DAFTAR TINDAKAN YANG PERLU INFORMED CONSENT

Sesuai Undang – Undang no 44 tahun 2009 tentang rumah sakit dan

Permenkes No 290/Menkes/Per/III/2008 tentang persetujuan tindakan
kedokteran, terdapat beberapa tindakan kedokteran dan kedokteran gigi
yang wajib diberikan informed consent. Tindakan tersebut yaitu :
A. Semua Tindakan Pembedahan dan Tindakan Invasive
B. Semua Tindakan Anestesi & Sedasi ( Sedasi Sedang dan
Sedasi Dalam )
C. Semua Tindakan Pemberian Produk Darah & Komponen Darah
D. Semua Tindakan Yang Berisiko Tinggi.

A. Tindakan Pembedahan dan Tindakan Invasive yang memerlukan

informed consent antara lain:

NO Unit / Instalasi Tindakan

1 Bedah syaraf Amygdala Hypocampectomy (Epilepsi)
Anterior Temporomesial Lobectomi (Epilepsi)
Biopsi Saraf Tepi/Otot
Blok Saraf Perifer I
Cingulotomy (Psichiatric)
Corpus Callosotomi (Epilepsi)
Debrimen Rekonstruksi Vulnus Kulit Kepala
Dekompresi Saraf Tepi
Dekompresi Tulang Durameter
Dekortikasi Sinus Frontalis
Denervasi Facet
DREZ Lession (Pain)
Eksisi Ensefalokel/Mielokel
Eksisi Kista Jinak Kulit Kepala
Eksisi Osteoma/Osteositosis
Elevasi Kraniotomi Fraktur Impresi,Dengan
Robekan
Dura
Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan
Extirpasi Tumor Jinak Saraf Kulit Kepala
Fusi Stabilisasi Corpus Vertebra
Graft/Transposisi Saraf Tepi
Hemisferektomi (Epilepsi)
Hemisferoktomi (Epilepsi)
Injeksi saraf perifer (dengan radiofrekuensi)
Injeksi spinal (Pain)
Insersi Elektrode Intradural
(Epilepsi,movement,psikiatrik)
Kordotomi Perkutan
Kordotomi Servikal Open (Pain)
Kordotomi Servikal Perkutan (Pain)
Kranioplasti dua sisi
Kranioplasti satu sisi
Kraniotomi Biopsi otak
Laminektomi Eksisi Tumor Spinal
Laminoplasti
Laminotomi Biopsi Mielum
Laminotomi Diskektomi HNP/Stenosis>1 level
Laminotomi Diskektomi HNP/Stenosis 1 level
Lesionectomy (Epilepsi)
Lobektomi (Epilepsi)
Mesencephalectomy (Pain)
Mikrodisekktomi HNP
MVD (Microvascular Decompression)
Neurektomi/Neurolise
Neuroendoskopi (Otak,Spinal)
Neuroplasti
Omaya drain
Pallidotomi (movement Disorder)
Paravertebral Blok Perkutan
Pemasangan Traksi Servikal
Penjahitan Saraf Tepi
Punksi Cairan Otak
Reseksi Extra-Temporal (Epilepsi)
Revisi VP Shunt
Rhizotomi Selektif (Spastisitas)
Rhizotomy (Pain)
Selective Nerve Root Block
Selective Thalamotomi (Movement Disorder)
Simpatektomi Open (Pain)
Simpatektomi Perkutan
SLTH
Stereotactic Ablative Procedure (Psichiatric)
Subthalamotomy (Movement Disorder)
Suturektomi Kraniostenosis
Thalomotomy (Pain)
Transposisi kraniostenosis,dengan orbital
advancement
Transposisi kraniostenosis,tanpa orbital
advancement
Trepanasi Cedera Kepala (<4jam)
Trepanasi Cedera Kepala (>4jam)
Trepanasi CVA Bleeding
Trepanasi kelainan Saraf Kranial
Trepanasi Kelainan Vascular Otak
Trepanasi Tumor Otak
VA Shunt
VP Shunt Multiple
VP Shunt Satu Sisi
2 Bedah kepala Aff Arch Barr
Leher Aff Arch Barr dan suspensi maksila
Biopsy Insisional dengan anastesi lokal
Deseksi submandibular
Diseksi leher radikal/radikal neck dissection
Eksisi gld submandibula
Eksisi higroma leher
Eksisi kista tiroglosus
Eksisi luas tumor ganas bibir dengan rekontruksi
flap lokal
Eksisi luas tumor ganas dengan rekontruksi flap jauh
Eksisi luas tumor ganas kulit dengan rekontruksi
flap lokal
Eksisi luas tumor ganas rongga mulut dengan
rekontruksi flap lokal
Eksisi parsial+marsupialisasi Ranula
Eksisi tumor ganas kulit dengan flap local atau graft
Kulit
Eksisi tumor ganas kulit dengan flap local jauh
Eksisi tumor ganas kulit tanpa rekontruksi
Eksisi tumor jinak dengan anastesi lokal
Ekskokleasi epulis
Ekskokleasi kista folikuler
Ekskokleasi kista radikuler
Ekstirpasi/eksisi tumor jinak jaringan lunak ukuran
<2cm
Ekstirpasi kista dermoid
Endoscopic thyroidectomy
Fiksasi interna fraktur maksilofasial 1-2 tempat
patahan
Fiksasi interna fraktur nasal
Fiksasi interna pan-facial
Hemiglosektomi
Insisi abses dengan anastesi lokal
Insisi flegmon dasar mulut
Internal Fiksasi fraktur condylus mandibula
Internal Fiksasi fraktur maksilofasial 3-4 tempat
patahan
Internal fiksasi fraktur maksilofasial 5 tempat patahan
atau lebih
Laringectomi

3 Bedah THT_KL Adenotonsilektomi

Anthrostomi+Sinuskopi
BLM Simple (Kista,Polip,Nodul,Granulasi)
Biopsi Tumor
Bronkoskopi Rigid
BLM Advance (Stenosis, Subjektif/Trakea, Papiloma
Laring/Trakea)
Cald Well Luc
Cochlear Implant/Implan Baha
Dekompresi Nervus Fasialis
DCR
Eksisi Ekstostosis
Ekstirpasi Kista Branchial
Ekstirpasi Kista Ductus Tiroglosus
Ekstraksi granulasi MAE/Kolesteatosis
Ekstraksi Polip
Esofagoskopi Rigid & Fleksibel
Ethmoidektomi (Intranasal)
Ekstraksi Korpus Alienum Kavum Nasi
Ekstraksi Korpus Alienum Kavum Nasi Endoskopi
Ekstirpasi Fistel Pre Aurikuler
Ekstraksi Korpus Alienum MAE
Ekstirpasi Kelenjar Sub Mandibula
Ekstirpasi Angiofibroma Nasofaring
Eksplorasi Abses Parafaringeal
Ekstirpasi Tumor Jinak Kepala & Leher (Aterom
Lipoma)
Faringotomi
FESS
FESS Advance
Frontal Sinusotomi
Fore Head Flap
Fronto Etmoidektomi (Ekstranasal)
FOL
Glosektomi Total/Parsial
Glosektomi Total/Hemiglosektomi+RND
Hemiglosektomi+SOHND
Insisi Abses Leher Dalam
Inversi Grommet
Insisi Perikondritis
Irigasi Sinus Maksila
Insisi Abses Peritonsil
Imunoterapi
Konka Reduksi
Kaustik Konka Inferior
Laringektomi
Laringektomi+ND
Laringo Fisur/Eksplorasi Laring
Ligasi A. Karotis Eksternal
Laringoskopi Rigid
Laringoskopi Fleksible
Laringoskopi Direkta
Maksilektomi Total+Rekontruksi
Mastoidektomi Radikal
 Mini FESS
Myocutaneus Flap (Pectoral Mayor)
Myringoplasty/Timpaniplasti
Mandibulekromi
Neurektomi Saraf Vidian
Osteotomi+Septum koreksi
Rekontruksi Fraktur Maksila Multiple
Rekontruksi Fraktur Maksila Sederhana
Rhinoplasti
Rinotomi Lateral+Maksilektomi Medial
Rekontruksi Laring Trakea
Reposisi Fraktur Os Nasal
Reposisi & Fiksasi Fraktur Mandibula
Septum Koreksi+Konkotomi
Stapedektomi
Skin Pricle Test
Tiroidektomi Sub-Total
Tonsilektomi/Adenoidektomi
Tracheostomi
Turbinektomi
Tiroidektomi Total+ND
Temporal Bone Resection
Terapi Wicara pada Anak-Anak dan dewasa
Terapi Wicara Tuna Laring

