FORMULIR PERMOHONAN KEWENANGAN KLINIS

Nama Dokter : Spesialisasi : Tanda Tangan :

Saya menyatakan bahwa saya kompeten untuk menangani kasus - kasus yang saya minta
dibidang spesialisasi saya, termasuk melayani konsultasi dari dokter-dokter lain. Saya
juga menyatakan kompeten untuk melakukan prosedur teknis seperti yang tercantum
bahwa 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.

Seritifikat/Ijazah : Tanggal dikeluarkan : Instansi (tempat ijazah

spesialisasi dikeluarkan) :

No. Ijazah spesialisasi :

Nomor Surat Rekomendasi Tanggal : Kolegium :

Kolegium :

Pelatihan : Tanggal : Institusi :

(3 tahun terakhir)

Surat Tanda Registrasi Konsil Kedokteran Indonesia

Spesialisasi : Berlaku Hingga Tanggal :

 Petunjuk

Untuk Dokter :
Tuliskan kode untuk dokter menurut permintaan sejawat sesuai daftar “Kode untuk
Dokter” yang tersedia. Setiap kategori yang ada dan/atau kewenangan klinis yang diminta
harus tercantum kodenya. Pengisian harus lengkap untuk seluruh kewenangan klinis yang
tercantum. Tanda tangan dicantumkan pada akhir bagian I (kewenangan klinis). Jika
terdapat revisi atau perbaikan, setelah daftar kewenangan klinis ini disetujui, maka harus
mengisi kembali formulir yang baru.

Untuk Mitra Bestari :

Mohon melakukan telaah pada setiap kewenangan klinis yang diminta oleh setiap dokter
sesuai dengan kode yang tersedia. Cantumkan persetujuan yang tersedia. Persetujuan mitra
bestari kepada komite medis untuk pemberian penugasan klinik (clinical appointment)
dari Direktur Rumah Sakit PKU Muhammadiyah Sekapuk. Bubuhkan tanda tangan mitra
bestari pada akhir bagian II (rekomendasi mitra bestari).

Kode untuk Dokter :

1. Kompeten sepenuhnya.
2. Memerlukan supervisi
3. Tidak dimintakan kewenangan klinisnya karena diluar kompetensinya.
4. Tidak dimintakan kewenangan klinisnya karena fasilitas tidak tersedia.

Kode untuk Mitra Bestari :

1. Disetujui berwenang penuh
2. Disetujui di bawah supervisi
3. Tidak disetujui , karena bukan kompetensinya
4. Tidak disetujui, karena fasilitas tidak tersedia

Tanggal :
Mengetahui,
Komite Medis Ketua KSM
 Bagian I. Kewenangan Klinis (Clinical Privilege)

Kewenangan klinis diberikan untuk memberikan pelayanan pengelolaan bidang Bedah

Orthopedi di Rumah Sakit PKU Muhammadiyah Sekapuk. Berdasarkan pada pelayanan yang
dibutuhkan pasien.

Jenis Pelayanan Diminta Rekomendasi

(yang bersangkutan)

1. 2. Operations on spinal cord and spinal canal

structure
3. 4. Exploration and decompression of spinal
canal.
Decompression: laminectomy, laminotomy.
Expansile laminoplasty
Exploration of spinal nerve root,
foraminotomy
5. 6. Diagnostic procedures on spinal cord and
spinal canal structueres
7. 8. Biopsy of spinal cord or spinal meninges (Cg)
9. 10. Excision or destruction of lesion of spinal
cord or spinal meninges
Curettage of spinal cord or spinal meninges
11.12. Repair of vertebral fracture
Elevation of spinal bone fragments
Reduction of fracture of vertebrae
Removal of bony spicules form pinal canal
13.14. Percutaneous denervation of facet
15.16. Release of carpal tunnel
17.18. Release of tarsal tunnel
19.20. Other peripheral nerve or ganglion
decompression or lysis of adhesions
peripheral nerve neurolysis NOS
21.22. Suture of vessel
Repair of laceration of blood vessel
23.24. Suture of artery (Bs)
25.26. Suture of vein (Bs)
27.28. Sequestrectomy
29.30. Wedge osteotomy
31.32. Other division of bone, osteoarthrotomy
33.34. Biopsy of bone
35.36. Excision of bone for graft
37.38. Bone graft
Bone : bank graft, graft (autogenous)
(heterogenous)
That with debridement of bone graft site
(removal of sclerosed, fibrous or necrotic
bone or tissue), transplantation of bone.
39.40. Application of external fixator device
Fixator with insertion of pins/wires/screws
into bone
 Jenis Pelayanan Diminta Rekomendasi
(yang bersangkutan)

