Perihal : Permohonan Kewenangan Klinis

Lampiran : 1 berkas

Kepada Yth,
Ibu Direktur RS ASSyifa Bandar Jaya
Di tempat.

Dengan hormat,
Dengan ini kami mengajukan permohonan surat penugasan klinis dan
rincian kewenangan klinis sebagai staf medis Rumah Sakit Assyifa
Bandar Jaya.
Demikianlah permohonan ini kami sampaikan, atas perhatiannya di
ucapkan terima kasih.

Metro, Desember 2019

Pemohon

dr. Muhammad Ridhaniar Rahman, Sp.U

Berkas yang diperlukan :

1. Foto copy STR
2. Foto copy Ijazah
3. Foto copy Surat Ijin praktek
4. Format Rincian kewenangan klinik yang sudah di isi
 LAMPIRAN
RINCIAN KEWENANGAN KLINIK DOKTER SPESIALIS UROLOGI

DISETUJUI DITOLAK
JENIS PELAYANAN DIMINTA KET
M DS TA TK
Operations on Adrenal
1. Adrenalectomy -
(abdominothoracal)
2. Adrenalectomy -
Operations on Kidney
3. Nephrotomy and nephrostomy √
4. Nephrotomy. √
Deroofing/unroofinfg cysta.
Pyelonephrolithotomy
5. Nephrostomy √
6. Percutaneous nephrostomy √
without fragmentation
Bivalve/anatropic
nephrolithotomy
7. Percutaneous nephrostomy -
with fragmentation
8. Pyelostomy and pyelostomy √
9. Pyelostomy. Pyelolithotomy √
10. Pyelostomy Extended √
pyelolithotomy
11. Diagnostic procedures on -
kidney. Pyelocalicotomy
12. Nephroscopy -
13. Pyeloscopy. Disesksi kelenjar -
getah bening pelvis per
laparoskopi
14. Closed (percutaneous) (needle) -
biopsy of kidney
15. Open biopsy of kidney -
16. Other diagnostic procedures -
on kidney
17. Local excision or distruction √
of lesion or tissue of kidney
18. Marsupialization of kidney √
lesion
19. Open ablation of renal lesion -
or tissue
20. Percutaneous ablation of -
renal lesion or tissu
21. Laparoscopic ablation or renal -
lesion or tissu
22. Other and unspecified -
ablation of renal lesion or
tissu
23. Other local excision or √
destruction of lesion or tissue
 of kidney
24. Partial nephrectomy: √
Calycectomy, Wedge resection
of kidney
25. Complete nephrectomy √
26. Nephroureterectomy. -
Nephroureterectomy with
bladder cuff Total
nephrectomy(unilat)
27. Nephrectomy of remaining √
kidney. Removal of solitary
kidney
28. Removal of transplated or -
rejected kidney. Radical
Nephrectomy
29. Bilat nephrectomy -
30. Transplant of kidney -
31. Renal autotransplantatlon -
32. Other kidney transplantation. -
Recipient transplantation
33. Nephropexy, Fixation or -
suspension of movable
(floating) kidney
34. Other repair of kidney √
35. Suture laceration of √
kidney/renoraphy
36. Closure of nephrostomy and √
pyelostomy
37. Closure of other fistula of √
kidney
38. Reduction of torsion of renal -
pedicle
39. Symphysiotomy for horseshoe -
kidney. Koreksi horseshoe
kidney
40. Anastomosis of kidney; -
Nephropyeloureterostomy,
Pyeloureterovesical anastomosis,
41. Ureterocalyceal anastomosis
42. Correction of ureteropelvic √
junction. Pyeloplasty
43. Other operation on kidney √
44. Decupsulation of kidney. -
Capsulectomy of kidney.
Decortications of kidney.
Nephrectomy for donor
transplant
45. Percutaneous aspiration of √
kidney (pelvis). Aspiration of
renal cyst. Renipuncture.
