SURAT PENUGASAN KLINISClinical Appointrnent

Nomor Penusasan KlinisNumber of Clinical Appointment

Nama DokterName of Doctor

Tempat Tanggal LahirPlace, date of birth

Komoetensi+

Competence

Tanggal LulusDate of Graduation

Perguruan TinggiUniversity

Nomor Surat Tanda RegistrasiNumber of Registration certiftcate

Berlaku sampaiValid until

44O 6 / KPTS/RS r- S A /Vrrr / 20 LB

Vera Provitasari

Yogyakarta, 13 Februari L9B6

Dokter Umum

21 Desember 2010

Universitas Islam Sultan Agung

33.2.1..L00.2.1, 6.L2725 6

1- September 2027

Semaran& 30 Agustus 201.8RSI SULTAN AGUNG

Sulton Agryng lslamic Hospital

LTA fu

G

r SULTANlncuNGtH AL

SU RAT KEPUTUSAN DIREKTUR

RUMAH SAKIT ]SIAM SULTAN AGUNG

NOMOR:zftt d /KPTS/RSI-SANill2OLgTENTANG

PEN UGASAN KU N tS lCLt N'CAL AppO \NTM E NT)RUMAH SAKIT ISI.AM SULTAN AGUNG

MENIMBANG

MENGINGAT

MEMPERHATIKAN

MENETAPKAN

KESATU

1.

2.

Bahwa profesionalisme staf medis perlu ditingkatkan untuk menjaminmutu pelayanan medik dan melindungi keselamatan pasien di rumahsakit;Bahwa staf medis perlu diberikan Penugasan Klinis lClinicolAppointmentldalam rangka melaksanakan pelayanan di rumah sakit sesuai denganperaturan perundang-undangan yang berlaku;Bahwa perwujudan dan maksud tersebut di atas, perlu ditetapkan dalamSurat Keputusan tentang Penugasan Klinis Rumah Sakit lslam SultanAgung.

1. Keputusan Kepala Badan Penanaman Modal Daerah Provinsi JawaTengah Nomor 4 S|OL|BPMD|O7l21l4 tentang Perpanjangan lzinOperasional Rumah Sakit lslam Sultan Agung;

2. Fatwa Dewan Syariah Nasional-Majelis Ulama lndonesia Nomor1O7/DSN-MU\|X|}OLS Tentang Pedoman Penyelenggaraan Rumah SakitBerdasarkan Prinsip Syariah;

3. Surat Keputusan Yayasan Badan Wakaf Sultan Agung Nomor:108/ISKIYBWSANllzO]^S tentang Struktur Organisasi dan Tata Kelola RSt

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

12/SK/YBW -SAl ll I}OLB tentang Pengangkatan kembali d r. Masyhudi AM,M.Kes sebagai Direktur Utama Rumah Sakit lslam Sultan Agung masabakti 20L8 -2022;

5. Surat Keputusan Pengurus Yayasan Badan Wakaf Sultan Alung Nomor:62/SK/YBW-SAllV|IOLS tentang Pengangkatan Direktur DirekturRumah Sakit lslam Sultan Agung Masa Bakti 2018 - 2022;

6. Surat Keputusan Direktur Rumah Sakit lslam Sultan Agung Nomor:L Z3(KPTS(RSI-SA/|l l/2017 tentang Pemberlakuan Fatwa Dewan SyariahNasional-Majelis Ulama lndonesia Nomor: 1,07/DSN-MUl/Xl2O76Tentang Pedoman Penyelenggaraan Rumah Sakit Berdasarkan PrinsipSyariah di Rumah Sakit lslam sultan Agung.

Rekomendasi Komite Medik Rumah Sakit lslam Sultan Agung nomor:041/KM/RSr-SA/Vr r t/2018.

