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 diberikaninformed 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 Invasiveyang memerlukan informed

consentantara lain:

KSM/INSTALAS
NO TINDAKAN
I/UNIT
KSM Bedah 1. Blok Saraf Perifer I
1 Saraf 2. Debrimen Rekonstruksi Vulnus Kulit Kepala

3. Dekompresi Saraf Tepi

4. Dekompresi Tulang Durameter

5. Dekortikasi Sinus Frontalis

6. Eksisi Ensefalokel/Mielokel

7. Eksisi Kista Jinak Kulit Kepala

8. Eksisi Osteoma/Osteositosis

9. Elevasi Kraniotomi Fraktur Impresi,Dengan Robekan

10.Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan

11 Extirpasi Tumor Jinak Saraf Kulit Kepala

12 Injeksi spinal (Pain)

Insersi Elektrode Intradural
13.
(Epilepsi,movement,psikiatrik)

14. Kranioplasti dua sisi

15. Kranioplasti satu sisi

16. Kraniotomi Biopsi otak

17. Laminektomi Eksisi Tumor Spinal

18. Laminoplasti

19. Laminotomi Biopsi Mielum

20. MVD ( Mocrovaskular Decompression)

1
NO KSM/INSTALAS TINDAKAN
I/UNIT
21. Paravertebral Blok Perkutan

22. Pemasangan Traksi Servikal

23. Penjahitan Saraf Tepi

24. Punksi Cairan Otak

25. Reseksi Extra-Temporal (Epilepsi)

26. Revisi VP Shunt

27. Rhizotomi Selektif (Spastisitas)

28. Simpatektomi Open (Pain)

29. Trepanasi Cedera Kepala (>4jam)

30. Trepanasi CVA Bleeding

31. Trepanasi kelainan Saraf Kranial

32. Trepanasi Kelainan Vascular Otak

33. Trepanasi Tumor Otak

34. VA Shunt

35. VP Shunt Multiple

36. VP Shunt Satu Sisi

2
2. 1 Adenotonsilektomi
KSM Bedah
THT-KL 2 Anthrostomi+Sinuskopi

3 BLM Simple (Kista,Polip,Nodul,Granulasi)

4 Biopsi Tumor

5 Eksisi Ekstostosis

6 Ekstirpasi Kista Branchial

7 Ekstirpasi Kista Ductus Tiroglosus

8 Ekstraksi granulasi MAE/Kolesteatosis

9 Ekstraksi Polip

10 Esofagoskopi Rigid & Fleksibel

11 Ethmoidektomi (Intranasal)

12 Ekstraksi Korpus Alienum Kavum Nasi

13. Ekstraksi Korpus Alienum Kavum Nasi Endoskopi

14 Ekstirpasi Fistel Pre Aurikuler

15 Ekstraksi Korpus Alienum MAE

16 Ekstirpasi Kelenjar Sub Mandibula

17 Eksplorasi Abses Parafaringeal

18 Ekstirpasi Tumor Jinak Kepala & Leher (Aterom Lipoma)

19 Faringotomi

20 FESS

21 FESS Advance

22 Frontal Sinusotomi

23 Fore Head Flap

24 Fronto Etmoidektomi (Ekstranasal)

25 FOL

26 Glosektomi Total/Parsial

27 Glosektomi Total/Hemiglosektomi+RND

28 Hemiglosektomi+SOHND

29 Insisi Abses Leher Dalam

30 Inversi Grommet

31 Insisi Perikondritis

32 Irigasi Sinus Maksila

3
 33 Insisi Abses Peritonsil

KSM/INSTALASI/
NO TINDAKAN
UNIT

34 Konka Reduksi
35 Kaustik Konka Inferior
36 Laringektomi
37 Laringektomi+ND
38 Laringo Fisur/Eksplorasi Laring
39 Ligasi A. Karotis Eksternal
40 Laringoskopi Rigid
41 Laringoskopi Fleksible
42 Laringoskopi Direkta
43 Maksilektomi Total+Rekontruksi
44 Mastoidektomi Radikal
45 Mini FESS

