RINCIAN KEWENANGAN KLINIS (CLINICAL PRIVILEGE)

DOKTER SUB SPESIALIS BEDAH DIGESTIF

Bagian I. Dokter Pemohon
Nama Dokter : Spesialisasi: Tanda tangan:
Dr. Dr. Sigit Adi Bedah
Prasetyo,M.Si.Med.SpB-KBD Digestif
Saya menyatakan bahwa saya kompeten untuk menangani kasus-kasus yang saya minta di
bidang spesialisasi saya, termasuk melayani konsultasi dari dokter-dokter lain.
Saya juga menyatakan kompeten untuk melakukan prosedur teknis seperti yang tercantum di
bawah ini sebagai bagian dari kewenangan klinis (clinical privilege) berdasarkan status
kesehatan saat ini, pendidikan, dan/atau pelatihan yang telah saya jalani, serta pengalaman yang
saya miliki.
SERTIFIKASI
Universitas : Undip Tanggal : 23 Agustus 2015
Pelatihan Bersertifikat : Tanggal : Institusi :

SURAT TANDA REGISTRASI KONSIL KEDOKTERAN

Sub Spesialisasi: Berlaku hingga tanggal:
Bedah Digestif
PETUNJUK

Kode untuk Dokter: Kode Rekomendasi Komite Medik:

1. Mengenali gambaran-gambaran klinik
sesuai penyakit.
2. Mampu membuat diagnosis klinik.
3. Mampu mendiagnosis klinik, memberi
terapi, pendahuluan.
4. Mampu mendiagnosis klinik,
memutuskan dan mampu menangani
problem itu secara mandiri hingga
tuntas.
1. Tidak disetujui karena fasilitas tidak
tersedia.
2. Tidak disetujui karena bukan
kompetensinya.
3. Disetujui dengan membentuk tim.
4. Disetujui berwenang penuh.

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 RINCIAN KEWENANGAN KLINIS

No. Kompetensi Diminta Rekomendasi

1 Menegakkan diagnosis penderita dengan cara:
• Melakukan anamnesa dan pemeriksaan fisik yang terarah
• Meminta dan menginterpretasi pemeriksaan penunjang
(laboratorium, pencitraan, dan biopsi)
2 Memberikan terapi, termasuk merencanakan terapi penunjang
3 Melakukan perawatan pre-operatif dan post-operatif
4 Mendeteksi komplikasi post-operatif dan menanganinya
5 Melakukan follow-up penderita dan KIE pada penderita/keluarga

TINDAKAN MEDIS

No. Kompetensi Diminta Rekomendasi

1 Other procedure for creation of esophagogastric sphincteric
competence
2 Laparoscopic procedure for creation of esophagogastric sphincteric
competence
3 Partial Gastrectomy with anastomosis to esophagus
4 Partial Gastrectomy with anastomosis to duodenum
5 Partial Gastrectomy with anastomosis to jejunum
6 Gastrotomi
7 Suture of peptic ulcer
8 Percutaneus endoscopic gastrotomy
9 Pyloroplasty
10 Dilation of pylorus by incision
11 Other Pyloroplasty
12 Total gastrectomy
13 Esophagostomy
14 Partial esophagectomy
15 Cervical esophagostomy
16 Excision of esophagus
17 Antesternal esophagogastrostomy
18 Other repair of esophagus
19 Antesternal anastomosis of esophagus
20 Vagotomy
21 Truncal Vagotomy
22 Highly selective Vagotomy
23 Other sective Vagotomy
24 Abdominoperineal resection of rectum (miles procedure)
25 Appendectomy
26 Laparoscopic Appendectomy
27 Other Appendectomy
28 Drainase abses appendiks
29 eksteriorisasi

