BORANG PERDATIN

8/16/2019 BORANG PERDATIN

1/12

PERDATIN Cabang : .......................

BORANG UJI-DIRIPROGRAM PENGEMBANGAN PENDIDIKAN

KEPROFESIAN BERKELANJUTAN

PERSATUAN DOKTER SPESIALIS ANESTESIOLOGI DAN

TERAPI INTENSIF INDONESIA


2/12

BORANG UJI-DIRI

PROGRAM PENGEMBANGAN PENDIDIKAN

KEPROFESIAN BERKELANJUTAN

Isi Borang Penilaian Diri

A. DATA DIRIB. KEGIATAN MANDIRIC. KEGIATAN INTERNAL

D. KEGIATAN EKSTERNALE. CATATAN KOMISI ETIK F. KONDISI KESEHATAN

Batasan minimal nilai ttal a!ala" #$ SKP %&'ta"(n) t&'!i'i !a'i :

*. K&giatan Man!i'i : + SKP,ta"(n

-. K&giatan Int&'nal : * SKP,ta"(n

/. K&giatan E0st&'nal : /$ SKP,ta"(n

A. DATA DIRI

Nama L&ng0a% : 1111111111111111111111111.

Tanggal La"i' : 1111111111111111111111111.

NPA PERDATIN Cabang : 1111111111111111111111111.

NPA PERDATIN : 1111111111111111111111111.Tgl,Bln,T"n. STR : .....................................................................................................

Pendidian Anes!esiologi

Ta"(n L(l(s : ....................................................................................................

T&m%at P&n!i!i0an : ....................................................................................................

Ala"a! R#"a$ : .....................................................................................................

.....................................................................................................

N. T&l%. , H% : ................................................ , ..................................................

&2mail : .....................................................................................................

Te"%a! Beer&a

Nama RS * : ...................................................................................................

Alamat RS : ...................................................................................................

...................................................................................................

Nama RS - : ...................................................................................................

Alamat RS : ...................................................................................................

...................................................................................................

Nama RS / : ...................................................................................................

Alamat RS : ...................................................................................................


3/12

...................................................................................................

B. DATA KEGIATAN MANDIRI

Presen!asi Maala$'Pos!er

(J#d#l)

Te"%a! Ser!i*ia! Nilai SKP

Pe"+ela&aran (To%i) Te"%a! Peer Re,ie Nilai SKP

P#+liasi Il"ia$ (J#d#l) Ma&ala$ Nilai SKP

M/0s Tes! (!o%i) Ma&ala$ Sor Nilai SKP

Kegia!an Mas1araa!

(Na"a Kegia!an)

Tanggal'Te"%a! Pen1elenggara Nilai SKP

To!al Nilai SKP ' 2 !a$#n

KETERANGAN 3


4/12

. DATA KEGIATAN INTERNAL

Penanganan %asien

3ang !ima0s(! !&ngan a0ti4itas %&nanganan %asi&n !i '(ma" sa0it a!ala" 5(mla"

%asi&n 6ang !itangani) !&ngan b&'bagai 0n!isi stat(s 7isi0. 8(mla" %asi&n ASA *2- 6ang

!itangani !alam s&ta"(n) minimal # %asi&n !&ngan 5(mla" nilai ma0simal 9 SKP. 8(mla"

Pasi&n ASA /2+ 6ang !itangani !alam s&ta"(n minimal *$ %asi&n !&ngan nilai ma0simal -

SKP. 8(mla" %asi&n ba'( ICU 6ang !itangani minimal *$ %asi&n !&ngan nilai ma0simal -

SKP.

P&ng&(alian %&nilaian bagi !0t&' an&st&silgi 6ang "an6a m&n5alan0an %'a0t&0

s(bs%&sialis) s&%&'ti 0a'!it'asi0. 3ang b&'sang0(tan !a%at m&nga5(0an %&'m"nan

a0'&!itasi nilai SKP 0&%a!a BP-KB PERDATIN !&ngan m&mba;a b(0( lg !an

%'t7li.

