Nomor Penusasan KlinisNumber of Clinical Appointment

Nama DokterName of Doctor

Tempat Tanggal LahirPlace, date of birth

Komnetensi

-

Competence

Tanssal Lulus+

Date of Graduation

Persuruan TinseiUniversity

Nomor Surat Tanda RegistrasiNumber of Registration certificate

Berlaku sampaiValid until

SURAT PENUGASAN KLINISClinical Appointment

5 0 8o/KPTS/RS r - S A lvrrr / 20 tB

Retno Widhiastuti

Semarang, 6 funi L974

Dokter Umum

22 Mei 2002

Universitas Islam Sultan Agung

33.2.1.L00.3.t7 .033 60 1

L September 2021

Semarang, 30 Agustus 20LB

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-

tH At

PERATURAN DIREKTUR RUMAH SAKIT ISTAM SULTAN AGUNG

NOMOR: 6'.o b /KprS/RSt-SANItlIOLstentang

PENUGASAN KUN rS ICUN tc/,L APPOTNTME NnRUMAH SAKIT ISIAM SULTAN AGUNG SEMARANG

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MENIMBANG

DIREKTUR RUMAH SAKIT ISIAM SULTAN AGUNG

: a. Bahwa profesionalisme staf medis perlu ditingkatkan untuk menjamin mutu

pelayanan medik dan melindungi keselamatan pasien di rumah sakit.

b. Bahwa staf medis perlu diberikan Penugasan Klinis (Clinicol Appointment)

dalam rangka melaksanakan pelayanan di rumah sakit sesuai dengan

peraturan perundang-undangan yang berlaku.

c. Bahwa penivujudan dan maksud tersebut di atas, perlu ditetapkan dalam

Surat Keputusan tentang Penugasan Klinis RLmah Sakit lslam Sultan Agung.

MENGINGAT :1. Surat Keputusan Kepala Badan Penanaman Modal Daerah Provinsi Jawa

Tengah Nomor M1IOL/BPMD/O7/2074 tentang Perpanjangan lzin

Operasional Rumah Sakit Islam Sultan Agung;

Fatwa Dewan Syariah Nasional-Majelis Ulama lndonesia Nomor :

107/DSN-MUllXlzOfG Tentang Pedoman Penyelenggaraan Rumah Sa[it

Berdasarkan Prinsip Syariah;

Surat Keputusan Dewan Syariah Nasional-Majelis Ulama lndonesia

Nomor : 008.55.09/DSN-MUl/Vllllz}LT tentang Penetapan Layanan dah'

Manajemen Rumah Sakit tslam Sultan Agung telah memenghi prinsip

syariah;

Surat Keputusan Yayasan Badan Wakaf Sultan Agung Nomor :

7OISK/YBW-SANL|}0LBtentang Pengesahan Struktur Orianisasi RSI

Sultan Agung;

Surat Keputusan Yayasan Badan Wakaf Sultan Agung Nomor :

12ISK/YBW -SN ll 120L8 tenta nB Penga ngkata n Di rektu r Uta ma RSI Su ltan

Agung Masa Bhakti2018 -2022;Surat Keputusan Pengurus Yayasan Badan Wakaf Sultan Agung Nomor:.

-62lSKAew-SAllV|aOLS tentang Pengangkatan Direkur Direktur

Rumah Sakit Islam Sultan Agung Masa Bakti 2078-2022;Surat Keputusan Pengurus Yayasan Badan Wakaf Sultan Agung Nomor:

62ISK/YBW-SA{IV(2OLB tentang Pengangkatan Direkur Direktur

Rumah Sakit lslam Sultan Agung Masa Bakti 20t8 -2022;

MEMPERHATIKAN : Rekomendasi Komite Medik Rumah Sakit lslam Sultan Agung nomor:

044/KM/RSt-SA/Vt r r/2018

Jl. Raya Kaligawe Km.4 Semarang 50112 lawa Tengah, lndonesiaTelp" +52 24 558 001 9 | Fax. +62 24 658 1928 | Hotline : +62 85 1AO 41 2424

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

3.

4.

7.

Menetapkan

Kesatu

Kedua

Ketiga

Keempat

TEMBUSAN Yth. :

t. Ketua Komite Medik RSI-SA.

