No : 288/DPD.PPNI/SE/K.

S/VI/2022 Kepada Yth,

Perihal : Edaran Pengajuan SIPP Mandiri 1. Dewan Pengurus Daerah PPNI Pati

Lamp : 1 bendel 2. Ketua DPK PPNI Se-Kabupaten Pati

3. Anggota FKPPM PPNI Pati
di -
PATI

Bersama ini kami sampaikan alur mekanisme Pengajuan Surat Ijin Praktik Perawat
(SIPP) Mandiri sebagai berikut:
1. Semua perawat Ners maupun D III yang telah memiliki tempat praktik diperbolehkan
untuk mengajukan SIPP Mandiri
2. Persyaratan Pengajuan SIPP Mandiri salah satunya adalah mendapatkan rekomendasi
dari DPD PPNI dengan persayaratan terlampir dalam edaran ini.
3. Persyaratan yang sudah dikumpulkan difoto di kirim via WA kepada ketua Tim untuk
dilakukan verifikasi
4. Hasil verifikasi akan diberitahukan kepada yang bersangkutan dan jika lulus akan
diberitahukan waktu pelaksanaan visitasi oleh Dinas Kesehatan dan Tim Visitasi DPD
PPNI Kabupaten Pati.
5. Pengajuan baru SIPP Mandiri akan dilakukan visitasi dan yang perpanjangan tidak
dilakukan visitasi.
6. Hal-hal terkait tehnis pengajuan SIPP Mandiri dapat menghubungi Ketua Tim visitasi
DPD PPNI Kab. Pati Ibu Widadi Tuk Rejeki (082220376111)
7. Apabila ada kesulitan dalam scan dokumen maupun upload dokumen dll di link
perijinan dinas kesehatan dapat menghubungi Sdr. Edi (085210216811) di sekretariat
DPD PPNI Kab.Pati Jl.Penjawi No.45 Pati

DEWAN PENGURUS DAERAH

PERSATUAN PERAWAT NASIONAL INDONESIA
KABUPATEN PATI

Ketua, Sekretaris,

H. Bunari, AMK., S.Pd., MH H. Yusuf Effendi, S.Kep., Ners

NIRA: 33180018367 NIRA: 33180018324
Tembusan :
1. Kepala Dinas Kesehatan Kab. Pati
2. Kepala DMPTSP Kab. Pati
3. Arsip
 LAMPIRAN

Perihal : Permohonan Rekomendasi Surat Ijin Praktik Perawat Mandiri

Lampiran : 1 bandel

Kepada Yth : Pati, ............................2022

Ketua Tim Visitasi Rekomendasi
DPD PPNI Kab. Pati

Dengan hormat,
Bersama ini saya kirimkan Komponen Pendukung Persyaratan Parktik Keperawatan Mandiri
untuk mendapatkan Surat Rekomendasi DPD PPNI Kabupaten Pati.
Adapun komponen tersebut sebagaimana kami lampirkan yang terdiri dari :
1. Komponen Perencanaan Praktik Perawat Mandiri
a. Visi
b. Misi
c. Tujuan
d. Area Praktik
2. Komponen Dokumen Persyaratan
a. Foto copy Ijazah Perawat
b. Foto copy STR yang masih berlaku
c. Sertifikat Kegawatdaruratan (BTCLS/ACLS) yang masih berlaku
d. Sertifikat Keahlian Tertentu
e. Surat Keterangan Sehat dari Dokter Pemerintah
f. Surat Pernyataan Memiliki Tempat Praktik
3. Komponen Dokumen Keperawatan dan Pelaporan
a. Formulir Pengkajian Keperawatan
b. Formulir Perencanaan Keperawatan
c. Formulir Catatan Implementasi
d. Formulir Catatan Perkembangan
e. Surat Rujukan
f. Formulir Pelaporan
g. SOP Pelayanan
4. Daftar Alat Keperawatan / Alat Tenun / Instrumen Keperawatan
5. Daftar Obat Bebas dan Obat Bebas terbatas
6. Foto/Vidio Sarana Prasarana
(Foto Ruangan ; Tempat Sampah ; Ventilasi ; Sumber Listrik)
7. Dokumen dikirim WA dan akan dilakukan verifikasi oleh Ketua Tim No.WA : 082220376111
8. Dokumen selesai diverifikasi dan dinyatakan lengkap pemohon mengisi link
https://bit.ly/3C3q5FX untuk mendapatkan rekomendasi DPD PPNI Kabupaten Pati.

Demikian untuk menjadikan periksa dan atas kebenaran dokumen komponen persyaratan ini dapat
saya pertanggungjawabkan.

