DAFTAR TINDAKAN TINDAKAN

YANG PERLU INFORMED CONSENT

Sesuai Undang Undang no 44 tahun 2009 tentang rumah sakit, terdapat beberapa tindakan
kedokteran dan kedokteran gigi yang wajib diberikan informed consent.
Tindakan tersebut yaitu :
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 Berisiko Tinggi.

A. Tindakan Pembedahan dan Tindakan Invasive yang memerlukan informed consent

antara lain:

NO KSM/ INSTALASI/ TINDAKAN

UNIT
1. KSM Bedah Saraf 1.Elevasi Kraniotomi Fraktur Impresi, tanpa robekan
2. KSM Bedah Kepala 1.Aff Arch Barr
Leher
2.Biopsy Insisional dengan anastesi lokal
3.Deseksi submandibula
4.Diseksi leher radikal/ radikal neck dissection
5.Eksisi gld submandibula
6.Eksisi higroma leher
7.Eksisi kista tiroglosus
8.Eksisi luas tumor ganas bibir dengan rekontruksi flap
lokal
9.Eksisi luas tumor ganas kulit dengan rekonstruksi Flap
lokal
10.Eksisi luas tumor ganas rongga mulut dengan
rekontruksi flap lokal
11. Eksisi parsial+marsupialisasi Ranula
5. Eksisi tumor ganas kulit dengan flap local atau graft
13. Eksisi tumor ganas kulit tanpa rekontruksi
14. Eksisi tumor jinak dengan anastesi lokal
15. Ekskokleasi epulsi
16. Ekskokleasi kista folikuler
17. Ekskokleasi kista Radikuler
18. Ekstirpasi kista dermoid
19. Fiksasi interna fraktur maksilofasial 1-2 tempat patahan
3. KSM Bedah 1. Mandibulektomi
2. Tracheostomi
4. KSM Orthopedi Dan 1. Achillotenotomy
Traumatologi
2. Adductor tenotomy of hip
3. Advancement of tendon
4. Advancement above knee
5. Amputation and disarticulation of finger-general
anaesthesia
6. Amputation and disarticulation of finger-local
anaesthesia
7. Amputation and disarticulation of thumb-general
anaesthesia
8. Amputation and disarticulation of thumb-local
anaesthesia
9. Amputation of ankel through malleoli of tibia and fibula
10. Amputation of toe-general anaesthesia
11. Amputattion of toe-local anaesthesia
12. Amputation through foot
13. Amputation through forearm
14. Amputation through hand, Amputation through carpals
15. Amputation through humerus, Upper arm amputation
16. Amputation, not otherwise specified
17. Ankle fusion
18. Application of external fixator device
19. Aspiration of bursa
20. Aspiration of bursa of hand
21. Aspiration of other soft tissue
22. Aspiration of other soft tissue of hand
23. Biopsy of bone
24. Biopsy of joint structure
25. Bone graft
26. Bursectomy
27. Bursectomy of hand
28. Bursectomy
29. Bursotomy of hand
30. Closed reduction of dislocation-General anaesthesia
31. Closed reduction of dislocation of ankle
32. Closed reduction of dislocation of elbow
33. Closed reduction of dislocation of foot and toe-general
anaesthesia
34. Closed reduction of dislocation of foot and toe-local
anaesthesia
35. Closed reduction of dislocation of hand and figer-
general anaesthesia
36. Closed reduction of dislocation of hand and finger-local
anaesthesia
37. Closed reduction of dislocation of hip
38. Closed reduction of dislocation of knee
39. Closed reduction of dislocation of other specified sites-
general anaesthesia
40. Closed reduction of dislocation of other specified sites-
local anaesthesia
41. Closed reduction of dislocation of shoulder
42. Closed reduction of dislocation of wrist
43. Closed reduction of dislocation-local anaesthesia
44. Closed reduction of fracture with internal fixation-
Carpal and metacarpal