41. Limb shortening procedures

Epiphyseal stapling, open epiphysiodesis,
percutaneous epiphysiodesis,
resection/osteotomy
42. Limb lengthening procedures
Bone graft with or without internal fixation
devices or osteotomy
Distraction technique with or without
corticotomy/osteotomy
43. Internal fixation of bone without fracture
reduction
Internal fixation of bone (prophylactic),
reinsertion of internal fixation device,
revisiom of displaced or broken fixation
device
44. Removal of implanted devices from bone
External fixator device (invasive), internal
fixation device, removal of bone growth
stimulator (invasive), removal of internal limb
lengthening device, removal of pedicle screw
(s) used in spinal fusion.
45. Reduction of fracture and dislocation
46. Close reduction of fracture without internal
fixation
47. Close reduction of fracture with internal
fixation
48. Open reduction of fracture without internal
fixation
49. Open reduction of fracture with internal
fixation
50. Closed reduction of separated epiphysis
Reduction with or without internal fixation
51. Open reduction of separated epiphysis
Reduction with or without internal fixation
52. Debridement of open fracture site
Debridement of compound fracture
53. Closed reduction of dislocation
Includes: closed reduction (with external
traction device)
54. Closed reduction of dislocation of unspecified
site
55. Closed reduction of dislocation of shoulder
56. Closed reduction of dislocation of elbow
57. Closed reduction of dislocation of wrist
58. Closed reduction of dislocation of hand and
finger
59. Closed reduction of dislocation of hip
60. Closed reduction of dislocation of knee
61. Closed reduction of dislocation of ankle
62. Closed reduction of dislocation offoot and toe
63. Closed reduction of dislocation of other
specified sites

Jenis Pelayanan Diminta Rekomendasi

(yang bersangkutan)

64. Open reduction of dislocation

Includes: open reduction (with internal and
external fixation devices)
65. Open reduction of dislocation of unspecified
site
66. Open reduction of dislocation of shoulder
67. Open d reduction of dislocation of elbow
68. Open reduction of dislocation of wrist
69. Open reduction of dislocation of hand and
finger
70. Open reduction of dislocation of hip
71. Open reduction of dislocation of knee
72. Open reduction of dislocation of ankle
73. Open reduction of dislocation offoot and toe
74. Open reduction of dislocation of other
specified sites
75. Unspecified operation on bone injury,
unspecified site
76. Unspecified operation on bone injury,
shoulder
77. Unspecified operation on bone injury, elbow
78. Unspecified operation on bone injury, wrist
79. Unspecified operation on bone injury, hand
and finger
80. Unspecified operation on bone injury, hip
81. Unspecified operation on bone injury, knee
82. Unspecified operation on bone injury, ankle
83. Unspecified operation on bone injury, foot
and toe
84. Unspecified operation on bone injury, other
specified sites
85. Incision of joint structure
86. Arthrotomy for removal of prosthesis
87. Other arthrotomy. Arthrostomy
88. Arthroscopy
89. Excision, destruction and other repair of
intervertebral disc
90. Excision or destruction of intervertebral disc,
unspecified
Unspecified as to excision or destruction
91. Excision of intervertebral disc, diskectomy
Removal of herniated nucleus pulposus
Level: cervical, thoracic, lumbar
(lumbosacral)
92. Repair of the anulus fibrosus with graft or
prosthesis, anular disc repair, closure (sealing)
of the annulus fibrosus defect
Includes: microsurgical suture repair with
facial autograft, soft tissue reapproximation
repair with tension bands, surgical mesh
 repair.

