Lampiran : Keputusan Direktur Rumah Sakit Permata Hati

Tentang : Surat Penugasan Klinis dan Rincian Kewenangan Klinis

Kepada dr. Muhammad Adan Yashar,Sp.U di Rumah Sakit Permata
Hati
Nomor : 012/Skep-Dir/RS-PH/I/2021
Tanggal : 03 Februari 2021

RINCIAN KEWENANGAN KLINIS

Rekomendasi Rincian Kewenangan Klinis untuk dokter dalam

menjalankan prosedur tindakan medis di Rumah Sakit Permata Hati diberikan
dalam rangka peningkatan kualitas pelayanan dan keselamatan pasien dengan
kemampuan bersikap secara bertanggung jawab dan mentaati semua disiplin
dan etika kedokteran serta moral yang baik kepada pasien, sejawat dan
masyarakat.

Kewenangan ini diberikan kepada :

Nama : dr. Muhammad Adan Yashar, Sp.U
Kualifikasi : Spesialis

Kewenangan prosedur yang diberikan termasuk inti pelayanan yaitu

melakukan diagnosis, pemeriksaan penunjang, penatalaksanaan dan terapi
konsultasi medis dalam penatalaksanaan penyakit dalam bidangannya sesuai
dengan rincian kewenangan klinis sebagai berikut :

Disetujui

Kemampuan
No Rincian Kewenangan Klinis
Klinis

1 2 3 4

Operations On Adrenal       4

1 Adrenalectomy (abdominothoracal)       4
2 Adrenalectomy 4
Operations On Kidney 4
1 Nephrotomy and nephrostomy 4
2 Nephrotomy, Deroofing/ Unroofinfg cysta, 4
Pyelonephrolithotomy
3 Nephrostomy 4

4 Percutaneous nephrostomy without fragmentation 4

bivalve/ anatropic nephrolithotomy

5 4
Percutaneous nephrostomy with fragmentation

6 Pyelostomy and pyelostomy 4

7 Pyelostomy, pyelolithotomy 4
8 Pyelostomy extended pyelolithotomy 4
9 Diagnostic procedures on kidney, pyelocalicotomy 4

10 Nephroscopy 4
11 Open biopsy of kidney 4
12 Other diagnostic procedures on kidney 4
13 Local excision or dictruction of lesion or tissue 4
of kidney
14 Marsupializatin of kidney lesion 4
15 Open ablation of renal lesion or tissue 4
16 Percutaneous ablation of renal lesion or tissue 4
17 Other and unspecified ablation of renal lesion or 4
tissu

18 Other local excision or destruction of lesion or 4

tissue of kidney
19 Complete nephrectomy 4

20 Nephroureterectomy, nephroureterectomy with 4

bladder cuff total nephrectomy (unilat)
Neprectomy of remaining kidney, removal of
21 4
solitary kidney
22 4
Bilat nephrectomy

23 Nephropexy, fixation or suspension of movable 4

24 (floating) kidney
Other repair of kidney 4
25 Suture laceration of kidney/ renoraphy 4
26 4
Closure of nephrostomy and pyelostomy

27 4
Closure of other fistula of kidney

28 Reduction of torsion of renal pedicle 4

29 Symphysiotomy for horseshoe kidney, koreksi 4
30 horseshoe kidney
Anastomisis of kidney; nephropyeloureterostomy, 4
31 pyeloureterovesical
Correction anastomisis,
of ureteropelvic ureterocalyceal
junction, pyeloplasty 4
32 Other operation on kidney 4
Percutaneous aspiration of kidney (pelvis),
33 4
aspiration renal cyst. Renipuncture, punksi dan
sklerosing kista ginjal
34 Replacement of nephrostomy tube 4
35 Replacement of pyelostomy tube 4
36 Other injection of therapeutic substance into 4
37 kidney injection
Implantation to renal cyst
or replacement of mechanical kidney 4

