Clinical Saudara (*mohon di

Kode ICD Pathway checklist)

No. Nama Diagnosa Nama ICD X X (pada KMK
514/2015 Ya Tidak *)
halaman --)
1 Abortus spontan Unspecified O03.9 707 √
komplit abortion, complete,
without
complication

2 Alergi makanan Dermatitis due to L27.2 66 √

ingested food

3 Anemia defisiensi Iron deficiency D50 693 √

besi pada anaemia
kehamilan

4 Askariasis Ascariaris B77.9 176 √

unspecified
5 Asma Bronkial Asthma J45 431 √
6 Astigmatism ringan Astigmatisme H52.2 212 √

7 Bell's Palsy Bells’ palsy G51.0 364 √

8 Benda asing di Foreign body in T17.1 481 √

hidung nostril
9 Benda asing di Foreign body on T15.9 209 √
konjungtiva external eye, part
unspecified

10 Blefaritis Blepharitis H01.0 204 √

11 Bronkitis akut Acute bronchitis, J20.9 427 √
unspecified

12 Buta senja Night blindness H53.6 196 √

13 Cutaneus larva Hookworm disease, B76.9 610 √
migran unspecified

14 Demam dengue, Dengue A91 79 √

DHF haemorrhagic fever

15 Demam tifoid Typhoid fever A01.0 125 √

16 Dermatitis atopik Atopic dermatitis L20 555 √
(kecuali
recalcitrant)

17 Dermatitis kontak Irritant contact L24 571 √

iritan dermatitis

18 Dermatitis Other atopic L20.8 561 √

numularis dermatitis
18 Dermatitis L20.8 561 √
numularis dermatitis
19 Dermatitis Seborrhoeic L21 552 √
seboroik dermatitis
20 Tinea kapitis Tinea barbae and B35.0 537 √
tinea capitis

21 Tinea barbae Tinea barbae and B35.0 537 √

tinea capitis

22 Tinea Imbricate Other B35.8 537 √

dermatophytoses
23 Tinea korporis Tinea corporis B35.4 537 √
24 Tinea manum Tinea manuum B35.2 537 √
25 Tinea unguium Tinea unguium B35.1 537 √
26 Tinea kruris Tinea cruris B35.6 537 √
27 Tinea pedis Tinea pedis B35.3 537 √
28 Diabetes melitus Diabetes insulin T89 Ada di √
tipe 1 dependent PMK no.5
tahun
2014 hal.
423

29 Diabetes melitus Non-insulin- E11 635 √

tipe 2 dependent diabetes
mellitus

30 Disentri basiler dan Acute amoebic A06.0 144 √

amuba dysentery

31 Dislipidemia Hiperlipidemia E78.5 652 √

32 Epistaksis Epistaxis R04.0 475 √

33 Exanthematous Generalized skin L27.0 604 √

drug eruption eruption due to
drugs and
medicament

34 Faringitis Acute pharyngitis, J02.9 411 √

unspecified
35 Filariasis Filariasis B74 42 √
36 Furunkel pada Abscess, furuncle J34.0 485 √
hidung and carbuncle of
nose

37 Gastritis Gastritis, K29.7 117 √

unspecified

38 Gastroenteritis Diarrhoea and A09 133 √

(termasuk kolera, gastroenteritis of
giardiasis) presumed infection
origin

39 Gonore Gonococcal A54.9 763 √

infection,
unspecified
39 Gonore Gonococcal A54.9 763 √
infection,
unspecified

40 Hemoroid grade 1- Haemorrhoids I84 154 √

2

41 Hepatitis A Acute Hepatitis A B15 157 √

42 Herpes simpleks Herpesviral B009 517 √
tanpa komplikasi infection,
unspecified

43 Herpes zoster Zoster without B02.9 514 √

tanpa komplikasi complication

44 Hipermetropia Hypermetropia H52.0 214 √

ringan
45 Hipertensi esensial Essential (primary) I10 280 √
hypertension

46 Hiperuricemia Gout M10 649 √

(Gout)

