SURAT PENUGASAN KLINISClinical Appointment

3206 / KPTS/RSr - S A / tt / 20t7Nomor Penugasan KlinisNumber of Clinical Appointment

Nama DokterName of Doctor

Temnat Taneeal LahirPloce, date of birth

Komoetensi

-

Competence

Tanssal Lulus

-

Date of Graduation

Persuruan TinseiUniversity

Nomor Surat Tanda RegistrasiNumber of Registration certificate

Berlaku samDaiValid until

Puspa Dwitiya Parahita Artad

Klaten, 2 5 November1989

Dokter Umum

1 April 20LS

Universitas Islam Sultan Agung

33.2.L.L00.L.76.L63 47 4

1 April 2A20

Semarang,3t Maret 20L7RSI SULTAN AGUNG

Sultan Afung Islamic Hospital

ULTAfu

ISTAMICTFACH

I iH',IfrilTHING HOSPITAL

SURAT KEPUTUSAN DIREKTUR

RUMAH SAKIT ISLAM SULTAN AGUNG

NoMOR: 3zo6 /KPTS/RSI-SAlttt/zoL7TENTANG

PEN UGASAN KLr N tS ICL' N'CAL AP PO t NT MEt{rlRUMAH SAKIT ISIAM SUTTAN AGUNG

MENIMBANG

MENGINGAT

MEMPERHATIKAN

MENETAPKAN

KESATU

KEDUA

: 1. Bahwa profesionalisme staf medis perlu ditingkatkan untuk menjaminmutu pelayanan medik dan melindungi keselamatan pasien di rumah

sakiU

Bahwa staf medis perlu diberikan Penugasan Klinis (Clinicol Appointmentldalam rangka melaksanakan pelayanan di rumah sakit sesuai dengan

peraturan perundang-undangan yang berlaku;

Bahwa perwujudan dan maksud tersebut di atas, perlu ditetapkan dalam

Surat Keputusan tentang Penugasan Klinis Rumah Sakit lslam Sultan

Agung.

1. Keputusan Kepala Badan Penanaman Modal Daerah Provinsi Jawa

Tengah Nomor 441|OL/BPMD(O7l20t4 tentang Perpanjangan lzin

Operasional Rumah Sakit lslam Sultan Agung;

2. Surat Keputusan Yayasan Badan Wakaf Sultan Agung Nomor:

LOgl|SK/YBWSA/V|/201.5 tentang Struktur Organisasi dan Tata Kelola RSI

Sultan Agung;3. Surat Keputusan Pengurus Yayasan Badan Wakaf Sultan Agung Nomor:

01s/sK/YBW-sA/lll20L4 tentang Pengangkatan kembali dr. Masyhudi

AM, M.Kes sebagai Direktur Utama Rumah Sakit lslam Sultan Agung;

4. Surat Keputusan Pengurus Yayasan Badan Wakaf Sultan Agung Nomor:

057/SK/YBW-SA||Vl2OL4 tentang Pengangkatan Direktur - direkturRumah Sakit lslam Sultan Agung Masa Bakti2OL4-2018;

Rekomendasi Komite Medik Rumah Sakit lslam Sultan Agung nomor:

084/KM/RS t-S Al w l 2OL7 .

MEMUTUSKAN

Memberikan Penugasan Klinis Kepada dr. Puspa Dwitiya Parahita Artatisesuai dengan rincian Kewenangan Klinis yang direkomendasikan oleh

Komite Medik RSI Sultan Agung sebagaimana terlampir dalam Surat

Keputusan ini;Masa berlaku Penugasan klinis terhitung mulai L April.ZOLT sampai dengan 1

April2020;

2.

3.

