hematocolpos
Endometriosis
Salpingitis
Adhesions
Ovarian cyst
Polycystic ovarian disease
Carcinoma of ovary
Ectopic pregnancy
Torsion tumour / ovarian
cyst
Rupture of ovarian cyst /
tubo - ovarian abscess
Uterine bleeding at
ovulation
Inflammations of breast
Mastopathy
Aplastic/hypoplastic anemia
Iron deficiency anemia
Macrocytic anemia
Hemolytic anemia
Hemoglobinopathy
Anemia associated with
chronic diseases
Polycytemia
Thrombocytopenia
Thrombocytosis
Hemophilia
Von willebrand's disease
DIC
Agranulocytosis
Haemorheologic disorders
Antiphospholipid syndrome

244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294

Uncomplicated SLE
Complicated SLE
Scleroderma
Polyarteritis nodosa
Vasculitis Lupus
Polymyalgia rheumatica
Rheumatoid arthritis
Anaphylactic reaction
Rheumatic fever
Juvenile chronic arthritis
Henoch-schoenlein purpura
Erythema multiforme
Atopy
Steven johnson's syndrome
Transplantation
immunology
Down's syndrome
Turner's syndrome
Klinefelter's syndrome
Gonadal xy-dysgenesis
Testicular feminization
Fragile x syndrome
PKU (Phenyl Ketonuria)
Galactosemia
Glycogen storage disease
Other storage diseases
Spina bifida
Anencephaly
Hydrocephalus
Cleft palate and/or lip
Marfan's syndrome
Hypothermia
Bacteraemia and septicemia
Respiratory stress syndrome
Bronchopulmonary
dysplasia
Aspiration pneumonia
Pneumo thorax
Apnea attacks
Jaundice of newborn
Severe neonatal jaundice
(kern icterus)
Hypoglycemia
Child of diabetic mother
Neonatal convulsion
Necrotizing enterocolitis
Retinopathy of prematurity
Anemia
Rhesus incompatibility
Blood group incompatibility
Vitamine k defficiency
Cerebral hemorrhage
Conjuctivitis
Infection of umbilicus
Sudden infant death

295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316

317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341

syndrome (sids)
IDDM
NIDDM
Complication of DM (acute
and chronic)
Hypoglycemia
Diabetes incipidus
Acromegaly, gigantism
Growth hormone deficiency
Hyperparathyroidism
Hypoparathyroidism
Hyperthyroidism
Hypothyroidism
Thyroiditis
Cushing's disease
Adrenal cortex failure
Primary hyperaldosteroidism
Phaeochromocytoma
Precocious puberty
Testicular feminization
syndrome
Hypogonadism
Adrenogenital syndrome
Addison's disease
Multiple
endocrinological
neoplasia (men
syndrome)
Tumor with ectopic
production of hormone
Kwashiorkor
Vitamin deficiencies
Hyperlipoproteinemia
Porphyria
Gout
Obesity
Metabolic Encephalopathy
Comatous
Brain death
Tension headache
Migraine
Cranial arteritis
Trigeminal neuralgia
Cluster headache
TIA
Cerebral infarction
Intracerebral hematoma
Subarachnoid hemmorhage
Hypertensive
encephalopathy
Bels palsy
Brain stem lesions
Menier's disease
Benign paroxysmal positional
vertigo
Vertigo Central

342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392

Vascular dementia
Alzheimer's disease
Pick's disease
Parkinson's disease
Tremor
Secondary parkinsonism
Huntington disease
Chorea sydenham
Dystonia
Hemifacial spasm
Focal epilepsy
Generalized epilepsy
Absence seizure
Status epilepticus
Narcolepsy
Sleep apnea syndrome
Multiple sclerosis
Optic neuromyelitis (Devic's
disease)
Amyotrphic lateral sclerosis
(ALS)
Complete spinal transection
Brown sequard syndrome
Cauda equina syndrome
Neurogenic bladder
Syringomyelia
Myelopathy
Dorsal root syndrome
Medulla compression acute
Radicular syndrome/HNP
Spondilitis TB
Horner syndrome
Carpal tunnel syndrome
Tarsal tunnel syndrome
Neuropathy
Peroneal palsy
Guillain Barre syndrome
Myasthenia gravis
Polymyositis
Duchenne muscular
dystrophy
Neurofibromatosis (von
reckling hausen disease)
Meningitis
Encephalitis
Malaria cerebral
Tetanus
Cerebral Toxoplasmosis
Tuberculoma
Brain abscess
HIV AIDS
Hydrocephalus
Spina bifida
Phenyl ketonuria
Meningitis

