DAFTAR TINDAKAN – TINDAKAN

YANG PERLU INFORMED CONSENT

Sesuai Undang – Undang no 44 tahun 2009 tentang rumah sakit, 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/BAGIAN TINDAKAN

1 Bedah
- Eksisi Kista Jinak Kulit Kepala
- Eksisi Osteoma/Osteositosis
- Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan
- Extirpasi Tumor Jinak Saraf Kulit Kepala
- Aff Arch Barr
- Aff Arch Barr dan suspensi maksila
- Biopsy Insisional dengan anastesi lokal
- Dieseksi submandibula
- Diseksi leher radikal/radikal neck dissection
- Eksisi gld submandibula
- Eksisi higroma leher
- Eksisi kista tiroglosus
- Eksisi luas tumor ganas bibir dengan rekontruksi
- 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 tanpa rekontruksi
- Eksisi tumor jinak dengan anastesi lokal
- Ekskokleasi kista folikuler
- Ekskokleasi kista radikuler
- Ekstirpasi/eksisi tumor jinak jaringan lunak ukuran <2cm
- Ekstirpasi kista dermoid
- Fiksasi interna fraktur maksilofasial 1-2 tempat patahan
- Fiksasi interna fraktur nasal
- Fiksasi interna pan-facial
- Insisi abses dengan anastesi lokal
- Insisi flegmon dasar mulut
- Internal Fiksasi fraktur maksilofasial 3-4 tempat
Patahan
- Internal fiksasi fraktur maksilofasial 5 tempat patahan
atau lebih
- Ekstraksi Korpus Alienum Kavum Nasi
- Fore Head Flap
- Reposisi Fraktur Os Nasal
- Reposisi & Fiksasi Fraktur Mandibula
- Tiroidektomi Sub-Total
- Tracheostomi
- Tiroidektomi Total+ND
- 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
- Application of external fixator device
- Arthrocentesis
- 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 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 -
Phalang of foot
- Closed reduction of fracture with internal fixation -
Phalang of hand
- Closed reduction of fracture with internal fixation - Tarsal
and metatarsal
- Excision of lesion of muscle of hand
- Excision of lesion of other soft tissue
- Ganglionectomy of tendon sheath (wrist)-General
anaesthesia
- Ganglionectomy of tendon sheath (wrist)-Local Anaestesi
- Excision of other lesion of soft tissue of hand
- Exploratory thoracotomy
- Fasciotomy
- Fasciotomy of hand
- Incision and drainage of palmar or thenar space
- Local excision of lesion or tissue of bone
- Lower limb amputation, not otherwise specified
- Myotomy
- Myotomy of hand
- Open biopsy of soft tissue
- 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-
Simple fracture
- Open reduction of fracture with internal fixation-humerus
- Simple fracture
- Open reduction of fracture with internal fixation-tibia and
fibula -Simple fracture
- Other amputation below knee
- Other excision of soft tissue
- Other excision of soft tissue of hand
- 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
- Suture of Artery
- Suture of muscle or fascia of hand
- Suture of tendon sheath
- Suture of tendon sheath of hand
- Suture of Vein
- Upper arm reattachment
- Upper limb amputation, not otherwise specified
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