38 Removal of mechanical kidney 4

39 Reconstruction of renovascular 4
Operation on Ureter 4
Transurethal removal of obstruction from ureter
and renal pelvis removal of : blood, clot,
1 4
calculus, foreign body, from ureter or renal
pelvis without incision, URS

2 Ureteral meatotomy 4

3 Ureterotomy incision of ureter for : drainage, 4

explration, removal of calculus ureterolithtomy
4 Ureterolithotomy proximal 4

5 Ureterolithotomy distal 4

6 Diagnostic procedures on ureter 4

7 Ureteroscopy 4

8 Closed percutaneous biopsy of ureter 4

9 Closed endoscopic biopsy of ureter 4

10 Open biopsy of ureter 4

Endoscopy of ileal conduit: cystoscopy,

11 4
looposcopy
12 Ureterectomy 4

13 Ureterectomy, NOS 4

Partial uretectomy, excision of lesion of ureter,

14 shortening of ureter with reimplantation, 4
reimplantasi ureter bilat

15 Total ureterctomy 4

16 Revision of cuntaneous uretero-ileostomy 4

17 Other external urinary diversion 4

Formation of other cutaneous ureterostomy,

18 anastomisis of ureter to skin, ureterostomy NOS, 4
Ureterokutaneostomi

Revision of other cutaneous ureterstomy

19 4
Revision of ureterostomy stoma

20 Other anastomosis or bypass of ureter 4

21 Urinary diversion to intestine 4

22 Revision of ureterointestinal anastomosis 4

23 Nephrocystanastomosdis, NOS 4

Ureteroneiocystostomy, Replasment of ureter with

bladder flap
24 4
Ureterovesical anastomosis. Reimplantasi ureter
unilateral

25 Transuretero-ureterostomy. Uretero-ureterostomy 4

26 Other. Anastomosis end to end ureter 4

27 Repair of ureter 4

28 Lysis of intraluminal adhesions of ureter 4

29 Suture of laceration 4
30 Closure of other fistula of ureter 4

31 Ureteropexy 4

32 Removal of ligature from ureter 4

33 Other repair of ureter. Tailoring ureter 4

34 Other operations on ureter 4

35 Dilation of uretral meatus 4

36 Ligation of ureter 4

37 Removal DJ stent 4

OPERATIONS ON URINARY BLADDER

Transurethral clearance of bladder

1 Drainage of bladder without incision 4

Removal of (blood clots, calculus, foreign body)

from bladder without incision
2 Cystostomy 4

3 Percutaneous aspiration of bladder 4

4 Lysis of intraluminal adhesions with incision 4

into bladder
Percutaneous cystostomy
5 4
Closed cystostomy, percutaneos suprapubic

6 Other suprapubic cystostomy. Railroading rupture 4

uretra
7 Other cystostomy. Lithopalaksi. Section 4
alta/vesikolithotomi
8 Vesicostomy 4

9 Revision or closure of vesicostomy 4

10 Diagnostic procedures on bladder 4

11 Cystoscopy through artificial stoma. Sistoskopi 4

ODS
12 Other cystoscopy. Transurethral cystoscopy 4

13 Closed (transurethral) biopsy of bladder. TUR 4

tumor buli
14 Open biopsy of bladder 4

15 Orther diagnostic procedure on bladder 4

16 Transurethral excision/destruction of bladder 4

tissue
17 Transurethral lysis of intraluminal adhesions 4
 Other transurethral excision/destruction of
lesion/tissue of bladder
18 4
Endoscopic resection of bladder lesion

19 Other excision/destruction of bladder tissue 4

20 Excision of urachus. Excision of urachal sinus of 4

bladder
Open excison/destruction of other lesion/tissue
of bladder
21 4
Endometrectomy of bladder. Suprapubic excision of
bladder lesion

Partial cystectomy Excision of bladder dome,

22 trigonectomy, wedge resection of 4
bladder. Reduction of cystoplasty

23 Total cystectomy. Total cystectomy with 4

urethrectomy
24 Radical cystectomy 4

25 Other total cystectomy 4

26 Other repair of urimary bladder 4

27 Suture of laceration of bladder 4

28 Closure of cystostomy 4

Repair of fistula involving bladder and intestine

Fistulectomy: (rectovesicovaginal,
29 vesicosigmoidovaginal) 4

Repair fistel enterovesika. Repair fistel

vesikorektal
Repair of other fistula of bladder

Fistulectomy: cervicovesical,
30 urethroperineovesical, uterovesical, 4
vaginovesical.