Hormat Saya,

Materai 10.0000
........................................
NIRA :
Lampiran 1 :
KOMPONEN PERENCANAAN PRAKTIK PERAWAT MANDIRI

VISI :
MISI :
TUJUAN :
AREA PRAKTIK :

Lampiran 2 :
KOMPONEN DOKUMEN PERSYARATAN

Lampiran 3 :
KOMPONEN DOKUMEN KEPERAWATAN DAN PELAPORAN

Lampiran 4 :
DAFTAR ALAT KEPERAWATAN/INSTRUMEN KEPERAWATAN

No Nama Alat/Instrumen Jumlah Keterangan

1
2
3
4
5
6
dst

Lampiran 5 :
DAFTAR OBAT BEBAS DAN OBAT BEBAS TERBATAS
No Nama Obat Jumlah Keterangan
1
2
3
4
5
dst

Lampiran 6 :
FOTO RUANGAN PRAKTIK DAN LOKASI PRAKTIK
CONTOH PERMOHONAN
Lampiran 1 :
KOMPONEN PERENCANAAN PRAKTIK PERAWAT MANDIRI

VISI : Mewujudkan Masyarakat Sehat penuh manfaat dan

bermartabat di wilayah kecamatan Tayu, Dukuh seti
dan sekitarnya

MISI : 1. Mengembangkan Praktek Keperawatan dengan

profesional dan modern
2. Berperan serta aktif dalam membantu pemerintah
meningkatkan derajat kesehatan masyarakat
3. Mengembangkan Praktik Keperawatan
komplementer secara komprehensif
4. Mengembangkan ilmu keperawatan melalui
berbagai penelitian.

TUJUAN :
1.Umum
Terselenggaranya praktik keperawatan mandiri yang
dapat mewujudkan masyarakat sehat dan sejahtera

a. Memberikan pelayanan kesehatan yang prima,

2.Khusus modern dan professional berlandaskan ilmu dan
kiat keperawatan dan peraturan/perundangan yang
berlaku di Indonesia
b. Membantu Pemerintah dalam meningkatkan derajat
kesehatan masyarakat
c. Memberikan asuhan keperawatan dengan
melakukan pengkajian secara holistik

AREA PRAKTIK : Ds. Kalikalong RT 5/IV Kec. Tayu Kab. Pati Jawa
Tengah
Lampiran 2 :
KOMPONEN DOKUMEN PERSYARATAN
a. Foto copy Ijazah Perawat
b. Foto copy STR yang masih berlaku
c. Sertifikat Kegawatdaruratan (BTCLS/ACLS)
d. Surat Keterangan Sehat dari Dokter Pemerintah
e. Surat Pernyataan Memiliki Tempat Praktik
Lampiran 3 :
KOMPONEN DOKUMEN KEPERAWATAN DAN PELAPORAN
a. Formulir Pengkajian Keperawatan
1. Identitas
a. Identitas Pasien
Nama :
..........................................................................................
Umur :
..........................................................................................
Agama :
..........................................................................................
Jenis Kelamin :
...........................................................................................
Status :
...........................................................................................
Pendidikan
:..................................................................................
..........
Pekerjaan :
............................................................................................
Suku Bangsa
:.............................................................................................
Alamat :
............................................................................................
Tanggal Masuk :
............................................................................................
Tanggal Pengkajian
:............................................................................................
No. Register :
............................................................................................
Diagnosa Medis :
............................................................................................
b. Identitas Penanggung Jawab
Nama :
.............................................................................................
Umur :
.............................................................................................
Hub. Dengan Pasien:
...............................................................................................
 Pekerjaan :
.............................................................................................
Alamat :
.............................................................................................

2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat ini)
.................................................................................................................
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2) Alasan masuk rumah sakit dan perjalanan penyakit saat ini

.................................................................................................................
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3) Upaya yang dilakukan untuk mengatasinya
.................................................................................................................
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b. Satus Kesehatan Masa Lalu

1) Penyakit yang pernah dialami
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2) Pernah dirawat
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3) Alergi
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4) Kebiasaan (merokok/kopi/alkohol dll)

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c. Riwayat Penyakit Keluarga

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d. Diagnosa Medis dan therapy
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3. Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)

a. Pola Persepsi dan Manajemen Kesehatan
.................................................................................................................
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...................
b. Pola Nutrisi-Metabolik
Sebelum sakit :
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...................
Saat sakit :
.................................................................................................................
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c. Pola Eliminasi
1) BAB
Sebelum sakit :
.................................................................................................................
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...................
 Saat sakit :
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2) BAK
Sebelum sakit :
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...................
Saat sakit :
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...................
d. Pola aktivitas dan latihan
1) Aktivitas
Kemampuan 0 1 2 3 4
Perawatan Diri
Makan dan
minum
Mandi
Toileting
Berpakaian
Berpindah

Ket:
0: mandiri, 1: Alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan
alat, 4: tergantung total
2) Latihan
 Sebelum sakit
.................................................................................................................
.................................................................................................................
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...................
Saat sakit
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...................

e. Pola kognitif dan Persepsi

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f. Pola Persepsi-Konsep diri
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g. Pola Tidur dan Istirahat
Sebelum sakit :
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Saat sakit :
.................................................................................................................
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h. Pola Peran-Hubungan
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i. Pola Seksual-Reproduksi
Sebelum sakit :
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 Saat sakit :
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j. Pola Toleransi Stress-Koping

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k. Pola Nilai-Kepercayaan
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...................

