KSM /

NO INSTALASI / TINDAKAN
UNIT
4. 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
8 Amputation and disarticulation of finger -local anaesthesia
Amputation and disarticulation of thumb-general
9
anaesthesia
Amputation and disarticulation of finger- general
10
anaesthesia
11 Amputation and disarticulation of finger -local anaesthesia
Amputation and disarticulation of thumb-general
12
anaesthesia
13 Amputation and disarticulation of thumb-local anaesthesia
14 Amputation of ankle through malleoli of tibia and fibula
15 Amputation of toe-general anaesthesia
16 Amputation of toe-local anaesthesia
17 Amputation through foot
18 Amputation through forearm
19 Amputation through hand, Amputation through carpals
20 Amputation through humerus, Upper arm amputation
21 Amputation, not otherwise specified
22 Ankle fusion
23 Application of external fixator device
24 Application of external fixator device, monoplanar system
25 Application of external fixator device, ring system
26 Application of hybrid external fixator device
27 Arthrocentesis
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 interphalangeal
36
joint with implant
Arthroplasty of metacarpophalangeal and interphalangeal
37
joint without implant
38 Arthroscopy
39 Arthrotomy for removal of prosthesis without 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 (all
49
procedures included in this class
50 Bunionectomy with soft tissue correction and arthrodesis
Bunionectomy with soft tissue correction and osteotomy
51
of the first metatarsal
52 Bursectomy
53 Bursectomy of hand
54 Bursotomy
55 Bursotomy of hand
56 Carporadial fusion
57 Closed reduction of dislocation -General anaesthesia
58 Closed reduction of dislocation of ankle
59 Closed reduction of dislocation of elbow
Closed reduction of dislocation of foot and toe-general
60
anaesthesia
Closed reduction of dislocation of foot and toe-local
61
anaesthesia
Closed reduction of dislocation of hand and finger-general
62
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 sites-
66
general anaesthesia
Closed reduction of dislocation of other specified sites-
67
local anaesthesia
Closed reduction of dislocation of other specified sites-
68
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 - Carpal
72
and metacarpal
Closed reduction of fracture with internal fixation - Femur
73
(Including : MIPO, interlocking nail, TEN)
Closed reduction of fracture with internal fixation -
74
Humerus (including : Interlocking nail, TEN, MIPO)

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 - Radius
78
and ulna (MIPO, TEN)
Closed reduction of fracture with internal fixation - Tarsal
79
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 column,
89
anterior technique
Dorsal and dorsolumbar fusion of the posterior column,
90
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
102 Excision of semilunar cartilage of knee
103 Excision of tendon for graft
104 Excision of tendon of hand for graft
105 Excision or correction of bunionette, That with osteotomy
106 Excision or destruction of intervertebral disc, 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
125 Implantation of other internal limb lengthening device
Implantation or replacement of peripheral neurostimulator
126
lead (s)
Implantation or replacement of spinal neurostimulator
127
lead(s)
128 Incision and drainage of palmar or thenar space
129 Injection of anesthetic into peripheral nerve for analgesia
130 Injection of anesthetic into spinal canal for analgesia
131 Injection of destructive agent into spinal canal
Injection of locally-acting therapeutic substance into other
132
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
136 Injection of therapeutic substance into joint or ligament
137 Injection of therapeutic substance into tendon
138 Injection of therapeutic substance into tendon of hand
139 Insertion of bone growth stimulator
140 Insertion of bone void filler
Insertion of catheter into spinal canal for infusion of
141
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)
142 Insertion of interbody spinal fusion device
143 Insertion of other spinal devices
144 Insertion of partial spinal disc prosthesis, cervical
145 Insertion of partial spinal disc prosthesis, lumbosacral
146 Insertion of recombinant bone morphogenetic protein
Insertion of spinal disc prosthesis, not otherwise specified,
147
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
153 Insertion or replacement of (cement) spacer
154 Insertion or replacement of facet replacement device(s)
155 Insertion or replacement of interspinous process 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
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- radius
197
and ulna-Simple fracture
Open reduction of fracture with internal fixation-
198
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-femur-
202
Comminutive or Segmental
Open reduction of fracture with internal fixation-femur-
203
Simple fracture
Open reduction of fracture with internal fixation-humerus
204
- 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
230 Other destruction of intervertebral disc
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
Other partial ostectomy (including : Bone curretage,
258
marginal resection/excision)
Other peripheral nerve or ganglion decompression or lysis
259
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 Percutaneous vertebral augmentation
288 Percutaneous vertebroplasty
289 Peripheral nerve injection, not otherwise specified
290 Plastic operation on hand with graft of muscle or fascia
291 Plastic operation on hand with other graft or implant
292 Pollicization operation carrying over nerves and blood
supply
293 Quadricepsplasty
294 Reattachment of muscle
295 Reattachment of muscle of hand
296 Reattachment of tendon
297 Reattachment of tendon of hand
298 Refusion of atlas-axis spine
299 Refusion of dorsal and dorsolumbar spine, anterior
column, anterior technique
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)
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
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