Repair fistel vesikokuta

Other anastomosis of bladder
31 4
Anastomosis of bladder to intestine NOS,
cystocolic anastomosis

32 Other repair of bladder. Neobladder 4

33 Other operations on bladder 4

34 Sphincterotomy of bladder Devision of bladder 4

neck
35 Dilation of bladder neck 4

36 Control of (post operative) hemorrhage of bladder 4

37 Insertion of indwelling urinary catheter 4

38 Replacement of indwelling urinary catheter 4

OPERATIONS ON URETHRA

1 Urethrotomy 4

2 Urethral meatotomy 4

3 diagnostic procedures on urethra 4

4 Perineal urethroscopy 4

5 Other urethroscopy. PER (primary endoscopic 4

realignment)
6 Biopsy of urethra 4

7 Biopsy of periurethral tissue 4

8 Other diagnostic procedure on urethra and 4

periurethral tissue
9 Excision/destruction of lesion or tissue of 4
urethra
10 Endoscopic excision: destruction of lesion or 4
tissue of urethra
11 Other local excision/destruction of lesion or 4
tissue of urethra
12 Repair of urethra 4

13 Suture of laceration of urethra 4

14 Closure of urethrostomy 4

15 Closure of other fistula of urethra. 4

Fistulektomi/repair fistel urethra
16 Reanastomosis of urethra. Anastomosis of urethra 4

17 Reopair of hypospadias/epipadias 4

18 Other reconstruction of urethra. Urethral 4

construction. Johanson
19 Urethral meatoplasty 4

20 Other repair of urethra 4

21 Release of urethral stricture. 4

22 Dilation of urethra 4

23 Other operations on urethra and periurethral 4

tissue
24 Incision of periurethral tissue. Drainage of 4
bulbourethral gland
25 Excision of periurethral tissue 4

26 Implantation of artificial urinary sphincter 4

27 Kalibrasi uretra 4

28 Insertion catheter 4

OTHER OPERATION ON URINARY TRACT

1 Dissection of retroperitoneal tissue 4

Retroperitoneal dissection, NOS

2 4
Limfadenektomi retroperitoneal/RPLND
Ureterolysis with freeing/repositioning of ureter
3 4
for retroperitoneal fibrosis

Other lysis of perirenal/periureteral adhesions

4 4
Ureterolysis
Other incision of perirenal/periureteral tissue
5 4
Exploration of perinephric area. Incision of
perirenal abscess
6 Incision of perivesical tissue 4

Other Incicion of perivesical tissue

7 Exploration of perivesical tissue. Incision of 4

hematoma of space of retzius

Retropubic exploration
Diagnostic procedure on perirenal and
8 4
perivessical tissue

9 Biopsy of perirenal or perivessical tissue 4

Other diagnostic procedure on perirenal tissue,

10 perivesical tissue and 4

retroperitoneum
11 Ureteral catheterization. Drainage of kidney by 4
catheter
12 Other operations on urinary system 4

13 Excision of perirenal or perivesical tissue 4

14 Other operations on perirenal or perivescal 4

tissue
15 Replacement of ureterostomy tube: Change, 4
reinsertion
16 Replacement of cystostomy tube 4

17 Ultrasonic fragmentation of urinary stones. 4

Shattered urinary stones
18 Ureterosigmoidostomy (Coffey) 4
 OPERATIONS ON PROSTATE AND SEMINAL VESICLES