47 Hipoglikemia hypoglycaemia E16.2 646 √

ringan unspecified

48 HIV AIDS tanpa Asymptomatic Z21 92 √

komplikasi Human
Immunodeficiency
Virus (HIV) infection
status

49 Hordeolum Hordeolum and H00.0 198 √

other deep
inflammation of
eyelid

50 Infeksi pada Omphalitis of P38 49 √

umbilikus newborn with or
without mild
haemorrhage

51 Infeksi saluran Urinary tract N39.0 666 √

kemih infection, site not
specified

52 Influenza Influenza, virus not J11 408 √

identified

53 Insomnia Insomnia non F51 396 √

organik pada
psikiatri

54 Intoleransi Malabsorption due K90.4 120 √

makanan to intolerance

55 Kandidiasis mulut Candidiasis B37.9 52 √

unspecified
56 Kehamilan normal Single spontaneous O80.9 678 √
delivery, unspecified

57 Kejang demam Febrile convulsions R56.0 378 √

58 Keracunan Other Ingested T62.2 63 √

makanan (parts of plant(s))

59 Konjungtivitis Conjunctivitis, H10.9 201 √

unspecified
60 Laringitis Acute laryngitis J04.0 416 √
61 Lepra Leprosy [Hansen A30 53 √
disease]
62 Leptospirosis Leptospirosis, A27.9 39 √
(tanpa komplikasi) unspecified

63 Limfadenitis Lymphadenitis B70 104 √

Acute
64 Lipoma Benign lipomatous D17.9 307 √
neoplasm

65 Luka bakar derajat burn and corrosion, T30 613 √

1 dan 2 body region
unspecified

66 Malaria Unspecified malaria B54 35 √

67 Malnutirisi energi- Unspecified protein- E46 662 √

protein energy malnutrition

68 Mastitis Inflammatory N61 742 √

disorders of breast

69 Mata kering Otherdisorders of H04.1 193 √

lacrimal gland

70 Migren Migraine, G43.9 313 √

unspecified
71 Miliaria Miliaria, unspecified L74.3 507 √

72 Miopia ringan Myopia H52.1 216 √

73 Moluskum Molluscum B08,1 521 √
kontagiosum contagiosum

74 Morbili tanpa Measles without B05.9 29 √

komplikasi complication
(Measles NOS).
75 Napkin eczema Diaper (napkin) L22 575 √
dermatitis
76 Obesitas obesity unspecified E66.9 628 √

77 Otitis eksterna Otitis externa, H60.9 246 √

unspecified
78 Otitis media akut Acute serous otitis H65.0 249 √
media

79 Parotitis Mumps B26 172 √

80 Pedikulosis kapitis Pediculosis due to B85.0 531 √
Pediculus humanus
capitis

81 Penyakit cacing Ankylostomiasis B76.0 180 √

tambang
82 Perdarahan Other specified H57.8 207 √
subkonjungtiva disorders of eye and
adnexa

83 Pertusis *tidak ditemukan √

Panduan Klinis di
KMK

84 Pitiriasis rosea L42 582 √

85 Pitiriasis versikolor Pityriasis versicolor B36.0 541 √

86 Pneumonia, Bronchopneumonia, J18.0 457 √

bronkopneumonia unspecified

87 Presbiopia Presbyopia H52.4 218 √

88 Reaksi anafilaktik Anaphylactic shock, T78.2 74 √
unspecified
89 Reaksi gigitan Venom of other T63.4 524 √
serangga arthropods
90 Refluks Gastro-oesophageal K21.9 114 √
gastroesofageal reflux disease
without
oesophagitis

91 Rhinitis akut Acute J00 487 √

nasopharyngitis
(common cold)

92 Rhinitis alergika Allergic rhinitis, J30.4 494 √

unspecified
93 Rhinitis vasomotor Vasomotor rhinitis J30.0 491 √

94 Ruptur perineum First degree O70.0 733 √

tingkat 1-2 perineal laceration
during delivery
95 Serumen prop Impacted cerumen H61.2 259 √

96 Skabies Scabies B86 528 √

97 Skistosomiasis Skistosomiasis B65.9 184 √
unspecified
98 Strongiloidiasis Strongyloidiasis B78.9 190 √
99 Taeniasis Taeniasis B68.9 187 √
100 Tension headache Tension–type G44.2 309 √
headache
101 Tetanus Other tetanus A35 327 √
102 Tonsilitis Acute tonsillitis J03 421 √
103 Tuberkulosis paru Respiratory A15 13 √
tanpa komplikasi tuberkulosis,
bacteriologically
and histologically
confirmed

