Anda di halaman 1dari 7

RUMAH SAKIT IBU DAN ANAK

Bunda arif
Jl. Jatiwinangun No. 16 Purwokerto Telp. (0281) 636555
SURAT PENUGASAN KERJA KLINIS
NOMOR : ........../RSIABa/...../...../20.....

Yang bertandatangan di bawah ini :


Nama

: dr. Bugar Wijiseno

Jabatan

: Direktur RSIA Bunda arif

Dengan ini memberi Kewenangan Klinis sebagaimana tercantum dalam lampiran Rincian
Kewenangan Klinis Keperawatan kepada :
Nama

: dr. Tri Wibowo S, Sp.A

NIK

Kualifikasi

: Dokter Spesialis Anak

Kepada yang bersangkutan berhak dan dapat memberikan asuhan keperawatan kepada pasien
sesuai Rincian Kewenangan Klinis Keperawatan.
Berlaku mulai ..................... sampai dengan .....................
Demikian Surat Penugasan Kerja Klinis ini untuk dilaksanakan.

Dikeluarkan di : .
Pada Tanggal :
Direktur
Rumah Sakit Ibu dan Anak Bunda arif

(dr. Bugar Wijiseno)

RUMAH SAKIT IBU DAN ANAK


Bunda arif
Jl. Jatiwinangun No. 16 Purwokerto Telp. (0281) 636555
Lampiran SPKK
RINCIAN KEWENANGAN KLINIS
(CLINICAL PRIVILEGE)
Identitas
Nama Petugas

: dr. Tri Wibowo S, Sp.A

Unit Kerja

: UGD, Poliklinik, Instalasi Rawat Inap

Pendidikan Formal

: Pendidikan Dokter Spesalis Anak

Kualifikasi

: Dokter Spesialis Anak

Daftar Kometensi petugas


No.

Diagnosa

Congenital Disorders

1
2
3
4
5

Esophagial atresia
Intestinal atresia
Anal atresia
Diapragmatic hernia (congenital )
Pyloric stenosis

Gastro-Hepatology

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

Gastro-enteritis
Gastro-enteritis dengan dehidrasi
Worms
Dehydration
Malabsorbsion
Food intolerance
Acute abdomen
Ileus
Peritonitis tuberculosis
Peritonitis pancreatitis
Intussussception
Malrotation
Umbilical hernia
Meckells diverticulum
Crohns disease
Ulcerative colitis
Hirschsprungs disease
Biliary atresia
Hepatitis
Reyes syndrome
Cirrhosis of the liver
Food allergy

Endrocrinological Disorders
IDDM
28
Disorders of Newborns

29
30
31

Hypothermia
Bacteraemia and septicemia
Respiratory stress syndrome

Diminta (penilaian dari

Rekomendasi dari

petugas sendiri)

Supervisor

No.

Diagnosa

32
33
34
35
36

Bronchopulmonary dysplasia
Aspiration pneumonia
Pneumo thorak
Apnea attacks
Jaundice of newborn
Severe neonatal jaundice (kern

37
38
39
40
41
42
43
44
45
46
47
48
49
50

icterus)
Hypoglycemia
Child of diabetic mother
Neonatal convulsion
Necrotizing enterocolitis
Retinopathy of prematurity
Anemia
Rhesus incompatibility
Blood group incompatibility
Vitamine k defficieny
Cerebral hemorrhage
Conjuctivitis
Infection of umbilicus
Sudden infant death syndrome

(sids)
Nutritional Deficiency

51
52
53

Marasmus
Kwashiorkor
Vitamin deficiencies
Cardiac Disorders

54
55

VSD
ASD
Pulmonology
Uncomplicated Pulmonary

56

Tuberculosis
TBC with HIV
TBC with pneumothorak
Acute Bronchitis
Bronchiolitis
Bronchial asthma
Status asmaticus
Lung emphysema
Atelectasis
Bronchiectasis
COPD
SARS
Pneumonia
Avian influenzae
Lung abscess
Pulmonary embolism
Lung infaction
Pleurisy TBC
Pleurisy Cancer
Pleurisy Lupus
Pneumothorax
Cystic fibrosis
Aspiration pneumonia
Epilepsy and other Seizures

57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78

Diminta (penilaian dari

Rekomendasi dari

petugas sendiri)

Supervisor

No.
79
80
81
82
83.