393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443

Encephalitis
Cerebral abscess
Epilepsi
Infantile spasms
Petit mal epilepsy
Febrile convulsion
Duchene muscular dystrophy
Poliomyelitis
Cerebral palsy
Kernicterus
Mental Retardation
Autism
ADHD
Amnesia Pasca trauma
Afasia
MCI (Mild Cognitive
Impairment)
VCI (Vascular Cognitive
Impairment)
Epidural hematom
Subdural hematom
SAH (Sub Arachnoid
Hemorrhage)
Trauma Medula Spinalis
Tumor primer
Tumor sekunder
Nyeri Nosiseptif
Nyeri neuropatik
Buta mendadak
Diplopia
Visual field disorders
Inflammation of auricle
Herpes zoster oticus
Pre-auricular fistula
Foreign body in ear
Wax (serumen)
Otitis externa
Acute otitis media
Otitis media serous (glue ear)
Chronic otitis media
Perforated tympanic
membrane
Bullous myringitis
Otosclerosis
Tymphanosclerosis
Cholesteatoma
Presbyacusis
Mastoiditis
Labyrinthitis
Benign postural vertigo
Motion sickness
Meniere's diseases
Vestibular neuritis
Acoustic neuroma
Acute acoustic trauma

444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495

Ear, other trauma


Perceptive hearing loss
Conductive hearing loss
Congenital deafness
Facial palsy or paralysis
Epistaxis
Furuncle of nose
Acute rhinitis (common cold)
Vasomotor rhinitis
Allergic rhinitis
Chronic rhinitis
Rhinitis medicamentosa
Acute frontal sinusitis
Acute maxillary sinusitis
Acute ethmoiditis
Chronic sinusitis
Deviation of nasal septum
Choanal atresia
Foreign body in nose
Pharyangitis
Tonsilitis
Hypertrophy of adenoids
Pseudo-croop acute
epiglotitis
Medial and lateral branchial
cyst and fistula
Cystic hygroma
Torticollis
Cyst Tiroid
Goitre
Hyperthyroidism
Hyperparathyroidism
Hypoparathyroidism
Aspiration
Foreign bodies
Tracheitis
Conjunctiva, foreign body
Conjunctivitis, allergy
Conjunctivitis, viral
Conjunctivitis, bacterial
Pterygium
Subconjunctival
haemorrhage
Blepharitis
Hordeolum
Chalazion
Eyelid laceration
Entropion
Trichiasis
Lagophtalmos
Epicanthus
Ptosis
Eyelid retraction
Xanthelasma
Dacryoadenitis

496
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546

Dacryocystitis
Dacryostenosis
Lacrimal duct, laceration
Scleritis/episcleritis
Erosion
Cornea, foreign body
Burn
Keratitis
Kerato-conjunctivitis sicca
Corneal oedema
Corneal dystrophy
Keratoconus
Endophtalmitis
Microphtalmos
Buphtalmos
Hyphaema
Hypopyon
Iridocyclitis, iritis
Tumour of iris
Glaucoma, congenital
Simple glaucoma
Acute glaucoma
Secondary glaucoma
Cataract
Aphakia
Psudoaphakia (artificial lens)
Lens dislocation
Hypermetropia
Myopia
Astigmatism
Presbyopia
Anisometropia
Amblyopia
Diplopia
Suppresion
Night-blindness
Scotoma
Hemianopia, bitemporal and
homonymous
Loss of vision and blindness
Retinal detachment
Retina, vessel occlusion or
bleeding
Degeneration of macula, age
dependent
Retinopathy of prematurity
(rop)
Diabetic retinopathy
Hypertensive retinopathy
Chorioretinitis
Vitreous haemmorrhage
Optic disc cupping
Papilloedema
Optic atrophy
Optic neuropathy

