RINCIAN KEWENANGAN KLINIS

Nama :
Spesialisasi : ..
Lulusan : ..
STR berlaku sampai : ..

Dengan ini saya menyatakan mempunyai kemampuan untuk melakukan pengelolaan kasus-kasus
yang telah diklasifikasikan dengan kompetensi saya sebagai Dokter/Dokter Spesialis/Dokter
Spesialis Konsultan/Dokter Gigi/Dokter Gigi Spesialis, yaitu melakukan hal-hal di bawah ini
sesuai kategori kewenangan :
1. Mengetahui dan menjelaskan mengenai jenis tindakan/layanan
2. Pernah melihat atau pernah didemostrasikan jenis tindakan/layanan
3. Pernah melakukan atau pernah menerapkan jenis tindakan/pelayanan di bawah supervisi
4. Mampu melakukan secara mandiri

Kategori
No Kewenangan Klinis
I II III IV
General Trauma
Cervical Spine
1 Anterior fixation fraktur/dislocation cervical spine
2 Aplication halo/tong traction cervical spine
3 MUA fraktur cervical spine
4 Posterior fixation fraktur/dislocation cervical spine
Thoracic Spine
5 Anterior decompression fixation thoracic spine
6 Posterior decompression thoracic spine
Ekstremitas Atas
Brachial Plexus
7 Exploration/repair/grafting brachial plexus
Clavicle
8 ORIF clavicle frakture
9 ORIF non-clavicle frakture
Shoulder
10 Anterior dislocation shoulder closed reduction
11 Anterior shoulder open reduction +/- fixation
12 Acromioclavicular joint dislocation acute ORIF
13 Frakture proximal humerus ORIF
14 Glenoid fracture ORIF
15 Posterior dislocation shoulder closed reduction
Elbow
16 Dislocated elbow +/- fracture closed reduction
Dislocated elbow +/- fracture open reduction
17
+/- fixation
18 Intraarticular distal humerus fracture ORIF
19 Lateral condyle fracture ORIF
20 Medial condyle/epicondyle fracture MUA/Kwire/ORIF
21 Olecranon fracture ORIF
22 Radial head/neck fracture MUA +/- Kwire

Page 1 of 8
 Kategori
No Kewenangan Klinis
I II III IV
Elbow
23 Radial head/neck fracture ORIF
24 Radial head replacement for fracture

Page 2 of 8
25 Supracondylar fracture MUA +/- Kwire
26 Supracondylar fracture open reduction
Wrist
27 Carpal fracture/dislocation MUA & percutaneus wires
28 Carpal fracture/dislocation MUA & POP
29 Carpal fracture/dislocation ORIF
30 Schapoid fracture non-op
31 Schapoid fracture ORIF
32 Schapoid fracture MUA & percutaneus wires
33 Schapoid fracture non-union
Hand
34 5th metacarpal fracture/ dislocation non-op
5th metacarpal fracture/ dislocation MUA &
35
percutaneus wires
36 5th metacarpal fracture/dislocation MUA & POP
37 5th metacarpal fracture/dislocation ORIF
38 Finger tip reconstruction
39 Infection
40 Infection hand drainage (not tendon sheath)
41 Infection tendon sheath drainage
42 IPJ fracture/dislocation
43 IPJ fracture/dislocation MUA & percutaneus wires
44 IPJ fracture/dislocation MUA +/- POP
45 IPJ fracture/dislocation ORIF
46 Ligament repair hand
47 Metacarpal fracture (not 1st or 5th)
Metacarpal fracture (not 1st or 5th) MUA &
48
percutaneus wires
49 Metacarpal fracture (not 1st or 5th) MUA & +/- POP
50 Metacarpal fracture (not 1st or 5th) ORIF
51 Phalangeal fracture non-op
52 Phalangeal fracture MUA & percutaneus wires
53 Phalangeal fracture MUA +/- POP
54 Phalangeal fracture ORIF
55 Tendon repair
56 Tendon repair extensor
57 Tendon repair flexor
58 MCPJ fracture/dislocation
59 MCPJ fracture/dislocation MUA & percutaneus wires
60 MCPJ fracture/dislocation MUA +/- POP
61 MCPJ fracture/dislocation ORIF