46 Myocutaneus Flap (Pectoral Mayor)

47 Myringoplasty/Timpaniplasti

48 Mandibulekromi

49 Neurektomi Saraf Vidian

50 Osteotomi+Septum koreksi

51 Rekontruksi Fraktur Maksila Multiple

52 Rekontruksi Fraktur Maksila Sederhana

53 Rhinoplasti

54 Rinotomi Lateral+Maksilektomi Medial

55 Rekontruksi Laring Trakea

56 Reposisi Fraktur Os Nasal

57 Reposisi & Fiksasi Fraktur Mandibula

58 Septum Koreksi+Konkotomi

59 Stapedektomi

60 Skin Pricle Test

61 Tiroidektomi Sub-Total

62 Tonsilektomi/Adenoidektomi

63 Tracheostomi

4
 KSM/INSTALASI/
NO TINDAKAN
UNIT

64 Turbinektomi

65 Tiroidektomi Total+ND

66 Temporal Bone Resection

67 Terapi Wicara pada Anak-Anak dan dewasa

68 Terapi Wicara Tuna Laring

5
 KSM/INSTALAS
NO TINDAKAN
I/UNIT
3 KSM Orthopedi 1 Abdominopelvic amputation
Dan 2 Achillotenotomy

Traumatologi 3 Adductor tenotomy of hip

4 Advancement of tendon

5 Advancement of tendon of hand

6 Amputation above knee

Amputation and disarticulation of finger- general

7 anaesthesia
Amputation and disarticulation of finger -local
8 anaesthesia
Amputation and disarticulation of thumb-general
9 anaesthesia
Amputation and disarticulation of finger- general
10 anaesthesia
Amputation and disarticulation of finger -local
11 anaesthesia
Amputation and disarticulation of thumb-general
12 anaesthesia
Amputation and disarticulation of thumb-local
13 anaesthesia
Amputation of ankle through malleoli of tibia and
14 fibula
15 Amputation of toe-general anaesthesia

16 Amputation of toe-local anaesthesia

17 Amputation through foot

18 Amputation through forearm

Amputation through hand, Amputation through

19 carpals
Amputation through humerus, Upper arm
20 amputation
21 Amputation, not otherwise specified

22 Ankle fusion

23 Application of external fixator device

Application of external fixator device, monoplanar

24 system
25 Application of external fixator device, ring system

26 Application of hybrid external fixator device

27 Arthrocentesis

6
 KSM/INSTALAS
NO TINDAKAN
I/UNIT

28 Arthrodesis of elbow

29 Arthrodesis of hip

30 Arthrodesis of knee

31 Arthrodesis of other specified joints

32 Arthrodesis of shoulder

33 Arthrodesis of unspecified joint

Arthroplasty of carpocarpal or carpometacarpal joint with

34 implant
Arthroplasty of carpocarpal or carpometacarpal joint
35 without implant
Arthroplasty of metacarpophalangeal and
36 interphalangeal joint with implant
Arthroplasty of metacarpophalangeal and
37 interphalangeal joint without implant
38 Arthroscopy

Arthrotomy for removal of prosthesis without

39 replacement
40 Aspiration of bursa

41 Aspiration of bursa of hand

42 Aspiration of other soft tissue

43 Aspiration of other soft tissue of hand

44 Atlas-axis spinal fusion

45 Biopsy of bone

46 Biopsy of joint structure

47 Biopsy of spinal cord or spinal meninges

48 Bone graft
Bone marrow or hematopoietic stem cell transplant
49
(all procedures included in this class
Bunionectomy with soft tissue correction and
50 arthrodesis
Bunionectomy with soft tissue correction and
51 osteotomy of the first metatarsal
52 Bursectomy

53 Bursectomy of hand

54 Bursotomy

7
NO KSM/INSTALAS TINDAKAN
I/UNIT
55 Bursotomy of hand

56 Carporadial fusion

Closed reduction of dislocation -General

57 anaesthesia

58 Closed reduction of dislocation of ankle

59 Closed reduction of dislocation of elbow

Closed reduction of dislocation of foot and toe-

60 general anaesthesia

Closed reduction of dislocation of foot and toe-local

61 anaesthesia

Closed reduction of dislocation of hand and finger-

62 general anaesthesia

Closed reduction of dislocation of hand and finger- local

63 anaesthesia

64 Closed reduction of dislocation of hip

65 Closed reduction of dislocation of knee

Closed reduction of dislocation of other specified

66 sites-general anaesthesia

Closed reduction of dislocation of other specified

67 sites-local anaesthesia

Closed reduction of dislocation of other specified

68 sites-local anaesthesia

69 Closed reduction of dislocation of shoulder

70 Closed reduction of dislocation of wrist

71 Closed reduction of dislocation-Local anaesthesia

Closed reduction of fracture with internal fixation -

72 Carpal and metacarpal

Closed reduction of fracture with internal fixation -

73 Femur (Including : MIPO, interlocking nail, TEN)

Closed reduction of fracture with internal fixation -

74 Humerus (including : Interlocking nail, TEN, MIPO)

8
NO KSM/INSTALAS TINDAKAN
I/UNIT
Closed reduction of fracture with internal fixation -
75 Intrarticular Major Bone
Closed reduction of fracture with internal fixation -
76 Phalang of foot
Closed reduction of fracture with internal fixation -
77 Phalang of hand
Closed reduction of fracture with internal fixation -
78 Radius and ulna (MIPO, TEN)
Closed reduction of fracture with internal fixation -
79 Tarsal and metatarsal
84 Excision of bone for graft

85 Excision of intervertebral disc

86 Excision of lesion of muscle

87 Excision of lesion of muscle of hand

88 Excision of lesion of other soft tissue

Dorsal and dorsolumbar fusion of the anterior

89 column, anterior technique
Dorsal and dorsolumbar fusion of the posterior
90 column, posterior technique
91 Excision of bone for graft

