Nama :
NIK :
Level : PK I / PK II / PK III / PK IV / PK V
LEVEL PK Evaluasi I Evaluasi II Evaluasi III
KATEGORI
No JENIS KETRAMPILAN Standart Paraf Paraf Paraf KET
TINDAKAN B I II III IV M Spv. M Spv. M Spv.
Koord/CI Koord/CI Koord/CI
PROSEDUR DI
1 Memberikan Oksigen melalui nasal/binasal 5 kali x x x x x
KAMAR BEDAH
Memberikan oksigen melalui simple mask dan mask
2 dengan reservoir.
5 kali x x x x
BEDAH
1 Anterior Cervical Fusion ( ACDF ) x x x
NEUROLOGI
2 Laminectomy x x x
3 Craniectomy for Decompression Fracture x x x
4 Burrholes for Subdural Hematoma x x x x
5 Meningocele Repair x x x
6 Clipping of Intracranial Aneurysm x x
7 Shunt Procedures; VP/VA/LP x x x x
8 Cranioplasty x x x
9 Laparoscopy x x x
10 Hypophysectomy x x x
11 Craniotomy x x x
UROLOGI 1 Vasectomy x x x x
2 Cystectomy x x x x
3 Hypospedius Repair ( Hispopadia ) x x x
4 Nephrectomy x x x
5 Circumcision x x x x
6 Protstectomy, suprapubic x x x
7 Cystoscopy x x x x
8 T.U.R. x x x
9 Orchidectomy x x x x
10 Ureterolithotomy x x x x
BEDAH THORAKS 1 Closed Thoracotomy x x x
2 Endocardial-Pacemaker Implantation x x x
3 Myocaridal-Pacemaker Implantation x x x
4 Open Heart Procedure/CP Bypass x x
5 Septal Defect Repairs x x
6 Heart Valve Replacement x x
7 Septal Defects, ASV,VSD x x
8 Coronary Artery Bypass Graft x x
BEDAH
1 Anastomose Vaskuler x x x x
VASKULER
2 A -V access grafts x x x x
ENDOSCOPI 1 Sigmoidoscopy x x x x
2 Bronchoscopy x x x x
3 Laryngoscopy x x x x
4 Esophagoscopy x x x x
MENGOPERASI
KAN 1 Defibrillator-Datascope 5 kali x x x x
PERALATAN
2 Portable Light 5 kali x x x x
3 Vaccum Curettage 5 kali x x x x
4 Blood Warmer 5 kali x x x x x
5 Nitrous Oxide 5 kali x x x x
6 Auto Suture, TA 30, Stapling Instrument 5 kali x x x
7 Auto Suture, TA 55, Stapling Instrument 5 kali x x x
8 Auto Suture, TA 90, Stapling Instrument 5 kali x x x
9 Auto Suture, GIA, Stapling Instrument 5 kali x x x
10 Pleur-e-vac Units (Disp. Chest Drainage) 5 kali x x x
11 Vac-pac Positioner 5 kali x x x x
12 Emerson-Thoracic Pump 5 kali x x x
13 Nerve Stimulator 5 kali x x x
14 Portable Cardiac Monitor 5 kali x x x x
15 Mesin Phaco 5 kali x x x x
16 Electrosurgical Unit 5 kali x x x x
17 Resuscitator bag 5 kali x x x x x
18 Electrodyne-Cardiac Montior & Pacemaker 5 kali x x x
19 Operating Microscope 5 kali x x x x
20 Operating Room Table 5 kali x x x x
21 Suction Units 5 kali x x x x
22 Tele-thermometer 5 kali x x x x x
23 Compression Set, Zimmer ( Torniquet ) 5 kali x x x x
24 Drills ( bor) 5 kali x x x x
25 Dermatome 5 kali x x x x