2
No. Kompetensi Diminta Rekomendasi
30 Feeding jejunostomy
31 Open and other partial excision of large intestin
32 Open and other sigmoidectomy
33 Other resection of rectum
34 Open and other right hemilocolectomy
35 Large to large intestinal anastomosis
36 Procedures on hemorrhoids
37 Exteriorization of small intestin
38 Insisi sinus pinoidal
39 Exteriorization of large intestin
40 Division of anal sphincter
41 Suture of laceration of small intestin
42 Suture of laceration of large intestin
43 Other repair of intestin
44 Clossure of stoma of large intestin
45 Clossure of stoma of small intestin
46 Other closure of intestine stoma non spesific
47 Insisi perineal abses
48 Proktoskopi
49 Anterior resection of rectum
50 Other Anterior resection of rectum
51 Anterior resection of rectum with shynchronous colostomy
52 Large to large intestine anastomose
53 Anastomosis to anus
54 Cholesistectomy
55 Laparoscopic Cholesistectomy
56 Laparoscopic partial Cholesistectomy
57 Cholesistotomy and Cholesistectomy
58 Percutaneus aspiration of gall bladder
59 Trocar Cholesistotomy
60 Other Cholesistotomy
61 Distal pacreatectomy
62 Paliative double by pass
63 Gastrojejunostomy
64 Small to small imtestinal anastomosis
65 Common duct exploration
66 Insertion of choledochohepatic tube (T tube) for decompression
67 Common duct exploration for relief obstruction
68 Anastomosis of hepatic duct to gastrointestinal tract
69 Cholangiography
70 Repair of liver
71 Other Repair of liver
72 Closure laseration of liver
73 Internal drainage of pancreatic
74 Anastomosis of pancreas to intestine

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No. Kompetensi Diminta Rekomendasi
75 Cannulation of pancreatic duct
76 Anastomosis of pancreas to intestine
77 Lobectomy of liver
78 Partial of hepatectomy
79 Marsupialization of lession of liver
80 Evacuation of hepatic lesion
81 Radical pancreatico duodenectomy
82 Anastomosis of pancreas to intestine
83 Gastrojejunostomy
84 Anastomosis of hepatic duct to gastrointestinal tract
85 Small to small intestinal anastomosis
86 Laparoscopic lysis of peritoneal adhesion
87 Other lysis of peritoneal adhesion
88 Incision of excision of anal fistula
89 Unilateral repair of femoral hernia with graft or prothesis
90 Bilateral repair of femoral hernia
91 Bilateral repair of femoral hernia with graft or prothesis
92 Other unilateral femoral herniorraphy
93 Other bilateral femoral herniorraphy
94 Other and open bilateral repair of indirect inguinal hernia with graft
or prothesis
95 Other and open bilateral repair of inguinal hernia
96 Other bilateral repair of inguinal hernia
97 bilateral repair of inguinal hernia not otherwise spesified
98 repair of inguinal hernia with graft or prothesis
99 Other and open bilateral repair of direct inguinal hernia
with graft or prothesis
100 Other and open bilateral repair of direct inguinal hernia
101 Unilateral repair of inguinal hernia
102 Bilateral inguinal hernia repair with graft or prothesis
103 Other open bilateral incisional hernia repair with graft or prothesis
104 Laparoscopic incisional hernia repair with graft or prothesis
105 Repair of umbilical hernia
106 Other open umbilical herniorraphy
107 Other and open repair of umbilical hernia with graft or prothesis
108 Laparoscopic repair of umbilical hernia with graft or prothesis
109 Laparoscopic repair of inguinal hernia with graft or prothesis
110 Reclosure of post operative disruption of abdominal wall
111 Other repair of abdominal wall and peritoneum
112 Other repair of abdominal wall
113 Total splenectomy
114 Spleenorraphy / partial splenectomy

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 DIAGNOSTIK DAN TINDAKAN MEDIS

No. Kompetensi Diminta Rekomendasi

1 Akalasia
2 Barrett’s esophagus
3 Benda asing esophagus
4 Divertikulum zenker
5 Varises esophagus
6 Esophageal web and ring
7 Esophagitis
8 Fistula trakeoesophagus
9 Gastroesophageal reflux disease
10 Karsinoma esophagus
11 Mallory weiss syndrome
12 Perdarahan Varises esophagus
13 Skleroderma esophagus
14 Striktur esophagus
15 Tumor jinak esophagus
16 Hernia bochdalek
17 Hernia hiatus
18 Hernia morgagni
19 Sliding hernia
20 Tumor diafragma
21 Divertikulum duodenum
22 Gastric dumping syndrome
23 Gastric leiomyomas and leiomyomasarcoma
24 Gastric outlet obstruction
25 Karsinoma gaster
26 Limfoma gaster
27 Tumor ganas duodenum
28 Perdarahan ulkus duodeni
29 Perdarahan ulkus ventrikuli
30 Perforasi gaster kausa tukak peptik
31 Polip gaster
32 Tumor jinak gaster
33 Ulkus duodenum
34 Ulkus gaster
35 Zollinger ellison syndrom
36 Enterocutaneus fistula
37 Gastrointestinal stromal tumor
38 Ileus batu empedu
39 Tuberculosis intestinal
40 Adenocarcinoma appendiks
41 Appendisitis akut
42 Appendicitis kronis
43 Adenocarcinoma colon