4. Orthopedi dan Abdominopelvic amputation

traumalogi Achillotenotomy
Adductor tenotomy of hip
Advancement of tendon
Advancement of tendon of hand
Amputation above knee
Amputation and disarticulation of finger- general
anaesthesia
Amputation and disarticulation of finger -local
anaesthesia
Amputation and disarticulation of thumb-general
anaesthesia
Amputation and disarticulation of finger- general
anaesthesia
Amputation and disarticulation of finger -local
anaesthesia
Amputation and disarticulation of thumb-general
anaesthesia
Amputation and disarticulation of thumb-local
anaesthesia
Amputation of ankle through malleoli of tibia and
fibula
Amputation of toe-general anaesthesia
Amputation of toe-local anaesthesia
Amputation through foot
Amputation through forearm
Amputation through hand, Amputation through
carpals
Amputation through humerus, Upper arm amputation
Amputation, not otherwise specified
Ankle fusion
Application of external fixator device
Application of external fixator device, monoplanar
system
Application of external fixator device, ring system
Application of hybrid external fixator device
Arthrocentesis
Arthrodesis of elbow
Arthrodesis of hip
Arthrodesis of knee
Arthrodesis of other specified joints
Arthrodesis of shoulder
Arthrodesis of unspecified joint
Arthroplasty of carpocarpal or carpometacarpal joint
with implant
Arthroplasty of carpocarpal or carpometacarpal joint
without implant
Arthroplasty of metacarpophalangeal and
interphalangeal joint with implant
Arthroplasty of metacarpophalangeal and
interphalangeal joint without implant
Arthroscopy
Arthrotomy for removal of prosthesis without
Replacement
Aspiration of bursa
Aspiration of bursa of hand
Aspiration of other soft tissue
Aspiration of other soft tissue of hand
Atlas-axis spinal fusion
Biopsy of bone
Biopsy of joint structure
Biopsy of spinal cord or spinal meninges
Bone graft
Bone marrow or hematopoietic stem cell transplant
(all procedures included in this class
Bunionectomy with soft tissue correction and
arthrodesis
Bunionectomy with soft tissue correction and
osteotomy of the first metatarsal
Bursectomy
Bursectomy of hand
Bursotomy
Bursotomy of hand
Carporadial fusion
Closed reduction of dislocation -General
anaesthesia
Closed reduction of dislocation of ankle
Closed reduction of dislocation of elbow
Closed reduction of dislocation of foot and toe-
general anaesthesia
Closed reduction of dislocation of foot and toe-local
anaesthesia
Closed reduction of dislocation of hand and finger-
general anaesthesia
Closed reduction of dislocation of hand and finger-
local anaesthesia
Closed reduction of dislocation of hip
Closed reduction of dislocation of knee
Closed reduction of dislocation of other specified
sites-general anaesthesia
Closed reduction of dislocation of other specified
sites-local anaesthesia
Closed reduction of dislocation of other specified
sites-local anaesthesia
Closed reduction of dislocation of shoulder
Closed reduction of dislocation of wrist
Closed reduction of dislocation-Local anaesthesia
Closed reduction of fracture with internal fixation -
Carpal and metacarpal
Closed reduction of fracture with internal fixation -
Femur (Including : MIPO, interlocking nail, TEN)
Closed reduction of fracture with internal fixation -
Humerus (including : Interlocking nail, TEN, MIPO)
Closed reduction of fracture with internal fixation -
Intrarticular Major Bone
Closed reduction of fracture with internal fixation -
Phalang of foot
Closed reduction of fracture with internal fixation -
Phalang of hand
Closed reduction of fracture with internal fixation -
Radius and ulna (MIPO, TEN)
Closed reduction of fracture with internal fixation -
Tarsal and metatarsal
Excision of bone for graft
Excision of intervertebral disc
Excision of lesion of muscle
Excision of lesion of muscle of hand
Excision of lesion of other soft tissue
Dorsal and dorsolumbar fusion of the anterior
column, anterior technique
Dorsal and dorsolumbar fusion of the posterior
column, posterior technique
Excision of bone for graft
Excision of intervertebral disc
Excision of lesion of muscle
Excision of lesion of muscle of hand
Excision of lesion of other soft tissue
Excision of lesion of tendon sheath
Excision of lesion of tendon sheath of hand,
Ganglionectomy of tendon sheath (wrist)-General
anaesthesia
Excision of lesion of tendon sheath of hand,
Ganglionectomy of tendon sheath (wrist)-Local Anaestesi
Excision of muscle or fascia for graft
Excision of other lesion of soft tissue of hand
Excision of semilunar cartilage of knee
Excision of tendon for graft
Excision of tendon of hand for graft
Excision or correction of bunionette, That with
osteotomy
Excision or destruction of intervertebral disc,
unspecified
Exploration of tendon sheath
Exploration of tendon sheath of hand
Exploratory thoracotomy
Fasciotomy
Fasciotomy of hand
Finger reattachment
Five-in-one repair of knee
Foot reattachment
Forearm, wrist, or hand reattachment
Fusion or refusion of 2-3 vertebrae
Fusion or refusion of 4- 8 vertebrae
Fusion or refusion of 9 or more vertebrae
Graft of muscle or fascia
Hip bearing surface, ceramic-on-ceramic
Hip bearing surface, ceramic-on-polyethylene, Hip
bearing surface, oxidized zirconium-on-polyethylene
Hip bearing surface, metal-on-metal
Hip bearing surface, metal-on-polyethylene
Implantation of internal limb lengthening device with
kinetic distraction
implantation of other internal limb lengthening
device
Implantation or replacement of peripheral
neurostimulator lead (s)
Implantation or replacement of spinal
neurostimulator lead(s)
Incision and drainage of palmar or thenar space
Injection of anesthetic into peripheral nerve for
analgesia
Injection of anesthetic into spinal canal for analgesia
Injection of destructive agent into spinal canal
Injection of locally-acting therapeutic substance into
other soft tissue
Injection of other agent into spinal canal, Intrathecal
injection of steroid, Subarachnoid perfusion of
refrigerated saline
Injection of therapeutic substance into bursa