547
548
549
550

568
569
570
571
572
573
574
575
576
577
578
579
580
581
582

Optic neuritis
Contact dermatitis irritant
Contact dermatitis allergica
Atopic dermatitis (kecuali
recalcitrant)
Nummular dermatitis
Lichen simplex chronicus
Napkin eczema
Psoriasis vulgaris
Plamoplantar pustulosis
Seborrheic dermatitis
Pityriasis rosea
Acne vulgaris
Rosacea
Hidradenitis suppurativa
Perioral dermatitis
Miliaria
Verruca vulgaris
Condyloma accuminata
Molluscum contagiosum
Herpes zoster
Impetigo
Ulcerative impetigo
(ecthyma)
Superficial folliculitis
Furuncle, carbuncle
Erythrasma
Erysipelas
Tinea capitis
Tinea barbae
Tinea faciale
Tinea corporis
Tinea Manus
Tinea unguium
Tinea Cruris
Mucocutaneous candidiasis
Tinea pedis
Tinea versicolor
Pediculosis capitis

583
584
585
586
587
588
589
590
591
592
593
594
595
596
597

Pediculosis pubis
Scabies
Insect bites reactions
Pemphigus vulgaris
Pemphigoid
Dermatitis herpetiformis
Toxic epidermal necrolysis
Stevens-johnson's disease
Dermatomyositis
Systemic sclerosis
Scleroderma/morphea
Lupus erythematosus
Alopecia areata
Androgenic alopecia
Trichotillomania

551
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
567

598
599
600
601
602
603
604
605
606
607
608
609
610
611
612
613
614
615
616
617
618
619

620
621
622
623
624
625
626
627
628
629
630
631
632
633
634
635
636
637
638
639
640
641
642
643

Telogen eflluvium
Ichthyosis vulgaris
Lichen planus
Granuloma annulare
Morphea
Lichen sclerosus er atrphicus
Exanthematous drug
eruption
Fixed drug eruption
Vitiligo
Melasma
Albinism
Post-inflammatory
hyperpigmentation
Post-inflammatory
hypopigmentation
Paronychia
Suppurative tenosynovitis
Human bite
Suppurative parotitis
Suppurative cervical adenitis
Peritonsilar abscess
Ludwig's angina
Bezold abscess
Superficial infections,
including folliculitis,
hidradenitis
suppurativa,
carbuncle.
Osteomyelitis
Staphylococcal pneumonia
Staphylococcal bacteremia
Rheumatic fever
Sinusitis, otitis media,
mastoiditis, pertonsilar
abscess - THT
Rheumatic heart disease
Meningitis (neuro)
Nasopharyngitis
Gonorrhea
Urinary tract infection (UTI)
Typhoid fever
Dysentry bacilli
Cholera
Pertussis
Plague (Pes)
Chancroid
Diphteria (THT)
Tetanus (pediatri)
Tuberculosis kutis
Leprosy
Lepra reaction
Syphilis
Yaws
Leptospirosis

644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
680
681
682
683
684
685

Actinomycosis
Chromoblastomycosis
Maduromycosis
Influenza
avian influenza (THT)
Viral gastroenteritis
Poliomyelitis
Rabies
Morbilli
Varicella
Herpes zoster
Herpes simplex
Mumps
CMV infections
Dengue hemorrhagic fever
(DHF)
HIV-AIDS
Amebiasis
Malaria
Leishmaniasis dan
tripanosomiasis
Toxoplasmosis
Giardiasis
Trichomoniasis
Hookworm diseases
Strongyloidiasis
Ascariasis
Filariasis
Schistosomiasis
Cutaneus larva migran
Taeniasis
Non-hodgkin's lymphoma
Hodgkin's lymphoma
Acute leukemia
Chronic leukemia
Myelodysplastic syndromes
Multiple myeloma
Langerhans' cell histiocytosis
Bronchogenic carcinoma
Bronchoalveolar carcinoma
Neuroendocrine tumor
(carcinoid tumor)
Mesothelioma
Leukoplakia
Polyps
Nasopharynx carcinoma
Pleomophic adenoma
Warthins tumor
Benign polyps
Squamous cell carcinoma
Adenocarcinoma
Carcinoid tumor
Lymphoma
Liver cell adenoma
Hepatocellular carcinoma