5
No. Kompetensi Diminta Rekomendasi
44 Adenocarcinoma rekti
45 Collitus ulseratif
46 Crohn’s disease
47 Divertikulitis
48 Familial adenomatous poliposis
49 Hirschprung disease
50 Prolap rekti
51 Villous adenoma
52 Abses perianal
53 Stenosis anal
54 Fissura ani akut dan kronik
55 Fistula ani
56 Hemoroid
57 Melanoma dan karsinoma sel basal anus
58 Recto vaginal fistula
59 Trombosis hemorroid eksterna
60 Batu kandung empedu
61 Billiary cyst
62 Caroli disease
63 Cholangitis
64 Cholesistitis akut
65 Kolangiocarcinoma
66 Koledokolithiasis
67 Kolesistitis kronis
68 Mirizzi syndrom
69 Polip kandung empedu
70 Striktur duktus biliaris
71 Tumor kandung empedu
72 Abses hati
73 Cystic disease of liver
74 Kista hydatid
75 Metastase neoplasma ke hepar
76 Tumor ganas hepar
77 Insulinoma
78 Pankreatitis akut
79 Pankreatitits kronik
80 Pseudo kista pankreas
81 Kista neoplasma pankreas
82 Adenocarcinoma ampula vateri
83 Hernia femoralis
84 Hernia inguinal
85 Hernia insisional
86 Hernia littre’s

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No. Kompetensi Diminta Rekomendasi
87 Hernia obturator
88 Hernia perineal
89 Hernia richter
90 Hernia umbilicalis
91 Sliding Hernia
92 Spigellian Hernia
93 Abdominal wall tumor
94 Abses limpa
95 Hipersplenisme
96 Limfoma limpa
97 Iskemi arteri mesentrika akut
98 Iskemi arteri mesentrika kronik
99 Sindroma arteri mesentrika superior
100 Trombosis vena lienalis
101 Torsio omentum
102 Tumor omentum
103 Abses intraperitoneal
104 Adhesi peritoneum
105 Akut abdomen
106 Peritonitis primer
107 Peritonitis
108 Tumor peritoneum
109 Abses retroperitoneal
110 Fibrosis retroperitoneal
111 Hematom retroperitoneal
112 Trauma abdomen pada kehamilan
113 Trauma colon
114 Trauma diafragma
115 Trauma duodenum
116 Trauma gaster
117 Trauma hernia diafragmatika
118 Trauma kaustik
119 Trauma lien
120 Trauma hepar
121 Trauma pankreas
122 Trauma rektum
123 Trauma tajam esophagus
124 Trauma tumpul abdomen
125 Trauma penetran abdomen
126 Trauma usus halus
127 Endoskopi diagnostik upper and lower GI tract
128 Endoskopi with biopsy
129 Therapeutic upper and lower GI endoscopy

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 Dokter Pemohon : Dr. Dr. Sigit Adi Prasetyo,M.Si.Med.SpB-KBD
Tanda Tangan Dokter Pemohon Tanggal :

1 Juli 2020

Bagian II.Komite Medik/Sub-Komite Kredensial

Tanggal:

Rekomendasi:
Menyetujui / tidak menyetujui Rincian Kewenangan Klinis
Merekomendasikan / tidak perekrutan kepada Direktur
Merekomendasikan / tidak penerbitan Surat Tidak Keberatan Praktek untuk mengurus SIP
Merekomendasikan / tidak untuk penerbitan Surat Penugasan Klinik

Ketua Komite Medik Mitra bestari, Ketua Sub-Komite Kredensial

dr. Sedyo Wahyudi, Sp.A Dr. Daniel Puguh,SpB dr. Sedyo Wahyudi, Sp.A