45. Closed reduction of fracture with internal fixation-
Femur (Including: MIPO, interlocking nail, TEN)
46. Closed reduction of fracture with internal humerus
(Including: Interlocking nail, TEN, MIPO)
47. Closed reduction of fracture with internal fixation-
Intrarticular Major Bone
48. Closed reduction of fracture with internal fixation-
Phalang of foot
49. Closed reduction of fracture with internal fixation-
Phalang of hand
50. Closed reduction of fracture with internal fixation-
Radius and ulna (MIPO, TEN)
51. Closed reduction of fracture with internal fixation-
Tarsal and metatarsal
52. Excision of bone for graft
53. Excision of intervertebral disc
54. Excision of lesion of muscle
55. Excision of lesion of muscle of hand
56. Excision of lesion of other soft tissue
57. Excision of bone for graft
58. Excision f intervertebral disc
59. Excision of lesion of muscle
60. Excision of lesion of muscel of hand
61. Excision of lesion of ather soft tissue
62. Excision of lesion of tendon sheath
63. Excision of muscle or fascia for graft
64. Excision of muscle or fascia of hand for graft
65. Excision of smilunar cartilage of knee
66. Excision of tendon for graft
67. Excision of tendon of hand for graft
68. Excision or correction of bunionette, That with
 osteotomy
69. Excision or destruction of intervertebral disc,
unspecified
70. Exploration of tendon sheath
71. Exploration of tendon sheath of hand
72. Fasciotomy
73. Fasciotomy of hand
74. Finger reattachment
75. Five-in-one repair of knee
76. Forearm, wrist, or hand reattachment
77. Graft of muscle or fascia
78. Incision and drainage of palmar or thenar space
79. Injection of anesthetic into peripheral nerve fo
analgesia
80. Insertion of catheter into spinal canal for infusion of
therapeutic or palliative substances, Insertion of
catheter into epidural, subarachnoid, or subdural space
of spine with intermittent or continuous infusion of
drug (with creation of any reservoir)
81. Open biopsy of soft tissue
82. Open reduction of dislocation of ankle-Neglected
dislocation
83. Open reduction of dislocation of elbow-Fresh
dislocation
84. Open reduction of dislocation of hand and finger-Fresh
dislocation
85. Open reduction of dislocation of hip-Fresh dislocation
86. Open reduction of dislocation of hip-Neglected
dislocation
87. Open reduction of dislocation of knee-Neglected
dislocation
88. Open reduction of dislocation of knee - Fresh
dislocation
89. Open reduction of dislocation of other specified sites
90. Open reduction of dislocation of shoulder-Fresh
dislocation
91. Open reduction of dislocation of shoulder-Neglected
dislocation
92. Open reduction of dislocation of unspecified site-Fresh
dislocation
93. Open reduction of dislocation of unspecified site-
Neglected dislocation
94. Open reduction of dislocation of wrist-Fresh
dislocation
95. Open reduction of fracture with internal fixation-radius
 and ulna-Simple fracture
96. Open reduction of fracture with internal fixation-
unspecified site (Periarticular Major Bone )
97. Open reduction of fracture with internal fixation-
carpals and metacarpals-plate& screws Hand NOS-
Plate& Screw
98. Open reduction of fracture with internal fixation-
carpals and metacarpals-plate & screws Hand NO-
Plate& Screw
99. Open reduction of fracture with internal fixation-
carpals and metacarpals-simple implants (K-wire) Hand