92 Excision of intervertebral disc

93 Excision of lesion of muscle

94 Excision of lesion of muscle of hand

95 Excision of lesion of other soft tissue

96 Excision of lesion of tendon sheath

Excision of lesion of tendon sheath of hand,
97 Ganglionectomy of tendon sheath (wrist)-General
anaesthesia
Excision of lesion of tendon sheath of hand,
98 Ganglionectomy of tendon sheath (wrist)-Local
Anaestesi
99 Excision of muscle or fascia for graft

100 Excision of muscle or fascia of hand for graft

101 Excision of other lesion of soft tissue of hand

9
NO KSM/INSTALAS TINDAKAN
I/UNIT
102 Excision of semilunar cartilage of knee

103 Excision of tendon for graft

104 Excision of tendon of hand for graft

Excision or correction of bunionette, That with

105 osteotomy
Excision or destruction of intervertebral disc,
106 unspecified
107 Exploration of tendon sheath

108 Exploration of tendon sheath of hand

109 Exploratory thoracotomy

110 Fasciotomy

111 Fasciotomy of hand

112 Finger reattachment

113 Five-in-one repair of knee

114 Foot reattachment

115 Forearm, wrist, or hand reattachment

116 Fusion or refusion of 2-3 vertebrae

117 Fusion or refusion of 4- 8 vertebrae

118 Fusion or refusion of 9 or more vertebrae

119 Graft of muscle or fascia

120 Hip bearing surface, ceramic-on-ceramic

Hip bearing surface, ceramic-on-polyethylene, Hip bearing

121 surface, oxidized zirconium-on-polyethylene
122 Hip bearing surface, metal-on-metal

123 Hip bearing surface, metal-on-polyethylene

Implantation of internal limb lengthening device with

124 kinetic distraction
Implantation of other internal limb lengthening
125 device
Implantation or replacement of peripheral
126 neurostimulator lead (s)
Implantation or replacement of spinal
127 neurostimulator lead(s)

10
 128 Incision and drainage of palmar or thenar space

Injection of anesthetic into peripheral nerve for

129 analgesia

KSM/INSTALASI TINDAKAN
NO
/UNIT
130 Injection of anesthetic into spinal canal for analgesia

131 Injection of destructive agent into spinal canal

Injection of locally-acting therapeutic substance into

132 other soft tissue
Injection of other agent into spinal canal, Intrathecal
133 injection of steroid, Subarachnoid perfusion of
refrigerated saline
134 Injection of therapeutic substance into bursa

135 Injection of therapeutic substance into bursa of hand

Injection of therapeutic substance into joint or

136 ligament
137 Injection of therapeutic substance into tendon

Injection of therapeutic substance into tendon of

138 hand
139 Insertion of bone growth stimulator

140 Insertion of bone void filler

Insertion of catheter into spinal canal for infusion of
therapeutic or palliative substances, Insertion of
141 catheter into epidural, subarachnoid, or subdural
space of spine with intermittent or continuous
infusion of drug (with creation of any reservoir)
142 Insertion of interbody spinal fusion device

143 Insertion of other spinal devices

144 Insertion of partial spinal disc prosthesis, cervical

Insertion of partial spinal disc prosthesis,

145 lumbosacral
Insertion of recombinant bone morphogenetic
146 protein
Insertion of spinal disc prosthesis, not otherwise
147 specified, Replacement of spinal disc, NOS
148 Insertion of spinal disc prosthesis, thoracic

149 Insertion of sternal fixation device with rigid plates

150 Insertion of total spinal disc prosthesis, cervical

152 Insertion of total spinal disc prosthesis, lumbosacral

11
153 Insertion or replacement of (cement) spacer

Insertion or replacement of facet replacement

154 device(s)

12
NO KSM/INSTALAS TINDAKAN
I/UNIT
Insertion or replacement of interspinous process
155
device(s)
Insertion or replacement of pedicle-based dynamic
156
stabilization device(s)
157 Insertion or replacement of skeletal muscle stimulator
158
Internal fixation of bone without fracture reduction
159
Interphalangeal fusion
160 Interthoracoscapular amputation, Forequarter
amputation
161 Intra-operative neurophysiologic monitoring -
Neuromonitoring
162
Intervertebral chemonucleolysis
163
Limb lengthening procedures
164
Limb shortening procedures
165
Local excision of lesion or tissue of bone
166
Lower leg or ankle reattachment
167
Lower limb amputation, not otherwise specified
168 Lumbar and lumbosacral fusion of the anterior
column, anterior technique
169 Lumbar and lumbosacral fusion of the anterior
column, posterior technique
170 Lumbar and lumbosacral fusion of the posterior
column, posterior technique
171
Lysis of adhesions of hand
172 Lysis of adhesions of muscle, tendon, fascia, and bursa

173
Lysis of adhesions of spinal cord and nerve roots
174
Metacarpocarpal fusion
175
Metacarpophalangeal fusion
176
Metatarsophalangeal fusion
177
Midtarsal fusion
178
Muscle transfer or transplantation
179
Myotomy
180
Myotomy of hand
181
Neurectasis

13
NO KSM/INSTALASI/ TINDAKAN
UNIT
182 Open biopsy of cranial or peripheral nerve or ganglion
183 Open biopsy of soft tissue