Punksi dan sklerosing kista
ginjal
46. Replacementt of nephrostomy √
 tube
47. Replacement of pyelostomy √
tube
48. Local perfusion of kidney -
49. Other injection of therapeutic -
substance into kidney
injection to renal cyst
50. Implantation or replacement -
of mechanical kidney
51. Removal of mechanical kidney -
52. Reconstruction of -
renovascular
Operations on Ureter
53. Transurethral removal of √
obstruction from ureter and
renal pelvis Removal of: blood,
clot, calculus, foreign body, From
ureter or renal pelvis without
incision. URS
54. Ureteral meatotomy √
55. Ureterotomy √
56. Incision of ureter for: drainage,
exploration, removal of
calculusUreterolithtomy
57. Ureterolithotomy proximal √
58. Ureterolithotomy distal √
59. Diagnostic procedures on √
ureter
60. Ureteroscopy √
61. Closed percutaneous biopsy of -
ureter
62. Closed endoscopic biopsy of -
ureter
63. Open biopsy of ureter √
64. Endoscopy of ileal conduit: √
cystoscopy, looposcopy
65. Ureterectomy √
66. Ureterectomy, NOS √
67. Partial ureterectomy. Excision √
of lesion of ureter. Shortening
of ureter with
68. reimplantation. Reimplantasi
ureter bilat
69. Total ureterctomy -
70. Contaneous uretero-ileostomy √
71. Formation of cuaneous √
uretero-ileostomy. heal
conduit (Bricker)
72. Revlslon of cuntaneous √
uretero-ileostomy
73. Other external urinary √
dlverslon
74. Formation of other cutaneous √
 ureterostomy. Anastomosis of
ureter to skin.
Ureterostomy NOS.
ureterokutaneostomi
75. Revision of other cutaneous √
ureterstomy
76. Revision of ureterostomy
stoma
77. Other anastomosis or bypass of √
ureter
78. Urinary diversion to intestine -
79. Revision of ureterointestinal √
anastomosis
80. Nephrocystanastomosdis, NOS √
81. Ureteroneiocystostomy, √
Replasment of ureter with
bladder flap
Ureterovesical anastomosis.
Reimplantasi ureter unilateral
Psoas Hitch/Boari flap
82. Transuretero-ureterostomy. √
Uretero-ureterostomy
83. Other. Anastomosis end to √
end ureter
84. Repair of ureter √
85. Lysis of intraluminal √
adhesions of ureter
86. Suture of laceration √
87. Closure of other fistula of √
ureter
88. Ureteropexy √
89. Removal of ligature from √
ureter
90. Other repair of ureter. √
Tailoring ureter
91. Other operations on ureter √
92. Dilation of uretral meatus √
93. Implantation of electronic -
ureteral stimulator
94. Replacement of electronic -
ureteral stimulator
95. Removal of electronic uretral -
stimulator
96. Ligation of ureter √
97. Removal DJ stent √
OPERATIONS ON URINARY BLADDER
98. Transurethral clearance of √
bladder Drainage of bladder
without incision Removal
of(blood clots, calculus, foreign
body) from bladder without
incision Lithotripsy batu buli
99. Cystostomy √
100. Percutaneous aspiration of √
bladder
101. Lysis of intraluminal √
adhesions with incision into
bladder
102. Percutaneous cystostomy √
Closed cystostomy,
percutaneos suprapubic
cystostomy
103. Other suprapubic √
cystostomy. Railroading
rupture uretra
104. Other cystostomy. √
Lithopalaksi. Section
alta/vesikolithotomi
105. Vesicostomy -
106. Revision or closure of -
vesicostomy
107. Diagnostic procedures on -
bladder
108. Cystoscopy through -
artificial stoma. Sistoskopi
ODS
109. Other cystoscopy. √
Transurethral cystoscopy
110. Closed (transurethral) √
biopsy of bladder. TUR
tumor buli
111. Open biopsy of bladder √
112. Orther diagnostic √
procedure on bladder
113. Transurethral √
excision/destruction of
bladder tissue
114. Transurethral lysis of √