686
687
688
689
690
691
692
693
694
695
696
697
698
699
700
701
702
703
704
705
706
707
708
709
710
711
712
713
714
715
716
717
718
719
720
721
722
723
724
725
726
727
728
729
730
731
732
733
734
735
736
737
738

Cholangiocarcinoma
Carcinoma of the pancreas
Cortical adenoma
Renal cell carcinoma
Wilm's tumor
Squamous cell carcinoma
Seminoma
Teratoma testis
Benign prostatic hyperplasia
Carcinoma of the prostate
Condyloma accuminata
Cervical carcinoma
Extramammary Paget's
disease
Endometrial hyperplasia
Endometrial carcinoma
Ovarial teratoma (dermoid
cyst)
Ovarian carcinoma
Hydatidiform mole
Choriocarcinoma
Fibrocystic change
Fibroadenoma mammae
Phyllodes tumor
Breast carcinoma
Paget's disease of the breast
Gynecomastia
Somatotropic adenoma
Prolactinoma
Thyroid adenoma
Thyroid carcinoma
Thymoma
Benign epithelial tumors
Seborrheic keratosis
Epithelial cyst
Actinic keratosis
Bowen's disease
Squamous cell carcinoma
Basal cell carcinoma
Xanthoma
Hemangioma
Lymphangioma
Angiosarcoma
Mycosis fungoides
Mastocytosis
Langerhans' cell histiocytosis
Lentigo
Nevus pigmentosus
Malignant melanoma
Osteoma
Osteoid osteoma
Osteoblastoma
Osteosarcoma
Osteochondroma
Chondroblastoma

739
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
757
758
759
760
761
762
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783

784
785

Chondrosarcoma
Fibrous dysplasia
Fibrosarcoma and mfh
Ewing sarcoma
Giant cell tumor
Ganglion cyst
Lipoma
Liposarcoma
Fibromatosis
Desmoid tumor
Fibroma
Fribrosarcoma
Benign fibrous histiocytoma
Malignant fibrous
histiocytoma (mfh)
Rhabdomyosarcoma
Leiomyoma
Leiomyosarcoma
Synovial sarcoma
Astrocytoma
Oligodendroglioma
Ependymoma
Medulloblastoma
Retinoblastoma
Meningioma
Neurofibroma
Schwannoma
Mental deficiency
Autistic disorder
Disorder of intellectual skills
Disorder of motor
development
Disorder of coodination
Behavior and attention
disorders
Anorexia nervosa
Bulimia
Pica
Rumination in infancy
Gilles de la tourette
syndrome
Chronic motor of vocal tic
disorders
Transient tic disorders
Functional encoperasis
Functional enuresis
Uncoordinated speech
Stammer
Schizophrenia
Other psychoses
including reactive
psychosis and puerperal
psychosis
Bipolar disorder, manic
episode
Bipolar disorder, depressive

786
787
788
789
790
791
792
793
794
795
796
797
798
799
800
801
802
803
804
805
806
807
808
809

810
811
812
813
814
815
816
817
818
819
820
821
822
823
824
825

episode
Cyclothymic disorder
Endogenous depression,
single episode and recurrent
Dysthymic disorder (or
neurotic depression)
Depressive disorder not
otherwise classified
Panic disorder with
agoraphobia
Panic disorder without
agoraphobia
Agoraphobia without history
of panic disorder
Social phobia
Simple phobia
Obsessive compulsive
disorder (neurosis)
Post traumatic stress disorder
Diffuse anxiety disorder
Anxiety disorder not
otherwise classified
Disorder of body sensation
Conversion disorder
(hysterical neurosis)
Hypochondriasis
(hypochondriacal neurosis)
Somatisation disorder
Somatoform pain disorder
Undifferentiated somatoform
disorder
Somatoform disorder not
otherwise classified
Multiple personality
Fugu states
Psychogenic amnesia
Depersonalisation
disorder or
depersonalisation
neurosis
Dissociative disorder, noc
Paraphilia
Disorder of sexual desire
Disorder of sexual exitement
Disorder of orgasm
Sexual pain disorders
Sexual dysfuctions, noc
Sexual disorders, noc
Insomnia
Hypersomnia
Sleep-wake cycle
disturbances
Nightmares
Night terrors
Sleep walking
Paranoid personality
Schizoid personalinty

