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Procedural sedation and analgesia PSA is a skill commonly required when dealing with patients in the emergency department ED.

Typical procedures performed under PSA in the ED or minor theatre setting are reduction of fractures and common dislocations, incision and drainage of abscesses, laceration repair in children, foreign body removal, and evacuation of retained products of conception RPOC. Insufficient analgesia is associated with unwanted physiological and psychological side-effects, including increased sympathetic outflow, peripheral vascular resistance, myocardial oxygen consumption, production of carbon dioxide, hypercoagulability, decreased gastric motility, decreased immune function, and the subsequent development of chronic pain.

There are few studies on PSA administration by non-specialists in the public health sector in South Africa. It is attended by a diverse patient population, including those from a very low socio-economic background and wealthier patients belonging to medical aids.

It is a district hospital with 75 inpatient beds, 2 operating theatres, an outpatient department, and an ED with an annual head count of about 14 patients.

When the study was conducted, the ED was staffed by MOs with post-graduation working experience between 5 and 12 years and no formal training in emergency medicine or anaesthetics. One of the authors GW-S attended an accredited 2-year diploma course in conscious sedation at the University of the Western Cape and subsequently provided in-house training to interested medical and nursing staff. Patients who received medications for the purpose of PSA, orally, by inhalation or intravenously, were included.

Patients who received any drugs usually administered for PSA for endotracheal intubation, seizure control or analgesia without an associated procedure were excluded.

All health care staff participating in PSA had in-house training in PSA medication, and standardised guidelines8 were followed. Drugs were used at doses suitable for PSA as opposed to anaesthetic doses. Propofol was mixed into a solution with ketamine, commenced at a dosage of 0. Ketamine, when used alone, was used at a starting dose of 0.

Drug choices were up to the attending MO. Fasting status and intoxication with alcohol were evaluated and the decision to proceed with or defer the procedure was made on a case-to-case basis by the responsible MO. Informed consent was obtained for the procedure and sedation. Each procedural sedation event was recorded on a standardised anaesthetic record sheet.

Recorded variables included age, sex, ASA status, presenting problem, fasting status, clinical impression of intoxication, PSA medications and dosages used, adverse effects, rescue manoeuvres performed, if any, and time to discharge if discharged or to other disposal of the patient. Patients were monitored throughout the procedure with continuous pulse oximetry, and heart rate and blood pressure were measured before and at 2-minute intervals after commencement of the procedure.

Results Data were entered into an Excel spreadsheet. Data analysis is largely descriptive and clinical and demographic data are presented as means standard deviations SDs , medians, ranges, and proportions as appropriate.

27 tahun 2009 psak ebook no

The mean age was 23 years SD The oldest patient was 88 years and the youngest patient 3 months old. Table I sets out the frequency of other demographic variables. The intended procedures could be completed in Patients who experienced side-effects from their treatment were older on average, with a median age of 40 years versus a median age of 22 years for those who did not experience side-effects.

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The youngest patient who experienced an adverse effect was 19 years old. The numbers were too low for statistical analysis of the different medication groups for complications. However, there was a trend towards a higher complication rate with addition of propofol and use of multiple sedation drugs.

The numbers were too small for statistically significant conclusions concerning adverse events in fasted versus non-fasted versus intoxicated patients, but there was a tendency for intoxicated patients to develop complications, while there was little difference in the adverse effect rate between fasted and non-fasted patients Table III.

Of the patients were discharged after their procedure; the remaining 23 required admission or referral for further treatment. None of the admissions or referrals was related to PSA. The mean discharge time was 73 minutes SD The adverse effect rate complication rate overall was low and in keeping with reports from other countries.

There may be two reasons for this. Firstly, advanced age is known to be a risk factor for anaesthetic complications and complications of PSA. As such, side-effects relating to the use of PSA medication would be less likely. We did not examine how far this might have led to under-dosing of the children involved, which might be an interesting topic for future research. Comparison of the PSA medication that children and adults received showed that while 55 A trend was found towards a higher risk of complications with multi-drug regimens and addition of propofol.

This is expected, as propofol has a respiratory depressant effect16 and a combination of benzodiazepines and opiates can cause respiratory side-effects. Intoxicated patients were also at an increased risk of adverse effects.

No 27 tahun 2009 ebook psak

Alcohol ingestion more than doubled the complication rate in our series. While this finding is not statistically significant owing to small patient numbers, it indicates that guidelines, especially regarding administration of PSA to intoxicated patients, were not always closely followed.

While it may be argued that later reduction of a dislocated joint is more difficult, and reduction should therefore be done as soon as possible 5 of 8 intoxicated patients had dislocated joints , this is not true for incision and drainage of an abscess 2 of 8 intoxicated patients received PSA for drainage of an abscess.