Incision of prostate. Drainage of prostatic

1 4
abscess. Prostatolithotomy

2 Diagnostic procedure on prostate and seminal 4

visicles
3 Closed (percutaneous) (neddle) biopsy of prostate 4

4 Open biopsy of prostate 4

5 Closed (percutaneous) biopsy of seminal vesicles 4

6 Open biopsy of periprostatic tissue 4

7 Biopsy of periprostatic tissue 4

Other diagnostic procedures on prostate and

8 4
periprostatic tissue

9 Other diagnostic procedures on seminal vesicles 4

10 Transurethral prostatectomy 4

Other transurethral prostatectomy:

Excision of median bar by transurethral approach,

11 TEVAP, transurethral enucleative 4

procedures, transurethral prostatectomy NOS,

TURP, TUIP, BNI, TVP, TMP
12 Suprapubic prostatectomy. Transvesical 4
prostatectomy
13 Retropubic prostatectomy 4

14 Radical prostatectomy. Prostatovesiculectomy 4

15 Other prostatectomy 4

16 Local excision of lesion of prostate. Open 4

prostatectomy
17 Perineal 4

18 Operations on seminal vasicles 4

19 Percutaneous aspiration of seminal vesicles 4

20 Incision of seminal vesicles 4

21 Excision of seminal vesicles 4

22 Other operations on seminal vesicles 4

23 Incision/excision of periprostatic tissue 4

24 Incision of periprostatic tissue. Drainage of 4
periprostatic tissue
Excision of periprostatic tissue
25 4
Excision of lesion of periprostatic tissue

26 Other operation on prostate 4

27 Percutaneous aspiration of prostate 4

28 Injection into prostate 4

29 Repair or prostate 4

30 Control of (postoperative) hemorrhage of prostate 4

31 Masase prostate 4

OPERATIONS ON SCROTUM AND TUNICA VAGINALIS

Incision and drainage of scrotum and tunica

1 4
vaginalis

Diagnostic procedures on scrotum and tunica

2 4
vaginalis

3 Biopsy of scrotum or tunica vaginalis 4

Other diagnostic procedures on scrotum and tunica

4 4
vaginalis

5 Excision of fhydrocele (of tunica vaginalis) 4

Excision/destruction of lesion or tissue of

6 scrotum: fulguration of lesion reduction of 4

elephantiasis, partial scrotectomy

7 Repair of scrotum and tunica vaginalis 4

Suture of laceration of scrotum and tunica

8 4
vaginalis

9 Repair of scrotal fistula 4

Other repair of scrotum and tunica vaginalis

10 4
Reconstruction with rotational or pedicle flaps.

11 Other repair on scrotum and tunica vaginalis 4

12 Percutaneous aspiration of tunica vaginalis 4

13 Excision of lesion of tunica vaginalis other than 4

hydrocele
OPERATIONS ON TESTIS 4
 Incision of testis. Explorasi testis
1 4
(microsurgery )
2 Diagnostic procedure of testis 4

3 Closed (percutenous) (needle) biopsy of testis 4

4 Open biopsy of testis 4

5 Other diagnostic procedure of testis 4

Excision/destruction of testicular lesion

6 4
Excision of appendix testis. Excision of cyst of

7 Unilat orchidectomy 4

8 Bilat orchedectomy. Male castration. Radical 4

bilat orchidectomy
Removal of both testis at same operative episode
9 4
Bilat orchidectomy NOS. Extended orchidectomy
Removal of remaining testis
10 4
Removal of solitary testis. Subcapsular
orchidectomy
11 Orchidopexy (UDT, torsio testis) 4

12 Repair of testis 4

13 Suture of laceration of testis 4

14 Other repair of testis. Testicular graft 4

15 Insertion of testicular prosthesis 4

16 Other operation on testis 4

17 Aspiration of testis 4

18 Injection of therapeutic substance into testis 4

OPERATION ON SPERMATIC CORD, EPIDIDYMIS, AND VAS

DEFERENS

Diagnostic procedure on spermatic cord,

1 4
epididymis, and vas deferens

2 Biopsy of spermatic cord, epididymis, and vas 4

deferens

Other diagnostic procedures on spermatic cord,

3 4
epididymis, and vas deferens
 Excision of varicocele and hydrocele of spermatic
cord

4 High ligation of spermatic vein. Hydrocelectomy 4

of canal of Nuck Funicocelectomy.