Injection of therapeutic substance into bursa of hand
Injection of therapeutic substance into joint or
ligament
Injection of therapeutic substance into tendon
Injection of therapeutic substance into tendon of
hand
Insertion of bone growth stimulator
Insertion of bone void filler
Insertion of catheter into spinal canal for infusion
of therapeutic or palliative substances, Insertion of
catheter into epidural, subarachnoid, or subdural
space of spine with intermittent or continuous
infusion of drug (with creation of any reservoir)
Insertion of interbody spinal fusion device
Insertion of other spinal devices
Insertion of partial spinal disc prosthesis, cervical
Insertion of partial spinal disc prosthesis,
lumbosacral
Insertion of recombinant bone morphogenetic
protein
Insertion of spinal disc prosthesis, not otherwise
specified, Replacement of spinal disc, NOS
Insertion of spinal disc prosthesis, thoracic
Insertion of sternal fixation device with rigid plates
Insertion of total spinal disc prosthesis, cervical
Insertion of total spinal disc prosthesis, lumbosacral
Insertion or replacement of (cement) spacer
Insertion or replacement of facet replacement
device(s)
Insertion or replacement of interspinous process
device(s)
Insertion or replacement of pedicle-based dynamic
stabilization device(s)
Insertion or replacement of skeletal muscle
stimulator
Internal fixation of bone without fracture reduction
Interphalangeal fusion
Interthoracoscapular amputation, Forequarter
amputation
Intra-operative neurophysiologic monitoring -
Neuromonitoring
Intervertebral chemonucleolysis
Limb lengthening procedures
Limb shortening procedures
Local excision of lesion or tissue of bone
Lower leg or ankle reattachment
Lower limb amputation, not otherwise specified
Lumbar and lumbosacral fusion of the anterior
column, anterior technique
Lumbar and lumbosacral fusion of the anterior
column, posterior technique
Lumbar and lumbosacral fusion of the posterior
column, posterior technique
Lysis of adhesions of hand
Lysis of adhesions of muscle, tendon, fascia, and
bursa
Lysis of adhesions of spinal cord and nerve roots
Metacarpocarpal fusion
Metacarpophalangeal fusion
Metatarsophalangeal fusion
Midtarsal fusion
Muscle transfer or transplantation
Myotomy
Myotomy of hand
Neurectasis
Open biopsy of cranial or peripheral nerve or
ganglion
Open biopsy of soft tissue
Open reduction of dislocation of ankle - Neglected
dislocation
Open reduction of dislocation of elbow -Fresh
dislocation
Open reduction of dislocation of hand and finger -
Fresh dislocation
Open reduction of dislocation of hip - Fresh
dislocation
Open reduction of dislocation of hip - Neglected
dislocation
Open reduction of dislocation of knee - Neglected
dislocation
Open reduction of dislocation of knee -Fresh
dislocation
Open reduction of dislocation of other specified sites
Open reduction of dislocation of shoulder -Fresh
dislocation
Open reduction of dislocation of shoulder -Neglected
dislocation
Open reduction of dislocation of unspecified site-
Fresh
dislocation
Open reduction of dislocation of unspecified site-
Neglected dislocation
Open reduction of dislocation of wrist -Fresh
dislocation
Open reduction of fracture with internal fixation-
radius and ulna-Simple fracture
Open reduction of fracture with internal fixation-
unspecified site (Periarticular Major Bone )
Open reduction of fracture with internal fixation-
carpals and metacarpals - plate & screws
Hand NOS -Plate & Screw
Open reduction of fracture with internal fixation-
carpals and metacarpals - plate & screws
Hand NOS -Plate & Screw
Open reduction of fracture with internal fixation-
carpals and metacarpals - simple implants (K-
wire) Hand NOS -implant sederhana (K-wire)
Open reduction of fracture with internal fixation-
femur- Comminutive or Segmental
Open reduction of fracture with internal fixation-
femur- Simple fracture
Open reduction of fracture with internal fixation-
humerus - Simple fracture
Open reduction of fracture with internal fixation-
humerus - Comminutive or Segmental
Open reduction of fracture with internal fixation-
other specified bone (Intraartikular Major Bone )
Open reduction of fracture with internal fixation-
phalanges of foot - simple implants (K-wire)
Open reduction of fracture with internal fixation-
phalanges of foot-Plate & Screws
Open reduction of fracture with internal fixation-
phalanges of hand- Plate & Screws
Open reduction of fracture with internal fixation-
phalanges of hand- simple implants
Open reduction of fracture with internal fixation-
tarsals and metatarsals- Plate & Screws
Open reduction of fracture with internal fixation-
tarsals and metatarsals- simple implants
Open reduction of fracture with internal fixation-
tibia and fibula -Simple fracture
Open reduction of fracture with internal fixation-tibia
and fibula-Comminutive or Segmental
Open reduction of fracture without internal
fixation
Open reduction of separated epiphysis
Osteoclasis (correction of bone deformity)
Other
Other (peripheral) vascular shunt or bypass
Other amputation below knee
Other anastomosis of cranial or peripheral nerve
Other and unspecified repair of the anulus
fibrosus
Other arthrotomy
Other bunionectomy
Other bunionectomy with soft tissue correction
Other cervical fusion of the anterior column, anterior
technique
Other cervical fusion of the posterior column,
posterior technique
Other change in hand muscle or tendon length
Other change in muscle or tendon length
Other destruction of intervertebral disc
Other diagnostic procedures on joint structures
Other diagnostic procedures on muscle, tendon,
fascia, and
bursa, including that of hand
Other division of bone
Other excision of joint
Other excision of soft tissue
Other excision of soft tissue of hand
Other excision or avulsion of cranial and
peripheral nerves
Other excision, fusion and repair of toes
Other exploration and decompression of spinal
canal,Decompression
Other fasciectomy
Other fasciectomy of hand
Other fusion of foot