Kategori
No Kewenangan Klinis
I II III IV
Ekstremitas Bawah
Pelvis
62 Acetabular fracture ORIF
Page 3 of 8
63 Pelvic fracture
64 Pelvic fracture external fixator application
65 Pelvic fracture ORIF
Hip
66 Dislocated hip
67 Dislocated hip closed reduction
68 Dislocated hip open reduction +/- fixation
69 Extracapsular fracture
70 Extracapsular fracture CHS/DHS
71 Extracapsular fracture intramedullary fixation
72 Extracapsular fracture other fixation
73 Intracapsular fracture
74 Intracapsular fracture hemiarthroplasty
75 Intracapsular fracture internal fixation
76 Intracapsular fracture THR
Femur
77 Diaphyseal fracture traction or spica in child
78 Diaphyseal fracture intramedullary nailling
79 Diaphyseal fracture plate/screw fixation
80 Fasciotomy for compartment syndrome
81 Subtrochanteric fracture
82 Subtrochanteric fracture plate/screw fixation
83 Supracondylar fracture (not intraarticular)
Supracondylar fracture (not intraarticular) DCS/blade
84
plate etc
Supracondylar fracture (not intraarticular)
85
intramedullary fixation
Knee
86 Acute ligament repair
87 Intraarticular fracture distal femur ORIF
88 Patella dislocation closed reduction +/- open repair
89 Patella fracture ORIF
90 Patella tendon repair
91 Quadriceps tendon repair
92 Tibial plateau fracture
93 Tibial plateau fracture ORIF with plates and wires
94 Tibial plateau fracture treatment with circular frame
Tibia & Fibula
Diaphyseal tibial fracture external fixation (including
95
frame)
96 Diaphyseal tibial fracture intramedullary nailling
97 Diaphyseal tibial fracture MUA & POP
98 Tibial shaft plating
99 Tibial non-union
100 Tibial non-union circular frame management
Tibial non-union intramedullary nailing +/- bone
101
grafting

Kategori
No Kewenangan Klinis
I II III IV
Ankle
102 Ankle fracture/dislocation
Page 4 of 8
103 Ankle fracture/dislocation MUA & POP
104 Ankle fracture/dislocation ORIF
105 Pilon fracture
106 Pilon fracture ORIF
107 Pilon fracture with circular frame
108 Tendonachilles repair
Foot
109 Ampitation toe/ray for trauma
110 Calcaneal fracture and ORIF
111 Metatarsal fracture ORIF
112 Phalangeal fracture MUA +/- Kwire +/- ORIF
113 Talar subtalar or midtarsal fracture/dislocation
Talar subtalar or midtarsal fracture/dislocation MUA
114
+/- POP +/- Kwire
115 Talar subtalar or midtarsal fracture/dislocation ORIF
Trauma General
116 Free flap
117 Full thickness skin graft
118 Muscle flap
119 Nerve repair
120 Pedicle flap
121 Removal external fixator or frame
122 Removal foreign body from skin/subcutaneous tissue
123 Removal Kwire or skeletal traction
124 Split skin graft
125 Transpositional flap
126 Wound closure, delayed primary or secondary
127 Wound debridement
Foream
128 Fasciotomy for compartment syndrome
129 Fracture distal radius-closed non-op
130 Fracture distal radius external fixation
131 Fracture distal radius MUA & percutaneus wires
132 Fracture distal radius MUA & POP
133 Fracture distal radius ORIF
134 Fracture shaft radius/ulna
135 Fracture shaft radius/ulna IM nailling
136 Fracture shaft radius/ulna MUA & percutaneus wires
137 Fracture shaft radius/ulna MUA & POP
138 Fracture shaft radius/ulna ORIF
Humerus
139 Fracture diaphysis humerus non-op
140 Non-union ORIF +/- bone grafting
141 Fracture diaphysis humerus IM nailling
142 Fracture diaphysis humerus MUA +/- POP
143 Fracture diaphysis humerus ORIF plating