Penanganan Pasien J#"la$ Pasien'!a$#n Nilai SKPGA RA Pedia!ri

P&nanganan Pasi&n ASA * < -

P&nanganan Pasi&n ASA / < +

P&nanganan Pasi&n ICU S('gial M&!ial

To!al Nilai SKP

Pendidian

3ang !ima0s(! !&ngan a0ti4itas %&n!i!i0an 0&!0t&'an a!ala" a0ti4itas 6ang!ila0(0an !iling0(ngan '(ma" sa0it t&m%at b&0&'5a ata( l&bi" l(as. B&nt(0 a0ti4itas !a%at

b&'(%a 0&giatan m&mb&'i 0(lia") t(t'ial) %&ng(5i ata( %&nga;as (5ian ma"asis;a

0&!0t&'an, %&s&'ta PPDS !an,ata( %&'a;at. S&tia% 0&giatan "a'(s !iatat !alam b(0( lg

!an %'t7li) s&'ta m&n6im%an !0(m&n 6ang !ib(t("0an (nt(0 0&%&'l(an 4&'i7i0asi

!an %&mb&'ian nilai 0'&!it

Jenis Kegia!an Pendidian Te"%a! Peer Re,ie Nilai SKP


5/12

A!i,i!as Il"ia$

A0ti4itas ilmia" 6ang !ila0(0an !iling0(ngan t&m%at b&0&'5a) b&'(%a siang 0lini0)

%&'t&m(an ilmia" 0mit& m&!i0) 'n!& b&sa') %&mba"asan 0as(s) a(!it m&!is !an lain2lain6ang b&'t(5(an (nt(0 %'s&s %&mb&la5a'an !alam 'ang0a %&ning0atan 0(alitas %&la6anan.

S&tia% 0&giatan "a'(s !iatat !alam b(0( lg !an %'t7li) s&'ta m&n6im%an !0(m&n

6ang !ib(t("0an (nt(0 0&%&'l(an 4&'i7i0asi !an %&mb&'ian nilai 0'&!it.

Jenis A!i,i!as Il"ia$ Te"%a! Peer Re,ie Nilai SKP

KETERANGAN


6/12

D. DATA KEGIATAN EKSTERNAL

3ang !ima0s(! !&ngan 0&giatan &0st&'nal a!ala" 0&giatan 6ang !is&l&ngga'a0an l&"

0&lm%0 lain !il(a' t&m%at b&0&'5a 6ang !a%at b&'s0ala '&ginal) nasinal ata( int&'nasinal.

PB PERDATIN !alam "al ini BP-KB PERDATIN) m&n6&l&ngga'a0an a0ti4itas ;'0s"%

CPD (nt(0 m&ning0at0an 0&mam%(an 0gniti7) a7&0ti7 !an %si0mt'. Saat ini a0ti4itas;'0s"% CPD 6ang s(!a" !is&t(5(i l&" PB PERDATIN !an KARI a!ala":

*. CPD Ai';a6 manag&m&nt ) PERDATIN 8a0a'ta

-. CPD R&ginal An&st"&sia ) PERDATIN 8a0a'ta

/. CPD Pain Manag&m&nt ) PERDATIN Ma0assa'

Hasil Kng'&s Nasinal PB PERDATIN !i Bali ta"(n -$$= m&n&ta%0an FEEA s&bagai a(an

!alam m&la0sana0an CPD An&st&si !i In!n&sia. FEEA m&n&ta%0an t%i0 6ang m&n5a!i

a(an !alam %'s&s %&mb&la5a'an. Dalam %&n&'a%ann6a !i In!n&sia) P-KB PERDATIN

m&'ang0(m t%i0 t&'s&b(t !alam sat( 0&giatan. D&ngan m&m%&'timbang0an 0&t&'s&!iaan

;a0t( !an 5(mla" anggta PERDATIN) CPD C('s& a0an !ila0sana0an #> !alam s&ta"(n)

!&ngan mat&'i 6ang b&'b&!a. S&tia% anggta PERDATIN ;a5ib m&ngi0(ti 0&giatan CPD

('s& s&!i0itn6a sat( 0ali !alam # ta"(n.

PERTEMUAN ILMIA4

Per!e"#an Il"ia$ Tanggal Te"%a! Ser!i*ia! Nilai SKP

KONAS

PIB

KPPIA

5ors$o% PD

PERDATIN

Tanggal Te"%a! Ser!i*ia! Nilai SKP

Di77i(lt Ai';a6Manag&m&nt

R&ginal An&st"&sia

Pain

PD o#rse

PERDATIN

Tanggal Te"%a! Ser!i*ia! Nilai SKP

To!al Nilai SKP

Na"a Kegia!an

Tanggal'Te"%a!

Par!isi%asi P&s&'ta , P&mbia'a

Organisasi

Ser!i*ia! 3a , ti!a0 B(0ti lain:

Nilai SKP ,eri*iasi

Na"a Kegia!an


7/12

Tanggal'Te"%a!


Organisasi


Nilai SKP ,eri*iasi

Na"a Kegia!anTanggal'Te"%a!