Diagnosa
Focal epilepsy
Generalizet epilepsy
Absence seizure
Status epilepticus
Narcolepsy

84. Sleep apnea syndrome


Acute Abdomen

85. Peritonitis
86. Abscess in pouch of Douglas
87. Illeus
88. Perforation
89. Salphingitis
90. Acute appendicitis
91. Appendicitis abscess
92. Mesenteric liymphadenitis
Stomach and Duodenum

93. Gastritis
94. Gastric/duodenal ulcer
95. Gastrointestinal bleeding
96. Zollinger-ellison syndrome
97. Mollory weiss syndrome
98. Gastroenteritis
99. Hepatitis A
100. Uncomplicated Hepatitis B
101. Active Hepatitis C
102. Colitis
103. Necrotizing enterocolitis
Nefrourologi

104.Acute renal failure


105.Chronic renal failure

Diminta (penilaian dari

Rekomendasi dari

petugas sendiri)

Supervisor

No.

Diagnosa

106.Nephrotic syndrome
107.Acute glomerulonephritis
108.Chronic glomerulonephritis
109.Interstitial nephritis
110.Renal colic
Urinary stone diseases ot
111.
urinary calculi without colic
Polycystic kidnays
112.
sympotomatic
113.Urinary tract infection
114.Acute tubular necrosis
115.Horse shoe kidney
Uncomplicated
116.
Pyelonephritis
117.Urinary incontinence
118.Nocturnal and diumal enuresis
Pediatric Neurologic Disorders

119.Meningitis
120.Encephalitis
121.Cerebral abscess
122.Epilepsi
123.Infantile spasms
124.Petit mal epilepsy
125.Febrile convulsion
126.Duchene muscular dystrophy
127.Poliomyelitis
128.Cerebral Palsy
129.Kernicterus
130.Mental Retardation
131.Autism
132.ADHD
Hematology

133.Aplastic/hypoplastic anemia
134.Iron deficiency anemia
135.Macrocytic anemia
136.Hemoglobinopathy
Anemia associated with chronic

137.

diseases

138.Polycytemia
139.Thrombocytopenia
140.Thrombocytosis
141.Hemophilia
142.Von willebrands disease
143.DIC
144.Agranulocytosis
145.Haemorheologic disorders
146.Antiphospholipid syndrome
Infectious Diseases

147.Meningitis
148.Encephalitis
149.Malaria cerebral
150.Tetanus
151.Cerebral Toxoplasmosis
152.Tuberculuma

Diminta (penilaian dari

Rekomendasi dari

petugas sendiri)

Supervisor

No.

Diagnosa

153.Brain abscess
154.HIV AIDS
Congenital Disorders

155.Hydrocephalus
156.Spina bifida
157.Phenyl ketonuria
Noses and Sinuses

158.Epistaxis
159.Furuncle of nose
160.Acute rhinitis (common cold)
161.Vasomotor rhinitis
162.Allergic rhinitis
163.Chronic rhinitis
164.Rhinitis medicamentosa
165.Acute frontal sinusitis
166.Acute maximallary sinusitis
167.Acute ethmoiditis
168.Chronic sinusitis
169.Deviation of nasal septum
170.Choanal atresia
171.Foreign body in nose
Larynx and Pharynx

172.Pharyangitis
173.Tonsilitis
174.Hypertrophy of adenoids
175.Pseudo-croop acute epiglotitis
Immunological/allergic Reaction
Autoimmune
rheumatological

176.and

autoimmune

orthopedic

disorder
177.Uncomplicated SLE
178.Complicated SLE
179.Scleroderma
180.Polyarteritis nodosa
181.Vasculitis lupus
182.Polymyalgia rheumatica
183.Rheumatoid arthritis
184.Anaphylactic reaction
185.Rheumatic fever
186.Juvenile chronic arthritis
187.Henoch-schoenlein purpura
188.Erythema multiforme
189.Atopy

Diminta (penilaian dari

Rekomendasi dari

petugas sendiri)

Supervisor

Demikianlah kewenangan klinis ini ditetapkan dengan berorientasi pada pedoman


kompetensi ............................. RSIA Bunda arif dan mempertimbangkan situasi serta kondisi
RSIA Bunda arif. Kewenangan klinis ............................. ini secara berkala akan dievaluasi dan
disempurnakan sesuai dengan perkembangan Ilmu Pengetahuan dan Teknologi Keperawatan
yang ada.
Disetujui : Tgl ..... Bln ...... Thn .....

Ditetapkan : di Purwokerto

Ka. .................................

Ka. Sub .................................

( ........................................ )

( ........................................ )
Mengetahui
Direktur RSIA Bunda arif

(dr. Bugar Wijiseno)