Belopa, 14 Desember 2023

Kepada
Lampiran : 1 Yth.Direktur RS Hikmah Sejahtera Belopa
Perihal : Permohonan Kredensialing Di,-
Tempat

Dengan Hormat,
Bersama dengan ini kami mengajukan permohonan Kredensialing untuk mendapatkan Surat
Penugasan Klinis dan Rincian Kewenangan Klinis sebagai tenaga medis Dokter Umum di Rumah
Sakit Hikmah Sejahtera Belopa. Adapun kelengkapan berkas kredensial terlampir sebagai berikut :

1. Fotokopi ijazah dokter umum dan transkrip nilai

2. Fotokopi Surat Tanda Registrasi (STR)
3. Fotokopi Surat Izin Praktek (SIP)
4. Surat Keterangan Berbadan Sehat

Demikian permohonan ini, atas perhatiannya di ucapkan terima kasih.

Pemohon,

(dr. Indah Kurniati)

 REKOMENDASI RINCIAN KEWENANGAN KLINIS
DOKTER UMUM

Nama : dr. Indah Kurniati

Pendidikan/Jabatan : Dokter Umum
Kewenangan Klinis Yang Diminta Yang Disetujui

Daftar Penyakit

Jenis Pelayanan :

1. Basic of Cardiovasculer ✓

2. Basic of Respiratory ✓

3. Basic of Gastrointestinal ✓

4. Basic of Nephro-urology ✓

5. Basic of Hematology ✓

6. Basic of Immunology ✓

7. Basic of Genetics / newborn /chromosomal ✓

disorders
8. Basic of Endocrine, metabolic disorders ✓
and nutrition
9. Basic of central and peripheral neural ✓
system
10. Basic of Ear, nose and throat ✓

11. Basic of eye ✓

12. Basic of infection and tropical medicine ✓

13. Basic of neoplasm ✓

14. Basic of psychiatry and mental health ✓

15. Basic of muscoleskeletal system ✓

16. Basic of traumatology ✓

17. Basic of reproduction system ✓

DAFTAR KETERAMPILAN KLINIS

Jenis Pelayanan :

Internal medicine

1. Physical examination ✓
- General surgery
- Head and neck
- The spine
- Thorax
- Abdomen
- Perineal
- Female genitalia
- Male genitalia
- extremities
2. diagnostic procedures ✓

3. therapeutic skills ✓

Neurology

Physical examination ✓

- cranial nerve function

- the motor system
 - coordination
- the sensory system
- radicular sensation disorders
- higher functions
- reflexes
- others…
Additional diagnostic investigations ✓

Therapeutic skills ✓

The spine ✓

Psychiatry

Diagnostic skills ✓

- history taking
- psychiatric examination
- identifying problems
- additional examination
therapy ✓

Paediatrics

History taking ✓

Physical examination ✓

- general
- newborn and infant
- all ages
Therapeutic skills, examination and operation ✓
of the child

Surgery

Diagnostic skills ✓

- physical examination
- orthophedic examination
- varicose veins
- arterial vascular disorders
- abdominal hernia
- male genitalia
- accident of emergency
additional examination ✓

Therapeutic skills ✓

Operative surgery ✓

Gynecology

Physical examination ✓

- general, including breast

- external genitalia
- speculum examination
- bimanual examination
- rectal examination
- combined recto-vaginal septum
Additional diagnostic examination ✓

Additional diagnostic for sub fertility ✓

Theraphy and prevention ✓

Contraception / sterilization ✓

Obstetry
 Selection of high risk pregnancy ✓

Pregnancy ✓

Normal delivery ✓

Puerperium ✓

Dermatology

Diagnostic skill ✓

- physical examination
- terminology of skin lesions
- additional examination
Therapy ✓

Prevention ✓

Otolaryngology (ENT)

Diagnostic skill ✓

- ears, hearing, aquilibrum

- noses. Sinuses
- mouth, throat, speech, esophagus,
neck
Therapeutic skill ✓

ENT surgery ✓

Ophthalmology

General Ophthalmology examination ✓

- vision
- refraction
- visual fields
- external infection
- position of eyes
- pupils
- media
- fundi
- intraocular pressure
Additional general Ophthalmology examination ✓

Special Ophthalmology examination ✓

Therapeutic skill ✓

Surgical therapy ✓

General practice – skill list

Eye ✓

Ear ✓

External and internal genitalia ✓

Arm ✓

Leg ✓

Skin, mucosa and subcutaneous tissue ✓

Laboratory investigation, blood ✓

Laboratory investigation, urine ✓

DAFTAR KETERAMPILAN TERTENTU

 1. Sistim TRIAGE ✓

2. Sistim Rujukan ✓

3. Melakukan tindakan medis preventif, ✓

kuratif dan rehabilitatif
4. Melakukan edukasi dan konseling ✓

5. Melakukan promosi kesehatan ✓

6. Menentukan indikasi rujuk ✓

7. Membuat diagnosis klinik dan ✓

memberikan terapi pendahuluan pada
keadaan gawat darurat demi
menyelamatkan nyawa atau mencegah
keparahan dan atau kecacatan pada
pasien
8. Resusitasi jantung, paru pada keadaan ✓
gawat darurat
9. Pemasangan ETT ✓

10. Menentukan rujukan tepat bagi ✓

penanganan pasien selanjutnya bila
diperlukan dan menindaklanjuti
sesudah kembali dari rujukan
berdasarkan Standar Kompetensi
Dokter Indonesia
11. Pemasangan ventilator ✓

12. Melakukan universal precaution ✓

Rekomendasi Disetujui Disetujui dengan Tidak disetujui

catatan

Tanggal :

Catatan :

Ketua Komite Medik, Ketua Sub Komite Kredensial,

dr. Sostro Mulyo, Sp.PD dr. Mahirina Marjani, Sp.A, M.Kes