NOS-implant sederhana (K-wire)
100. Open reduction of fracture with internal fixation-femur-
Comminutive or Segmental
101. Open reduction of fracture with internal fixation-femur-
Simple fracture
102. Open reduction of fracture with internal
fixationhumerus
Simple fracture
103. Open reduction of fracture with internal fixation
humerus Comminutive or Segmental
104. Open reduction of fracture with internal fixationother
specified bone (Intra artikular Major Bone )
105. Open reduction of fracture with internal
fixationphalanges of foot-simple implants (K-wire)
106. Open reduction of fracture with internal
fixationphalanges of foot-Plate& Screws
107. Open reduction of fracture with internal
fixationphalanges of hand- Plate& Screws
108. Open reduction of fracture with internal
fixationphalanges of hand- simple implants
109. Open reduction of fracture with internal fixationtarsals
and metatarsals- Plate& Screws
110. Open reduction of fracture with internal fixationtarsals
and metatarsals- simple implants
111. Open reduction of fracture with internal fixation-tibia
and fibula -Simple fracture
112. Open reduction of fracture with internal fixation-tibia
and fibula-Comminutive or Segmental
113. Open reduction of fracture without internal fixation
114. Other amputation below knee
115. Other change in hand muscle or tendon length
116. Other change in muscle or tendon length
117. Other excision of joint
118. Other excision of soft tissue
119. Other excision of soft tissue of hand
120. Other excision or avulsion of cranial and peripheral
nerves
121. Other incision of bone without division
122. Other incision of soft tissue
123. Other incision of soft tissue of hand
124. Other local excision or destruction of lesion of joint
125. Other plastic operations on hand
126. Other plastic operations on muscle
127. Other suture of tendon
128. Release of tarsal tunnel
129. Removal of (cement) spacer
130. Removal of implanted devices from bone-carpals and
metacarpals-Plate & screw
131. Removal of implanted devices from bone-carpals and
metacarpals-simple implants (K-wire)
132. Removal of implanted devices from bone-External
fixator device (invasive)
133. Removal of implanted devices from bone-femur
134. Removal of implanted devices from bone-humerus
135. Removal of implanted devices from bone-radius and
ulna
136. Removal of implanted devices from bone-scapula,
clavicle, and thorax (ribs and sternum)
137. Removal of implanted devices from bone-unspecified
site (Phalanges (of foot) (of hand))-Plate& Screw
138. Removal of implanted devices from bone-unspecified
site (Phalanges (of foot) (of hand) -simple implants (K-
wire)
139. Removal of implanted devices from bone -patella
140. Removal of implanted devices from bone- tarsals and
metatarsals-simple implants (K-wire)
141. Removal of implanted devices from bone-tibia and
fibula
142. Removal of implanted devices from bone-tarsals and
metatarsals-Plate & Screw
143. Removal of internal limb lengthening device
144. Removal of pedicle screw(s) used in spinal fusion
145. Repair of claw toe
146. Repair of cleft hand
147. Repair of hammer toe
148. Repair of hip, not elsewhere classified
149. Repair of macrodactyly
150. Repair of mallet finger
151. Suture of capsule or ligament of other lower extremity
152. Suture of capsule or ligament of upper extremity