MEMUTUSKAN

Mencabut Surat Keputusan Direktur Rumah Sakit lslam Sultan Agung nomor:4635 I KPTSI RSI-SA/|X/20L5 tentang Pe nugasa n Klinis (C/inrcol Appointme nt)dr. Vera Provitasari

Jl. Raya Kaligawe Km. 4 Semarang 50112 Jawa Tengah, lndonesiaTelp. +52 24658 0019 lFax. +6224 658 1928 lHotline: +62 85 10041 2424

email : rs@rsisultanagung.co.id I wwwrsisuttanagung.co.id

KEDUA

KETlGA

KEEMPAT

Tembusan Yth. :

1. Ketua Komite Medik RS!-SA.

2- Ketua KSM Dokter Umum.3. Manajer Pelayanan Medis.4. Yang Bersangkutan.

Memberikan Penugasan Klinis Kepada dr. Vera Provitasari sesuai denganrincian Kewenangan Klinis yang direkomendasikan oleh Komite Medik RSI

Sultan Agung sebagaimana terlampir dalam Surat Keputusan ini;Masa berlaku Penugasan klinis terhitung mulai 1 September 2018 sampaidengan 1 September ZOZL;

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

Ditetapkandi: SemarangPada tanggal : 18 Dzulhiiiah 1439 H

30 Agustus 201.8 M

RUMAH SAIOT ISI.AM SUTTAN AGUNG

SEMARANG

Direktur Utama

J1. Raya Kaligawe Km. 4 Semarang 50112 Jawa Tengah, lndonesiaTelp. +62 24658 0019 lFax. +6224 558 1928 lHotline: +62 85 10041 2424

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

1 Angina Pectoris 4

2 Ustable angina 4

3 Myocardial Infarction 4

4 Imminent Myocardial Infarction 4

5 Sinus Tachycardi 4

6 Supraventricular tachycardia 4

7 Atrial flutter 4

8 Ventricular extrasystole 4

9 BBB 4

10 Other arrhytmias 4

11 Endocarditis 4

12 Pericarditis 4

13 Myocarditis 4

1 Essential hypertension 4

2 Secondary hypertension 4

3 Pulmanory hypertension 4

4 Cardiogenic shock 4

5 Septic shock 4

6 Hypovolemic shock 4

1 Varises (Primary, secondary) 4

2 Thrombophlebitis 4

1 Lymphangitis 4

2 Lymphadenitis 4

3 Lymphedema, primary and secondary 4

Cardiac Disorders

Lymph vessels

Aorta-arteries disorders

Veins

Lampiran SK nomor: 4406/KPTS/RSI-SA/VIII/2018

Kewenangan Klinis (Clinical Privilege)

dr. Vera Provitasari

Kategori Kewenangan

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

Islam Sultan Agung Semarang, berdasarkan kebutuhan pasien.

Keterangan Kode:

1 = Tidak disetujui karena fasilitas tidak tersedia

2 = Tidak disetujui karena bukan kompetensinya

3 = Disetujui di bawah supervisi

4 = Disetujui berwenang penuh

Jenis PelayananKode

Cardiovasculer

1

1 Uncomplicated Pulmonary Tuberculosis 4

2 TBC with HIV 4

3 Acute Bronchitis 4

4 Bronchiolitis 4

5 Bronchial asthma 4

6 Status asmaticus 4

7 Pleurity TBC 4

8 Pneumothorax 4

1 Mouth ulcers (aphthous, herpes) 4

2 Gossitis 4

1 Salphingitis 4

2 Acute appendicitis 4

1 Gastritis 4

2 Gastric/duodenal ulcer 4

3 Gastrointestinal bleeding 4

4 Zollinger-ellison syndrome 4

5 Mallory-weiss syndrome 4

6 Gastroenteritis 4

1 Fatty liver 4

2 Hepatitis A 4

3 Uncomplicated Hepatitis B 4

4 Active Hepatitis C 4

5 Cirrosi Hepatitis 4

6 Amoebic liver abscess 4

1 Acute cholecystitis 4

2 Pancreatitis 4

1 Enteritis 4

1 Colitis 4

2 Hemorrhoids 4

3 (peri)anal abcess 4

1 Gastro-enteritis 4

2 Gastro-enteritis dengan dehidrasi 4

3 Worms 4

4 Dehydration 4

5 Malabsorbsion 4

6 Food intolerance 4

7 Ileus 4

8 Peritonitis tuberculosis 4

9 Peritonitis pancreatitis 4

10 Ulcerative colitis 4

Respiratory

Gastrointestinal

Colon

Mouth

Acute abdomen

Stomach and duodenum

Liver

Gall bladder, bile duct and pancreas

Jejunum, ileum

Pediatrics

2

11 Hepatitis 4

12 Cirrhosis of the liver 4

13 Food Allergy 4

1 Acute renal failure 4

2 Chronic renal failure 4

3 Neprotic syndrome 4

4 Acute glomerulonephritis 4

5 Chronic glomerulonephritis 4

6 Renal colic 4

7 Urinary stone diseases or urinary calculi without 4

8 colic 4

9 Urinary tract infection 4

10 Uncomplicated Pyelonephritis 4

11 Urinary incontinence 4

12 Noctural and diurnal enuresis 4

13 Prostatitis 4

1 Epididymitis 4

2 Phimosis 4

3 Paraphimosis 4

4 Erection disorders 4

5 Ejaculation disorder 4

1 Vulvitis 4

2 Condylomata acuminata 4

1 Vaginitis 4

2 Foreign body 4

1 Cervicitis 4

1 Salpingitis 4

1 Inflammations 4

1 aplastic/hypoplastic anemia 4

2 Iron deficiency anemia 4

3 Macrocytic anemia 4

4 Hemolytic anemia 4

5 Thrombocytopenia 4

6 Thrombocytosis 4

7 Hemophilia 4

Cervix

Adnexae

Breast

Hematology

Nefrourologi

Male genitalia

Vulva

Vagina

3

1 Autoimmune rheumatological and autoimmune 2

2 Rheumatoid arthritis 4

3 Rheumatic fever 4

4 Immunodeficiency - HIV 4

1 PKU (Phenyl Ketonuria) 2

1 Hypothermia 4

2 Pneumothorax 4

3 Apnea attacks 4

4 Jaundice of newborn 4

5 Hypoglycemia 4

6 Child of diabetic mother 4

7 Neonatal convulsion 4

8 Anemia 4

9 Blood group incompatibility 2

10 Vitamine k defficiency 4

11 Conjuctivitis 4

12 Infection of umbilicus 4

1 Endocrinological disorders 4

2 IDDM 4

3 NIDDM 4

4 Complication of DM (acute and chronic) 4

5 Hypoglycemia 4

6 Diabetes Incipidus 4

7 Hyperthyroidism 4

8 Hypothyroidism 4

9 Thyroiditis 4

1 Marasmus 4

2 Kwashiorkor 4

3 Vitamin deficiencies 4

1 Hyperlipoproteinemia 4

2 Phorphyria 4

3 Gout 4

4 Obesity 4

1 Metabolic Encephalopathy 4

2 Comatous 4

3 Brain death 4

Genetics/newborns/chromossal disorder

Endocrine, metabolic disorder and nutrition

Nutritional deficiency

Error of metabolism

Central and peripheral neural system

Disorders of newborns

Immunology

Loss of consciousness

4

1 Tension headache 4

2 Migraine 4

3 Cranial arteritis 4

4 Trigeminal neuralgia 4

5 Cluster headache 4

1 TIA 4

1 Bels` palsy 4

1 Menier`s disease 4

