DAFTAR ISI

1. SK PEMBERLAKUAN PEDOMAN PELAYANAN BEDAH

2. BAB I PENDAHULUAN ....................................................................................................1

A. Latar Belakang ..............................................................................................................1

B. Tujuan ...........................................................................................................................2

C. Ruang Lingkup ..............................................................................................................2

D. Batasan Operasional ......................................................................................................3

E. Landasan Hukum ..........................................................................................................5

3. BAB II STANDAR KETENAGAAN ................................................................................7

A. Kualifikasi Sumber Daya Manusia ...............................................................................7

B. Distribusi Ketenagaan ...................................................................................................17

C. Prosedur Rekrutmen dan Seleksi....................................................................................17

D. Pengaturan Dinas ...........................................................................................................19

4. BAB III STANDAR FASILITAS ......................................................................................20

A. Denah Ruangan .............................................................................................................20
B. Standar Fasilitas.............................................................................................................21

5. BAB IV TATA LAKSANA PELAYANAN.......................................................................25

A. Penjadwalan Operasi ...................................................................................................25
B. Penerimaan Dan Penyerahan Pasien .........................................................................25
C. Persiapan Operasi ........................................................................................................25
D. Pelayanan Kamar Operasi ..........................................................................................25
I. Manajemen Intra Operatif .......................................................................................26
II. Manajemen Post Operatif .......................................................................................33
E. Kerjasama Antar Disiplin ..........................................................................................37
a. Pre Operasi ...............................................................................................................37
b. Durante Operasi .......................................................................................................38
c. Post Operasi .............................................................................................................38
F. Pelayanan Anestesi ......................................................................................................39
1. Sign In .....................................................................................................................39
 2. Pengelolaan Pre Anestesi .........................................................................................39
3. Standar Pengelolaan Pre Anestesi ............................................................................39
4. Pemantauan Selama Anestesi Umum Dan Regional ...............................................40
5. Standar Pengelolaan Selama Anestesi .....................................................................39
6. Pengelolaan Pasca Anestesi .....................................................................................41
7. Standar Pengelolaan Pasca Anestesi ........................................................................41
8. Standar Pencatatan dan Pelaporan ..........................................................................42
G. Pelayanan Bedah .........................................................................................................43
1. Pemeriksaan pra bedah dan perencanaan pra bedah yang terdokumentasi .............43
2. Penandaan Luka Operasi .........................................................................................44
3. Edukasi Pasien dan Keluarga...................................................................................44
4. Time Out dan Sign Out ...........................................................................................44
5. Laporan Operasi ......................................................................................................44
6. Pemantauan Keadaan Pasien Selama Tindakan Bedah ...........................................45
7. Tata Laksana Pasca Bedah ......................................................................................45
8. Pemeriksaan pra bedah dan perencanaan pra bedah yang terdokumentasi .............43
9. Pemeriksaan pra bedah dan perencanaan pra bedah yang terdokumentasi .............43

6. BAB V LOGISTIK .............................................................................................................46

A. Logistik Farmasi ............................................................................................................46
B. Logistik Umum ...............................................................................................................47
C. Logistik Linen .................................................................................................................47

7. BAB VI KESELAMATAN PASIEN .................................................................................49

A. Latar Belakang ...............................................................................................................49
B. Tujuan .............................................................................................................................49
C. Tata Laksana Keselamatan Pasien Rumah Sakit .......................................................49

8. BAB VII KESELAMATAN KERJA ................................................................................51

A. Latar Belakang ...............................................................................................................51
B. Risiko Kerja di Kamar Bedah ......................................................................................52
C. Keselamatan dan Kesehatan Kerja ..............................................................................53

9. BAB VIII PENGENDALIAN MUTU................................................................................55

10. BAB IX PENUTUP..............................................................................................................57