Diminta Rekomendasi
Jenis Pelayanan (yang bersangkutan)
93. Other and unspecified repair of the anulus
fibrosus, anular disc repair, closure (sealing) of
the anulus fibrosus defect, microsurgical suture
repair without fascial autograft, percutaneous
repair of the annulus fibrosus.
94. Excision of semilunar cartilage of knee,
excision of meniscus of knee
95. Synovectomy, complete or partial resection of
synovial membrane
96. Spinal fusion
Includes: arthrodesis of spine with: bone graft,
internal fixation
97. Spinal fusion, not otherwise specified
98. Atlas-axis spinal fusion
Craniocervical fusion by anterior, transoral or
posterior technique, anterolateral technique C1-
C2 fusion by anterior, transoral or posterior
technique.
Occiput C2 fusion by anterior, transoral or
posterior technique
99. Other cervical fusion, posterior technique
Arthrodesis of C2 level or below: anterior
(interbody) technique, anterolateral technique
100. Other cervical fusion, posterior technique
Arthrodesis of C2 level or below: posterior
(interbody) technique, posterolateral technique
101. Dorsal and dorsolumbar fusion, anterior
technique
Arthrodesis of thoracic or thoracolumbar
region: posterior (interbody) technique,
posterolateral technique.
102. Lumbar and lumbosacral fusion, anterior
technique
Anterior lumbar interbody fusion (ALIF)
Arthrodesis of lumbar or lumbosacral region:
anterior (interbody) technique, anterolateral
technique
103. Lumbar and lumbosacral fusion, lateral
transverse process technique
104. Lumbar and lumbosacral fusion, posterior
technique
Arthrodesis of lumbar or lumbosacral region:
Posterior (interbody) technique, posterolateral
technique
Posterior lumbar interbody fusion (PLIF),
Transforaminal lumbar interbody fusion (TLIF)
105. Arthrodesis and arthroereisis of foot and ankle,
includes: arthrodesis of foot and ankle with:
bone graft, external fixation device
106. Ankle fusion, tibiotalar fusion
107. Triple arthrodesis. Talus to calcaneus and
calcaneus to cuboid and navicular
 Jenis Pelayanan Diminta Rekomendasi
(yang bersangkutan)

108. Subtalar fusion

109. Midtarsal fusion
110. Tarsometatarsal fusion
111. Metatarsophalangeal fusion
112. Other fusion of foot
113. Subtalar joint arthroereisis
114. Arthrodesis of other joint
Includes: arthrodesis with: bone graft,
external fixation device, excision of bone
ends and compression
115. Arthrodesis of unspecified joint
116. Arthrodesis of hip
117. Arthrodesis of knee
118. Arthrodesis of shoulder
119. Artthrodesis of elbow
120. Carporadial fusion
121. Metacarpocarpal fusion
122. Metacarpophalangeal fusion
123. Interphalangeal fusion
124. Arthrodesis of other specified joints
125. Refusion of spine, not otherwise specified
126. Refusion of atlas-axis spine,
Carniocervical fusion by anterior, transoral or
posterior technique, C1-C2 fusion by anterior,
transoral or posterior technique.
Occiput C2 fusion by anterior, transoral or
posterior technique
127. Refusion of other cervical spine, anterior
technique
Arthrodesis of C2 level or below: anterior
(interbody) technique, anterolateral technique
128. Refusion of other cervical spine, posterior
technique.
Arthrodesis of C2 level or below: posterior
(interbody) technique, posterolateral
technique
129. Refusion of dorsal and dorsolumbar spine,
anterior technique.
Arthrodesis of thoracic or thoracolumbar
region: anterior (interbody) technique,
anterolateral technique
130. Refusion of dorsal and dorsolumbar spine,
posterior technique.
Arthrodesis of thoracic or thoracolumbar
region: posterior (interbody) technique,
posterolateral technique
131. Refusion of lumbar and lumbosacral spine,
anterior technique.
Anterior lumbar interbody fusion (ALIF)
 Arthrodesis of lumbar or lumbosacral region:
anterior (interbody) technique, antreolateral
technique.