2. Ketua KSM Dokter Umum.

3. Manajer Pelayanan Medis

4. Arsip.

Jl. Raya Kaligawe Km,4 Semarang 50112 Jawa Tengah, lndonesiaTelp- +52 24 558 0019 | Fax. +6224 658 1928 | Hotline; +52 85 100 412424

email ; rs@rsisultanagung.co.id I www.rsisultanagung.co.id

MEMUTUSKAN

Mencabut surat l(eputusan Direktur Rumah sakit lslarn sultan Agung nornor:452UKPT s lRsl-sA/V2015 tentang PenuEasan Klinis {cti n ico I Appointment) dr.Retno Widhiastuti

Memberikan Penugasan Klinis Kepada dr. Retno widhiastuti sesuai denganrincian Kewenangan Klinis yang direkomendasikan oleh Komite Medik RSI SultanAgung sebagaimana terlampir dalam Surat Keputusan ini;

Masa bedaku Penugasan klinis terhitung mulai 1 September 2O18 sampai

dengan t September 202L;

Surat Keputusan ini berlaku sejak tanggal ditdtapkan dan apabila di kemudianhari terdapat kekeliruan dan atau kesalahan dalam penetapan ini, akan diadakanperubahan dan atau perbaikan sebagaimana mestinya

Ditetapkan di : Semarang

Pada tanggal : 18 Dzulhiiiah 1439 H

30 Agustus 2018 M

RUMAH SAKIT ISIAM SUTTAN AGUNG

SEMARAilG

Direktur Utama

1 Angina Pectoris 42 Ustable angina 43 Myocardial Infarction 44 Imminent Myocardial Infarction 45 Sinus Tachycardi 46 Supraventricular tachycardia 47 Atrial flutter 48 Ventricular extrasystole 49 BBB 4

10 Other arrhytmias 411 Endocarditis 412 Pericarditis 213 Myocarditis 2

1 Essential hypertension 42 Secondary hypertension 43 Pulmanory hypertension 44 Cardiogenic shock 45 Septic shock 46 Hypovolemic shock 4

1 Varises (Primary, secondary) 22 Thrombophlebitis 2

1 Lumphangitis 22 Lumphadenitis 43 Lymphedema, primary and secondary 4

Kategori KewenanganKewenangan Klinis diberikan untuk memberikan pelayanan pengelolaan bidang Dokter Umum di Rumah SakitIslam Sultan Agung Semarang, berdasarkan kebutuhan pasien.Keterangan Kode:1 = Tidak disetujui karena fasilitas tidak tersedia2 = Tidak disetujui karena bukan kompetensinya3 = Disetujui di bawah supervisi4 = Disetujui berwenang penuh

Jenis Pelayanan KodeCardiovasculer

Lampiran SK nomor: 5080/KPTS/RSI-SA/ VIII/2018

Kewenangan Klinis (Clinical Privilege)dr. Retno Widhiastuti

Cardiac Disorders

Lymph vessels

Aorta-arteries disorders

Veins

1

1 Uncomplicated Pulmonary Tuberculosis 42 TBC with HIV 43 Acute Bronchitis 44 Bronchiolitis 45 Bronchial asthma 46 Status asmaticus 47 Pleurity TBC 48 Pneumothorax 4

1 Mouth ulcers (aphthous, herpes) 42 Gossitis 4

1 Salphingitis 42 Acute appendicitis 4

1 Gastritis 42 Gastric/duodenal ulcer 43 Gastrointestinal bleeding 14 Zollinger-ellison syndrome 45 Mallory-weiss syndrome 46 Gastroenteritis 4

1 Fatty liver 22 Hepatitis A 43 Uncomplicated Hepatitis B 44 Active Hepatitis C 25 Cirrosi Hepatitis 26 Amoebic liver abscess 2

1 Acute cholecystitis 22 Pancreatitis 2

1 Enteritis 4

1 Colitis 42 Hemorrhoids 23 Perianal abcess 2

1 Gastro enteritis 42 Gastro enteritis dengan dehidrasi 43 Worms 44 Dehydration 45 Malabsorbsion 46 Food intolerance 47 Ileus 28 Peritonitis tuberculosis 2

Pediatrics

Respiratory

Gastrointestinal

Colon

Mouth

Acute abdomen

Stomach and duodenum

Liver

Gall bladder, bile duct and pancreas

Jejunum, ileum

2

9 Peritonitis pancreatitis 210 Ulcerative colitis 211 Hepatitis 412 Cirrhosis of the liver 413 Food Allergy 4

1 Acute renal failure 22 Chronic renal failure 23 Neprotic syndrome 24 Acute glomerulonephritis 25 Chronic glomerulonephritis 26 Renal colic 47 Urinary stone diseases or urinary calculi without 48 Colic 4

1 Epididymitis 42 Phimosis 43 Paraphimosis 44 Erection disorders 45 Ejaculation disorder 4

1 Vulvitis 42 Condylomata acuminata 4

1 Vaginitis 42 Foreign body 4

1 Cervicitis 4

1 Salpingitis 4

1 Inflammations 4

1 Aplastic/hypoplastic anemia 22 Iron deficiency anemia 23 Macrocytic anemia 24 Hemolytic anemia 25 Thrombocytopenia 26 Thrombocytosis 27 Hemophilia 2