intraluminal adhesions
115. Other transurethral √
excision/destruction of
lesion/tissue of bladder
Endoscopic resection of
bladder lesion
116. Other excision/destruction √
of bladder tissue
117. Excision of urachus. √
Excision of urachal sinus of
bladder
118. Open excison/destruction -
of other lesion/tissue of
bladder
Endometrectomy of
bladder. Suprapubic
excision of bladder lesion
Diverticulectomy of
 bladder
119. Partial cystectomy Excision -
of bladder dome,
trigonectomy, wedge
resection of
bladder. Reduction of
cystoplasty
120. Total cystectomy. Total -
cystectomy with
urethrectomy
Radical cystectomy
121. Radical cystectomy -
122. Other total cystectomy -
123. Other repair of urimary √
bladder
124. Suture of laceration of √
bladder
125. Closure of cystostomy √
126. Repair of fistula involving -
bladder and intestine
Fistulectomy:
(rectovesicovaginal,
vesicosigmoidovaginal)
Repair fistel enterovesika.
Repair fistel vesikorektal
127. Repair of other fistula of -
bladder
Fistulectomy: cervicovesical,
urethroperineovesical,
uterovesical, vaginovesical.
Repair fistel vesikokutan
128. Cystourethroplastyand plastic -
repair of bladder neck
Placation of sphincter of
urinary bladder
Reconstruction/v-+ plasty of
bladder neck
129. Repair of bladder extropy -
130. Reconstruction of urinary -
bladder
Anastomosis of bladder with
isolated segment of ileum,
augmentation of bladder,
replacement of bladder with
ileum/sigmoid (closed ileal
bladder)
131. Other anastomosis of -
bladder
Anastomosis of bladder to
intestine NOS, cystocolic
anastomosis
132. Other repair of bladder. √
Neobladder
133. Other operations on √
bladder
134. Sphincterotomy of bladder √
Devision of bladder neck
135. Dilation of bladder neck √
136. Control of (post operative) √
hemorrhage of bladder
137. Insertion of indwelling √
urinary catheter
138. Replacement of indwelling √
urinary catheter
139. Implantation of electronic -
bladder stimulator
140. Replacement of electronic -
bladder stimulator
141. Removal of electronic -
bladder stimulator
OPERATIONS ON URETHRA
142. Urethrotomy √
Excision of urethral septum,
formation of urethrovaginal
fistula, perineal
urethrostomy removal of
calculus from urethra by
incision
143. Urethral meatotomy √
144. diagnostic procedures on √
urethra
145. Perineal urethroscopy √
146. Other urethroscopy. PER √
(primary endoscopic
realignment)
Urethroscopy/
uretrossistoskopi
147. Biopsy of urethra √
148. Biopsy of periurethral √
tissue
149. Other diagnostic procedure √
on urethra and periurethral
tissue
150. Excision/destruction of √
lesion or tissue of urethra
151. Endoscopic excision: √
destruction of lesion or
tissue of urethra
Fulguration of urethral
lesion Kauterisa'si
152. Other local √
excision/destruction of
lesion or tissue of urethra
Excision of: (congenital
valve, lesion, stricture) of
urethra Uretrectomy.
 Divertikulum uretra. lnsisi
posterior urethral valve
153. Repair of urethra √
154. Suture of laceration of √
urethra
155. Closure of urethrostomy √
156. Closure of other fistula of √
urethra.
Fistulektomi/repair fistel
urethra
157. Reanastomosis of urethra. √
Anastomosis of urethra
Reseksi-anastomosis uretra
158. Reopair of √
hypospadias/epipadias
159. Other reconstruction of √
urethra. Urethral
construction. Johanson
160. Urethral meatoplasty √
161. Other repair of urethra √
Beneneti rotation of bulbous
urethra. Repair of old
obstetric laceration of
urethra. Urethral placation.