Varicocelectomy (palomo)

5 Excision of cyst of epididymis. Spermatocelectomy 4

Excision of other lesion or tissue of spermatic

6 cord and epididymis 4

Excision of appendix epididymis

7 Epididymectomy 4

8 Repair of spermatic cord and epididymis 4

Suture of laceration of spermatic cord and

9 4
epididymis

10 Reduction of torsion of testis or spermatic cord 4

11 Transplantation of spermatic cord 4

12 Other repair of spermatic cord and sepididymis 4

13 Vasotomy. Vasostomy. Vasovasostomy 4

14 Vasectomy and ligation of vas deferens 4

15 Male sterilization procedure, NOS 4

16 (ligation, crushing, division) of vas deferens 4

17 Ligation of spermatic cord 4

18 Vasectomy 4

19 Repair of vas deferens and epididymis 4

20 Suture of laceration of vas deferens and 4

epididymis

21 Reconstruction of surgically divided vas deferens 4

22 Epidfidymovasostomy 4

23 Removal of ligature from vas deferens 4

24 Other repair of vas deferens and epididymis 4

25 Other operations on spermatic cord, epididymis 4

and vas deferens
26 Aspiration of spermatocele 4

27 Epididymotomy 4

28 Incision of spermatic cord 4

29 Lysis of adhesions of spermatic cord 4

30 Insertion of valve in vas deferens 4

OPERATION ON PENIS

1 Circumscision (male) 4

2 Diagnostic procedures on the penis 4

3 Biopsy of penis 4

4 Other diagnostic procedures on penis 4

Local excision/destruction of lesion of penis

5 4
Eksisi plaque (peyronie diseae). Excise webbed
penis
6 Amputation of penis 4

7 Repair and plastic operation of penis 4

8 Release of chordate/chordectomy 4

9 Contruction of penis 4

10 Reconstruction of penis. Eksisi fibroma 4

Other repair of penis. Operasi priapismus

11 4
(prosedur Winter)

12 Koreksi priapismus 4

13 Other operations on male genital organs 4

14 Dorsal or lateral slit of prepuce 4

15 Incision of penis 4

16 Devision of penile adhesions 4

Other operations on penis, corpora cavermosa-

17 corpus spongiosum shunt corpura-sarphenous shunt, 4
irrigation of corpus cavernosum
18 Dissection of lymp node of inguinal 4

19 Hidrokelektomi per ingunal/ ligasi tinggi 4

20 Incise abses perineum 4
21 Lymphasdenectomy illioninguinal 4
22 Dissection of lymp node of pelvis 4
23 Laparotomy exploration 4
24 Operasi sistokel 4

25 Insersi catheter tenckhoff untuk CAPD 4

26 Infiltrasi sitostatika intravesica 4

KETERANGAN KEMAMPUANKLINIS DOKTER :
Tingkat Kemampuan 1 : Mengenali gambaran-gambaran klinis sesuaipenyakit.
Tingkat Kemampuan 2 : Mampu membuat diagnosis klinis
TingkatKemampuan 3 : Mampu mendiagnosis klinis, memberi terapi
pendahuluan
TingkatKemampuan4: Mampu mendiagnosis klinis, memutuskan dan mampu
menangani problem itu secara mandiri hingga
tuntas.

Demikianlah Rincian Kewenangan Klinis ini diberikan sebagai acuan

dalam melaksanakan penatalaksaan prosedur tindakan, dengan ketentuan
dilarang melakukan prosedur tindakan diluar rincian kewenangan klinis
kecuali dalam keadaan darurat dan tidak ada sejawat lain yang memiliki
kewenangan tersebut.

Direktur Rumah Sakit Permata Hati

dr. EFRIANTI, M. Kes, CBA