Open reduction of dislocation of ankle - Neglected

184 dislocation
185 Open reduction of dislocation of elbow -Fresh dislocation

Open reduction of dislocation of hand and finger -Fresh

186 dislocation
187 Open reduction of dislocation of hip - Fresh dislocation

Open reduction of dislocation of hip - Neglected

188 dislocation
Open reduction of dislocation of knee - Neglected
189 dislocation
190 Open reduction of dislocation of knee -Fresh dislocation

191 Open reduction of dislocation of other specified sites

Open reduction of dislocation of shoulder -Fresh

192 dislocation
Open reduction of dislocation of shoulder -Neglected
193 dislocation
Open reduction of dislocation of unspecified site-Fresh
194 dislocation
Open reduction of dislocation of unspecified site-
195 Neglected dislocation
196 Open reduction of dislocation of wrist -Fresh dislocation

Open reduction of fracture with internal fixation-

197 radius and ulna-Simple fracture
Open reduction of fracture with internal
198 fixation- unspecified site (Periarticular Major
Bone )
Open reduction of fracture with internal fixation-carpals
199 and metacarpals - plate & screws
Hand NOS -Plate & Screw
Open reduction of fracture with internal fixation-carpals
200 and metacarpals - plate & screws
Hand NOS -Plate & Screw
Open reduction of fracture with internal fixation-carpals
201 and metacarpals - simple implants (K-wire)
Hand NOS -implant sederhana (K-wire)
Open reduction of fracture with internal fixation-
202 femur- Comminutive or Segmental
Open reduction of fracture with internal fixation-
203 femur- Simple fracture

14
15
 KSM/INSTALAS TINDAKAN
NO
I/UNIT
Open reduction of fracture with internal fixation-
204 humerus - Simple fracture
205 Open reduction of fracture with internal fixation-
humerus - Comminutive or Segmental
206 Open reduction of fracture with internal fixation-
other specified bone (Intraartikular Major Bone )
207 Open reduction of fracture with internal fixation-
phalanges of foot - simple implants (K-wire)
208 Open reduction of fracture with internal fixation-
phalanges of foot-Plate & Screws
209 Open reduction of fracture with internal fixation-
phalanges of hand- Plate & Screws
210 Open reduction of fracture with internal fixation-
phalanges of hand- simple implants
211 Open reduction of fracture with internal fixation-
tarsals and metatarsals- Plate & Screws
212 Open reduction of fracture with internal fixation-
tarsals and metatarsals- simple implants
213 Open reduction of fracture with internal fixation-tibia
and fibula -Simple fracture
214 Open reduction of fracture with internal fixation-tibia
and fibula-Comminutive or Segmental
215
Open reduction of fracture without internal fixation
216
Open reduction of separated epiphysis
217
Osteoclasis (correction of bone deformity)
218
Other
219
Other (peripheral) vascular shunt or bypass
220
Other amputation below knee
221
Other anastomosis of cranial or peripheral nerve
222
Other and unspecified repair of the anulus fibrosus
223
Other arthrotomy
224
Other bunionectomy
225
Other bunionectomy with soft tissue correction
226 Other cervical fusion of the anterior column, anterior
technique
227 Other cervical fusion of the posterior column,
posterior technique
228
Other change in hand muscle or tendon length
229
Other change in muscle or tendon length

16
 230
Other destruction of intervertebral disc

KSM/INSTALAS TINDAKAN
NO
I/UNIT
231 Other diagnostic procedures on joint structures
Other diagnostic procedures on muscle, tendon, fascia, and
232
bursa, including that of hand

233 Other division of bone

234 Other excision of joint

235 Other excision of soft tissue

236 Other excision of soft tissue of hand

237 Other excision or avulsion of cranial and peripheral nerves

238 Other excision, fusion and repair of toes

Other exploration and decompression of spinal canal,
239
Decompression
240 Other fasciectomy

241 Other fasciectomy of hand

242 Other fusion of foot

243 Other hand muscle transfer or transplantation

244 Other hand muscle transposition

245 Other hand tendon transfer or transplantation

246 Other hand tendon transposition

247 Other incision of bone without division

248 Other incision of soft tissue

249 Other incision of soft tissue of hand

Other injection of locally-acting therapeutic substance into
250
soft tissue of hand