104 Urtikaria (akut & Urticaria L50 599 √

kronis)
105 Vaginitis Acute Vaginitis N76.0 767 √
106 Varisela tanpa Varicella without B01.9 32 √
komplikasi complication
(Varicella NOS)

107 Vertigo (Benign Dizziness and R42 319 √

paroxysmal giddiness
positional vertigo)

108 Veruka vulgaris Viral warts B07 511 √

109 Vulvitis Acute Vaginitis N76.0 771 √

110 Gangguan Somatoform F45 387 √
somatoform disorders

111 Trikiasis Entropion and H02 229 √

trichiasis of eyelid
112 Episkleritis Episcleritis H15.1 232 √
113 Mabuk perjalanan *tidak ditemukan √
Panduan Klinis di
KMK

114 Ulkus mulut Stomatitis and K12 108 √

(aptosa, herpes) related lesions
115 Pielonefritis tanpa Acute tubulo- N10 669 √
komplikasi interstitial nephritis
(applicable to: acute
pyelonephritis)
116 Fimosis Phimosis N47 673 √
117 Parafimosis Paraphimosis N47.2 676 √
118 Sindrom duh Complication N98.9 751 √
(discharge) genital associated with
(gonore dan artificial
nongonore) fertilization,
unspecified

119 Infeksi saluran Urinary tract N39.0 666 √

kemih bagian infection, site not
bawah specified

120 Vaginosis Acute Vaginitis N76.0 767 √

bakterialis
121 Salpingitis *tidak ditemukan √
Panduan Klinis di
KMK

122 Abses folikel *tidak ditemukan √

rambut atau Panduan Klinis di
kelenjar sebasea KMK

123 Cracked nipple Cracked nipple O9212; 748 √

associated with the
puerperium; O9213
Cracked nipple
associated with
lactation

124 Inverted nipple Retracted nipple O92.02; 745 √

associated with the O92.03
puerperium;
Retracted nipple
associated with
lactation

125 Defisiensi vitamin *tidak ditemukan √

Panduan Klinis di
KMK
126 Defisiensi mineral *tidak ditemukan √
Panduan Klinis di
KMK
127 Anemia defisiensi Iron Deficiency 280 88 √
besi Anemias
128 Ulkus pada tungkai Varicose veins of I83.0; L97 618 √
lower extremities
with ulcer; Ulcer of
lower limb,
notelsewhere
classified

129 Sifilis stadium 1 *tidak ditemukan √

dan 2 Panduan Klinis di
KMK
129 Sifilis stadium 1 *tidak ditemukan √
dan 2 Panduan Klinis di
KMK

130 Impetigo Impetigo L01 544 √

131 Impetigo ulseratif Impetigo L02 545 √
(ektima)
132 Folikulitis Pioderma L08.0 544 √
superfisialis
133 Furunkel, Cutaneous abscess, L02 544 √
karbunkel furuncle and
carbuncle

134 Eritrasma Erythrasmay L08.1 584 √

135 Erisipelas Erysipelas A46 549 √
136 Skrofuloderma Tuberculosis of skin A18.4 587 √
and subcutaneous
tissue

137 Kandidosis Candidiasis B37.9 52 √

mukokutan ringan unspecified

138 Pedikulosis pubis Pthiriasis B85.3 535 √

139 Akne vulgaris Acne vulgaris L70.0 594 √
ringan
140 Hidradenitis Hidradenitis L73.2 590 √
supuratif suppurativa

141 Dermatitis perioral Perioral dermatitis L71.0 578 √

142 Vulnus laseratum, Open wound of T14.1 303 √

punctum unspecified body
region

143 Kekerasan tumpul *tidak ditemukan √

Panduan Klinis di
KMK

144 Kekerasan tajam *tidak ditemukan √

Panduan Klinis di
KMK
 Kendala
(Agar dituliskan dengan lengkap tiap jenis kendala)
1. Tidak ada obat 4. Tidak ada sarana lain
- ……………………… - ……………………………………….
2. Tidak ada alkes 5. Kompetensi Nakes
- ………………………… □ Mampu
- ………………………… □ Tidak Mampu
- ……………………………
3. Tidak ada Lab/RO 6. Lainnya (sebutkan; misal sdm, dll)
- …………………………… - ……………………………………….