Organisasi


Nilai SKP ,eri*iasi

Na"a Kegia!an

Tanggal'Te"%a!


Organisasi

Ser!i*ia! 3a , ti!a0 B(0ti lain:Nilai SKP ,eri*iasi

Na"a Kegia!an

Tanggal'Te"%a!


Organisasi


Nilai SKP ,eri*iasi

Na"a Kegia!an

Tanggal'Te"%a!


Organisasi


Nilai SKP ,eri*iasi

Ttal Nilai SKP 0&giatan &0st&'nal : .......................SKP

KETERANGAN3

To!al Nilai SKP dala" 2 !a$#n3

Kegia!an Ta$#n 6 Ta$#n 7 Ta$#n 8 Ta$#n 9 Ta$#n 2

Man!i'i

Int&'nal

E0st&'nal

To!al Nilai SKP

Dala" 2 !a$#n: nilai SKP !o!al 1ang di%erole$ 3 .................... SKP

Sa6a 6ang b&'tan!a tangan !i ba;a" ini) m&n6ata0an b&'tangg(ng 5a;ab atas 0&b&na'an

%&la%'an !ata t&'s&b(t !i atas !an b&'s&!ia (nt(0 m&mb&'i0an %&mb(0tian a%abila

!i%&'l(0an.


8/12

..........................)tgl......................................

D'. .........................................


9/12

DIISI OLE4 E;ALUATOR (BP7KB)

ATATAN KOMISI ETIK

R&0m&n!asi Kmisi Eti0.A%abila !iangga% %&'l() Tim BP-KB b&'0&;a5iban (nt(0 b&'tan6a 0&%a!a D&;an

K&"'matan Eti0 K&!0t&'an ? %a!a l0asi 0&'5a @ t&ntang &ti0a !an %&'ila0( %'7&sinalism&

!0t&' 6ang b&'sang0(tan. Catatan %&'ila0( &ti0 ata( t&g('an DKEK m&'(%a0an (ns(' 6ang

%&nting !alam %&mb&'ian s&'ti7i0asi (lang.

Ke!erangan 3

TEGURAN TIDAK ADA

KOMISI ETIK ADA

KONDISI KESE4ATAN

A%abila !iangga% %&'l( Tim BP-KB b&'"a0 m&minta s('at 0&t&'angan !0t&'.

D0t&' 6ang m&mb&'i 0&t&'angan:

Nama : .........................................................................................................

T&m%at P'a0t&0 : .........................................................................................................

NPA IDI : .........................................................................................................

N , Tanggal s('at 0&t&'angan: ............................................................................................

Nama : .........................................................................................................

T&m%at P'a0t&0 : .........................................................................................................

NPA IDI : .........................................................................................................


Nama : .........................................................................................................

T&m%at P'a0t&0 : .........................................................................................................

NPA IDI : .........................................................................................................


Ke!erangan 3

KONDISI BAIK

KESE4ATAN KURANG BAIK

TIDAK LA


10/12

Di+erian Ser!i*iasi Ulang Tan%a Ke!erangan 3

S1ara!

Di+erian Ser!i*iasi Ulang Dengan Ke!erangan 3

Progra" Re"edial

Di!ola ' Degradasi Ke!erangan 3

4ASIL E;ALUASI

a. S&'ti7i0asi Ulang Tan%a S6a'at

Dib&'i0an bila aln !a%at m&m&n("i s&m(a 0'it&'ia minimal 6ang !i%&'s6a'at0an.

b. S&'ti7i0asi Ulang D&ngan P'g'am R&m&!ial

Dib&'i0an bila aln ti!a0 !a%at m&m&n("i 0'it&'ia minimal %&'s6a'atan s&a'a %&n(".

P'g'am R&m&!ial a!ala" %'as6a'at 6ang "a'(s !i%&n("i t&'l&bi" !a"(l( l&" aln) s&b&l(m!a%at !ib&'i0an S&'ti7i0asi Ulang. 8&nis !an laman6a '&m&!ial !is&s(ai0an !&ngan %&'s6a'atan

minimal 6ang ti!a0 t&'%&n("i. Misaln6a) m&ngi0(ti 0&giatan P&ngab!ian Mas6a'a0at) '&2

&!(0asi (nt(0 %&'i!& t&'t&nt( 6ang !it&nt(0an !an !inilai l&" instit(si %&n!i!i0an 6ang

!it(n5(0 l&" BP-KB PERDATIN.