Such procedures should be done electively with a fasted and sober patient. Of the 8 intoxicated patients one suffered a short spell of apnoea, having received a combination of ketamine and midazolam for PSA after being given morphine for pain relief by ambulance staff en route to the hospital for a painful dislocated shoulder. In this case the combination of alcohol, morphine and midazolam with the added ketamine predisposed the patient to adverse effects.

2009 ebook tahun no 27 psak

The complication rates between fasted and non-fasted patients differed little. In fact, fasted patients had a slightly higher complication rate 6. These findings were not statistically significant owing to low patient numbers, as well as a low overall number of complications.

27 2009 ebook psak tahun no

While fasting rules have been propagated for PSA as an extension of anaesthesia practice, in recent years applicability of nil per os guidelines for PSA has been questioned. The expected numbers of sedation-induced deaths or permanent neurological injuries are small, in the order of one in tens of thousands.


Patient numbers in the order of 50 would be needed to investigate these events. In this study PSA was judged to be successful if the procedure could be completed. The condition of the patient was not described further. A patient satisfaction questionnaire is probably the only way to ascertain true success of a procedure in a holistic, patient-centred way, and more research on PSA should be planned using this approach.

Some might feel that lack of a standardised drug regimen was a limitation. However, the research question was not to prove superiority of a certain drug for providing PSA, but to prove that PSA can be administered safely by non-specialised but trained medical staff.

Future research should expand on PSA research in this setting, focusing not just on safety but also on patient satisfaction with PSA. Newly qualified doctors in South Africa are likely to spend their first few years in district level care. Safe provision of PSA should therefore be taught to more doctors as a postgraduate course and even to undergraduate medical students.

Adherence to PSA guidelines, knowledge of drugs and basic airway management are of the upmost importance. Dalam kasus lain, manajemen perlu memerhatikan faktor yang mempengaruhi profitabilitas masa kini maupun masa yang akan datang, jadual pembayaran utang dan sumber potensial pembiayaan pengganti sebelum dapat menyimpulkan bahwa asumsi kelangsungan usaha telah sesuai.

Dasar Akrual Entitas menyusun laporan keuangan atas dasar akrual, kecuali laporan arus kas. Ketika akuntansi berbasis akrual digunakan, entitas mengakui pos-pos sebagai aset, laibilitas, ekuitas, pendapatan dan beban unsur-unsur laporan keuangan ketika pos-pos tersebut memenuhi definisi dan kriteria pengakuan untuk unsur-unsur tersebut dalam Kerangka Dasar Penyusunan dan Penyajian Laporan Keuangan.

Materialitas dan Agregasi Entitas menyajikan secara terpisah kelompok pos sejenis yang material. Entitas menyajikan secara terpisah pos yang mempunyai sifat atau fungsi berbeda kecuali pos tersebut tidak material.

Laporan keuangan merupakan hasil dari pemrosesan sejumlah transaksi atau peristiwa lain yang diklasifikasikan sesuai sifat atau fungsinya. Tahap akhir dari proses penggabungan dan pengklasifikasian adalah penyajian dalam laporan keuangan. Jika suatu klasifikasi pos tidak material, maka dapat digabungkan dengan pos lain yang sejenis dalam laporan keuangan atau dalam catatan atas laporan keuangan. Suatu pos mungkin tidak cukup material untuk disajikan terpisah dalam laporan keuangan tetapi cukup material untuk disajikan terpisah dalam catatan atas laporan keuangan.

Entitas tidak diperlukan untuk memberikan suatu pengungkapan khusus yang diminta oleh suatu PSAK jika informasi tersebut tidak material. Entitas tidak boleh melakukan saling hapus atas aset dan laibilitas atau pendapatan dan beban, kecuali disyaratkan atau diijinkan oleh suatu PSAK.

Entitas melaporkan secara terpisah untuk aset dan laibilitas serta pendapatan dan beban. Saling hapus dalam laporan laba rugi komprehensif atau laporan posisi keuangan atau dalam laporan laba rugi terpisah jika disajikan mengurangi kemampuan pengguna laporan keuangan baik untuk memahami transaksi, peristiwa dan kejadian lain yang telah terjadi maupun untuk menilai arus kas entitas di masa depan, kecuali jika saling hapus mencerminkan substansi transaksi atau peristiwa.

Pengukuran aset secara neto setelah dikurangi penyisihan penilaian misalnya, penyisihan keusangan atas persediaaan dan penyisihan piutang tak tertagih tidak termasuk kategori saling hapus.

PSAK Pendapatan mendefinisikan pendapatan dan mensyaratkan entitas untuk mengukurnya berdasarkan nilai wajar dari jumlah yang diterima atau akan diterima, dengan mempertimbangkan jumlah potongan dagang dan rabat volume yang diperbolehkan. Dalam aktivitas normal, entitas juga melakukan transaksi lain yang bukan merupakan penghasil utama pendapatan dan bersifat insidentil. Entitas menyajikan hasil dari transaksi tersebut dengan mengurangkan setiap pendapatan dengan beban terkait yang timbul dari transaksi yang sama sepanjang penyajian tersebut mencerminkan substansi dari transaksi atau peristiwa lain.