1 Autoimmune rheumatological and autoimmune 22 Rheumatoid arthritis 43 Rheumatic fever 44 Immunodeficiency-HIV 2

1 PKU (Phenyl Ketonuria) 2

Nefrourologi

Male genitalia

Vulva

Vagina

Cervix

Adnexae

Breast

Hematology

Immunology

Genetics/newborn/chromossal disorder

3

1 Hypothermia 42 Pneumothorax 43 Apnea attacks 44 Jaundice of newborn 25 Hypoglycemia 46 Child of diabetic mother 47 Neonatal convulsion 48 Anemia 49 Blood group incompatibility 4

10 Vitamine k defficiency 411 Conjuctivitis 412 Infection of umbilicus 4

1 Endocrinological disorders 42 IDDM 43 NIDDM 44 Complication of DM (acute and chronic) 45 Hypoglycemia 46 Diabetes Incipidus 47 Hyperthyroidism 28 Hypothyroidism 29 Thyroiditis 2

1 Marasmus 42 Kwashiorkor 43 Vitamin deficiencies 4

1 Hyperlipoproteinemia 42 Phorphyria 43 Gout 44 Obesity 4

1 Metabolic Encephalopathy 22 Comoteus 23 Brain death 2

1 Tension headache 42 Migraine 43 Cranial arteritis 24 Trigeminal neuralgia 45 Cluster headache 2

1 TIA 2

1 Bels palsy 2

Loss of consciousness

Headache

Cardio Vascular Diseases

Cranial nerve and brain stem lesions

Error of metabolism

Disorders of newborns

Central and peripheral neural system

Nutritional deficiency

Endocrine, metabolic disorder and nutrition

4

1 Menier`s disease 2

1 Focal epilepsy 22 Generalized epilepsy 23 Absence seizure 24 Status epilepticus 25 Narcolepsy 26 Sleep apnea syndrome 2

1 Multiple sclerosis 22 Optic neuromyelitis (Devic`s disease) 2

1 Myelopathy 2

1 Meningitis 22 Encephalitis 23 Malaria cerebral 24 Tetanus 45 Cerebral toxoplasmosis 26 Tuberculoma 27 Brain abscess 28 HIV AIDS 2

1 Meningitis 42 Epilepsi 4

1 Nyeri Nosiseptif 42 Nyeri Neuropatik 4

1 Inflammation of auricle 42 Herpes zoster oticus 43 Pre-auricular fistula 24 Forign body in ear 45 Wax (serumen) 46 Otitis externa 47 Acute otitis media 48 Otitis media serous (glue ear) 49 Cholesteatoma 2

10 Mastoiditis 2

1 Epistaxis 42 Furuncle of nose 23 Acute rhinitis (common cold) 44 Vasomotor fhinitis 45 Allergic rhinitis 46 Chronic Rhinitis 2

Ears, hearing and equilibriumEar, nose and throat

Noses and sinuses

Pain

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

7 Rhinitis Medikamentosa 48 Acute Frontal sinusitis 49 Acute maxillary sinusitis 4

10 Acute ethmoiditis 411 Foreign body in nose 4

1 Pharyangitis 42 Tonsilitis 43 Hypertrophy of adenoids 44 Pseudo-croop acute epiglotitis 4

1 Torticollis 4

1 Conjunctiva, foreign body 42 Conjunctivitis, allergy 43 Conjunctivitis, viral 44 Conjunctivitis, bacterial 45 Pterygium 2

1 Blepharitis 22 Hordeolum 23 Chalazion 24 Eyelid laceration 25 Eyelid retraction 26 Xanthelasma 2

1 Erosion 22 Cornea, foreign body 23 Burn 24 Keratitis 25 Kerato-conjunctivitis sicca 26 Corneal oedema 27 Corneal dystrophy 28 Keratoconua 2

1 Hypermetropia 22 Myopia 23 Astigmatism 24 Presbyopia 25 Anisometropia 2

1 Loss of vision and blindness 2

1 Retinopathy of prematurity (rop) 22 Diabetic retinopathy 23 Hypertensive retinopthy 2

Refraction and accommodation

Cornea

Eyelids

Eye Conjunctiva

Neck

Larynx and pharynx

Vision and Visual Field

Retina

6

1 Contact dermatitis irritant 42 Contact dermatitis allergica 43 Atopic dermatitis (kecuali recalcitrant) 44 Nummular dermatitis 45 Lichen simplex chronicus 46 Napkin eczema 4

1 Psoriasis vulgaris 42 Plamoplantar pustulosis 43 Seborrheic dermatitis 44 Pityriasis rosea 4

1 Eczematous dermatitis 22 Acne vulgaris 43 Rosacea 44 Hidradenitis suppurativa 45 Perioral dermatitis 46 Miliaria 4

1 Verruca vulgaris 42 Condyloma accuminata 43 Molluscum contagiosum 24 Herpes zoster 4

1 Impetigo 42 Ulcerative impetigo (ecthyma) 43 Superficial folliculitis 44 Furuncle, carbuncle 45 Erythrasma 46 Erysipelas 4