Jl. Raya Kaligawe Km. 4 Semarang 50112 Jawa Tengah lndonesiaTelp. +62 24658 0019lFax. +6224 658 1928 lHotline: +62 85 100412424

email: rs@rsisultanagung.co.id I web : www.rsisultanagung.co.id

KETIGA

Tembusan Yth. :

L. Ketua Komite Medik RSI-SA.

2. Ketua SMF Umum.3. Manajer Pelayanan Medis.

4. Yang Bersangkutan.

Jl. Raya Kaligawe Km. 4 Semarang 501 12 Jawa Tengah lndonesiaTelp. +62 24 6580019 | Fax. +62 24658 1928 | Hotline :, +62 85 100 41 2424

email: rs@rsisultanagung.co.id I web : www.rsisultanagung.co.id

Surat Keputusan ini berlaku sejak tanBgal ditetapkan dan apabila dikemudian hariterdapat kekeliruan dan atau kesalahan dalam penetapan ini,akan diadakan perubahan dan atau perbaikan sebagaimana mestinya.

Diletapkan di : SemarangPada tanggal : 03 Raiab 1438 H

31 Maret 2017 M

RUMAH SAKIT ISIAM SUTTAN AGUNG

Lampiran SK nomor: 32OGIKPTSIRSI-SA/Ill/2017

Kewenangan Klinis lClinicol Privilege)dr. Puspa Dwitiya Parahita Artati

Kategori Kewenangan

Kewenangan Klinis diberikan untuk memberikan pelayanan pengelolaan bidang Dokter Umum di Rumah Sakit

lslam Sultan Agung Semarang, berdasarkan kebutuhan pasien.

Keterangan Kode:

l. = Tidak disetujui karena fasilitas tidak tersedia2 = Tidak disetujui karena bukan kompetensinya