1 Focal epilepsy 4

2 Generalized epilepsy 4

3 Absence seizure 4

4 Status epilepticus 4

5 Narcolepsy 4

6 Sleep apnea syndrome 4

4

1 Multiple sclerosis 4

2 Optic neuromyelitis (Devic`s disease) 4

1 Myelopathy 4

1 Meningitis 4

2 Encephalitis 4

3 Malaria cerebral 4

4 Tetanus 4

5 Cerebral toxoplasmosis 4

6 Tuberculoma 4

7 Brain abscess 4

8 HIV AIDS 4

1 Meningitis 4

2 Epilepsi 4

1 Nyeri Nosiseptif 4

2 Nyeri Neuropatik 4

1 Inflammation of auricle 4

2 Herpes zoster oticus 4

3 Pre-auricular fistula 4

4 Forign body in ear 4

Ear, nose and throat

Ears, hearing and equilibrium

Headache

Cardio Vascular Diseases

Pain

Cranial nerve and brain stem lesions

Disorder of vestibular system

Epilepsy and other seizures

Infectious diseases

Pediatrics neurologic disorders

Diseases of spine and spinal cord

Diseases of spine and spinal cord

5

5 Wax (serumen) 4

6 Otitis externa 4

7 Acute otitis media 4

8 Otitis media serous (glue ear) 4

9 Cholesteatoma 4

10 Mastoiditis 4

1 Epistaxis 4

2 Furuncle of nose 4

3 Acute rhinitis (common coid) 4

4 Vasomotor rhinitis 4

5 Allergic rhinitis 4

6 Chronic rhinitis 4

7 Rhinitis Medikamentosa 4

8 Acute Frontal sinusitis 4

9 Acute maxillary sinusitis 4

10 Acute ethmoiditis 4

11 Foreign body in nose 4

1 Pharyangitis 4

2 Tonsilitis 4

3 Hypertrophy of adenoids 4

4 Pseudo-croop acute epiglotitis 4

1 Torticollis 4

1 Conjunctiva, foreign body 4

2 Conjunctivitis, allergy 4

3 Conjunctivitis, viral 4

4 Conjunctivitis, bacterial 4

5 Pterygium 4

1 Blepharitis 4

2 Hordeolum 4

3 Chalazion 4

4 Eyelid laceration 4

5 Eyelid retraction 4

6 Xanthelasma 4

1 Erosion 4

2 Cornea, foreign body 4

3 Burn 4

4 Keratitis 4

5 Kerato-conjunctivitis sicca 4

6 Corneal oedema 4

7 Corneal dystrophy 4

8 Keratoconua 4

1 Hypermetropia 4

2 Myopia 4

3 Astigmatism 4

Noses and sinuses

Larynx and pharynx

Eye Conjunctiva

Eyelids

Cornea

Neck

Refraction and accommodation

6

4 Presbyopia 4

5 Anisometropia 4

1 Loss of vision and blindness 4

1 Retinopathy of prematurity (rop) 4

2 Diabetic retinopathy 4

3 Hypertensive retinopthy 4

1 Contact dermatitis irritant 4

2 Contact dermatitis allergica 4

3 Atopic dermatitis (kecuali recalcitrant) 4

4 Nummular dermatitis 4

5 Lichen simplex chronicus 4

6 Napkin eczema 4

1 Psoriasis vulgaris 4

2 Plamoplantar pustulosis 4

3 Seborrheic dermatitis 4

4 Pityriasis rosea 4

1 Eczematous dermatitis 4

2 Acne vulgaris 4

3 Rosacea 4

4 Hidradenitis suppurativa 4

5 Perioral dermatitis 4

6 Miliaria 4

1 Verruca vulgaris 4

2 Condyloma accuminata 4

3 Molluscum contagiosum 4

4 Herpes zoster 4

1 Impetigo 4

2 Ulcerative impetigo (ecthyma) 4

3 Superficial folliculitis 4

4 Furuncle, carbuncle 4

5 Erythrasma 4

6 Erysipelas 4

1 Tinea capitis 4

2 Tinea barbae 4

3 Tinea faciale 4

4 Tinea corporis 4

5 Tinea manus 4

6 Tinea unguinum 4

7 Tinea cruris 4

8 Tinea pedis 4

9 Tinea versicolor 4

Viral skin infections

Bacterial Infections

Superficial fungal infections

Skin

Eczematous dermatitis

Erythro-squamous lesions

Disorders of skin eccrine and sebaceous glads

Vision and Visual Field

Retina

7

10 Mucocutaneous candidiasis 4

1 Pediculosis capitis 4

2 Pediculosis pubis 4

3 Scabies 4

4 Insect bites reactions 4

1 Pemphigus vulgaris 4

2 Pemphigoid 4

3 Dermatitis herpetiformis 4

4 Toxic epidermal necrolysis 4