Other hand muscle transfer or transplantation
Other hand muscle transposition
Other hand tendon transfer or transplantation
Other hand tendon transposition
Other incision of bone without division
Other incision of soft tissue
Other incision of soft tissue of hand
Other injection of locally-acting therapeutic
substance into soft tissue of hand
Other local excision or destruction of lesion of
joint
Other muscle transposition
Other myectomy
Other myectomy of hand
Other neuroplasty
Other operations on muscle, tendon, fascia, and
bursa Suture of bursa
Other partial ostectomy (including : Bone curretage,
marginal resection/excision)
Other peripheral nerve or ganglion
decompression or lysis of adhesions Peripheral
nerve neurolysis NOS
Other plastic operations on fascia
Other plastic operations on hand
Other plastic operations on muscle
Other repair of ankle
Other repair of elbow
Other repair of hand, fingers and wrist
Other repair of joint
Other repair of knee
Other repair of shoulder
Other repair of the collateral ligaments
Other repair of the cruciate ligaments
Other repair or plastic operations on bone
Other suture of flexor tendon of hand
Other suture of muscle or fascia
Other suture of other tendon of hand
Other suture of tendon
Other tendon transposition
Other tenodesis of hand
Other tenonectomy
Other tenonectomy of hand
Other tenoplasty of hand
Other tenotomy
Other total shoulder replacement
Partial hip replacement
Partial shoulder replacement
Patellar stabilization
Percutaneous denervation of facet
Percutaneous vertebral augmentation
Percutaneous vertebroplasty
Peripheral nerve injection, not otherwise
specified
Plastic operation on hand with graft of muscle or
fascia
Plastic operation on hand with other graft or
implant
Pollicization operation carrying over nerves and
blood supply
Quadricepsplasty
Reattachment of muscle
Reattachment of muscle of hand
Reattachment of tendon
Reattachment of tendon of hand
Refusion of atlas-axis spine
Refusion of dorsal and dorsolumbar spine,
anterior column, anterior technique
Refusion of dorsal and dorsolumbar spine,
posterior column, posterior technique
Refusion of lumbar and lumbosacral spine, anterior
column, anterior technique
Refusion of lumbar and lumbosacral spine, anterior
column, posterior technique
Refusion of lumbar and lumbosacral spine,
posterior column, posterior technique
Refusion of other cervical spine, anterior
column, anterior technique
Refusion of other cervical spine, posterior
column, posterior technique
Refusion of spine, not elsewhere classified
Refusion of spine, not otherwise specified
Release of carpal tunnel
Release of clubfoot, not elsewhere classified
Release of tarsal tunnel
Removal of (cement) spacer
Removal of bone growth stimulator (invasive)
Removal of foreign body from spinal canal
Removal of implanted devices from bone - carpals
and metacarpals-Plate & screw
Removal of implanted devices from bone - carpals
and metacarpals-simple implants (K-wire)
Removal of implanted devices from bone -
External fixator device (invasive) (
Removal of implanted devices from bone - femur
Removal of implanted devices from bone -
humerus
Removal of implanted devices from bone - radius
and ulna
Removal of implanted devices from bone -
scapula, clavicle, and thorax (ribs and sternum)
Removal of implanted devices from bone -
unspecified site (Phalanges (of foot) (of hand)) –
Plate & Screw
Removal of implanted devices from bone -
unspecified site (Phalanges (of foot) (of
hand)) - simple implants (K-wire)
Removal of implanted devices from bone -
patella
Removal of implanted devices from bone-
tarsals and metatarsals- simple implants (K-wire)
Removal of implanted devices from bone- tibia and
fibula
Removal of implanted devices from bone-other
(Pelvic bone and Vertebraae)
Removal of implanted devices from bone-tarsals and
metatarsals - Plate & Screw
Removal of internal limb lengthening device
Removal of pedicle screw(s) used in spinal fusion
Removal of peripheral neurostimulator lead(s)
Removal of skeletal muscle stimulator
Removal of spinal neurostimulator lead(s)
Reopening of laminectomy site
Repair of claw toe
Repair of cleft hand
Repair of hammer toe
Repair of recurrent dislocation of shoulder
Repair of the anulus fibrosus with graft or prosthesis
Repair of vertebral fracture, Elevation of spinal bone
fragments, Reduction of fracture of vertebrae,
Removal of bony spicules from spinal canal
Replacement of joint of foot and toe
Resurfacing hip, partial, acetabulum, Hip resurfacing
arthroplasty, partial, acetabulum
Resurfacing hip, partial, femoral head
Revision of total knee replacement, tibial insert
(liner), Replacement of tibial insert (liner)
Revision or replacement of artificial spinal disc
prosthesis, cervical
Revision or replacement of artificial spinal disc
prosthesis, lumbosacral
Revision or replacement of artificial spinal disc
prosthesis, not otherwise specified
Revision or replacement of artificial spinal disc
prosthesis, thoracic
Rotator cuff repair
Separation of equal conjoined twins
Separation of unequal conjoined twins
Sequestrectomy
Spinal fusion, not otherwise specified
Suture of Artery
Suture of capsule or ligament of ankle and foot
 Suture of capsule or ligament of other lower
extremity
Suture of capsule or ligament of upper extremity
Suture of cranial and peripheral nerves
Suture of muscle or fascia of hand
Suture of tendon sheath
Suture of tendon sheath of hand
Suture of Vein
Synovectomy
Tarsometatarsal fusion
Tendon graft
Tendon pulley reconstruction
Tendon pulley reconstruction
Tendon transfer or transplantation
Tenotomy of hand
Thigh reattachment
Thumb reattachment
Toe reattachment
Total ankle replacement
Total elbow replacement
Total ostectomy
Total wrist replacement
Transplant from cadaver
Transposition of cranial and peripheral nerves -
Nerve transplantation
Triad knee repair
Triple arthrodesis
Unspecified operation on bone injury
Upper arm reattachment
Upper limb amputation, not otherwise specified
Wedge osteotomy