3 = Disetujuidi bawah supervise

4 = Disetujui berwenang penuh

Jenis PelayananKode

Cardiovasculer

Cardiac Disorders

t Angina Pectoris 4

2 Ustable angina 4

3 Mvocardial lnfarction 4

4 lmminent Mvocardial lnfarction 4

5 Sinus Tachvcardi 4

6 Su praventricula r tachycardia 47 Atrial flutter 48 Ventricula r extrasystole 4

9 BBB 4

10 Other arrhvtmias 3

7L Endocarditis 3

L2 Pericarditis 3

13 Myocarditis 3

Aorta-arteries disorders

1 Essential hypertension 4

2 Secondary hypertension 3

3 Pulmanorv hvpertension 2

4 Cardiosenic shock 3

5 Septic shock 3

5 Hvpovolemic shock 3

Lymph vessels

I Varises (Primary, secondary) 2

2 Thrombophlebitis 3

Lymph vessels

L Lymphangitis 3

2 Lvmphadenitis 3

3 Lymphedema, primary and secondary 3

Respiratory

L Uncomplicated Pulmonary Tuberculosis 42 TBC with HIV 3

3 Acute Bronchitis 44 Bronchiolitis 3

5 Bronchialasthma 45 Status asmaticus 3

7 Pleurity TBC 3

8 Pneumothorax 3

Gastrointestinal

Mouth

1 Mouth ulcers (aphthous, herpes) 42 Gossitis 3

Acute abdomen

L Salphingitis 3

2 Acute appendicitis 3

Acute abdomen

t Gastritis 42 Gastric/duodenal ulcer 3

3 Gastrointestinal bleeding 3

4 Zollinger-el lison synd rome 2

5 Mallory-weiss syndrome 2

6 6astroenteritis 4Liver

L Fatty liver 3

2 Hepatitis A 3

3 Uncomplicated Hepatitis B 3

Active Hepatitis C 3

4 Cirrosi Hepatitis 3

5 Amoebic liver abscess 3

Gall bladder, bile duct and pancreas

L Acute cholecystitis 3

2 Pancreatitis 3

lejunum, ileum

L Enteritis 3

Colon

L Colitis 3

2 Hemorrhoids 3

3 Perianal abcess 3

Pediatrics

T Gastro enteritis 42 Gastro enteritis dengan dehidrasi 3

3 Worms 44 Dehydration 3

5 Malabsorbsion 3

6 Food intolerance 3

7 lleus 3

8 Peritonitis tuberculosis 3

9 Peritonitis pancreatitis 3

10 Ulcerative colitis 3

LL Hepatitis 3

72 Cirrhosis of the liver 3

13 Food Allergy 4

Nefrourologi

L Acute renal failure 3

2 Chronic renal failure 3

3 Neprotic syndrome 3

4 Acute Blomerulonephritis 3

5 Chronic glomerulonephritis 3

6 Renal colic 3

7 Urinary stone diseases or urinary calculi without 3

8 Urinary tract infection 49 Uncomplicated Pyelonephritis 3

10 Urinary incontinence 3

tt Noctural and diurnal enuresis 3

t2 Prostatitis 3

Male genitalia

L Epididymitis 3

2 Phimosis 43 Paraphimosis 44 Erection disorders 2

5 Ejaculation disorder 2

Vulva

L Vulvitis 42 Condylomata acuminata 3

Vagina

1 Vaginitis 42 Foreign body 3

Cervix

L Cervicitis 3

Adnexae

t Salpingitis 3

Breast

L lnflammations 3

Hematology

7 aplastic/hypoplastic anemia 42 lron deficiency anemia 4

3 Macrocytic anemia 44 Hemolytic anemia 4

5 Thrombocytopenia 4

6 Thrombocytosis 4

7 Hemophilia 4

!mmunology

L Autoimmune rheumatglogical and autoimmune 2

2 Rheumatoid arthritis 3

3 Rheumatic fever 3

4 lmmunodeficiencv - HIV 2

Genetics/newborns/chromossal disorder

1 PKU (Phenyl Ketonuria) 2

Disorders of newborns

L Hypothermia 4

2 Pneumothorax 3

3 Apnea attacks 3

4 laundice of newborn 3

5 Hypoglycemia 3

6 Child of diabetic mother 3

7 Neonatal convulsion 3

8 Anemia 3

9 Blood group incompatibility 2

10 Vitamine k defficiency 2

t7 Coniuctivitis 3

t2 lnfection of umbilicus 3

Endocrine, metabolic disorder and nutritionL Endocrinological disorders 2

2 IDDM 4

3 NIDDM 4

4 Complication of DM (acute and chronic) 3

5 Hypoglycemia 3

6 Diabetes lncipidus 2

7 Hyperthyroidism 3

8 Hypothyroidism 2

9 Thvroiditis 2

Nutritional deficiency

1 Marasmus 4

2 Kwashiorkor 4

3 Vitamin deficiencies 4

Error o metabolism

1 Hyperlipoproteinemia 3

2 Phorphyria T

3 Gout 4

4 Obesitv 4

Centra! and peripheral neura! system

Loss of consciousness

L Metabolic Encephalopathy 3

2 Comoteus 3

3 Brain death 2

Headache

L Tension headache 4

2 Migraine 4

3 Cranial arteritis 2

4 Trigeminal neuralgia 3

5 luster headache 3

Cardio Vascular Diseases

7 flA 3

Cranial nerve and brain stem lesions

7 Bels palsy 4