153. Suture of cranial and peripheral nerves
 154. Suture of muscle or fascia of hand
155. Suture of tendon sheath
156. Suture of tendon sheath of hand
157. Suture of Vein
5. KSM bedah Thoraks
dan Kardiovaskular
1. Torakotomi / sternotomi Eksplorasi
2. Torakotomi Eksplorasi pada Trauma jantung/Repair
Laserasi Jantung
6. Eksisi biopsi tumor 1. Eksisi Tumor Pembuluh Darah Perifer (Hemangioma)
pembuluh darah
2. Eksplorasi Vaskular (Trauma/Non trauma)
7. KSM bedah digistive 1. Abdominoperineal resection (miles) tanpa penyulit
2. Apendektomi
3. Apendektomi dgn penyulit major
4. Apendektomi dgn penyulit minor
5. Bilio-difgestif anastomosis tanpa penyulit
6. Biopsi insisional, local anastesi
7. Biopsi rectum
8. Eksisi hemoroid eksterna
9. Eksplorasi duktus bilier & cholangiografi intra operatif
10. Fistulotomi
11. Fistulotomi dgn penyulit mayor
12. Fistulotomi dgn penyulit minor
13. Gastrostomi
14. Hemikolektomi dengan penyulit mayor
15. Hemikolektomi dengan penyulit minor
16. Hemikolektomi tanpa penyulit
17. Hemoroid stapling (diluar alat)
18. Hemoroidektomi
19. Herniotomi
20. Herniotomi dgn penyulit mayor
21. Herniotomi dgn penyulit minor
22. Jejunostomi / ileostomi
23. Laparotomi dengan penyulit minor
24. Laparotomi tanpa penyulit
25. Ligasi hemoroid (diluar alat)
26. Polipektomi
27. Potong kolostomi
28. Rektopexy
29. Repair fistel usus
30. Repair fistel vesicorectal
31. Repair hernia cicatricalis
32. Repair hernia cicatricalis dgn penyulit mayor (diluar
alat)
 33. Repair hernia cicatricalis dgn penyulit minor (diluar
alat)
34. Repair Hernia Diafragmatika (diluar alat)
35. Reseksi anterior dengan penyulit mayor
36. Reseksi anterior dengan penyulit minor
37. Reseksi anterior tanpa penyulit
38. Splenektomi / splenoraphy traumatika
39. Tutup burst abdomen (tanpa alat)
40. Tutup burst abdomen dengan penyulit mayor
41. Tutup burst abdomen dengan penyulit minor
42. Tutup kolostomi / ileostomi
43. Tutup kolostomi / ileostomi dengan penyulit mayor
44. Tutup kolostomi / ileostomi dengan penyulit minor
8. KSM bedah urologi 1. Biopsi Penis
2. Biopsi Prostat
3. Biopsi Testis
4. Bladder Neck Rekonstruksi
5. Businasi/Dilatasi Uretra
6. Diseksi Kelenjar Getah Bening Inguinal
7. Divertikulektomi Buli
8. Divertikulum Uretra
9. Dorsumsisi
10. Ekstraksi Batu
11. Evakuasi Bekuan Darah (Clot)
12. Fistulektomi/Repair Fistel Uretra
13. Hidrokel per Inguinal/Ligasi Tinggi
14. Hidrokel per Skrotal
15. Insisi Abses Perineum
16. Insisi Abses Skrotum
17. Masase Prostat
18. Meatoplasti
19. Meatotomi
20. Operasi Repair Buli Trauma
21. Operasi Sistokel
22. Herniotomi elektif tanpa penyulit
23. Hernitomi dgn penyulit / komplikasi
24. Hidrokolektomi
25. Jejenostomi / ileostomi dengan penyulit mayor
26. Jejenostomi / ileostomi dengan penyulit minor
27. Jejenostomi / ileostomi tanpa penyulit
28. Kolesistektomi
29. Kolostomi / sigmoidostomi
30. Ligasi hemoroid
31. Operasi kelainan umbilikal lain
32. Orchidopexy
33. Other Repair of Abdominal Wall (Repair Omphacele)
34. Polipektomi
35. Potong kolostomi
36. Potong Stump
37. Repair defek diafragma
38. Repair hernia diafragma
39. Repair of Gastrochisis
40. Sirkumsisi dengan general anesthesia
41. Sirkumsisi dengan local anesthesia
42. Tutup burst abdomen dengan penyulit
43. Tutup burst abdomen tanpa penyulit
44. Tutup ileostomi dengan penyulit
45. Tutup kolostomi / ileostomi
46. Tutup Stoma