5 Bedah thoraks Biopsi Terbuka Bronkhus

Dan Biopsi Terbuka Diafragma
kardiovaskuler Biopsi Terbuka Mediastinum
Biopsi Terbuka Paru
Biopsi Terbuka Pleura
Biopsi Terbuka Pleura dengan VATS
Biopsi Terbuka Tumor Dinding Thoraks
Debridement Mediastinum (Sternotomi)
Eksisi Pada Bronkhus
Eksisi Pada Paru (Lung Volume Reduction)
Eksisi Pada Paru dengan VATS
Eksisi Tumor Dinding Dada dengan Rekonstruksi
Dinding
Dada
Eksisi Tumor Mediastinum (Thymoma, Teratoma,
Neurogenic dsb)
Ekstraksi Corpus Alienum di Regio Toraks
Ekstraksi Corpus Alienum di Regio Toraks dengan
VATS
Evakuasi Efusi Pleura/Empyema secara
Torakoskopik (VATS)
Fiksasi Costae (Clipp, Wire) (diluar Clipp)
Fiksasi Sternum (Wire, Plate) (diluar wire/plate)
Lobektomi Parsial (Reseksi Paru segmental)
Lobektomi Parsial (Reseksi Paru segmental)
dengan VATS
Lumbal Simpatektomi
Mediastinostomy
Pemasangan thorak drain/water sealed drainage
(WSD) (diluar alat)
Pleural window (Eloeser Flap)
Pleurektomi
Pleurodesis (Pleurosklerosis)
Plikase Bulae / Bleb Emfisematous
Plikasi diafragma
Pneumonectomy
Pneumonectomy dengan VATS
Pulmonary Decortication
Pulmonary Decortication dengan VATS
Pulmonary Lobectomy/Bilobectomy
Pulmonary Lobectomy/Bilobectomy dengan VATS
Redo Torakotomi
Rekonstruksi Sternum&Dinding Dada
repair deformitas Pectus
Repair Fistula Bronkopleural
Repair Laserasi Diafragma
Revisi Thoraks drain/water sealed drainage (WSD)
(diluar alat)
Thoracal Symphatectomy dengan Video Assissted
Thoracoscopic Surgery (VATS)
Thoracocentesis
Thymectomy
Thymectomy dengan VATS
Torakoplasti (Air Plumbage/Muscle Plumbage)
Torakotomi / sternotomi Eksplorasi
Torakotomi Eksplorasi pada Trauma jantung/Repair
Laserasi Jantung
Bedah Kardio (Jantung)
Aortic Valve Repair (AVR)
Aortic Valve Repair (AVR) dengan Bioprosthesis
Valve
Aortic Valve Repair (AVR) dengan Mechanical Valve
Atrial septal Defect (ASD) Closure
Bidirectional Cavo-Pulmonary Shunt (BCPS)
Biopsi Jantung
Biopsi Perikardium
Blalock-Taussing Shunt (BT Shunt)
Coronary Artery Bypass Graft (CABG)
Eksisi Cardiac Myxoma
Fontan Operation (Atrium-Pulmonary Artery
Conduit)
Internal Resusitasi/Cardiac Massage (Operasi
Terbuka)
Ligasi Patent Ductus Arteriosus (PDA)
Mitral valve repair (MVr)
Mitral Valve Repair (MVR) dengan Bioprosthesis
Valve
Mitral Valve Replacement (MVR) dengan
Mechanical Valve
Operasi Redo Open Heart (Valve Replacement)
Operasi Reopen oleh Karena sebab Perdarahan,
Tamponade Jantung
Pemasangan IABP
Pemasangan Pace Maker Permanen (diluar alat)
Pericardiocentesis
Perikardiektomi
Perikardiotomi/Pericardial Window
Pulmonal Valve Repair (PVR)
Pulmonal Valve Repair (PVR) dengan Bioprosthesis
Valve
Pulmonal Valve Repair (PVR) dengan Mechanical
Valve
Pulmonary Artery Banding (PA)
Rastelli Procedure (right Ventricle-Pulonary Artery
Conduit)
Repair (Eksisi) Aneurisma Jantung
Repair Aorta Torakalis (38.34)
Repair Atrioventricular Septal Defect (35.54)
Repair Total Anomalous Pulmoanry Venous
Connection (TAPVC) (35.82)
Repair Transposition of Great Arteries (TGA)
(35.84)
Repair Trunkus Arteriosus (35.83)
Revisi/Aff Pace Maker Permanen (diluar alat)
(37.89)
Septostomi Terbuka Septum Atrium (35.41)
Total Koreksi Tetralogy of Fallot (TOF) (35.81)
Tricuspid Valve Repair (TVR) (35.14)
Tricuspid Valve Repair (TVR) dengan Bioprosthesis
Valve (35.27)
Tricuspid Valve Repair (TVR) dengan Mechanical Valve
(35.28)
Ventricle Septal Defect (VSD) Closure (35.5)
Amputasi Above Knee (AK) (84.17)
Amputasi Below Knee (BK) (84.14)
Arterial Pungsi, Kanulasi, Sectie (38.91)
Arteriovenous Shuntt (AV Shunt) Brakiosefalika (39.42)
 Arteriovenous Shuntt (AV Shunt) Radiosefalika (39.27)
Bedah Varises Insisi Babcock (38.5)
Biopsi Pembuluh Darah (Perifer) (38.21)
Debriment-Nekrotomi Luka Gangren (86.22)

6 Eksisi biopsi Eksisi Tumor Pembuluh Darah Perifer

tumor (Hemangioma)
Pembuluh darah Eksplorasi Vaskular (Trauma/Non trauma)
Embolektomi/Trombektomi Aorta
Embolektomi/Trombektomi Pembuluh Darah Arteri
Abdominal
Embolektomi/Trombektomi Pembuluh Darah Arteri
Ekstremitas Bawah
Embolektomi/Trombektomi Pembuluh Darah
Ekstremitas Atas (diluar alat)
Embolektomi/Trombektomi Pembuluh Darah
Ekstremitas Bawah(diluar alat)
Embolektomi/Trombektomi Pembuluh Darah Regio
servikal (Karotis, Jugular) (diluar alat)
Evakuasi Hematom di Ekstremitas (Pasca Pungsi
HD/ Traumatik)
Fasciotomy
Ligasi Vaskular Ekstremitas
Mutilasi Digiti Ekstermitas
Pasang Double Lumen Hemodialisis (HD) (diluar alat)
Pasang Implantable Central Venous Access (diluar
alat: porth-a-cath, celsite)
Pemasangan Central Venous Catheter (CVC) (diluar
alat)

Pemasangan Intra Aortic Baloon Pump (IABP) (diluar

alat)
Pemasangan Peritoneal Dyalisis (PD) Catheter
(diluar alat)
Pembedahan Teleangiectasis
Repair Aneurisma (True/false) Ekstremitas Superior
(diluar graft)
Repair Aneurisma Aorta Abdominalis (Diluar
Protesa)

Repair Pembuluh Darah Regio Servikal (Karotis, Jugular)

Repair Ruptur Pembuluh Arteri Abdominal
Revisi Arteriovenous Shunt
Skleroterapi Vena (Varises, Hemangioma)
Stripping Varises Ekstremitas Inferior
Vascular Shunting (Splenorenal Shunt, De Palma
Shunt)
Vena Punctie, Kanulasi, Sectie

7 Bedah digestive Abdominal pull through (sfingter saving procedure)

Abdominoperineal resection (miles) dengan penyulit
mayor
Abdominoperineal resection (miles) dengan penyulit
minor
Abdominoperineal resection (miles) tanpa penyulit
Abdominoplasty
Apendektomi
Apendektomi dgn penyulit major
Apendektomi dgn penyulit minor
Apendektomi laparoskopik
Bilio-difgestif anastomosis tanpa penyulit
Biliodigestif dengan penyulit mayor
Biliodigestif dengan penyulit minor
Biopsi insisional, local anastesi
Biopsi rectum
Eksisi hemoroid eksterna
Eksplorasi duktus bilier & cholangiografi intra
operatif
Esofagotomi
Fistulotomi
Fistulotomi dgn penyulit mayor
Fistulotomi dgn penyulit minor
Gastrostomi
Hemikolektomi dengan penyulit mayor
Hemikolektomi dengan penyulit minor
Hemikolektomi tanpa penyulit
Hemoroid stapling (diluar alat)
Hemoroidektomi
Herniotomi
Herniotomi dgn penyulit mayor
Herniotomi dgn penyulit minor
Herniotomi laparoskopik
Jejunostomi / ileostomi
Laparotomi dengan penyulit minor
Laparotomi tanpa penyulit
Ligasi hemoroid (diluar alat)
Pankreatiko-duodenektomi cephalis (Whipple)
dengan penyulit mayor
Peritoneal dreanse (CAPD)
Peritoneal lavase
Polipektomi
Potong kolostomi
Prosedur Heller
Rektopexy
Repair fistel usus
Repair fistel vesicorectal
Repair hernia cicatricalis
Repair hernia cicatricalis dgn penyulit mayor (diluar
alat)
Repair hernia cicatricalis dgn penyulit minor (diluar
alat)
Repair Hernia Diafragmatika (diluar alat)
Reseksi anterior dengan penyulit mayor
 Reseksi anterior dengan penyulit minor
Reseksi anterior tanpa penyulit
Reseksi esofagus-colon / ileum transposisi
Reseksi esofagus-end to end
Reseksi esofagus-esofago-gastrectomy
Reseksi hati
Second look laparoscopy
Splenektomi / splenoraphy traumatika
Splenektomi non trauma
Terminal esofagus proksimal gastrektomi (TEPG)
Total gastrektomi
Total pantreaktomi
Total prokto-kolektomi
Tutup burst abdomen (tanpa alat)
Tutup burst abdomen dengan penyulit mayor
Tutup burst abdomen dengan penyulit minor
Tutup kolostomi / ileostomi
Tutup kolostomi / ileostomi dengan penyulit mayor
Tutup kolostomi / ileostomi dengan penyulit minor
Repair Aorta Torakalis (38.34)
Repair Atrioventricular Septal Defect (35.54)