Disorder of vestibular system

L Menier's disease 3

Epilepsy and other seizures

t Focal epilepsy 3

2 Generalized epilepsy 3

3 Absence seizure 3

4 Status epilepticus 3

5 Narcolepsy 2

6 Sleeo aonea svndrome 2

Diseases of spine and spinal cord

L Multiple sclerosis 2

2 Optic neuromyelitis (Devic's disease) 2

Diseases of spine and spinal cord

L Myelopathy 2

lnfectious diseases

1 Meningitis 3

2 Encephalitis 3

3 Malaria cerebral 2

4 letanus 3

5 Cerebral toxoplasmosis 2

6 Iuberculoma 2

7 Brain abscess 3

8 HIV AIDS 3

Pediatrics neu rologic disorders

L Meningitis 3

2 Epilepsi 3

Pain

7 Nyeri Nosiseptif 4

2 Nyeri Neuropatik 3

Ear, nose and throatEars, hearing and equilibrium

L lnflammation of auricle 4

2 Herpes zoster oticus 3

3 Pre-auricular fistula 3

4 Forign body in ear 4

5 Wax (serumen) 4

6 Otitis externa 4

7 Acute otitis media 3

8 Otitis media serous (glue ear) 3

9 Cholesteatoma 2

10 Mastoiditis 3

Noses and sinuses

t Epistaxis 4

2 Furuncle of nose 4

3 Acute rhinitis (common coid) 4

4 Vasomotor fhinitis 4

5 Allergic rhinitis 4

5 Chronic Rhinitis 3

7 Rhinitis Medikamentosa 3

8 Acute Frontal sinusitis 3

9 Acute maxillary sinusitis 3

10 Acute ethmoiditis 2

tl Foreisn bodv in nose 4

Larynx and pharynx

7 Pharvaneitis 4

2 Ionsilitis 4

3 Hvoertrophv of adenoids 2

4 Pseudo-croop acute epiglotitis 3

Neck

t Torticollis 3

Eye Conjunctiva

L Coniunctiva, foreign body 4

2 Coniunctivitis. allerev 4

3 Conjunctivitis, viral 4

4 Coniunctivitis, bacterial 4

5 Ptervgium 3

Eyelids

7 Blepharitis 4

2 Hordeolum 4

3 Chalazion 3

4 Eyelid laceration 2

5 Eyelid retraction 2

6 Xanthelasma 2

6

Cornea

1 Erosion 2

2 Cornea, foreign body 2

3 Burn 2

4 Keratitis 3

5 Kerato-conjunctivitis sicca 2

6 Corneal oedema 2

7 Corneal dystrophy 2

8 Keratoconua 2

Refraction and accommodation

L Hypermetropia 42 Myopia 43 Astigmatism 44 Presbyopia 45 Anisometropia 3

Vision and Visua! Field

t Loss of vision and blindness 2

Retina

L Retinopathy of prematurity (rop) 2

2 Diabetic retinopathy 2

3 Hypertensive retinopthy 2

Skin

Eczematous dermatitis

L Contact dermatitis irritant 4

2 Contact dermatitis allergica 3

3 Atopic dermatitis (kecuali recalcitrant) 4

4 Nummular dermatitis 4

5 Lichen simplex chronicus 3

5 Napkin eczema 4Erythro-squamous lesions

I Psoriasis vulgaris 3

2 Plamoplantar pustulosis 3

3 Seborrheic dermatitis 44 Pityriasis rosea 4

Disorders of skin eccrine and sebaceous glads

L Eczematous dermatitis 3

2 Acne vulgaris 3

3 Rosacea 3

4 Hidradenitis suppurativa 3

5 Perioral dermatitis 4

5 Miliaria 4

Viralskin infections

1 Verruca vulgaris 4

2 Condyloma accuminata 3

3 Molluscum contagiosum 4

4 Herpes zoster 4

Bacterial !nfections

L lmpetigo 42 Ulcerative impetigo (ecthyma) 3

3 Superficial folliculitis 44 Furuncle, carbuncle 45 Erythrasma 46 Erysipelas 4

Superficial fungal infections

7 Iinea capitis 42 Iinea barbae 43 Iinea faciale 44 linea corporis 45 Iinea manus 46 linea unguinum 47 finea cruris 48 Tinea pedis 49 Tinea versicolor 4

L0 M ucocutaneous candidiasis 3

lnsect bites and infestations

L Pediculosis capitis 4

2 Pediculosis pubis 4

3 Scabies 4

4 lnsect bites reactions 4Vesicobullous diseases

7 Pemphigus vulgaris 3

2 Pemphigoid 3

3 Dermatitis herpetiformis 3

4 Toxic epidermal necrolvsis 3

5 Stevens-iohnson's disease 3

Allercic skin diseases

L Urticaria 42 Angiodema 3

3 Allergic vasculitis 3

Autoimmune diseases

7 Dermatomyositosis 2

Disorders of keratinizations

L lchthvosis vulgaris 3

Drug reactions

t Exanthematous drug eruption 3

2 Fixed drug eruption 3

lnfectious and tropical diseases

Localized infections and abscesses infections of the hand

7 Paronychia 4

2 Suppurative tenosynovitis 3

3 Human bite 4

lnfections ofthe head and neck

L Suppurative parotitis 42 Suppurative cervical adenitis 33 Peritonsilar abscess 3