9. 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
7 Cryopexy Kornea
8 Cyclo Cryo
9 Dacryocystorinostomi (Without Silicon Tube)
10 Dekompresi Orbital/Lateral Orbitotomi
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
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
32 Piggy Back IOL
33 Pneumoretinopexy
34 Repair Canalis Lacrimalis (Without Silicon Tube)
35 Repair Coloboma Palpebra (Skin/Mucosal Graft)
 36 Reposisi IOL
37 Reposisi Iris
38 Resesi & Reseksi 2 Otot
39 Resesi & Reseksi 3 Otot
40 Resesi & Reseksi 4 Otot
41 Resesi/Reseksi 1 Otot
42 Sekunder Implant (Posterior Chamber)
43 Sekunder Implant Claw Lens / Fiksasi Sulcus
44 SICS
45 SICS & IOL
46 Simpel Vitrektomi
47 Skleral Buckle
48 Socket Repair (Contracted Socket)
49 Trabekulektomi
50 Trabekuletomi & Ollogen
51 Trabulektomi & Goniotomi pada Pediatric Glaucoma
52 Tube Shunt (Express)
53 Viscocanulostomy
54 Vitrektomi +++
55 Vitrektomi Lengkap & Skleral Buckle
56 Wide Eksisi Tumor Kelopak Mata
57 Wide Eksisi Tumor Kelopak Mata + Flap + graft

KSM / INSTALASI TINDAKAN

NO
/ UNIT
13. OBGYN 1 Cauter serviks
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

Laparoskopi (Kistektomi Ovarium, Salphingektomi,

15
Adhesiolisis)
16 Laparoskopi Histerektomi
17 Laparoskopi steril
 18 Laparoskopik Diagnostik
19 Laparotomi dengan penyulit mayor
20 Laparotomi dengan penyulit minor
21 Laparotomi tanpa penyulit
22 LEEP
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
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
41 Secound look surgery Ca ovarium
42 Seksio sesaria
43 Seksio sesaria dengan penyulit penyulit
44 Sirklase serviks
45 Seksio sesaria dengan penyulit penyulit
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

15. DIVISI 1 Intubasi Endotrakea

PEDIATRI
GAWAT 2 Krikotirotomi
 DARURAT 3 Kanulasi vena perifer
ILMU 4 Vena sectie
KESEHATAN 5 Pungsi lumbal
ANAK 6 Pungsi Pleura
16. PENYAKIT 1 ecokardiografi
JANTUNG & 2 CVC
PEMBULUH 3
DARAH 4
5 IABP
6 Perikardiosintesis
PENYAKIT Endoscopy
17. DALAM

A. 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 Drain Intra Thorakal/Punksi Thorax
Pemasangan IABP
Pemasangan Drain Intra Abdominal
Pemasangan Gemo
Cardioversi
Bronchoskopi-FOB
TEE