4. Pengkajian Fisik
a. Keadaan umum : ……………………………………….
Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma
GCS : verbal:……….Psikomotor:……….Mata :……………..
b. Tanda-tanda Vital : Nadi = ……… , Suhu =…………. ,
TD =…………, RR =………
c. Keadaan fisik
a. Kepala dan leher :
......................................................................................................
......................................................................................................
......................................................................................................
..........................................................................................
b. Dada :
Paru
......................................................................................................
......................................................................................................
......................................................................................................
..........................................................................................
Jantung
.......................................................................................................
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 .......................................................................................................
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c. Payudara dan ketiak :

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d. abdomen :
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e. Genetalia :
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f. Integumen :
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g. Ekstremitas :
Atas
.......................................................................................................
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Bawah
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h. Neurologis :
Status mental da emosi :
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Pengkajian saraf kranial :
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Pemeriksaan refleks :
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b. Pemeriksaan Penunjang
1. Data laboratorium yang berhubungan
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2. Pemeriksaan radiologi
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3. Hasil konsultasi
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4. Pemeriksaan penunjang diagnostic lain

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b. Formulir Perencanaan Keperawatan
I. ANALISA DATA
 Tabel Analisa Data

DATA Etiologi MASALAH

  B. Tabel Daftar Diagnosa Keperawatan /Masalah Kolaboratif
Berdasarkan Prioritas

TANGGAL /
TANGGAL
NO JAM DIAGNOSA KEPERAWATAN Ttd
TERATASI
DITEMUKAN

 Rencana Tindakan Keperawatan

Rencana Perawatan
No
Hari/Tgl Tujuan dan Kriteria Ttd
Dx Intervensi Rasional
Hasil
 Formulir Catatan Implementasi
Implementasi Keperawatan
Hari/ Tindakan
No Dx Evaluasi proses Ttd
Tgl/Jam Keperawatan

Evaluasi Keperawatan
No Hari/Tgl/Jam No Dx Evaluasi TTd

Formulir Catatan Perkembangan

No Hari/Tgl Diagnosa Implementasi Evaluasi
Keperawatan
Surat Rujukan

PRAKTEK MANDIRI KEPERAWATAN

DESA KALIKALONG RT 05/RW04
KEC.TAYU KAB.PATI
No. SIPP..................................

Kepada. Yth
Dr.............................
Di.............................

SURAT RUJUKAN
Nomor:.................

Dengan hormat,
Berdasarkan ini kami kirimkam pasien:
Nama :..........................................................
Umur : .........................................................
Alamat : .........................................................
Diagnosa Sementara : .........................................................
............................................................
.............................................................
Tindakan yang telah kami berikan: .........................................................
.........................................................
.........................................................

Atas bantuannya kami ucapkan banyak terimakasih

Pati, .........................2021
Hormat kami,

Edy Sugiarto,S.Kep,Ners
NIRA :33180018993
Formulir Pelaporan
No Nama Klien/Suami Umur Alamat Tempat Tinggal Diagnosa Keterangan
Kelurahan/RT/RW

Penanggung Jawab
Lampiran 4 :
DAFTAR ALAT KEPERAWATAN/INSTRUMEN KEPERAWATAN

No Nama Alat/Instrumen Jumlah Keterangan

1 Perlak 2
2 Steak Laken 2
3 Sprei 2
4 Sarung Bantal 2
5 Tensimeter 1
6 Stetoskop 1
7 Bak Instrument 2
8 Pinset Sirugis 2
9 Pinset Anatomis 2
10 Gunting Jaringan 1
11 Gunting Benang 1
12 Bengkok 2
13 COM 1
14 Klem Lurus 7
15 Klem Bengkok 2

Lampiran 5 :
DAFTAR OBAT BEBAS DAN OBAT BEBAS TERBATAS
A. OBAT BEBAS
No Nama Obat Jumlah Keterangan
1 Fasidol 15 Blister
2 Mirasic 15 Blister
3 Emturnas 10 Blister
4 Sakaneuron 8 Blister
5 Beneuron 10 Blister
6 Daneuron 4 Blister
7 Vitamin C 50 20 Tablet
8 Trianta 14 Blister
No Nama Obat Jumlah Keterangan
9 Trimabion 9 Blister
10 Paratenza sirup 3 Botol
11 Bufantasid Forte sirup 5 Botol
12 OBH 3 Botol
 B. OBAT BEBAS TERBATAS
No Nama Obat Jumlah Keterangan
1 Orphen 10 Blister
2 Dimenhidrinate 9 Blister
3 Paratenza Sirup 3 Botol
4 Flutop C Sirup 3 Botol
5 Demacolin 9 Blister
6 Guafenisin Tablet 100 Tablet

Lampiran 6 :
FOTO RUANGAN PRAKTIK DAN LOKASI PRAKTIK