47. Vena Sectie Aksilaris
48. Vena sectie Femoralis / saphena magna
49. Wound repair
50. Aff archbar, Lokal Anastesi
51. Amputasi above elbow
52. Amputasi bellow elbow
53. Amputasi digital
54. Amputasi jari >1
55. Amputasi jari single
56. Closed Reduction Fr. Nasal
57. Eks mamma aberan bilateral
58. Eksisi neoplasma jinak (lipoma, atheroma dll)
59. Ekstraksi ateroma / keloid
60. Ekstraksi korpus alienum
61. Elevasi ear rim cartilago
62. Excise hemangioma + rekonstruksi
63. Excise intra keloid
64. Excise polydactyly
65. Excise reduksi lymedema
66. Fasciotomy burn injury
67. Fasciotomy with complication
68. Flap lokal sederhana
69. Fraktur Prosesus alveolaris dengan inter dental wiring
(IDW) (per rahang)
70. Fraktur Prosesus alveolaris luas dengan IDW ( per
rahang)
71. Fraktur rahang reduksi terbuka & inter oseus wiring
(IOW)
72. Mamma aberan unilateral
73. Multiple facial fraktur + implant
74. Orif fraktur hand
75. Orif fraktur mandibula
76. Orif fraktur maxilla
 77. Orif maksila plating
78. Orif mandibula plating
79. Orif mandibula wiring
80. Orif zygoma wiring
81. Pasang archbar
82. Pasang back slab/ fore slab
83. Pasang cast/ gips tanpa reposisi
84. Rekonstruksi facial cleft
85. Rekonstruksi nasal
86. Released syndactyly kompleks
87. Reposisi fraktur nasal sederhana
88. Reseksi mandibula + bone graft
89. Skin flap
90. Skin graft >5 cm
91. Skin graft sedang 5 cm
92. Skin grafting kecil
93. Skin grafting luas
94. Skin grafting sedang
95. Skin grafting with complication
96. Wound Dressing
97. Wound Repair
9. KSM Mata 1. Angkat Jahitan
2. Angkat Jahitan dengan GA
3. Anterior Chamber Tap/Parasintesis
4. Aspirasi Massa Lensa
5. Blefaroplasty (2 Kelopak Mata)
6. Claw Lens
7. Disisi Aspirasi & IOL
8. ECCE
9. ECCE & IOL
10. Eksisi Hordeolum / Chalazion
11. Ekstirpasi Corpus Alienum di Kornea
12. Ekstirpasi Pterygium + Graft Konjungtiva
13. Ekstripasi Corpus Alienum di Bilik Mata Depan
14. Enukleasi/Eviscerasi (DFG/Bonegraft)
15. Evakuasi Silikon Oil
16. Fornix Repair
17. ICCE
18. ICCE & IOL
19. Injeksi Intra Vitreal
20. Injeksi Periokuler Terapetik
21. IOL Explant
22. Iridectomi
23. Jahit Kelopak Mata Full Thickness & Lid Margin
24. Jahit Kornea
25. Konjungtival Flap/Amnion Graft
 26. Piggy Back IOL
27. Reposisi IOL
28. Reposisi Iris
29. Sekunder Implant (Posterior Chamber)
30. Sekunder Implant Claw Lens / Fiksasi Sulcus
31. Trabekulektomi
32. Wide Eksisi Tumor Kelopak Mata
10. KSM Obgyn 1. Cauter serviks
2. Cordosentesis
3. Eksplorasi vagina
4. Embryotomi
5. Extirpasi + kuret polip endoserviks
6. Extirpasi geboren mioma
7. Extirpasi geboren mioma+kuiretasi
8. Histeroctomy pada mola / chorio Ca
9. Histeroctomy radikal
10. Kistektomi
11. Kuret abortus incompletes
12. Lap op: myomektomi
13. Laparotomi dengan penyulit minor
14. Laparotomi tanpa penyulit
15. Micro kuretase DUB
16. Mikrokuret
17. Miomectomy
18. Painless labor
19. Persalinan normal
20. Persalinan normal dengan penyulit
21. Persalinan pervaginam tindakan operatif
22. Persalinan sungsang
23. Salfingektomi unilateral
24. Salvingoovarectomi unilateral
25. Seksio sesaria
26. Seksio sesaria dengan penyulit penyulit
27. Sirklase serviks
28. TAH+BSO dengan Penyulit
29. TAH+BSO dengan Penyulit Pemasangan Tampon
Abdomen
30. Total abdominal hysterectomy+bilateral salfingektomi
31. Tubektomi klinik
32. Tutup burst abdomen
33. Inseminasi