Uretroplasty
162. Release of urethral √
stricture.
Cutting of urethral
sphincter. Internal urethral
Sphincter. Urethrolysis.
Uretrotomi interna (Sachse)
163. Dilation of urethra √
Dilation of urethrovesical
junction Passage of sound
through urethra
Removal of calculus from
urethra without incision
Businasi/silatasi uretra
164. Other operations on √
urethra and periurethral
tissue
165. Incision of periurethral √
tissue. Drainage of
bulbourethral gland
166. Excision of periurethral √
tissue
167. Implantation of artificial √
urinary sphincter
168. Kalibrasi uretra √
169. Insertion catheter √
OTHER OPERATION ON URINARY TRACT
170. Dissection of -
retroperitoneal tissue
171. Retroperitoneal dissection, -
NOS
Llmfadenektomi
retroperitoneal/RPLND
172. Ureterolysis with -
freeing/repositioning of
ureter for retroperitoneal
fibrosis
173. Other lysis of √
perirenal/periureteral
adhesions
Ureterolysis
174. Laparoscopic lysis of -
perirenal/periureteral
adhesions
175. Other incision of √
perirenal/periureteral
tissue
Exploration of perinephric
area. Incision of perirenal
abscess
176. Incision of perivesical tissue √
177. Other lysis of perivesical √
adhesions
178. Laparoscopic lysis of -
perivesical adhesions
179. Other Incicion of perivesical √
tissue
Exploration of perivesical
tissue. Incision of hematoma
of space of retzius Retropubic
exploration
180. Diagnostic procedure on √
perirenal and perivessical
tissue
181. Biopsy of perirenal or √
perivessical tissue
182. Other diagnostic procedure on √
perirenal tissue, perivesical
tissue and retroperitoneum
183. Placation of urethrovesical -
junction
184. Suprapubic sling operation. -
MMK/sling uretra
185. Retropubic uretral -
suspension
186. Paraurethral suspension -
187. Other repair of urinary -
stress incontinence
188. Levator muscle operation -
for urethrovesical
suspension
189. Injection of implant into -
 urethra and/or bladder
neck
Collagen implant. Collagen
implant. Endoscopic injection
of implant Fat implant.
Polytel implant
190. Other -
Anterior urethropexy, repair of
stress incontinence NOS,
tudor “rabbitear”
urethropexy
191. Ureteral catheterization. √
Drainage of kidney by
catheter•
Insertion of ureteral stent/DJ
stent. Ureterovesical orifice
dilation Drainage periureter.
Insersi ureter kateter for
RPG
192. Other operations on urinary √
system
193. Excision of perirenal or √
perivesical tissue
194. Other operations on √
perirenal or perivescal
tissue
195. Replacement of √
ureterostomy tube: Change,
reinsertion
196. Replacement of cystostomy √
tube
197. Ultrasonic fragmentation of -
urinary stones. Shattered
urinary stones
198. Ureterosigmoidostomy -
(Coffey)
OPERATIONS ON PROSTATE AND SEMINAL VESICLES.
