BERITA ACARA

PEER REVIEW DIAGNOSIS NON SPESIALISTIK

Pada hari ini Selasa Tanggal Dua Puluh Lima bulan September tahun Dua Ribu Delapan Belas,
yang bertanda tangan di bawah ini:

Nama :

FKTP :

Jabatan :

Telah menyepakati tentang hasil Peer Review Diagnosis Non Spesialistik yang dapat ditangani
tuntas di FKTP ……………………………sebanyak …………. diagnosis sebagaimana terlampir.

Demikianlah kesepakatan ini dibuat untuk dapat dipergunakan sesuai kebutuhan.

Hormat kami,

………………………………..

*ditandatangani dan di
stempel FKTP
Lampiran Diagnosis Non Spesialistik Tuntas di FKTP

Berikan tanda √ pada kolom tuntas/tidak tuntas

No

Nama dan Kode Diagnosis

Tuntas
Tidak Tuntas

1
A01.0
- Typhoid fever

2
A06.0
- Acute amoebic dysentery

3
A09.0
- Other and unspecified gastroenteritis and colitis of infectious origin

4
A15.0
- Respiratory tuberculosis, bacteriologically and histologically confirmed

5
A27.9
- Leptospirosis, unspecified

6
A30.0
- Indeterminate leprosy

7
A35 - Other tetanus

8
A54.9
- Gonococcal infection, unspecified

9
A90 - Dengue fever [classical dengue]

10
A91 - Dengue haemorrhagic fever

11
B00.9
- Herpesviral infection, unspecified

12
B01.9
- Varicella without complication

13
B02.9
- Zoster without complication

14
B05.9
- Measles without complication

15
B07 - Viral warts

16
B08.1
- Molluscum contagiosum

17
B15 - Acute hepatitis A

18
B26.0
- Mumps orchitis

19
B35 - Dermatophytosis

20
B35.0
- Tinea barbae and tinea capitis

21
B35.1
- Tinea unguium

22
B35.2
- Tinea manuum

23
B35.3
- Tinea pedis

24
B35.4
- Tinea corporis

25
B35.6
- Tinea cruris

26
B35.8
- Other dermatophytoses
27
B36.0
- Pityriasis versicolor

28
B37.9
- Candidiasis, unspecified

29
B54 - Unspecified malaria

30
B65.0
- Schistosom due schis haematobium [urin schistosom]

31
B65.2
- Schistosomiasis due to Schistosoma japonicum

32
B65.9
- Schistosomiasis, unspecified

33
B68.0
- Taenia solium taeniasis

34
B68.9
- Taeniasis, unspecified

35
B74.0
- Filariasis due to wuchereria bancrofti

36
B76.0
- Ancylostomiasis

37
B76.9
- Hookworm disease, unspecified

38
B77.9
- Ascariasis, unspecified

39
B78.0
- Intestinal strongyloidiasis
Lampiran Diagnosis Non Spesialistik Tuntas di FKTP

Berikan tanda √ pada kolom tuntas/tidak tuntas

No

Nama dan Kode Diagnosis

Tuntas
Tidak Tuntas

40
B78.9 - Strongyloidiasis, unspecified

41
B85.0 - Pediculosis due to pediculus humanus capitis

42
B85.3 - Phthiriasis

43
B86 - Scabies

44
D17.9
- Benign lipomatous neoplasm, unspecified

45
D50.0
- Iron deficiency anaemia secondary to blood loss (chronic)
46
D50.9
- Iron deficiency anaemia, unspecified

47
E11.9 - Non-insulin-dependent diabetes mellitus without complications

48
E16.2 - Hypoglycaemia, unspecified

49
E46 - Unspecified protein-energy malnutrition

50
E66.9 - Obesity, unspecified

51
E78.5 - Hyperlipidaemia, unspecified

52
E79.0 - Hyperuricaem without sign inflamm arthritis+tophaceous dis

53
F45.0 - Somatization disorder
54
F51.0 - Nonorganic insomnia

55
G43.0 - Migraine without aura [common migraine]

56
G43.9 - Migraine, unspecified

57
G44.2 - Tension-type headache

58
G51.0 - Bell's palsy

59
H00.0
- Hordeolum and other deep inflammation of eyelid

60
H01.0
- Blepharitis
61
H02.0
- Entropion and trichiasis of eyelid

62
H04.1
- Other disorders of lacrimal gland

63
H10.1
- Acute atopic conjunctivitis

64
H10.9
- Conjunctivitis, unspecified

65
H15.1
- Episcleritis

66
H52.0
- Hypermetropia

67
H52.1
- Myopia
68
H52.2
- Astigmatism

69
H52.4
- Presbyopia

70
H53.6
- Night blindness

71
H57.8
- Other specified disorders of eye and adnexa

72
H60.9
- Otitis externa, unspecified

73
H61.2
- Impacted cerumen
74
H65.0