. Ditla0

P&nla0an %&mb&'ian S&'ti7i0asi Ulang !ila0(0an a%abila aln ti!a0 !a%at m&m&n("i

s&bagian b&sa' %&'s6a'atan) t&'(tama bila !alam 0&a!aan 0&s&"atan 6ang b('(0.

E;ALUATOR

6. BP7KB PERDATIN 3

7. BP7KB a+ang 3


11/12

on!o$ Por!o*olio

To%i3

Tanggal %resen!asi3 Pen1elia3

?tan!a tangan@Jenis egia!an3

La%'an 0as(s Masala"

Mana5&m&n

R&4i&; Kas(s Tin5a(an P(sta0a

Desri%si as#s3

KU

Ria1a! %en1ai!

Ria1a! el#arga

Ria1a! %engo+a!an'!indaan

Ria1a! %eer&aan

Pe"erisaan *isi'la+ Diagnosis

Masala$ #!a"a (%oo dis#si)

Rang#"an (#raian singa!) $asil %e"+ela&aran3

*-

/

+

#

Da*!ar P#s!aa3

*

-

/

Peer 1ang $adir3

Nama Tan!a tangan Nama Tan!a tangan

*

- =

/ 9

+

# *$


12/12

La"%iran 2

PENGAKUAN ATAS SUATU KEGIATAN P7KB

Ta!a =ara "enda%a!an %enga#an dari IDI3

*. M&nga5(0an s('at %&'m"nan a0'&!itasi 0&%a!a IDI-. M&lam%i'0an TOR 0&giatan 6ang m&n5&las0an

a. K('i0(l(m: t(5(an) t&ma) m&t!a) assessment

b. Aa'a l&ng0a%: 'inian ;a0t() t%i0) %&mbia'a) m!&'at'

c. R&nana &4al(asi %&n6&l&ngga'aan

d. S(s(nan %anitia

/. M&lam%i'0an 'i;a6at "i!(% %&mbia'a !an m!&'at') s&'ta %&'n6ataan 0&s&!iaan !a'i

%&mbia'a

Pers1ara!an %enga#an s#a!# egia!an3

• Dis&l&ngga'a0an l&" l&mbaga,'ganisasi 6ang 0m%&t&n !an t&'a0'&!itasi l&" BP-KB

• K&giatan 5&las m&mili0i– T(5(an (m(m,0"(s(s

– K('i0(l(m 6ang '&l&4an !&ngan 0m%&t&nsi !0t&' aln %&s&'ta

– P&nga5a' 0m%&t&n !i bi!angn6a !an m&mb&'i0an %&'n6ataan t&'t(lis ba";a ia ti!a0

m&m%(n6ai 0&%&ntingan t&'t&nt(.

• K&giatan 6ang !ila0sana0an %a'al&l !i b&b&'a%a t&m%at) ata( b&'s&'i "a'(s !iminta0an

a0'&!itasi s&a'a s&n!i'i2s&n!i'i

• Dalam %&la0sanaan 0&giatan:

– Lama ;a0t( &'ama" minimal -# m&nit) !an t&'s&!ia ;a0t( (nt(0 !is0(si int&'a0ti7

– A!a assessment bagi %&s&'ta ?misaln6a pretest !an posttest @.

• Dila0(0an &4al(asi atas %&n6&l&ngga'aan

•Dalam 0n!isi %&mbia'a !iangga% ti!a0 m&m&n("i 0(ali7i0asi) ma0a 0&giatan P-KB t&'0aitti!a0 a0an !ia0(i !an ti!a0 m&m%&'l&" 0'&!it P-KB ;ala(%(n 0('i0(l(m !an l&mbaga

%&n6&l&ngga'a t&'a0'&!itasi.

• Bila 0&giatan !ila0sana0an !alam 0&'5a sama !&ngan l&mbaga !i LN ma0a nilai 0'&!it

%&n!i!i0ann6a s&s(ai !&ngan nilai 6ang !is&%a0ati l&" %&n6&l&ngga'a

Pers1ara!an %e"+i=ara

P&mbia'a "a'(s m&m%(n6ai 0&a"lian !alam mat&'i 6ang !iba;a0ann6a.

Km%&t&nsi %&mbia'a s&s(ai !&ngan t&ma 0&giatan !an !ia0(i l&" peer group

?%&'"im%(nan@

Dalam "al %&mbia'a b&'"alangan) ma0a %&mbia'a %&ngganti "a'(s m&m%(n6ai 0(ali7i0asi

6ang sama !&ngan %&mbia'a 6ang !iganti0an !an a!a %&'n6ataan,'&0m&n!asi t&'t(lis !a'i %&mbiaa'a 6ang !iganti0an.

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