Jenis Pelayanan Diminta Rekomendasi

(yang bersangkutan)

132. Refusion of lumbar and lumboscral spine,

lateral transverse process technique
133. Refusion of lumbar and lumbosacral spine,
posterior technique
Arthrodesis of lumbar or lumbosacral region:
posterior (interbody) technique, posterolateral
technique.
Posterior lumbar interbody fusion (PLIF),
Transforaminal lumbar interbody fusion
(TLIF)
134. Refusion of spine, not elsewhere classified
135. Patellar srabilization. Roux-Goldwait
operation for recurrent dislocation of patella
136. Other repair of the cruciate ligaments
137. Other repair of the collateral ligaments
138. Joint replacement of lower extremity
Includes: arthroplasty of lower extremity
with: external traction or fixation, graft of
bone (chips) or cartilage, internal fixation
device of prosthesis.
139. Total hip replacement
Replacement of both femoral head and
acetabulum by prosthesis
Total reconstruction of hip
140. Partial hip replacement. Bipolar
endoprosthesis
141. Total knee replacement
Bicompartmental, tricompartmental,
unicompartmental (hemijoint)
142. Total knee replacement
143. Other procedures on spine
144. Fusion or refusion of 2-3 vertebrae
145. Fusion or refusion of 4-8 vertebrae
146. Fusion or refusion 0f 9 or more vertebrae
147. Arthroplasty and repair of hand, fingers and
wrist
Includes: arthroplasty of hand and finger
with: external traction or fixation, graft of
bone (chips) or cartilage, internal fixation
device or prosthesis
148. Arthroplasty and repair of shoulder and elbow
Inclues: arthroplasty of upper limb NEC with:
external traction or fixation, graft of bone
(chips) or cartilage, internal fixation device or
prosthesis.
149. Total shoulder replacement
150. Repair of recurrent dislocation of shoulder
151. Total elbow replacement
152. Arthrocentesis. Joint aspiration
153. Injection of therapeutic substance into joint or
ligament

Jenis Pelayanan Diminta Rekomendasi

(yang bersangkutan)

154. Operations on muscle, tendon and fascia of

hand
Includes: operation on: aponeurosis, synovial
membrane (tendon sheath), tendon sheath
155. Incision and drainage of palmar or thenar
space
156. Reattachment of tendon of hand
157. Other hand tendon transfer or tansplantation
158. Tendon pulley reconstruction. Recosntruction
for opponenspalsty
159. Repair of mallet finger
160. Achillotenotomy
161. Adductor tenotomy of hip
162. Fasciotomy. Division of fascia, division of
iliotibial band, fascia stripping, release of
volkmann’s contracture by fasciotomy
163. Excision of lesion of tendon sheath. Excision
of ganglion of tendon sheath, except of hand
164. Bursectomy
165. Suture of muscle, tendon and fascia
166. Other suture of tendon. Achillorrhaphy,
aponeurorrhaphy
167. Tendon pulley reconstruction
168. Amputation of upper limb
169. Amputation and disarticulation of finger
170. Amputation and disarticulation of thumb
171. Amputation through hand
172. Disarticulation of wrist
173. Amputation through forearm. Forearm
amputation
174. Disarticulation of elbow
175. Amputation through humerus. Upper arm
amputation
176. Disarticulation of shoulder
177. Interthoracoscapular amputation. Forequarter
amputation
178. Amputation of lower limb
179. Lower limb amputation, not otherwise
specified.
Closed flap amputation of lower limb NOS
Kineplastic amputation of lower limb NOS
Open or guillotine amputation of lower limb
NOS
Revision of current traumatic amputation of
lower limb NOS
180. Amputation of toe. Amputation through
metatarsophalangeal joint
Disarticulation of toe.
Metatarsal head amputation
 Ray amputation of foot (disarticulation of the
metatarsal head of the toe)

Jenis Pelayanan Diminta Rekomendasi

(yang bersangkutan)