OBGYN - Cauter serviks/Biopsi Serviks

- Cordosentesis
- Debulking tumor ovarium
- Eksplorasi vagina
- Embryotomi
- Extirpasi polip servix+kuret endometrium
- Extirpasi mioma Geburt
- Extirpasi mioma+ Gubert +kuretase
- Histerectomy pada mola / chorio Ca
- Laporotami Kistektomi
- Kuret abortus
- Laparotomi myomektomi
- (Kistektomi Ovarium, Salphingektomi, Adhesiolisis)
- Laparotomi dengan penyulit mayor
- Laparotomi Histerektomi
- Laparotomi salfingo oofarectomy
- Repair Vagina ( cdpoperineoraphy)
- Eksisi Kista Bartholini/kista vagina/kista periurethia
- Cauterisasi candiloma occeminata
- Incisi Hymen Imperforatia
- Repair Fistula rectovagina 1/3 Distal
- Induksi Persalinan
- Painless Labor
- Persalinan spontan
- Persalinan spontan dengan penyulit
- Persalinan pervaginam tindakan operatif
(Vakum/Forceps)
- Persalinan sungsang
- Rekanalisasi tuba
- Laparotomi salfingektomi uniteral (Laparotomi KET)
- Seksio sesaria
- Seksio seksaria dengan penyulit
- Sirklase serviks
- Laparotomy supra vaginal hysterectomy
- Laparotomy surgical staging
- Laparotomy TAH+BSO+dengan penyulit
- Laparotomy TAH+BSO+dengan penyulit
 pemasangan tampon abdomen ( packing)
- Mini Laparotomy bilateral (MOW)
- Tutup Burst abdomen /Reheacting
- Repair rupture perineum total ?RPTL
- Pemasangan IUD (AKDR)
- Pemasangan Implant (AKBK)
- Manual Plasenta
- Laparotomy Biopsy
- Kuretase AUB
- Kuretase plasenta restan
- Vagina plasty Biopsi
- Neovagina
- Ca vagina
- Operasi kanker corpus uteri
- Operasi tuimor ganas ovarium
- Induksi persalinan
- Painless labor
- Persalinan spontan
GIGI & MULUT - Debriment Mukosa dan Pengelolaan Luka Sayat
- Dislokasi Sendi Mandibula
- Eksisi Epulis Per Rahang
- Enukleasi Kista radikuler Per Rahang + Extraksi Gigi
Penyebab
- Extraksi Gigi Anak dengan Kelainan Jantung Per
Rahang
- Extraksi Gigi Anak Per Rahang
- Extraksi Gigi Dewasa Per Rahang
- Fissure Sealant pada Autis
- Fraktur Dento alveolar Dengan Wire (belum
termasuk bahan)
- Frenektomi Per Rahang
- Gingivektomi Per Rahang
- Odontektomi Per Gigi
GAWAT - Intubasi Endotrakea
DARURAT - Krikotirotomi
ILMU - Kanulasi vena perifer
KESEHATAN - Vena sectie
ANAK - Pungsiv Pleura
JANTUNG - Deforiksi
- Cardiologi Elektrik
- Trombolisist
- Ecocardiografi
- Doplerr Vascular Ultrasonografi

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

memerlukan informed consent tersebut antara lain:
 a. Semua tindakan anestesi dan sedasi di dalam kamar operasi
b. Semua tindakan anestesi dan sedasi di ICU
Tindakan Anestesi di ICU

Pemasangan intubasi ventilator

Pemasangan vena central
Pemasangan CRRT
Pemasangan Swan Ganz (Kateter Arteri Pulmonal)
Pemasangan Intra Arterial Catheher (Kateter Intra Arterial)
Pemasangan Percutaneous Dilatational Tracheostomy
Pemasangan IABP
Pemasangan Drain Intra Abdominal
Cardioversi
Bronchoskopi-FOB
TEE

C. Tindakan Pemberian Produk Darah dan Komponen Darah,tindakan yang

memerlukan informed consent tersebut antara lain:
Transfusi darah:
a. Plasma sel
b. PRC
c. Whole Blood Cell
d. Trombosite
e. Albumin
f. lain – lain

D. Semua Tindakan Yang Berisiko Tinggi :

N UNIT NAMA TINDAKAN

O
1 ANAK Chest tube
Pemasangan Ventilator
Intubasi Endotrakea
Krikotirotomi
Infus intraosseus
Kanulasi vena perifer
Vena sectie
Pengambilan darah intra vena dan intra arteri
Pungsiv Pleura
Pemasangan kateter urine
 Pemasangan keteter rectal
Pemasangan orogastrik tube
Pemasangan nasogastrik tube
2 GIGI MULUT Insisi debriment mukosa dan pengelolaan luka sayat
Dislokasi sendi mandibula
Eksisi epulis per rahang
Ekstraksi gigi anak per rahang
Ekstraksi gigi dewasa per rahang
Fissure sealant pada autis
Fraktur dento alveolar dengan wire (belum termasuk
bahan)
Curettage/root planning (jika diperlukan anestesi)
Gingivektomi per rahang
Frenektomi per rahang
Odontektomi per gigi
Flap operasi (bone graft/membrance/GTR/interseptif)
Implant
Vital pulpektomi dan Partial Nekrose
Cauter
Retraksi Gingiva pada prep.crown
Anestesi
Pencabutan Gigi
Odontektomi per rahang
Replantasi (splinting)
Alveolektomi
Curettage /root planning (jika diperlukan anestesi)
Gingivektomi
Frenektomi
Flap operasi(bone graft/membrance/GTR/interseptif)
Implant
Vital pulpektomi dan partial nekrose
Cauter
Anestesi
Pencabutan gigi
Odontektomi
Replantasi (splinting)
Alveolektomi

3 RADIOLOGI Tindakan Radiologi pada pasien dengan KU yang

menurun ( Foto Polos)
Tindakan Radiologi pada Ibu hamil yang memerlukan
foto.
Semua Injeksi
Berisiko Tinggi