826
827
828
829
830
831
832
833
834
835
836

837
838
839
840
841
842

843
844
845
846
847
848
849
850
851
852
853
854
855
856
857
858
859
860
861
862
863
864
865

Schizotypal personality
Antisocial personality
Borderline personality
Histerionic personality
Narcisistic personality
Avoidance personality
Dependent personality
Obsessive-compulsive
personality
Passive-aggressive
personality
Personality disorders, noc
Extrapyramidal side effects
(eg. Acute dystonia, tradive
dyskenia, parkinsonism)
Anticholinergic side effects
Sedative side effects
Malignant neuroleptic
syndrome
Knowledge of forensic
psychiatry
Knowledge of indication
for involuntary admission
to hospital
Knowledge of basic
principles of methods
used by different
psychotherapeutic
schools (eg. Rogerrian,
psychoanalytic, etc)
Pseudoconstipation
Encopresis
Anorexia nervosa
Bulemia
Tics, neuropathic behavior
Hyperkinetic syndrome
Primary infantile autism
Disorders of mother-child
relationship
Disorders due to social
deprivation
Neurotic disorder of chilhood
Breath holding due to
exitement
Congenital dislocation of the
hips
Arthritis
Genu varum (bow legs)
Genu valgum (knock knee)
Pes planus
Scoliosis
Kyphosis
Lordosis
Terthes disease
Slipped epiphysis
Osgood-schlatter diseasev
Chondromalacia patellae

866
867
868
869
870
871
872
873
874
875
876
877
878
879
880
881
882
883
884
885
886
887
888
889
890
891
892
893
894
895
896
897
898
899
900
901
902
903
904
905
906
907
908
909
910
911
912
913

914
915

Club foot
Marfan's disease
Osteogenesis imperfecta
Bone cyst
Achondroplasia
Rickets, osteomalacia
Osteoporosis
Fibrous dysplasia
Paget's disease
Physical overload
Aseptic necrosis of bone
Osteomyelitis, acute
Arthritis
Trauma of joint cartilage
Trauma of joint capsule
Ganglion
Primary bone tumors
Bone metastasis
Pathological fracture
Arthrosis deformans
Crystal arthropathy
Rheumatoid arthritis
Bechterew disease
Spina bifida
Sacrococcygeal teratoma
Scoliosis
Kyphosis
Lordosis
Spondylarthrosis, spondylosis
Spondylitis, spondylodiscitis
Hernia of nucleus pulposus
Spondylolisthesis
Spondylolysis
Metastases from elsewhere
Pathological fractures
Fractures and dislocations of
spine
Spinal transaction
Congenital hip dislocation
Hip dysplasia
Femoral head necrosis
Intermittent arthritis of the
hip
Fractures of pelvis
Fractures of hip
Dislocation of hip
Ligamentous lesions of hip
Arthritis of hip
Fractures of femur
Fractures, capsule, tendon
and ligament lesions of
knee
Lesion of meniscus, medial
and lateral
Abnormal patellear cartilage

916
917
918
919
920
921
922
923
924
925
926
927
928
929
930
931
932
933
934
935
936
937
938
939
940
941
942
943
944
945
946
947
948
949
950
951
952
953
954
955
956
857
858
859
860
861
862
863
864