8 Bedah urologi Adrenalektomi

Adrenalektomi (Abdominotorakal)
Anastomosis end to end Ureter
Augmentasi Buli
Biopsi Ginjal perkutan
Biopsi Ginjal Terbuka
Biopsi Penis
Biopsi Prostat
Biopsi Testis
Bladder Neck Rekonstruksi
Buried Penis
Businasi/Dilatasi Uretra
Cabut DJ Stent
Defooring Kista Ginjal per Laparoskopi
Deroofing/Unroofing Kista
Diseksi Kelenjar Getah Bening Inguinal
Diseksi Kelenjar Getah Bening pelvis
Diseksi Kelenjar Getah Bening Pelvis per
Laparoskopi
Divertikulektomi Buli
Divertikulum Uretra
Dorsumsisi
Drainase Periureter
Eksisi Chordae/Chordektomi
Eksisi Fibroma/Rekonstruksi Penis
Eksisi Plaque (Peyronie Disease)
Eksisi Webbed Penis
Eksplorasi testis (Microsurgery)
Fistulektomi/Repair Fistel Uretra
Funikokelektomi
Ganti Nefrostomy
Hidrokel per Inguinal/Ligasi Tinggi
Hidrokel per Skrotal
Hipospadia Subkoronal
Holmium YaG Laser (Sewa)
Ileal Conduit (Bricker)
Insersi DJ Stent
Insisi Abses Perineum
Insisi Abses Skrotum
Insisi Posterior Urethral Valve
Johanson
Johanson I
Johanson II
Kalibrasi Uretra
Kauterisasi
Koreksi Horseshoe Kidney
Koreksi Priapismus
Laparoskopi Adrenalektomi
Laparotomi Eksplorasi
Ligasi V.Spermatika Interna (Microsurgery)
Limfadenektomi Ilioinguinal
Limfadenektomi Retroperitoneal/RPLND
Litholapaksi
Lithotripsi
Masase Prostat
Meatoplasti
Meatotomi
MMK/Sling Uretra
Nefrektomi
Nefrektomi Donor Transplant
Nefrektomi Parsial
Nefrektomi per Laparoskopi
Nefrektomi Radial
Nefropeksi/Renopeksi
Nefrostomi Perkutan/Temporer
Nefrostomi Terbuka/Permanen
Nefroureterektomi
Neobladder
Operasi Priapismus (prosedur Winter)
Operasi Repair Buli Trauma
Operasi Sistokel
Operasi Trauma Ginjal
Operasi Urakhus/Reseksi urakhus
Orkhidektomi
Orkhidektomi extended
Orkhidektomi Ligasi Tinggi
Orkhidektomi Subkapsuler
Orkhidopeksi (Torsio Testis)
Orkhidopeksi (UDT)
Orkhidopeksi per Laparoskopi
Pasang Kateter
Pasang Kateter dengan Mandrain
Pasang Kateter Tenckhoff untuk CAPD
PCNL/PNL
Penektomi Parsial
Penektomi Total/Amputasi Penis
PER (Primary Endoscopic Realignment)
Pielokalikotomi
Pielolitotomi
Pieloplasti
Pieloplasti per Laparoskopi
Prostatektomi Radikal
Prostatektomi Retropubik
Prostatektomi Terbuka
Prostatektomi Terbuka dan Sectio Alta
Psoas Hitch/Boari Flap
Punksi dan sklerosing Kista Ginjal
Railroading Rupture Uretra
Reimplantasi Ureter Bilateral
Reimplantasi Ureter
Unilateral/Ureteroneosistostomi
Rekontruksi Renovaskuler
Repair Fistel Enterovesika
Repair Fistel Vesikokutan
Repair Fistel Vesikorektal
Repair Fistel Vesikovagina
Repair Fistel Vesikovagina Kompleks
Reparasi Penis
Reseksi-anastomosis Uretra
RPG
Sectio Alta/Vesikolithotomi
Sirkumsisi
Sistektomi Parsial/Sistoplasti Reduksi
Sistektomi Per Laparoskopi
Sistektomi Total/Radikal
Sistoskopi
Sistoskopi ODS
Sistostomi perkutan
Sistostomi Terbuka
Skrotoplasti
Spermatokelektomi
Tailoring Ureter
Transplan Resipien
Transuretero-ureterostomi
TUR Prostat/TUIP/BNI
TUR Tumor Buli
TVP/TMP
Ureterokutaneostomi
Ureterolisis
 Ureterolithotomi
Ureterolithotomi Distal
Ureterolithotomi Proksimal
Ureterosigmoidostomi (Caffey)
Ureterostomi
Ureterouretostomi
Uretroplasti Hipospadia
Uretroskopi/Uretrosistoskopi

9 Ongkologi Aspirasi Kista Mamma Single dan Multiple

Biopsi Core Lokal Anestesi
Biopsi Eksisi Lokal
Biopsi Eksisi Narkose
Biopsi Insisi Lokal
Biopsi Narkose
Breast Conserving Surgery (BCS)
Breast Conserving Surgery + LD Flap
Debriment Mamma
Diseksi Axilla
Eksisi Fibroadenoma Lokal Anestesi Single Satu
Sisi
Eksisi Fibroadenoma Multiple Narkose
Eksisi Tumor Metastase Loco-regional
Eksplorasi Duktus Mama
Eksplorasi Duktus Mama+VC
Insisi Absces Mastitis Lokal
LD Flap + Eksisi Tumor
Mastectomy + Tram Flap
Modified Radical Mastectomy + Flap/Single Grafting
Modified Radical Mastectomy Single
Quadrantectomy / Partial Mastectomy
Simple Mastektomy + Flap/Skin Grafting
Simple Mastektomy Single
Tram Flap + Eksisi Tumor
Operasi Tumor Kulit
Biopsi Insisi Tumor Kulit Lokal
Biopsi Eksisi Tumor Kulit Narcose
Eksisi Tumor Jinak ≤ 3cm
Eksisi Tumor Jinak + Flap/Skin Graft
Eksisi Tumor Jinak Kulit >3cm
Wide Eksisi + Diseksi KGB
Wide Eksisi Tumor Ganas Kulit
Wide Eksisi Tumor Ganas Kulit+Flap / Skin Graft
Operasi Soft Tissue Tumor
Amputasi + Diseksi KGB
Amputasi Jari + Flap / Skin Graft
Amputasi Tungkai / Lengan
Biopsi Core soft Tissue
Biopsi Insisi Tumor Sof Tissue dengan Narcose
Biopsi Insisi Tumor Soft Tissue Lokal Anestesi
 Eksisi Tumor Jinak > 3cm
Eksisi Tumor Jinak Ø<3cm
Wide Eksisi + Compartement Procedure
Wide Eksisi + Diseksi KGB
Wide Eksisi Tumor Ganas
Wide Eksisi Tumor Jinak + Flap/Skin Graft
Operasi Tindakan Tertentu
Advancement Flap
Aspirasi Effusi Pleura
Aspirasi Paru + Pleurodhesis
Delto Pectoral Flap (DP Flap)
Diseksi Axilla
Diseksi Inguinal
Diseksi Para Aorta
Eksisi Tumor Lidah
Eksisi Tumor Sub Mandibula/Sub Mental
Insersi Chest Tube
Ismulobectomy
Kemoterapi Perinfus
Latissimus Dorsi Flap (LD Flap)
Maksilektomi Total
Mastopexy
Modifikasi RND
Operasi Compartement Otot
Ovariectomy Bilateral
Reseksi Mandibula
Rotation Flap
Skin Grafting
Sub Total Thyroidectomy
Superficial Parotidectomy
Thoraco Abdominal Flap (TA-Flap)
Total Parotidectomy
Total Thyyroidectomy
Transversus-Rectus Abdominis Flap (Tram Flap)