B. 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
C. Semua Tindakan Yang Berisiko Tinggi :
KSM /
No NAMA TINDAKAN
INSTALASI
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
1 KSM Anak
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
1 Pemeriksaan Audiometri
2 Pemeriksaan Timpanometri
3 Pemeriksaan Audiometri Tutur
2 THT-KL
4 Pemeriksaan Sisi&Tore Decay
5 Pemeriksaan Pendengaran Pada Anak
6 Pemeriksaan Brainstem Evoked Response Audiometry
Patologi
3 FNAB (Fine Needle Aspiration Biopsy)
Anatomi
Inst.
4 Tindakan Radiotherapi
Radiotherapi
1 Cerebral Angiografi
2 AVM&Embolisasi
3 Aneurisma Coiling
4 Embolisasi pre operasi
5 Diagnosis DSA
6 Lumbal Punksi
5 7 Pain Intervention
Neurologi
8 Injeksi Triger point
9 Injeksi Triger Fringer
10 Injeksi CTS
11 Sub Optical Functional
12 Injeksi botox
13 EMG
6 Patologi Klinik Phlebotomi
 1 Scaling
2 Curettage/root planning (jika diperlukan anestesi)
3 Gingivektomi
4 Frenektomi
Gigi dan
7 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
8 Poli Andrologi Suntik Intra Cavernosal Penis
1 Dobutamin Stress Ekhokardiografi
Kardiologi dan
2 Transophegal Ekhokardiografi
Kedokteran
9 3 Treadmill Tes
Vaskular
4 Exercise Stress Ekhokardiografi
1 Bronchoscopy/FOB
2 Tindakan kemotherapi
3 Thoracoscopy
4 Contra Ventil/WSD
Pulmonologi 5 Punctie Pleura
dan Ilmu 6 FNAB
10 Kedokteran 7 Scalene Biopsy
Respirasi 8 Reposisi
9 Pleurodesis
10 AFF WSD
11 Perawatan Luka WSD
12 USG Thorax Marker
1 Tindakan Radiologi Injectee contrast
2 Tindakan Radiologi pada pasien dengan kelainan
cardiovaskuler
3 Tindakan Radiologi pada pasien dengan alergi berat
4 Tindakan Radiologi pada pasien dengan KU yang
11 Radiologi menurun
5 Tindakan Radiologi yang memerlukan FNAB Guiding
MSCT pada pasien dengan kelainan yang berdekatan
dengan organ vital
6 Tindakan Radiologi pada Ibu hamil yang memerlukan
foto
1 Cerebral Angiografi
2 AVM&Embolisasi
3 Aneurisma Coiling
12 Neurologi 4 Embolisasi pre operasi
5 Diagnosis DSA
6 Lumbal Punksi
7 Pain Intervention
 8 Injeksi Triger point
9 Injeksi Triger Fringer
10 Injeksi CTS
11 Sub Optical Functional
12 Injeksi botox
13 EMG
14 Neuro endovaskuler: Coiling,Embolisasi,DSA
Instalasi
13 Setiap kali melakukan tindakan Hemodialisis
Hemodialisis

14 Rehabilitasi
Elektromiografi dan Kecepatan Hantar Saraf
Medik
1 Psycho Analisa
2 Psycho Therapy Dalam
3 Pemeriksaan Calon Pimpinan Publik
4 Aborsi Provocatus Medicinalis
16 IRNA Jiwa
5 Tindakan terapi elektroconfusi
6 Pemeriksaan kandungan zat narkotika
7 Restraint / Fiksasi : mekanik dan psikotropika
8 Pemeriksaan sengketa/ konflik dalam keluarga
15 Semua injeksi dengan obat risiko tinggi

KSM /
TINDAKAN
NO INSTALASI /
UNIT
14. GIGI dan 1 Augmentasi Tulang Per Regio (Belum Termasuk Bahan)
MULUT 2 Debriment Mukosa dan Pengelolaan Luka Sayat
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
16 Extraksi Gigi Anak dengan Kelainan Jantung Per 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 termasuk
21
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 Intermaksila
26
Fiksasi
27 Frenektomi Per Rahang
28 Genioplasty
29 Gingivektomi Per Rahang
30 Hemi Maksilektomi Tanpa Rekonstruksi
31 Insisi Abses / Phlegmon
32 Insisional Biopsi Neoplasma Jinak
33 Mandibular Distraksi
34 Odontektomi Per Gigi
ORIF Maksila + Zygoma + Mandibula (belum termasuk
35
implant)

36 ORIF Maksila Plating (belum termasuk implant)

37 ORIF Mandibula Plating (belum termasuk implant)
38 ORIF Zygoma Plating (belum termasuk implant)
39 Osteotomi Maksila le Fort I
40 Osteotomi Maksila le Fort II
41 Pelepasan Arch Bar (Intermaksila Fiksasi)