251 Other local excision or destruction of lesion of joint

252 Other muscle transposition

253 Other myectomy

254 Other myectomy of hand

255 Other neuroplasty

256 Other operations on muscle, tendon, fascia, and bursa

Other operations on muscle, tendon, fascia, and bursa,
257
Suture of bursa

17
 Other partial ostectomy (including : Bone curretage,
258
marginal resection/excision)

18
 KSM/INSTALAS TINDAKAN
NO
I/UNIT
Other peripheral nerve or ganglion decompression or
259 lysis of adhesions Peripheral nerve neurolysis NOS
260 Other plastic operations on fascia
261 Other plastic operations on hand
262 Other plastic operations on muscle
263 Other repair of ankle
264 Other repair of elbow
265 Other repair of hand, fingers and wrist
266 Other repair of joint
267 Other repair of knee
268 Other repair of shoulder
269 Other repair of the collateral ligaments
270 Other repair of the cruciate ligaments
271 Other repair or plastic operations on bone
272 Other suture of flexor tendon of hand
273 Other suture of muscle or fascia
274 Other suture of other tendon of hand
275 Other suture of tendon
276 Other tendon transposition
277 Other tenodesis of hand
278 Other tenonectomy
279 Other tenonectomy of hand
280 Other tenoplasty of hand
281 Other tenotomy
282 Other total shoulder replacement
283 Partial hip replacement
284 Partial shoulder replacement
285 Patellar stabilization
286 Percutaneous denervation of facet
287 Peripheral nerve injection, not otherwise specified
288 Plastic operation on hand with graft of muscle or fascia
289 Plastic operation on hand with other graft or implant
290 Pollicization operation carrying over nerves and blood
supply
291 Quadricepsplasty
292 Reattachment of muscle
293 Reattachment of muscle of hand
294 Reattachment of tendon
295 Reattachment of tendon of hand

19
 KSM/INSTALAS TINDAKAN
NO
I/UNIT
300 Refusion of dorsal and dorsolumbar spine, posterior
column, posterior technique
301 Refusion of lumbar and lumbosacral spine, anterior
column, anterior technique
302 Refusion of lumbar and lumbosacral spine, anterior
column, posterior technique
303 Refusion of lumbar and lumbosacral spine, posterior
column, posterior technique
304 Refusion of other cervical spine, anterior column,
anterior technique
305 Refusion of other cervical spine, posterior column,
posterior technique
306 Refusion of spine, not elsewhere classified
307 Refusion of spine, not otherwise specified
308 Release of carpal tunnel
309 Release of clubfoot, not elsewhere classified
310 Release of tarsal tunnel
311 Removal of (cement) spacer
312 Removal of bone growth stimulator (invasive)
313 Removal of foreign body from spinal canal
314 Removal of implanted devices from bone - carpals and
metacarpals-Plate & screw
315 Removal of implanted devices from bone - carpals and
metacarpals-simple implants (K-wire)
316 Removal of implanted devices from bone - External
fixator device (invasive) (
317 Removal of implanted devices from bone - femur
318 Removal of implanted devices from bone - humerus
319 Removal of implanted devices from bone - radius and ulna

320 Removal of implanted devices from bone - scapula,

clavicle, and thorax (ribs and sternum)
321 Removal of implanted devices from bone -
unspecified site (Phalanges (of foot) (of hand)) - Plate
& Screw
322 Removal of implanted devices from bone -
unspecified site (Phalanges (of foot) (of hand)) -
simple implants (K-wire)
323 Removal of implanted devices from bone -patella
324 Removal of implanted devices from bone- tarsals and
metatarsals- simple implants (K-wire)
325 Removal of implanted devices from bone- tibia and
fibula
326 Removal of implanted devices from bone-other
(Pelvic bone and Vertebraae)

20
 KSM/INSTAL TINDAKAN
NO
ASI/UNIT
327 Removal of implanted devices from bone-tarsals and
metatarsals - Plate & Screw
328 Removal of internal limb lengthening device
329 Removal of pedicle screw(s) used in spinal fusion
330 Removal of peripheral neurostimulator lead(s)
331 Removal of skeletal muscle stimulator
332 Removal of spinal neurostimulator lead(s)
333 Reopening of laminectomy site
334 Repair of claw toe
335 Repair of cleft hand
336 Repair of hammer toe
337 Repair of hip, not elsewhere classified
338 Repair of macrodactyly
339 Repair of mallet finger
340 Repair of old traumatic injury of cranial and peripheral
nerves
341 Repair of recurrent dislocation of shoulder
342 Repair of the anulus fibrosus with graft or prosthesis
343 Repair of vertebral fracture, Elevation of spinal bone
fragments, Reduction of fracture of vertebrae, Removal of
bony spicules from spinal canal
344 Replacement of joint of foot and toe
345 Resurfacing hip, partial, acetabulum, Hip resurfacing
arthroplasty, partial, acetabulum
346 Resurfacing hip, partial, femoral head
347 Revision of total knee replacement, tibial insert (liner),
Replacement of tibial insert(liner)
348 Revision or replacement of artificial spinal disc
prosthesis, cervical
349 Revision or replacement of artificial spinal disc
prosthesis, lumbosacral
350 Revision or replacement of artificial spinal disc
prosthesis, not otherwise specified
351 Revision or replacement of artificial spinal disc
prosthesis, thoracic
352 Rotator cuff repair
353 Separation of equal conjoined twins
354 Separation of unequal conjoined twins
355 Sequestrectomy
356 Spinal fusion, not otherwise specified
357 Subtalar fusion
358 Subtalar joint arthroereisis
359 Suture of Artery
360 Suture of capsule or ligament of ankle and foot