Genu varum, genu valgum


Osteochondritis dissecans
Arthritis of the knee
Achilles tendonitis
Rupture of achilles tendon
Tarsal tunnel syndrome
Instability of ankle
In growing toe nail
Pes planus
Club foot
Claw foot
Hallux valgus
Hammer toe
Metatarsalgia
Onychogryposis
Anisomelia
Caput succedaneum
Brachial plexus injury
Fracture (clavicle, humerus,
rib)
Drowning
Head injury
Burning
Poisoning
Suffocation
Bleeding
Hypovolemic shock
Dislocation of jaw
Fracture of jaw
Dislocation of knee
Dislocation of patella
Prepatellar bursitis
Fractures of tibia
Rib fractures/contusion
Injury caused by rib fractures
Sternal fractures
Fractures of toes
Crush injury to the heel (in
children)
Fractures of fibula
Whiplash
Fractures, capsule, tendon
and ligament lesions of
ankle
Pneumothorax
Hemothorax
Injury to specific
internal organs, such as
liver, kidney, lung, etc
Injury of peripheral nerves
Fractures of shoulder
Dislocation of shoulder
Ligamentous lesions of
shoulder
Instability of shoulder
Frozen shoulder

865
866
867

868
869

870
871
872
873
874
875
876
877
878
879
880
881
882
883
884
885
886
887
888
889
890
891
892
893
894
895
896
897
898
899
900
901
902
903
904
905

Fracture of clavicle
Fracture of humerus
Fracture of radius/ulna
Fractures, capsule,
tendon, ligament
lesions of elbow
Fractures, capsule, tendon,
ligament lesions of wrist
Fractures, capsule,
tendon, ligament
lesions of fingers and
thumb
Lateral epicondylitis (tennis
elbow)
Dislocation of distal radius
Dislocation of wrist
Progressive inflammation of
finger following injury
Olecranon bursitis
Carpal tunnel syndrome
Injury to finger tendon, e.g.
Boutonniere-deformity
Mallet finger
Dupuytren's contracture
Nail loss
Subungual hematome
Traumatic vessel injury
Head injuries
Diffuse brain damage
Cerebral concussion and
contusion
Brain death
Extradural hemorrhage
Subdural hemorrhage
Basilar fracture scalp
Acute traumatic spinal
transaction
Injury of plexus and
peripheral nerves
Syphillis
Rubella
CMV infection
Toxoplasmosis
AIDS
Gonorrhoea
Herpes virus infection type 2
Hepatitis B
Mother taking tobacco
Mother taking drugs of
addiction
Mother taking tobacco
Mother taking drugs of
addiction
Vasa previa
Abruptio placenta - SOL
Cervical incompetence

906
907
908
909
910
911
912
913
914
915
916
917
918
919
920
921
922
923
924
925
926
927
928
929
930
931
932
933
934
935
936
937
938
939
940

941
942
943
944
945
946
947
948

Polyhydramnion
Jaundice late in pregnancy
Urinary tract infection
Pyelitis in pregnancy
Iron dificiency anaemia
Megaloblastic anaemia
Dead fetus
Premature contractions
Premature delivery
Rupture of uterus
Postmature infant
Premature rupture of
membranes
Unstable lie / malposition
after 36 weeks
Dystocia, fetal and passage
Malpresentation of fetus
Prolonged delivery
Primary mild contractions
IMININ
Secondary mild contractions
Cord presentation / cord
prolapse
Hypoxia of fetus
Failure to rotate / incorrect
rotation
Rupture of cervix
Rupture of perineum
Shoulder distortion, infant
Retained placenta
Retained placental tissue
Uterine inversion
Postpartum haemorrhage
Thrombo embolism
Blood group incompatibility
Mastitis
Cracked nipple
Inverted nipple
Endometritis
Inflammation of pelvis
(salpingitis,
pelviperitonitis,
perimetritis etc)
Incontinence of urine
Incontinence of faeces
Deep venous thrombosis
Thrombophlebitis
Embolism
Post-natal psychoses
Post-natal depression
Subinvolution of uterus

KETERANGAN KEMAMPUAN KLINIK DOKTER UMUM :


Tingkat Kemampuan 1
: Mengenali gambaran-gambaran klinik sesuai penyakit
Tingkat Kemampuan 2
: Mampu membuat diagnosis klinik
Tingkat Kemampuan 3
: Mampu mendiagnosis klinik, memberi terapi, pendahuluan