10 Bedah anak Abdominal pull through (sfingter saving procedure)

Adhesiolisis
Appendektomi dgn penyulit
Appendektomi laparoskopik
Appendektomi tanpa penyulit
Biliodigesif dengan penyulit mayor
Biliodigestif anastomosis tanpa penyulit atau penyulit
minor
Biopsi rectum
By pass usus dengan penyulit mayor / minor
Divertikulektomy
Drainase abses dengan general anasthesia
Drainase abses local anasthesia
Eksisi hygroma colli
Eksisi kista brachialis
Eksisi kista duktus tiroglossus
Eksisi neoplasma Jinak ( lipoma, atheroma dll )
Eksisi sinus/granuloma umbilikalis
Eksisi soft tissue tumor dengan penyulit
Eksisi soft tissue tumor tanpa penyulit
Eksisi teratoma dengan penyulit dan rekonstruksi
Eksisi teratoma tanpa penyulit
Eksisi tumor jinak wajah
Eksisi urachus
Ekstirpasi fistel pre aurikulae
Ekstirpasiranula
Endoskopik diagnostik
Endoskopik terapeutik
Gastrostomi
Hemikolektomi
Herniotomi elektif tanpa penyulit
Herniotomi laparoskopik
Hernitomi dgn penyulit / komplikasi
Hidrokolektomi
Intraoperatif kolangiografi
Intraoperatif kolangiografi laparoskopik
Jejenostomi / ileostomi dengan penyulit mayor
Jejenostomi / ileostomi dengan penyulit minor
Jejenostomi / ileostomi tanpa penyulit
Koledokotomi dengan penyulit mayor
Kolesistektomi
Kolesistektomi laparoskopik
Kolostomi / sigmoidostomi (46.11)
LADD Operation (54.95)
Laparoskopik diagnostik (61.6)
Ligasihemoroid (49.4)
Operasi kelainan umbilikal lain (54.3)
Orchidopexy (62.5)
Orchidopexy laparoskopik (62.5 + 61.6)
Other Repair of Abdominal Wall (Repair Omphacele)
(954.72)
Polipektomi (48.36)
Posterosagital anorectoplasty (49.79)
Posterosagital anorectoplasty urethro vaginoplasty
(70.79)
Potong kolostomi (46.14)
Potong Stump (84.3)
Prosedur Heller (44.6)
Prosedur Kasai (51.37)
Repair atresia esofagus (42.5)
Repair defek diafragma (53.8)
Repair ekstrofia buli (57.8)
Repair hernia diafragma (53.7/53.8)
Repair of Gastrochisis (54.71)
RPLND (40.59)
 Separasi conjoined twin (84.9)
Sirkumsisi dengan general anesthesia (64.0)
Sirkumsisi dengan local anesthesia (64.0)
Splenektomi (41.5)
Splenorenal shunt (39.1)
Transnasal endorectal pullthrough laparascopic
assisted (48.42)
Transplantasi organ
Tutup burst abdomen dengan penyulit (54.61)
Tutup burst abdomen tanpa penyulit (54.61)
Tutup ileostomi dengan penyulit (46.5)
Tutup kolostomi / ileostomi (46.5)
Tutup Stoma (46.5)
Urethroplasty / chordectomy (64.42)
Vena Sectie Aksilaris (38.94)
Vena sectie Femoralis / saphena magna (38.94)
Wound repair (86.8)

11 Bedah plastik Abdominoplasty

Aff archbar, Lokal Anastesi
Aff Suspensi, Lokal Anastesi
Amputasi above elbow
Amputasi bellow elbow
Amputasi digital
Amputasi jari >1
Amputasi jari single
Augmentasi mamae
Blefaroplasty (2 kelopak mata)
Blefaroplasty pada kasus sulit
Blefaroptosis
Bone rekonstruksi facial cleft
Bone rekonstruksi facial cleft
Cheilonasoraphy
Chordectomy
Chordectomy+urethroplasty
Closed Reduction Fr. Nasal
Comisuroplasty
Eks mamma aberan bilateral
Eksisi neoplasma jinak (lipoma, atheroma dll)
Eksisi luas + Deltopectoral flap
Eksisi luas + Fore head flap
Eksisi luas + Muskulocutan flap
Eksisi luas + rekonstruksi dengan bedah
mikrovaskular
Eksisi malformasi lymphatik / vaskuler
Ekstraksi ateroma / keloid
Ekstraksi korpus alienum
Elevasi ear rim cartilago
Excise hemangioma + rekonstruksi
Excise intra keloid
Excise polydactyly
Excise reduksi lymedema
Facial sling dengan allograft
Fasciotomy burn injury
Fasciotomy with complication
Flap lokal sederhana
Fr. Condylus mandibula open red
LD flap
Le fort I osteotomy
Liposuction
Lobuloplasti
Malarplasty
Mamma aberan unilateral
Mandibular distraksi
Mandibular rekonstruksi dengan costochondral graft
Mastopexi
Mentoplasty
Microsurgery
Multiple facial fraktur + implant
Muskulokutaneus flap
Myokutaneus flap/pectoralis mayor flap
Nasal repair dan rekonstruksi
Neo vagina
Operasi bedah mikro
Orif fraktur zygoma
Orif fraktur hand
Orif fraktur mandibula
Orif fraktur maxilla
Orif maksila plating
Orif mandibula plating
Orif mandibula wiring
Orif orbital wall
Orif orbital wall
Orif zygoma wiring
Osteotomy craniosynostosis reconstruction
Osteotomy facial rekonstruksi
Osteotomy genioplasti tanpa tarif bahan
Osteotomy maksila Le fort I
Osteotomy maksila Le fort II
Palatoplasti bilateral komplit
Palatoplasti bilateral tak komplit
Palatoplasti unilateral komplit
Palatoplasti unilateral tak komplit
Palatoraphy
Pasang archbar
Pasang back slab/fore slab
Rekonstruksi facial cleft
Rekonstruksi nasal
Rekonstruksi palpebra
Released buried penis
Released syndactyly kompleks
Repair canalis lacrimalis (without silicon tube)
Repair coloboma palpebra (skin/mucosal graft)
Repair ductus nasolacrimalis
Repair fingertip injury
Repair fistel urethra
Replantation
Reposisi fraktur nasal sederhana
Reposisi fraktur os nasalis (complicated)
Reseksi mandibula + bone graft
Rhinoplasty
Rotation flap
Sagital Split osteotomi mandibula
Simple bone grafting
Simple skin grafting
Skin flap
Skin graft >5 cm
Skin graft sedang 5 cm
Skin grafting kecil
Skin grafting luas
Skin grafting sedang
Skin grafting with complication
Tendon reconstruction
Tendon transfer
Tendon transfer with complication
Tennoraphy
Tennoraphy with complication
TMJ arthroplasty
TMJ arthrostomy
Tram flap
Wound Dressing
Wound Repair
Operasi Ca vagina
Operasi kanker corpus uteri
Operasi tumor ganas ovarium
Operative histeroscopy/Ablasi
endometrium
Overectomi
Painless labor
Persalinan normal
Persalinan normal dengan penyulit
Persalinan pervaginam tindakan
operatif
Persalinan sungsang
Rekanalisasi
Rekanalisasi tuba
Salfingektomi unilateral
Salvingoovarectomi unilateral
 Secound look surgery Ca ovarium
Seksio sesaria
Seksio sesaria dengan penyulit
penyulit
Sirklase serviks
Seksio sesaria dengan penyulit
penyulit
Sirklase serviks
Supra vaginal hyterectomy
Surgical staging
TAH+BSO dengan Penyulit
TAH+BSO dengan Penyulit
Pemasangan Tampon
Abdomen