4 Ludwig's angina 3

5 Bezold abscess 2Gram-positive cocci Staphylococcal and streptococcal infections

L Superfi cial infections, including folliculitis, 42 hidradenitis suppurativa, carbuncle 3

3 Osteomyelitis 3

4 Staphylococcal pneumonia 3

5 Staphylococcal bacteremia 3

Streptococcal infection

L Rheumatic fever 3

2 Sinusitis, otitis media, mastoiditis, pertonsilar 3

3 Abscess - THT 3

4 Rheumatic heart disease 3

Gram-negative cocci Meningococcal infection (neuro)

7 Meningitis (neuro) 3

2 Nasopharyngitis 4Gonococcal infections

L Gonorrhea 4Gram-negative bacilli

L Urinary tract infection (UTl) 42 fyphoid fever 43 Dysentry bacilli 44 Cholera 45 Pertussis 46 Plague (Pes) 47 Chancroid 3

Toxin producing bacteria

L Diphteria (THT) 3

2 Tetanus (pediatri) 3Mycobacterial diseases

L Tuberculosis kutis 3

2 Leprosy 43 Lepra reaction 3

Spirochetal diseases

L Syphilis 3

2 Yaws 2

3 Leptospirosis 4Viral infections

7 lnfluenza 42 avian influenza (THT) 3

3 Viral gastroenteritis 44 Poliomyelitis 35 Rabies 3

6 Morbilli 4

7 Varicella 4

8 Herpes zoster 4

9 Herpes simplex 4

10 Mumps 4LL CMV infections 3

L2 Dengue hemorrhagic fever (DHF) 413 HIV-AIDS 3

Protozoal infections

7 Amebiasis 4

2 Malaria 4

3 Leishmaniasis dan tripanosomiasis 2

4 Ioxoplasmosis 3

5 Glardiasis 3

5 Irichomoniasis 3

Worms infestations

L Hookworm diseases 4

2 Strongyloidiasis 4

3 Ascariasis 4

4 Filariasis 4

5 Schistosomiasis 4

6 Cutaneus larva migran 4

7 Taeniasis 4

Psychiatry and mental health

Eating Disorder

7 Anorexia Nervosa 2

Psych-organic syndromes and disorders due to drugs

L lntoxication 3

2 Withdrawal syndrome 3

3 Delirium 3

4 Dementia 3

5 Misuse of psychoactive drugs 3

Psych-organic syndromes and disorders due to drugs

t Panic disorder with agoraphobia 2

2 Panic disorder without agoraphobia 3

3 Agoraphobia without history of panic disorder 2

4 Social phobia 2

5 Simple phobia 2

6 Obsessive compulsive disorder (neurosis) 2

7 Post traumatic stress disorder 3

8 Diffuse anxiety disorder 3

9 Anxiety disorder not otherwise classified 3

Somatic disorder

1 Disorder of bodv sensation 2

2 Conversion disorder (hysterical neurosis) 2

3 Hypochondriasis (hypochondriacal neurosis) 2

4 Somatisation disorder 3

5 Somatoform pain disorder 3

10

5 U ndifferentiated somatoform disorder 3

7 Somateform disorder not othenrvise classified 3

Sexual dysfunctions

1 disorder of orgasm 3

2 Sexual pain disorders 3

3 Sexual dysfunctions, noc 3Other sexual disorders

L Sexualdisorders 3

Sleeping disorders

t lnsomnia 42 Hypersomnia 3

Semarang,03 Raiab 1438 H

3l Maret 2OL7 M

RUMAH SAKIT ISI.AM SULTAN AGUNG

Direktur Utama

MARANG

SULTAN

11