Tingkat Kemampuan 4

No
1
2
3
4

: Mampu mendiagnosis klinik, memutuskan dan mampu menangani


problem itu secara mandiri hingga tuntas

Kewenangan Klinik
Tindakan Resusitasi Jantung
Paru
Penanganan sesak napas
ringan sampai berat (tanpa
ventilator)
Penanganan awal
kegawatdaruratan pada
jantung
Penanganan Pasien dengan
Syok

Permohonan
Kemampuan Klinik
1

Disetujui Kemampuan
Klinik
1

5
6
7
8
9
10
11
12

Menjahit luka ringan sampai


sedang
Pemasangan tampon hidung
bagian anterior
Partus normal dengan posisi
kepala sudah di pintu vagina
Penanganan awal luka bakar
Penanganan kejang
Penanganan keracunan dan
gigitan binatang
Penanganan awal trauma
kepala
Penanganan awal fraktur
terbuka dan fraktur tertutup

KETERANGAN KETERAMPILAN KLINIK DOKTER UMUM :


Tingkat Keterampilan 1

: Memiliki pengetahuan teoritis

Tingkat Keterampilan 2

: Pernah melihat, atau didemonstrasikan keterampilan ini

Tingkat Keterampilan 3

: Menerapkan dibawah supervisi

Tingkat Keterampilan 4

: Mampu menangani problem itu secara mandiri hingga tuntas

CATATAN:
a. Mengkonsultasikan semua kebutuhan pasien rawat inap kepada DPJP
b. Apabila dokter DPJP tidak bisa dihubungi, dokter jaga boleh memberikan terapi sesuai
dengan keluhannya.
c. Dokter jaga IGD dan Dokter jaga rawat inap merujuk pasien ke RS lain dengan fasilitas
yang lebih lengkap setelah dikonsultasikan ke dokter spesialis yang berkaitan
d. Diluar kewenangan klinis diatas dokter umum wajib mengkonsultasikan ke dokter
spesialis sesuai dengan kewenangan klinis dokter spesialis tersebut.
e. Sudah mengikuti pelatihan ATLS/ ACLS/ PPGD
Majalengka,
...
Pemohon

Ketua Komite Kredensial

..

Anggota :

1. ..
2. ..

Nomor

: / Kred / KM-RSMJL / . / 20..

Perihal

: Kewenangan Klinik Dokter Umum

Lampiran : 1 Berkas
Kepada Yth,
Ketua Komite Medik RSUD Majalengka
Di Tempat
Dengan Hormat,
Menganai permohonan dr. Dewi Nurmalasari, sebagai dokter umum yang melamar untuk
menjadi staff medis di RSUD Majalengka, setelah kami mengevaluasi kompetensi, perilaku etis
dan kelengkapan berkas-berkas permohonan yang bersangkutan, maka dengan ini kami
merekomendasikan untuk memberikan / tidak memberikan / belum memberikan* kewenangan
klinik sebagai dokter umum, purna waktu / paruh waktu* dengan alasan:
..
..
..
Untuk itu dapat diproses penugasan klinik sesuai dengan ketentuan/ prosedur yang berlaku.
Adapun wewenang klinis yang dapat diberikan terlampir.
Majalengka,..
Ketua Komite Kredensial

Anggota:
1. ..
2. ..

Keterangan:
* Coret yang dianggap tidak perlu

Nomor

: ../ KM-RSMJL/ ./ 20

Perihal

: Kewenangan Klinik Dokter Umum

Lampiran

: 1 (satu) berkas

Kepada Yth,
Direktur RSUD Majalengka
Di tempat
Dengan Hormat,
Setelah

Komite

Rekredensial,

melakukan

kredensialing,

maka

dengan

ini

kami

merekomendasiklan nama dokter umum dr. Dewi Nurmalasari dapat diberikan kewenangan
klinik (terlampir) sebagai staff medis di Rumah Sakit Umum Daerah Majalengka.
Untuk itu diusulkan kepada Direktur Rumah Sakit Umum Majalengka untuk dapat memproses
penugasan klinik.
Demikian surat ini kami sampaikan, atas perhatiannya diucapkan terimakasih.

Majalengka,
Hormat Kami,

Ketua Komite Medik

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