21
 KSM/INSTALASI TINDAKAN
NO
/UNIT
361 Suture of capsule or ligament of other lower
extremity
362 Suture of capsule or ligament of upper extremity
363 Suture of cranial and peripheral nerves
364 Suture of muscle or fascia of hand
365 Suture of tendon sheath
366 Suture of tendon sheath of hand
367 Suture of Vein
368 Synovectomy
369 Tarsometatarsal fusion
370 Tendon graft
371 Tendon pulley reconstruction
372 Tendon pulley reconstruction
373 Tendon transfer or transplantation
374 Tenotomy of hand
375 Thigh reattachment
376 Thumb reattachment
378 Toe reattachment
379 Total ankle replacement
380 Total elbow replacement
381 Total ostectomy
382 Total wrist replacement
383 Transplant from cadaver
384 Transposition of cranial and peripheral nerves -
Nerve transplantation
389 Triad knee repair
390 Triple arthrodesis
391 Unspecified operation on bone injury
392 Upper arm reattachment
393 Upper limb amputation, not otherwise specified
394 Wedge osteotomy

22
 KSM/INSTALASI TINDAKA
NO
/UNIT N
8 KSM BEDAH 1 Adrenalektomi
UROLOGI 2 Adrenalektomi (Abdominotorakal)
3 Anastomosis end to end Ureter
4 Augmentasi Buli
5 Biopsi Ginjal perkutan
6 Biopsi Ginjal Terbuka
7 Biopsi Penis
8 Biopsi Prostat
9 Biopsi Testis
10 Bladder Neck Rekonstruksi
11 Buried Penis
12 Businasi/Dilatasi Uretra
13 Cabut DJ Stent
14 Defooring Kista Ginjal per Laparoskopi
15 Deroofing/Unroofing Kista
16 Diseksi Kelenjar Getah Bening Inguinal
17 Diseksi Kelenjar Getah Bening pelvis
18 Divertikulektomi Buli
19 Divertikulum Uretra
20 Dorsumsisi
21 Drainase Periureter
22 Eksisi Chordae/Chordektomi
23 Eksisi Fibroma/Rekonstruksi Penis
24 Eksisi Plaque (Peyronie Disease)
25 Eksisi Webbed Penis
26 Ekstraksi Batu
27 Evakuasi Bekuan Darah (Clot)
28 Extended Pyelolithotomy
29 Fistulektomi/Repair Fistel Uretra

23
 KSM/INSTALASI TINDAKAN
NO
/UNIT
30 Funikokelektomi
31 Ganti Nefrostomy
32 Hidrokel per Inguinal/Ligasi Tinggi
33 Hidrokel per Skrotal
34 Hipospadia Subkoronal
35 Holmium YaG Laser (Sewa)
36 Insersi DJ Stent
37 Insisi Abses Perineum
38 Insisi Abses Skrotum
39 Insisi Posterior Urethral Valve
40 Johanson
41 Johanson I
42 Johanson II
43 Kalibrasi Uretra
44 Kauterisasi
50 Koreksi Horseshoe Kidney
51 Koreksi Priapismus
53 Laparotomi Eksplorasi
55 Limfadenektomi Ilioinguinal
56 Limfadenektomi Retroperitoneal/RPLND
57 Litholapaksi
58 Lithotripsi
59 Masase Prostat
60 Meatoplasti
61 Meatotomi
62 MMK/Sling Uretra
63 Nefrektomi
64 Nefrektomi Donor Transplant
65 Nefrektomi Parsial
67 Nefrektomi Radial
68 Nefropeksi/Renopeksi
69 Nefrostomi Perkutan/Temporer
70 Nefrostomi Terbuka/Permanen
71 Nefroureterektomi
73 Operasi Priapismus (prosedur Winter)
74 Operasi Repair Buli Trauma
75 Operasi Sistokel
 KSM/INSTALASI TINDAKAN
NO
/UNIT
76 Operasi Trauma Ginjal
77 Operasi Urakhus/Reseksi urakhus
78 Orkhidektomi
79 Orkhidektomi extended
80 Orkhidektomi Ligasi Tinggi
81 Orkhidektomi Subkapsuler
82 Orkhidopeksi (Torsio Testis)
83 Orkhidopeksi (UDT)
85 Pasang Kateter
86 Pasang Kateter dengan Mandrain
87 Pasang Kateter Tenckhoff untuk CAPD
88 PCNL/PNL
 89 Penektomi Parsial
90 Penektomi Total/Amputasi Penis
91 PER (Primary Endoscopic Realignment)
92 Pielokalikotomi
93 Pielolitotomi
94 Pieloplasti
95 Pieloplasti per Laparoskopi
96 Prostatektomi Radikal
97 Prostatektomi Retropubik
98 Prostatektomi Terbuka
99 Prostatektomi Terbuka dan Sectio Alta
101 Punksi dan sklerosing Kista Ginjal
102 Railroading Rupture Uretra
103 Reimplantasi Ureter Bilateral
Reimplantasi Ureter
104
Unilateral/Ureteroneosistostomi
106 Repair Fistel Enterovesika
107 Repair Fistel Vesikokutan
108 Repair Fistel Vesikorektal
109 Repair Fistel Vesikovagina
110 Repair Fistel Vesikovagina Kompleks
111 Reparasi Penis
112 Reseksi-anastomosis Uretra
113 RPG
114 Sectio Alta/Vesikolithotomi
115 Sirkumsisi
115 Sistektomi Parsial/Sistoplasti Reduksi
116 Sistektomi Per Laparoskopi
117 Sistektomi Total/Radikal
118 Sistoskopi
119 Sistoskopi ODS