Misalnya: a entitas menyajikan keuntungan dan kerugian atas pelepasan aset tidak lancar, termasuk investasi dan aset operasional, dilaporkan dengan mengurangkan penerimaan dari pelepasan dengan nilai tercatat dan beban yang timbul dari pelepasan aset tersebut; b entitas dapat mengurangkan pengeluaran yang terkait dengan ketentuan yang diakui sesuai dengan PSAK 57 dan diganti berdasarkan perjanjian kontraktual dengan pihak ketiga seperti perjanjian garansi dari pemasok dengan penggantian yang diterima.

Entitas menyajikan keuntungan dan kerugian yang timbul dari suatu kelompok transaksi yang sejenis secara neto, misalnya keuntungan dan kerugian dari transaksi mata uang asing atau keuntungan dan kerugian yang timbul dari instrumen keuangan yang dikategorikan sebagai diperdagangkan. Namun, entitas menyajikan keuntungan dan kerugian tersebut secara terpisah jika keuntungan atau kerugian tersebut material.

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Frekuensi Pelaporan Entitas menyajikan laporan keuangan lengkap termasuk informasi komparatif setidaknya secara tahunan. Jika akhir periode pelaporan entitas berubah dan laporan keuangan tahunan disajikan untuk periode yang lebih panjang atau lebih pendek dari periode satu tahun, sebagai tambahan terhadap periode cakupan laporan keuangan, maka entitas mengungkapkan: a alasan penggunaan periode pelaporan yang lebih panjang atau lebih pendek; dan b fakta bahwa jumlah yang disajikan dalam laporan keuangan tidak dapat diperbandingkan secara keseluruhan.

Umumnya entitas secara konsisten menyiapkan laporan keuangan untuk periode satu tahun. Namun, untuk alasan praktis, beberapa entitas lebih memilih untuk melaporkan, sebagai contoh, untuk periode 52 minggu. Pernyataan ini tidak menghalangi praktik seperti ini. Informasi Komparatif Informasi kuantitatif diungkapkan secara komparatif dengan periode sebelumnya untuk seluruh jumlah yang dilaporkan dalam laporan keuangan periode berjalan, kecuali dinyatakan lain oleh SAK.

Informasi komparatif yang bersifat naratif dan deskriptif dari laporan keuangan periode sebelumnya diungkapkan kembali jika relevan untuk pemahaman laporan keuangan periode berjalan. Entitas yang mengungkapkan informasi komparatif menyajikan minimal dua laporan posisi keuangan, dua laporan untuk tiap jenis laporan lainnya, dan catatan atas laporan keuangan.

Jika entitas menerapkan kebijakan akuntansi secara retrospektif atau membuat penyajian kembali secara retrospektif atas pos-pos dalam laporan keuangan atau mereklasifikasi pos-pos dalam laporan keuangan, maka entitas menyajikan minimal tiga laporan posisi keuangan, dua laporan untuk tiap jenis laporan lainnya, dan catatan atas laporan keuangan.

Entitas menyajikan laporan posisi keuangan pada: a akhir periode berjalan, b akhir periode sebelumnya yang sama dengan awal periode berjalan , dan c permulaan dari periode komparasi terawal.

Pada beberapa kasus, informasi naratif yang disajikan pada laporan keuangan periode sebelumnya masih tetap relevan untuk diungkapkan pada periode berjalan.

Misalnya, rincian tentang sengketa hukum yang dihadapi dengan hasil akhirnya belum diketahui secara pasti pada periode sebelumnya dan masih dalam proses penyelesaian, perlu diungkapkan kembali pada periode berjalan. Pengguna akan memperoleh manfaat dari informasi adanya ketidakpastian pada akhir periode pelaporan sebelumnya, dan langkah yang telah dilakukan selama periode berjalan untuk mengatasi ketidakpastian tersebut.

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Jika entitas mengubah penyajian atau pengklasifikasian pos-pos dalam laporan keuangan, maka entitas mereklasifikasi jumlah komparatif kecuali reklasifikasi tersebut tidak praktis untuk dilakukan. Jika entitas mereklasifikasi jumlah komparatif, maka entitas mengungkapkan: a sifat reklasifikasi; b jumlah masing-masing pos atau gabungan beberapa pos yang direklasifikasi; dan c alasan reklasifikasi.

Jika reklasifikasi jumlah komparatif tidak praktis untuk dilakukan, maka entitas mengungkapkan: a alasan tidak mereklasifikasi jumlah tersebut, dan b sifat penyesuaian yang akan dilakukan jika jumlah tersebut direklasifikasi.