199. Incision of prostate. √
Drainage of prostatic
abscess. Prostatolithotomy
200. Diagnostic procedure on √
prostate and seminal visicles
201. Biopsy prostat
202. Closed (percutaneous) √
(neddle) biopsy of prostate
203. Open biopsy of prostate √
204. Closed (percutaneous) biopsy of √
seminal vesicles Needle biopsy
of seminal vesicles
205. Open biopsy of periprostatic √
tissue
206. Biopsy of periprostatic -
tissue
207. Other diagnostic procedures -
on prostate and periprostatic
tissue
208. Other diagnostic procedures √
on seminal vesicles
209. Transurethral √
prostatectomy
210. Transurethral (ultrasound) -
guided laser induced
prostatectomy (TULIP) TRUS
211. Other transurethral √
prostatectomy:
Excision of median bar by
transurethral approach,
TEVAP, transurethral
enucleative procedures,
transurethral prostatectomy
NOS, TURP, TUIP, BNI, TVP,
TMP
212. Suprapubic prostatectomy. √
Transvesical prostatectomy
213. Retropubic prostatectomy √
214. Radical prostatectomy. -
Prostatovesiculectomy
215. Other prostatectomy √
216. Local excision of lesion of √
prostate. Open
prostatectomy
217. Perineal -
218. Operations on seminal √
vasicles
219. Percutaneous aspiration of √
seminal vesicles
220. Incision of seminal vesicles √
221. Excision of seminal vesicles -
Excision of Mullerian duct
cyst, spermatocystectomy
222. Other operations on seminal -
vesicles
223. Incision/excision of -
periprostatic tissue
224. Incision of periprostatic -
tissue. Drainage of
periprostatic tissue
225. Excision of periprostatic -
tissue
226. Excision of lesion of
periprostatic tissue
227. Other operation on prostate √
228. Percutaneous aspiration of -
prostate
229. Injection into prostate -
230. Repair or prostate √
231. Control of (postoperative) √
hemorrhage of prostate
Coagulation of prostetic bed
232. Cystoscopy for control of
prostatic hemorrhage
233. Transurethral ballon -
dilation of the prostatic
urethra
234. Transurethral destruction of -
prostate tissue by microwave
thermotherapy Transurethral
microwave thermotherapy
(TUMT) of prostate
235. Other transurethral -
destruction of prostate
tissue by other
Thermotherapy.
Radiofrequency thermotherapy
Transurethral needle ablation
(TUNA) of prostate
236. Masase prostate √
OPERATIONS ON SCROTUM AND TUNICA VAGINALIS
237. Incision and drainage of √
scrotum and tunica vaginalis
238. Diagnostic procedures on √
scrotum and tunica vaginalis
239. Biopsy of scrotum or tunica √
vaginalis
240. Other diagnostic procedures √
on scrotum and tunica
vaginalis
241. Excision of fhydrocele (of √
tunica vaginalis)
242. Excision/destruction of lesion √
or tissue of scrotum:
fulguration of lesion reduction
of elephantiasis, partial
scrotectomy
243. Repair of scrotum and tunica √
vaginalis
244. Suture of laceration of √
scrotum and tunica
vaginalis
245. Repair of scrotal fistula √
246. Other repair of scrotum and √
tunica vaginalis
Reconstruction with rotational
or pedicle flaps. Scrotoplasty
247. Other repair on scrotum and √
tunica vaginalis
248. Percutaneous aspiration of -
tunica vaginalis
249. Excision of lesion of tunica √
 vaginalis other than
hydrocele
OPERATIONS ON TESTIS
250. Incision of testis. Explorasi -
testis (microsurgery)
251. Diagnostic procedure of √
testis
252. Closed (percutenous) (needle) -
biopsy of testis
253. Open biopsy of testis -
254. Other diagnostic procedure -
of testis
255. Excision/destruction of -
testicular lesion
Excision of appendix testis.
Excision of cyst of Morgagni
in the male
256. Unilat orchidectomy √
257. Bilat orchedectomy. Male √
castration. Radical bilat
orchidectomy
258. Removal of both testis at same √
operative episode
Bilat orchidectomy NOS.
Extended orchidectomy
259. Rem f remaining testis √
Removal of solitary testis.
Subcapsular orchidectomy
260. Orchidopexy (UDT, torsio √
testis)
261. Repair of testis √
262. Suture of laceration of √
testis
263. Other repair of testis. √
Testicular graft.