KSM/INSTALASI TINDAKAN
NO
/UNIT
120 Sistostomi perkutan
121 Sistostomi Terbuka
122 Skrotoplasti
123 Spermatokelektomi
124 Tailoring Ureter
125 Transplan Resipien
126 Transuretero-ureterostomi
127 TUR Prostat/TUIP/BNI
128 TUR Tumor Buli
129 TVP/TMP
130 Ureterokutaneostomi
131 Ureterolisis
 132 Ureterolithotomi
133 Ureterolithotomi Distal
134 Ureterolithotomi Proksimal
136 Ureterostomi
137 Ureterouretostomi
138 Uretroplasti Hipospadia
139 Uretroskopi/Uretrosistoskopi
140 Uretrotomi Interna (Sachse)
141 URS/Lithotripsi
142 Varikokelektomi (Palomo)
143 Vasektomi (anestesi lokal)
144 Vasektomi (narkose)
145 Vasoepididimostomi
146 Vasografi
147 Vasovasostomi
9 KSM ILMU 1 Angkat Jahitan
KESEHATAN 2 Angkat Jahitan dengan GA
MATA 3 Anterior Chamber Tap/Parasintesis
4 Aspirasi Massa Lensa
5 Blefaroplasty (2 Kelopak Mata)
6 Claw Lens
9 Dacryocystorinostomi (Without Silicon Tube)
11 Disisi Aspirasi & IOL
12 ECCE
13 ECCE & IOL
14 Eksenterasi
15 Eksisi Hordeolum / Chalazion
16 Ekstirpasi Corpus Alienum di Kornea
17 Ekstirpasi Pterygium + Graft Konjungtiva

KSM/INSTALASI TINDAKAN
NO
/UNIT
18 Ekstripasi Corpus Alienum di Bilik Mata Depan
19 Enukleasi/Eviscerasi (DFG/Bonegraft)
20 Evakuasi Silikon Oil
21 Fornix Repair
22 ICCE
23 ICCE & IOL
24 Injeksi Intra Vitreal
25 Injeksi Periokuler Terapetik
26 IOL Explant
27 Iridectomi
28 Jahit Kelopak Mata Full Thickness & Lid Margin
29 Jahit Kornea
 30 Keratoplasti (Corneal Transplantation)
31 Konjungtival Flap/Amnion Graft
34 Repair Canalis Lacrimalis (Without Silicon Tube)
35 Repair Coloboma Palpebra (Skin/Mucosal Graft)
36 Reposisi IOL
37 Reposisi Iris
42 Sekunder Implant (Posterior Chamber)
43 Sekunder Implant Claw Lens / Fiksasi Sulcus
44 SICS
45 SICS & IOL
46 Simpel Vitrektomi
49 Trabekulektomi
56 Wide Eksisi Tumor Kelopak Mata
57 Wide Eksisi Tumor Kelopak Mata + Flap + graft

KSM/INSTALASI/ TINDAKAN
NO
UNIT
13 KSM 1 Cauter serviks
OBGYN 2 Cordosentesis
3 Debulking tumor ovarium

4 Eksplorasi vagina

5 Embryotomi

6 Extirpasi + kuret polip endoserviks

7 Extirpasi geboren mioma

8 Extirpasi geboren mioma+kuiretasi

 9 Histeroctomy pada mola / chorio Ca

10 Histeroctomy radikal

11 Kistektomi

12 Konisasi serviks

13 Kuret abortus incompletes

14 Lap op: myomektomi

19 Laparotomi dengan penyulit mayor

20 Laparotomi dengan penyulit minor

21 Laparotomi tanpa penyulit

23 Micro kuretase DUB

24 Mikrokuret

25 Miomectomy

26 Neovagina

27 Operasi Ca vagina

28 Operasi kanker corpus uteri

29 Operasi tumor ganas ovarium

30 Operative histeroscopy/Ablasi endometrium

31 Overectomi

KSM/INSTALASI TINDAKAN
NO
/UNIT
32 Painless labor

33 Persalinan normal

34 Persalinan normal dengan penyulit

35 Persalinan pervaginam tindakan operatif

36 Persalinan sungsang

37 Rekanalisasi

38 Rekanalisasi tuba
 39 Salfingektomi unilateral

40 Salvingoovarectomi unilateral

42 Seksio sesaria

43 Seksio sesaria dengan penyulit penyulit

44 Sirklase serviks

46 Sirklase serviks

47 Supra vaginal hyterectomy

48 Surgical staging

49 TAH+BSO dengan Penyulit

TAH+BSO dengan Penyulit Pemasangan Tampon
50
Abdomen
51 Total abdominal hysterectomy+bilateral salfingektomi