- Acute serous otitis media

75
H65.1
- Other acute nonsuppurative otitis media

76
H66.0
- Acute suppurative otitis media

77
I10 - Essential (primary) hypertension

78
I83.9 - Varicose veins lower extremities without ulcer or inflamm
Lampiran Diagnosis Non Spesialistik Tuntas di FKTP

Berikan tanda √ pada kolom tuntas/tidak tuntas

No

Nama dan Kode Diagnosis

Tuntas
Tidak Tuntas

79
I84.0 - Internal thrombosed haemorrhoids

80
I84.2 - Internal haemorrhoids without complication

81
I84.9 - Unspecified haemorrhoids without complication

82
J00 - Acute nasopharyngitis [common cold]

83
J02 - Acute pharyngitis

84
J02.9
- Acute pharyngitis, unspecified

85
J03 - Acute tonsillitis
86
J03.9
- Acute tonsillitis, unspecified

87
J04.0
- Acute laryngitis

88
J11.0
- Influenza, virus not identified

89
J18.0
- Bronchopneumonia, unspecified

90
J18.9
- Pneumonia, unspecified

91
J20.9
- Acute bronchitis, unspecified
92
J30.0
- Vasomotor rhinitis

93
J30.4
- Allergic rhinitis, unspecified

94
J34.0
- Abscess, furuncle and carbuncle of nose

95
J35.0
- Chronic tonsillitis

96
J45.9
- Asthma, unspecified

97
K12 - Stomatitis and related lesions

98
K21.9 - Gastro-oesophageal reflux disease without oesophagitis
99
K29.7 - Gastritis, unspecified

100
K90.4 - Malabsorption due to intolerance, not elsewhere classified

101
L01.0
- Impetigo [any organism] [any site]

102
L02.0
- Cutaneous abscess, furuncle and carbuncle of face

103
L02.2
- Cutaneous abscess, furuncle and carbuncle of trunk

104
L02.8
- Cutaneous abscess, furuncle and carbuncle of other sites

105
L04.9
- Acute lymphadenitis, unspecified
106
L08.0
- Pyoderma

107
L08.1
- Erythrasma

108
L20.8
- Other atopic dermatitis

109
L21.0
- Seborrhoea capitis

110
L22 - Diaper [napkin] dermatitis

111
L24.0
- Irritant contact dermatitis due to detergents
112
L27.0
- Generalized skin eruption due to drugs and medicaments

113
L27.2
- Dermatitis due to ingested food

114
L42 - Pityriasis rosea

115
L50.0
- Allergic urticaria

116
L50.9
- Atrophic disorder of skin, unspecified

117
L70.0
- Acne vulgaris
Lampiran Diagnosis Non Spesialistik Tuntas di FKTP

Berikan tanda √ pada kolom tuntas/tidak tuntas

No

Nama dan Kode Diagnosis

Tuntas
Tidak Tuntas

118
L71.0
- Perioral dermatitis

119
L73.2
- Hidradenitis suppurativa

120
L74.3
- Miliaria, unspecified

121
L97 - Ulcer of lower limb, not elsewhere classified

122
M10 - Gout

123
N10 - Acute tubulo-interstitial nephritis

124
N39.0 - Urinary tract infection, site not specified

125
N47 - Redundant prepuce, phimosis and paraphimosis

126
N61 - Inflammatory disorders of breast

127
N76.0 - Acute vaginitis

128
N98.9 - Complication associated with artificial fertilization, unspecified

129
O03.9 - Spontaneous abortion, Complete or unspecified, without complication

130
O70.0 - First degree perineal laceration during delivery
131
O80.9 - Single spontaneous delivery, unspecified

132
O92.0 - Retracted nipple associated with childbirth

133
P38 - Omphalitis of newborn with or without mild haemorrhage

134
R04.0 - Epistaxis

135
R42 - Dizziness and giddiness

136
R56.0 - Febrile convulsions

137
T14 - Injury of unspecified body region
138
T14.1
- Open wound of unspecified body region

139
T15.9
- Foreign body on external eye, part unspecified

140
T17.1
- Foreign body in nostril

141
T30.1
- Burn of first degree, body region unspecified

142
T30.2
- Burn of second degree, body region unspecified

143
T63.4
- Venom of other arthropods
144
T78.2
- Anaphylactic shock, unspecified

145
Z21 - Asymptomatic human immunodeficiency virus [HIV] infection status

Tasikmalaya, 25 September 2018

(………………………………………….)

*ditandatangani dan di stempel FKTP