5 Stevens-johnson`s disease 4

1 Urticaria 4

2 Angiodema 4

3 Allergic vasculitis 4

1 Dermatomyositosis 4

1 Ichthyosis vulgaris 4

1 Exanthematous drug eruption 4

2 Fixed drug eruption 4

1 Paronychia 4

2 Suppurative tenosynovitis 4

3 Human bite 4

1 Suppurative parotitis 4

2 Suppurative cervical adenitis 4

3 Peritonsilar abscess 4

4 Ludwig`s angina 4

5 Bezold abscess 4

1 Superficial infections, including folliculitis, 4

2 hidradenitis suppurativa, carbuncle 4

3 Osteomyelitis 4

4 Staphylococcal pneumonia 4

5 Staphylococcal bacteremia 4

1 Rheumatic fever 4

2 Sinusitis, otitis media, mastoiditis, pertonsilar 4

3 Abscess - THT 4

4 Rheumatic heart disease 4

1 Meningitis (neuro) 4

2 Nasopharyngitis 4

Insect bites and infestations

Vesicobullous diseases

Allergic skin diseases

Autoimmune diseases

Disorders of keratinizations

Drug reactions

Infectious and tropical diseases

Localized infections and abscesses infections of the hand

Infections of the head and neck

Gram-positive cocci Staphylococcal and streptococcal infections

Streptococcal infection

Gram-negative cocci Meningococcal infection (neuro)

8

1 Gonorrhea 4

1 Urinary tract infection (UTI) 4

2 Typhoid fever 4

3 Dysentry bacilli 4

4 Cholera 4

5 Pertussis 4

6 Plague (Pes) 4

7 Chancroid 4

1 Diphteria (THT) 4

2 Tetanus (pediatri) 4

1 Tuberculosis kutis 4

2 Leprosy 4

3 Lepra reaction 4

1 Syphilis 4

2 Yaws 4

3 Leptospirosis 4

1 Influenza 4

2 avian influenza (THT) 4

3 Viral gastroenteritis 4

4 Poliomyelitis 4

5 Rabies 4

6 Morbilli 4

7 Varicella 4

8 Herpes zoster 4

9 Herpes simplex 4

10 Mumps 4

11 CMV infections 4

12 Dengue hemorrhagic fever (DHF) 4

13 HIV-AIDS 4

1 Amebiasis 4

2 Malaria 4

3 Leishmaniasis dan tripanosomiasis 4

4 Toxoplasmosis 4

5 Giardiasis 4

6 Trichomoniasis 4

1 Hookworm diseases 4

2 Strongyloidiasis 4

3 Ascariasis 4

4 Filariasis 4

5 Schistosomiasis 4

6 Cutaneus larva migran 4

7 Taeniasis 4

Spirochetal diseases

Viral infections

Protozoal infections

Worms infestations

Gonococcal infections

Gram-negative bacilli

Toxin producing bacteria

Mycobacterial diseases

9

1 Anorexia Nervosa 4

1 Intoxication 4

2 Withdrawal syndrome 4

3 Delirium 4

4 Dementia 4

5 Misuse of psychoactive drugs 4

1 Panic disorder with agoraphobia 4

2 Panic disorder without agoraphobia 4

3 Agoraphobia without history of panic disorder 4

4 Social phobia 4

5 Simple phobia 4

6 Obsessive compulsive disorder (neurosis) 4

7 Post traumatic stress disorder 4

8 Diffuse anxiety disorder 4

9 Anxiety disorder not otherwise classified 4

1 Disorder of body sensation 4

2 Conversion disorder (hysterical neurosis) 4

3 Hypochondriasis (hypochondriacal neurosis) 4

4 Somatisation disorder 4

5 Somatoform pain disorder 4

6 Undifferentiated somatoform disorder 4

7 Somatoform disorder not otherwise classified 4

1 Disorder of orgasm 4

2 Sexual pain disorders 4

3 Sexual dysfunctions, noc 4

1 Sexual disorders 4

1 Insomnia 4

2 Hypersomnia 4

Semarang, 18 Dzulhijjah 1439 H

30 Agustus 2018 M

RUMAH SAKIT ISLAM SULTAN AGUNG

SEMARANG

dr. H. Masyhudi AM, M.Kes.

Direktur Utama

Other sexual disorders

Sleeping disorders

Psychiatry and mental health

Psych-organic syndromes and disorders due to drugs

Psych-organic syndromes and disorders due to drugs

Somatic disorder

Sexual dysfunctions

Eating Disorder

10