52 Tubektomi klinik

53 Tutup burst abdomen

KSM/INSTALASI TINDAKAN
NO
/UNIT
 Augmentasi Tulang Per Regio (Belum Termasuk
14 KSM GIGI 1
Bahan)
dan 2 Debriment Mukosa dan Pengelolaan Luka Sayat
MULUT 3 Dislokasi Sendi Mandibula
4 Eksisi Epulis Per Rahang

5 Eksisi Kelenjar Ludah Submandibula

6 Eksisi Kista Odontogenik Keratosis + Ostektomi

7 Eksisi Neoplasma Jinak Extra Oral Ukuran Kecil
8 Eksisi Parsial + Marsupialisasi Ranula

9 Eksisi Plunging Ranula

10 Eksisional Biopsi Neoplasma Jinak

11 Enukleasi Kista Dentigerous + Extraksi Gigi Impaksi

Enukleasi Kista radikuler Per Rahang + Extraksi Gigi
12
Penyebab
13 Extirpasi Kista Dermoid

14 Extirpasi Sialolith
15 Extraksi Corpus Alienum dengan Teknik Lindorf
Extraksi Gigi Anak dengan Kelainan Jantung Per
16
Rahang
17 Extraksi Gigi Anak Per Rahang
18 Extraksi Gigi Dewasa Per Rahang

19 Fissure Sealant pada Autis

20 Fraktur Dento alveolar Dengan arch Bar

Fraktur Dento alveolar Dengan Bracket (belum

21 termasuk bahan)
22 fraktur Dento Alveolar dengan Eyelet

23 Fraktur Maksila dengan Suspensi Wiring

24 Fraktur Nasal close Reduksi

25 Fraktur Nasal Open Reduksi

Fraktur Rahang Reduksi Tertutup dengan
26
Intermaksila Fiksasi
27 Frenektomi Per Rahang

28 Genioplasty

KSM/INSTALASI TINDAKAN
NO
/UNIT
 29 Hemi Maksilektomi Tanpa Rekonstruksi

30 Insisi Abses / Phlegmon

31 Insisional Biopsi Neoplasma Jinak

32 Mandibular Distraksi

33 Odontektomi Per Gigi

ORIF Maksila + Zygoma + Mandibula (belum

34 termasuk implant)
35 ORIF Maksila Plating (belum termasuk implant)

36 ORIF Mandibula Plating (belum termasuk implant)

37 ORIF Zygoma Plating (belum termasuk implant)

38 Osteotomi Maksila le Fort I

39 Osteotomi Maksila le Fort II

40 Pelepasan Arch Bar (Intermaksila Fiksasi)

KSM PENYAKIT Endoscopy

17
DALAM

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

memerlukan informed consenttersebut 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

C. Tindakan Pemberian Produk Darah dan Komponen Darah,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 Berisiko Tinggi :

 KSM /
No NAMA TINDAKAN
INSTALASI
1 Chest tube
2 Pemasangan Ventilator
3 Intubasi Endotrakea
4 Pemasangan Laryngeal mask
5 Infus intraosseus
6 Kanulasi vena perifer
7 Vena sectie
KSM Anak 8 Pengambilan darah intra vena dan intra arteri
1
9 Pemasangan kateter urine
10 Pemasangan orogastrik tube
11 Pemasangan nasogastrik tube
1 Aneurisma Coiling
2 Lumbal Punksi
3 Pain Intervention
4 Injeksi Triger point
5 Injeksi Triger Fringer
KSM 6 Injeksi CTS
2 Neurologi 7 Injeksi botox

KSM Patologi
3 Phlebotomi
Klinik

1 Scaling
2 Curettage/root planning (jika diperlukan anestesi)
3 Gingivektomi
KSM Gigi dan 4 Frenektomi
4 5 Flap operasi (bone graft/membrance/GTR/interseptif)
Mulut
6 Implant
7 Vital pulpektomi dan Partial Nekrose
8 Cauter
9 Retraksi Gingiva pada prep.crown
10 Exercise Stress Ekhokardiografi

KSM 1 Contra Ventil/WSD

Pulmonologi 2 Punctie Pleura
dan Ilmu 3 Reposisi
Kedokteran 4 AFF WSD
Respirasi 5 Perawatan Luka WSD
5 6 USG Thorax Marker

1 Tindakan Radiologi pada pasien dengan kelainan

cardiovaskuler
2 Tindakan Radiologi pada pasien dengan alergi berat
 3 Tindakan Radiologi pada pasien dengan KU yang
6 KSM menurun
Radiologi
4 Tindakan Radiologi yang memerlukan FNAB Guiding
MSCT pada pasien dengan kelainan yang berdekatan
dengan organ vital
5 Tindakan Radiologi pada Ibu hamil yang
memerlukan foto

KSM
7 1 Lumbal Punksi
Neurologi 2 Pain Intervention
3 Injeksi Triger point
4 Injeksi Triger Fringer
5 Injeksi CTS
6 Sub Optical Functional
Injeksi botox

Instalasi
13 Setiap kali melakukan tindakan Hemodialisis
Hemodialisis