181. Amputation through foot. Amputation of

forefoot
Amputation through middle of foot. Chopart’s
amputation
Midtarsal amputation. Transmetatarsal
amputation (amputation of the fore foot,
including all the toes)
182. Disarticulation of ankle
183. Amputation of ankle through malleoli of tibia
and fibula
184. Disarticulation of knee. Batch, spitler and
McFaddin amputation
Mazet amputation S.P Rogers’s amputation
185. Amputation above knee. Amputation of leg
through femur
Amputation of high. Conversion of below-
knee amputation into above-knee amputation.
Supracondylar above-knee amputation
186. Disarticular of hip
187. Reattachment of extremity
188. Thumb reattachmnet
189. Finger reattachment
190. Forearm, wrist or hand reattachment
191. Revision of amputation stump
Reamputation of stump, secondary closure of
stump, trimming of stump.
192. Insertion of spinal disc prosthesis, not
otherwise specified
Replacement of spinal disc, NOS
Includes: diskectomy
193. Insertion of partial spinal disc prosthesis,
cervical.
Nuclear replacement device, cervical
Partial artificial disc prosthesis (flexible),
cervical.
Replacement of nuclear disc (nucleus
pulposus), cervical
Includes: diskectomy
194. Insertion of total spinal disc prosthesis,
cervical.
Replacement of cervical spinal disc, NOS
Replacement of total spinal disc, cervical.
Total artificial disc prosthesis (flexible),
cervical.
Includes: diskectomy
195. Insertion of spinal disc prosthesis, thoracic.
Artificial disc prosthesis (flexible), thoracic.
Replacement of thoracic spinal disc, partial or
total
 Includes : diskectomy

Jenis Pelayanan Diminta Rekomendasi

(yang bersangkutan)

196. Insertion of total spinal disc prosthesis,

lumbosacral.
Replacement of lumbar spinal disc, NOS
Replacement of total spinal disc, lumbar
Total artificial disc prosthesis (flexible),
lumbar
Includes: diskectomy
197. Revision or replacement of artificial spinal
disc prosthesis, cervical.
Removal of (partial) (total) spinal disc
prosthesis with synchronous insertion of new
(partial) (total) spinal disc prosthesis, cervical.
Repair of previously inserted spinal disc
prosthesis, cervical.
198. Revision or replacement of artificial spinal
disc prosthesis, thoracic.
Remove of (partial) (total) spinal disc
prosthesis with synchronous insertion of new
(partial) (total) spinal disc prosthesis,
thoracic. Repair of previously inserted spinal
disc prosthesis, thoracic.
199. Revision or replacement of artificial spinal
disc prosthesis, lumbosacral.
Remove of (partial) (total) spinal disc
prosthesis with synchronous insertion of new
(partial) (total) spinal disc prosthesis,
lumbosacral. Repair of previously inserted
spinal disc prosthesis, lumbosacral.
200. Application of external fixator device,
monoplanar system
201. Application of external fixator device, ring
system
202. Insertion of replacement of interspinous
process device
Interspinous process decompression device
Interspinous process distraction device
203. Insertion or replacement of pedicle-based
dynamic stabilization device
204. Pedicle grafts or flaps
205. Pedicle or flap graft, not otherwise specified
206. Advancement of pedicle graft
207. Correction of syndactyly
208. Skeletal traction and other traction
209. Spinal traction using skull device. Traction
using: caliper tongs
Cructhfield tongs, halo device, vinke tongs
210. Other spinal traction. Cotrel’s traction
 Jenis Pelayanan Diminta Rekomendasi
(yang bersangkutan)

211. Other skeletal traction.

Bryant’s traction, dunlop’s traction, lyman
smith traction, russell’s traction
212. Thomas splint traction
213. Other skin traction of limbs
Adhesive tape traction, boot traction, buck’s
traction, gallows traction
214. Application of plaster jacket
215. Application of neck support. Application of:
cervical collar, minerva jacket, molded neck
support
216. Application of other cast
217. Application of splint. Plaster splint, tray splint
218. Application of pressure dressing. Application
of: gibney bandage, robert jones’ bandage,
shanz dressing.
 Bagian II. Rekomendasi Mitra Bestari

Disetujui : Disetujui dengan Catatan Tidak disetujui

Tanggal :

Catatan :

Daftar Mitra Bestari

No. Nama Spesialisasi Tanda Tangan

1.
2.
3.
4.
5.

Bagian III. Komite Medik / Subkomite Kredensial

Disetujui : Disetujui dengan Catatan Tidak Disetujui

Tanggal :

Catatan :

Ketua Komite Medik Ketua Subkomite Kredensial