264. Insertion of testicular -
prosthesis
265. Other operation on testis √
266. Aspiration of testis √
267. Injection of therapeutic -
substance into testis
OPERATION ON SPERMATIC CORD, EPIDIDYMIS, AND VAS DEFERENS
268. Diagnostic procedure on √
spermatic cord, epididymis,
and vas deferens
269. Biopsy of spermatic cord, √
epididymis, and vas deferens
270. Other diagnostic procedures √
on spermatic cord,
epididymis, and vas deferens
271. Excision of varicocele and √
hydrocele of spermatic cord
High ligation of spermatic vein.
 Hydrocelectomy of canal of
Nuck Funicocelectomy.
Varicocelectomy (palomo)
272. Excision of cyst of √
epididymis.
Spermatocelectomy
273. Excision of other lesion or √
tissue of spermatic cord and
epididymis
Excision of appendix
epididymis
274. Epididymectomy √
275. Repair of spermatic cord and -
epididymis
276. Suture of laceration of -
spermatic cord and
epididymis
277. Reduction of torsion of -
testis or spermatic cord
278. Transplantation of -
spermatic cord
279. Other repair of spermatic -
cord and sepididymis
280. Vasotomy. Vasostomy. -
Vasovasostomy
281. Vasectomy and ligation of √
vas deferens
282. Male sterilization √
procedure, NOS
283. (ligation, crushing, division) √
of vas deferens
284. Ligation of spermatic cord √
285. Vasectomy √
286. Repair of vas deferens and √
epididymis
287. Suture of laceration of vas √
deferens and epididymis
288. Reconstruction of surgically -
divided vas deferens
289. Epidfidymovasostomy -
290. Removal of ligature from vas -
deferens
291. Removal of valve from vas -
deferens
292. Other repair of vas deferens √
and epididymis
293. Other operations on √
spermatic cord, epididymis
and vas deferens
294. Aspiration of spermatocele √
295. Epididymotomy √
296. Incision of spermatic cord -
297. Lysis of adhesions of -
 spermatic cord
298. Insertion of valve in vas -
deferens
OPERATION ON PENIS
299. Circumscision (male) √
300. Diagnostic procedures on the √
penis
301. Biopsy of penis √
302. Other diagnostic procedures √
on penis
303. Local excision/destruction √
of lesion of penis
Eksisi plaque (peyronie
diseae). Excise webbed penis
304. Amputation of penis √
305. Repair and plastic √
operation of penis
306. Release of √
chordate/chordectomy
307. Contruction of penis √
308. Reconstruction of penis. √
Eksisi fibroma
309. Replantation of penis. √
Reattachment of amputated
penis
310. Other repair of penis. √
Operasi priapismus
(prosedur Winter)
311. Koreksi priapismus √
312. Other operations on male √
genital organs
313. Dorsal or lateral slit of √
prepuce
314. Incision of penis √
315. Devision of penile adhesions √
316. Fitting of external -
prosthetis of penis
317. Insertion or replacement of -
non-inflatable penile
prosthesis
Insertion of semi-rigid rod
prosthesis into shaft of
penis
318. Removal of internal -
prosthesis of penis
319. Insertion or replacement of -
inflatable penile prosthesis
Insertion of cylinders into
shaft of penis and
placement of pump and
reservoir
320. Other operations on penis. √
Corpora cavermosa-corpus
 spongiosum shunt
Corpora-saphenous shunt.
Irrigation of corpus
cavernosum
321. Dissection of lymp node of -
inguinal
322. Hidrokelektomi per √
inguinal/ligasi tinggi
323. lncise abses perineum √
324. Lymphasdenectomy -
ilioninguinal
325. Vasography -
326. Dissection of lymp node of -
pelvis
327. ESWL -
328. Laparotomy exploration √
329. USG Urology √
330. Operasi sistokel -
331. Insersi catheter Tenckhoff -
untuk CAPD
332. Uroflowmetri -
333. Infiltrasi sitostatika -
intravesica
334. Chemotherapy -

KETERANGAN :
M : Mandiri
DS : Dibawah Supervisi
TA : Tak Ada Alat
TK : Tak Ada Kompetensi