1 Tinea capitis 42 Tinea barbae 43 Tinea faciale 44 Tinea corporis 45 Tinea manus 46 Tinea unguinum 47 Tinea cruris 48 Tinea pedis 49 Tinea versicolor 4

1 Pediculosis capitis 42 Pediculosis pubis 43 Scabies 44 Insect bites reactions 4

1 Pemphigus vulgaris 4

Disorders of skin eccrine and sebaceous glads

Viral skin infections

Bacterial Infections

Superficial fungal infections

Insect bites and infestations

Vesicobullous diseases

SkinEczematous dermatitis

Erythro-squamous lesions

7

2 Pemphigoid 43 Dermatitis herpetiformis 44 Toxic epidermal necrolysis 45 Stevens-johnson`s disease 4

1 Urticaria 42 Angiodema 43 Allergic vasculitis 4

1 Dermatomyositosis 2

1 Ichthyosis vulgaris 2

1 Exanthematous drug eruption 22 Fixed drug eruption 2

1 Paronychia 42 Suppurative tenosynovitis 43 Human bite 4

1 Suppurative parotitis 42 Suppurative cervical adenitis 43 Peritonsilar abscess 44 Ludwig`s angina 45 Bezold abscess 4

1 Superficial infections, including folliculitis, 22 hidradenitis suppurativa, carbuncle 23 Osteomyelitis 24 Staphylococcal pneumonia 25 Staphylococcal bacteremia 2

1 Rheumatic fever 42 Sinusitis, otitis media, mastoiditis, pertonsilar 43 Abscess - THT 44 Rheumatic heart disease 4

1 Meningitis (neuro) 42 Nasopharyngitis 4

1 Gonorrhea 4

1 Urinary tract infection (UTI) 42 Typhoid fever 43 Dysentry bacilli 44 Cholera 45 Pertussis 4

Gram-negative cocci Meningococcal infection (neuro)

Gonococcal infections

Gram-negative bacilli

Infectious and tropical diseasesLocalized infections and abscesses infections of the hand

Infections of the head and neck

Gram-positive cocci Staphylococcal and streptococcal infections

Streptococcal infection

Allergic skin diseases

Autoimmune diseases

Disorders of keratinizations

Drug reactions

8

6 Plague (Pes) 47 Chancroid 4

1 Diphteria (THT) 42 Tetanus (pediatri) 4

1 Tuberculosis kutis 42 Leprosy 43 Lepra reaction 4

1 Syphilis 42 Yaws 43 Leptospirosis 4

1 Influenza 42 avian influenza (THT) 43 Viral gastroenteritis 44 Poliomyelitis 45 Rabies 46 Morbilli 47 Varicella 48 Herpes zoster 49 Herpes simplex 4

10 Mumps 411 CMV infections 412 Dengue hemorrhagic fever (DHF) 413 HIV-AIDS 4

1 Amebiasis 42 Malaria 43 Leishmaniasis dan tripanosomiasis 44 Toxoplasmosis 45 Glardiasis 26 Trichomoniasis 2

1 Hookworm diseases 42 Strongyloidiasis 43 Ascariasis 44 Filariasis 45 Schistosomiasis 46 Cutaneus larva migran 47 Taeniasis 4

1 Anorexia Nervosa 4

1 Intoxication 42 Withdrawal syndrome 4

Psych-organic syndromes and disorders due to drugs

Eating DisorderPsychiatry and mental health

Spirochetal diseases

Viral infections

Protozoal infections

Worms infestations

Toxin producing bacteria

Mycobacterial diseases

9

3 Delirium 44 Dementia 2

1 Panic disorder with agoraphobia 22 Panic disorder without agoraphobia 23 Agoraphobia without history of panic disorder 24 Social phobia 25 Simple phobia 26 Obsessive compulsive disorder (neurosis) 27 Post traumatic stress disorder 28 Diffuse anxiety disorder 29 Anxiety disorder not otherwise classified 2

1 Disorder of body sensation 22 Conversion disorder (hysterical neurosis) 23 Hypochondriasis (hypochondriacal neurosis) 24 Somatisation disorder 25 Somatoform pain disorder 26 Undifferentiated somatoform disorder 27 Somatoform disorder not otherwise classified 2

1 disorder of orgasm 22 Sexual pain disorders 23 Sexual dysfunctions, noc 2

1 Sexual disorders 2

1 Insomnia 22 Hypersomnia 2

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

Psych-organic syndromes and disorders due to drugs

Somatic disorder

Sexual dysfunctions

10