Total abdominal hysterectomy+bilateral

salfingektomi

Tubektomi klinik

Tutup burst abdomen

B. Tindakan Anestesi &Sedasi ( Sedang dan Dalam), tindakan yang

memerlukan informed consenttersebut antara lain:
- Semua tindakan anestesi dan sedasi di dalam kamar operasi
- Semua tindakan anestesi dan sedasi di ICU

Tindakan Anestesi di ICU

1. Pemasangan intubasi ventilator

2. Pemasangan vena central
3. Pemasangan CRRT
4. Pemasangan Swan Ganz (Kateter Arteri Pulmonal)
5. Pemasangan Intra Arterial Catheher (Kateter Intra Arterial)
 6. Pemasangan Percutaneous Dilatational Tracheostomy
7. Pemasangan Drain Intra Thorakal/Punksi Thorax
8. Pemasangan IABP
9. Pemasangan Drain Intra Abdominal
10. Pemasangan Gemo
11. Cardioversi
12. Bronchoskopi-FOB
13. TEE

C. Tindakan Pemberian Produk Darah dan Komponen Darah

Beberapa tindakan yang memerlukan informed consenttersebut antara
lain:
Transfusi darah:
a. Plasma sel
b. PRC
c. Whole Blood Cell
d. Trombosite
e. Albumin
f. lain – lain

d. Semua Tindakan yang beresiko tinggi

1. Chest tube
2. Tindakan kemotherapi
3. Pemasangan Ventilator
4. Intubasi Endotrakea
5. Pemasangan Laryngeal mask
6. Krikotirotomi
7. Infus intraosseus
8. Kanulasi vena perifer
9. Vena sectie
10. Pengambilan darah intra vena dan intra arteri
11. Pungsi lumbal
12. Pungsiv Pleura
13. Pemasangan kateter urine
14. Pemasangan keteter rectal
15. Pemasangan orogastrik tube
16. Pemasangan nasogastrik tube
17. Pemeriksaan Audiometri
18. Pemeriksaan Timpanometri
19. Pemeriksaan Audiometri Tutur
20. Pemeriksaan Sisi&Tore Decay
21. Pemeriksaan Pendengaran Pada Anak
22. Pemeriksaan Brainstem Evoked Response Audiometry
23. FNAB (Fine Needle Aspiration Biopsy)
24. Tindakan Radiotherapi
25. Cerebral Angiografi
26. AVM&Embolisasi
27. Aneurisma Coiling
28. Embolisasi pre operasi
29. Diagnosis DSA
30. Lumbal Punksi
31. Pain Intervention
32. Injeksi Triger point
33. Injeksi Triger Fringer
34. Injeksi CTS
35. Sub Optical Functional
36. Injeksi botox
37. EMG
38. Phlebotomi
39. Scaling (KSM/ instalasi gigi mulut)
40. Curettage/root planning (jika diperlukan anestesi) (KSM/ instalasi gigi
mulut)
41. Gingivektomi (KSM/ instalasi gigi mulut)
42. Frenektomi (KSM/ instalasi gigi mulut)
43. Flap operasi (bone graft/membrance/GTR/interseptif) (KSM/ instalasi
gigi mulut)
44. Implant (KSM/ instalasi gigi mulut) (KSM/ instalasi gigi mulut)
45. Vital pulpektomi dan Partial Nekrose (KSM/ instalasi gigi mulut)
46. Cauter (KSM/ instalasi gigi mulut)
47. Retraksi Gingiva pada prep.crown
48. Suntik Intra Cavernosal Penis
49. Dobutamin Stress Ekhokardiografi
50. Transophegal Ekhokardiografi
51. Treadmill Tes
52. Exercise Stress Ekhokardiografi
53. Bronchoscopy/FOB
 54. Tindakan kemotherapi
55. Thoracoscopy
56. Contra Ventil/WSD
57. Punctie Pleura
58. FNAB
59. Scalene Biopsy
60. Reposisi
61. Pleurodesis
62. AFF WSD
63. Perawatan Luka WSD
64. USG Thorax Marker
65. Tindakan Radiologi Injectee contrast
66. Tindakan Radiologi pada pasien dengan kelainan cardiovaskuler
67. Tindakan Radiologi pada pasien dengan alergi
68. berat
69. Tindakan Radiologi pada pasien dengan KU yang menurun
70. Tindakan Radiologi yang memerlukan FNAB Guiding MSCT pada
pasien dengan kelainan yang
71. berdekatan dengan organ vital
72. Tindakan Radiologi pada Ibu hamil yang memerlukan foto
73. Cerebral Angiografi
74. AVM&Embolisasi
75. Aneurisma Coiling
76. Embolisasi pre operasi
77. Diagnosis DSA
78. Lumbal Punksi
79. Pain Intervention
80. Injeksi Triger point
81. Injeksi Triger Fringer
82. Injeksi CTS
83. Sub Optical Functional
84. Injeksi botox
85. EMG
86. Neuro endovaskuler: Coiling,Embolisasi,DSA
87. Setiap kali melakukan tindakan Hemodialisis
88. Elektromiografi dan Kecepatan Hantar Saraf
89. Psycho Analisa ( KSM/ instalasi jiwa)
90. Psycho Therapy Dalam (KSM/instalasi jiwa)
91. Pemeriksaan Calon Pimpinan Publik (KSM/instalasi jiwa)
92. Aborsi Provocatus Medicinalis
93. Tindakan terapi elektroconfusi (KSM/instalasi jiwa)
94. Pemeriksaan kandungan zat narkotika
95. Restraint / Fiksasi : mekanik dan psikotropika (KSM/instalasi jiwa)
96. Semua injeksi dengan obat risiko tinggi