11. KSM penyakit dalam

Bidang Alergi 1. Spirometri
Imunologi Klinik
 Bidang Geriatric 1. Pemasangan sonde lambung
2. Pemasangan chateter
3. Keterampilan perawatan ulkus dekubitus
Bidang Ginjal 1. USG Ginjal
Hipertensi
2. Pemasangan Chateter urine
Bidang Kardiologi 1. Elektrocardiografi (EKG)
2. Treadmill
3. Cardio Pulmonari Recucitation (CPR)
4. Pemasangan ETT
Bidang Pulmonologi 1. Fungsi Pleura Terapeutik dan Water Seald Drainage
(WSD)
2. Suction Faring dan ETT
3. Terapi Oksigen
4. Terapi Inhalasi
5. Fisioterapi Dada
6. Spirometri
7. USG Paru
Bidang Rheumatologi 1. Aspirasi Cairan sendi lutut dan menganalisanya
1. Injeksi kortikosteroid struktur periartikular
2. Suntikan Intra artikular
Bidang Tropic 1. Vaksinasi
12. Semua injeksi dengan obat risiko tinggi

B. Tindakan Anestesi &Sedasi ( Sedang dan Dalam), tindakan yang

memerlukan informed consent tersebut antara lain:

a. Semua tindakan anestesi dan sedasi di dalam kamar operasi

b. Semua tindakan anestesi dan sedasi di ICU
Tindakan Anestesi di ICU

1. Pemasangan intubasi ventilator

2. Pemasangan vena central
3. Pemasangan Drain Intra Thorakal/Punksi Thorax

C. Tindakan Pemberian Produk Darah dan Komponen Darah,tindakan yang

memerlukan informed consent tersebut antara lain:
Transfusi darah
Produk darah :
a. Darah penuh (Whole Blood)
 b. Packed Red Cell (PRC)
c. Trombocyte Concentrate (TC)
d. Fresh Frozen Plasma (FFP)
e. Cryoprecipitate
f. Darah merah cuci (Washed Red Cell)
g. Albumin
D. Semua Tindakan/ Pengobatan Yang Berisiko Tinggi.

No KSM/INSTALASI/UNIT TINDAKAN
1. KSM Anak 1.Tindakan kemoterapi
1. Pemasangan ventilator
2. Intubasi endotrakea
3. Pemasangan laryngeal mask
4. Infus intraosseus
5. Punksi lumbal
6. pemasangan kateter urine
7. Pemasangan orogastrik tube
8. Pemasangan nasogastrik tube
2. KSM THT-Kl 1. Pemeriksaan audiometri
3. KSM Neurologi 1. Punksi lumbal
2. Pain intervention
3. Injeksi Triger point
4. Injeksi CTS
4. KSM gigi dan mulut 1. Scaling
2. Curretage/root planning(jika diperlukan anesthesi)
3. Gingivektomi
4. Frenektomi
5. Flap operasi (bone graft/membrane/GTR/interseptif)
6. Odontektomi
7. Vital pulpektomi dan partial nekrose
8. Retraksi gingiva pada prep.crown
5. KSM kardiologi dan 1.Treadmil tes
kedokteran vaskuler
6. KSM pulmonologi dan 1. Contra ventil/WSD
ilmu kedokteran respirasi
2. Punksi pleura
3. Pleurodesis
4. AFF WSD
5. Perawatan luka WSD
6. USG thorax marker
Ditetapkan di : Lubuklinggau
Pada Tanggal : 21 April 2016

dr.Sarah Ainar Rahman