Kategori
No Kewenangan Klinis
I II III IV
Ellective

Page 5 of 8
Thoracic Spine
144 Anterior decompression +/- fixation/fusion
145 Biopsy thoracic spine
146 Posterior decompression +/- fixation/fusion
147 Scoliosis correction-anterior release +/- instrumentation
Scoliosis correction-posterior release +/-
148
instrumentation
Brachial Plexus
149 Exploration/repair/grafting brachial plexus
Lumbal Spine
150 Caudal epidural injection
151 Decompression lumbar spine with fusion +/- fixation
Decompression lumbar spine without fusion (not
152
disectomy alone)
153 Disectomy open/micro
154 Nerve root/facet joint injection lumbal spine
Shoulder
Acromioclavicular joint excision-arthroscopic/open
155
lateral clavicle
156 Acromioclavicular joint reconstruction
157 Acromioplasty open
158 Anterior repair for instability arthroscopic
159 Arthroscopic subacromial decompression
160 Arthroscopic diagnostic
Rotator cuff repair (open or arthroscopic) +/-
161
acromioplasty
162 Total shoulder replacement
Foot
163 Amputation toe/ray
164 Calcaneal osteotomy
165 CTEV correction
166 Fifth toe soft tissue correction
167 First metatarsal osteotomy
168 First MTPJ arthrodesis
169 First MTPJ soft tissue correction
170 Hindfoot arthrodesis
171 Ingrowing toenail operation
172 Lesser metatarsal osteotomy
173 Lesser toe arthrodesis
174 Lesser toe excision part/all phalax
175 Lesser toe tenotomy
176 Tendon decompression or repair
177 Tendon transfer foot
178 Wedge tarsectomy
Elbow
179 Arthrolysis elbow (open/arthroscopic)
180 Arthrotomy elbow
181 Excision radial head +/- synovectomy

Kategori
No Kewenangan Klinis
I II III IV
Elbow
Page 6 of 8
182 Radial head replacement
183 Tennis/golfer elbow release
184 Total elbow replacement
185 Ulnar nerve decompression/transposition
Elective site non-specific
186 Aspiration/injection joint
187 Benign tumour excision (soft tissue and bone)
188 Biopsy bone-needle
189 Biopsy bone-open
190 Bursa excision
191 Cyst bone curettage +/- bone graft
192 Epiphy siodesis (geser ke pediatrik)
193 Malignant tumour excision (soft tissue and bone)
Ankle
194 Arthrodesis ankle
195 Arthrotomy ankle
196 Decompression tension at ankle
197 Tendoachilles lengthening
Knee
198 ACL reconstruction
199 Arthroscopic lateral release
200 Arthroscopic partial meniscectomy
201 Arthroscopic removal loose bodies knee
202 Arthroscopic synovectomy
203 Arthroscopic knee diagnostic
204 Osteotomy distal femoral
205 Osteotomy proximal tibia
206 Patella realignment
207 Patella resurfacing alone
208 Revision TKR
209 TKR
210 Unicompartmental knee replacement
Tibia & Fibula
211 Amputation below knee
212 Tibia lengthening
Femur
213 Amputation above knee
214 Femoral lengthening
215 Osteotomy corrective (not for DDH)
Hip
216 Arthrodesis hip
217 Arthrotomy hip
218 Excision arthroplasty hip (e.q. Gidlestone)
219 Open reduction for DDH
220 Osteotomy hip-pelvic for DDH
221 Osteotomy hip-proximal femoral for DDH
222 Osteotomy pelvis-not for DDH
223 Revision Total Hip Replacement

Kategori
No Kewenangan Klinis
I II III IV
Hip
Page 7 of 8
 224 Revision THR acetabular component
225 Revision THR both component
226 Revision THR femoral component
227 Slipped upper femoral epiphysis
228 Slipped upper femoral epiphysis open reduction
229 Slipped upper femoral epiphysis pinning
230 Total Hip Replacement
231 THR cemented
232 THR hybrid
233 THR surface replacement
234 THR uncemented
Wrist
235 Arthrodesis wrist (includes partial arthrodesis)
236 Carpal tunnel decompression
237 De Quervians decompression
238 Excision distal ulna
239 Ganglion excision at wrist
240 Ulna shortening
241 Ulnar nerve decompression
Hand
242 Excision synovial cyst
243 Fusion of MCPJ or IPJ
244 MCPJ replacement
245 Soft tissue reconstruction hand
246 Tendon transfer hand
247 Trapezium excision
248 Trigger finger release
249 Trigger thumb release
Cervical Spine
250 Anterior decompression +/- fixation/fusion (C2-C7)
251 Atlantoaxial fixation +/- fusion
252 Biopsy cervical spine
253 Excision cervical spine
254 Nerve root/facet joint injection cervical spine
255 Occipito- cervical fusion +/- fixation
256 Posterior decompression +/- fixation/fusion

Demikian hal ini saya perbuat sebagaimana mestinya dan dengan penuh tanggung jawab.

Medan,
Hormat saya,

(....)

Page 8 of 8