FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : JEMURSARI
BULAN : November 2018

NO NAMA ALAMAT NIK UMUR BPJS

L P PBI MANDIRI
1 SITI ROCHMAH JEMURWONOSARI Gg. I / 39 C 3578025302850002 33 0001395929158
2 NOVITASARI JEMUR NGAWINAN I /41 3578045112970003 21
3 ANGGA ASPRILA BASUKI JEMUR NGAWINAN I /41 3578041804950010 23 0001288322627
4 RAHMAWATI JEMURWONOSARI BUNTU 36 3578044905820001 36 0001336784512
5 AHMAD SYAIFULLAH WONOCOLO VI / 3 3507132108810004 37
6 NURUL AULIA WONOCOLO VI / 3 3578025208910002 27
7 IKA ANDRIANI JEMURWONOSARI BUNTU 25 3578024903990001 19 0001395933592
8 M.MAHFUDIN RUNGKUT KIDUL 5 3516080107980004 20
9 RYAN ADJI WONOCOLO BENTENG I / 25 3578020602930001 25 0001395932973
10 BAMBANG ERTANTO JEMURWONOSARI LEBAR 48 B 3578021805780003 40
11 WANDA ADERYANITA WONOCOLO VI / 15 3578046305920010 23
12 ANDY WAHYU SETIANTO WONOCOLO VI / 15 3578020204870002 31 0001703227702
13 ANNISA RIZKI JEMURSARI 3 /3 3578024308900003 28
14 DHEDY ADI N JEMURSARI 3 /3 3171011612810002 37
15 NOVIANTI CITRA JEMURWONOSARI JG / 1 3578225911880001 30
16 JEFFREY ARDANI ADAM JEMURWONOSARI JG / 1 357802150680003 38
17 YURIKE PUTRI DAMAYANTI JEMURWONOSARI 3 / 15 D 3506156606940001 24
18 FAISAL REZA R JEMURWONOSARI 3 / 15 D 3504091909940001 24
19
20
21
22
23
24
25
26
27
28
29
30

JUMLAH TOTAL 9 17
APORAN PASIEN THALASEMIA

BPJS UMUM HASIL LABORATORIUM HASIL

KONSELING
ASKES JAMSOSTEK JAMKESDA NON KUOTA Hb HCT RBC MCV MCH MCHC RDW POS NEG
12.5 38 4.43 85.8 28.2 32.9 12.2
√ 12.7 37.7 4.5 83.8 28.2 33.7 13.2
13.7 40.8 4.7 86.8 29.1 33.6 12.4
14.6 43.8 4.79 86.2 30.5 35.4 15.8
√ 15.9 47.2 5.43 86.9 29.3 33.7 13.2
√ 13.2 39.3 4.67 84.2 28.3 33.6 11.9
10.1 34.7 4.93 70.4 20.5 29.1 17.9
√ 14.4 42 4.61 91.1 31.2 34.3 11.7
14.9 42.7 4.77 89.5 31.2 34.9 12.9
√ 15.4 46.5 5.26 88.4 29.3 33.1 12.5
√ 12.1 38.7 5.25 73.7 23 31.3 15.2
15 44.4 5.1 87.1 29.4 33.8 13.5
√ 13.4 41.1 4.52 90.9 29.6 32.6 12.9
√ 15.8 46 5.3 86.8 29.8 34.3 13.1
√ 13.3 39.4 4.49 87.8 29.6 33.8 13.1
√ 17.4 51.8 5.46 94.9 31.9 33.6 13.6
√ 13.5 40.3 4.61 87.4 29.3 33.5 12.9
√ 14.1 42.4 5.58 76 25.3 33.3 14
Kepala Puskesmas
RUJUK KET
 LAPORAN PEMERIKSAAN SKRINING THALASEMIA
DINAS KESEHATAN KOTA SURABAYA
PUSKESMAS………………………………….
BULAN………………TAHUN…………………….
FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS :
BULAN :

NO NAMA ALAMAT NIK UMUR BPJS UMUM PENYAKIT HASIL

KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA RIWAYAT KELUARGA POS NEG

Surabaya, ……………………………..

Mengetahui
Kepala Puskesmas

(………………………………………..)
PUSKESMAS : JEMURSARI
BULAN : NOVEMBER 2018

NO NAMA ALAMAT

1 SITI ROCHMAH JEMURWONOSARI Gg. I / 39 C

2 NOVITASARI JEMUR NGAWINAN I /41
3 ANGGA ASPRILA BASUKI JEMUR NGAWINAN I /41
4 RAHMAWATI JEMURWONOSARI BUNTU 36
5 AHMAD SYAIFULLAH WONOCOLO VI / 3
6 NURUL AULIA WONOCOLO VI / 3
7 IKA ANDRIANI JEMURWONOSARI BUNTU 25
8 M.MAHFUDIN RUNGKUT KIDUL 5
9 RYAN ADJI WONOCOLO BENTENG I / 25
10 BAMBANG ERTANTO JEMURWONOSARI LEBAR 48 B
11 WANDA ADERYANITA WONOCOLO VI / 15
12 ANDY WAHYU SETIANTO WONOCOLO VI / 15
13 ANNISA RIZKI JEMURSARI 3 /3
14 DHEDY ADI N JEMURSARI 3 /3
15 NOVIANTI CITRA JEMURWONOSARI JG / 1
16 JEFFREY ARDANI ADAM JEMURWONOSARI JG / 1
17 YURIKE PUTRI DAMAYANTI JEMURWONOSARI 3 / 15 D
18 FAISAL REZA R JEMURWONOSARI 3 / 15 D
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 UMUR HASIL
NIK MCV RBC INDEX
L P POS NEG
3578025302850002 33 85.8 4.43 19.37
3578045112970003 21 83.8 4.5 18.62
3578041804950010 23 86.8 4.7 18.47
3578044905820001 36 86.2 4.79 18.00
3507132108810004 37 86.9 5.43 16.00
3578025208910002 27 84.2 4.67 18.03
3578024903990001 19 70.4 4.93 14.28
3516080107980004 20 91.1 4.61 19.76
3578020602930001 25 89.5 4.77 18.76
3578021805780003 40 88.4 5.26 16.81
3578046305920010 23 73.7 5.25 14.04
3578020204870002 31 87.1 5.1 17.08
3578024308900003 28 90.9 4.52 20.11
3171011612810002 37 86.8 5.3 16.38
3578225911880001 30 87.8 4.49 19.55
357802150680003 38 94.9 5.46 17.38
3506156606940001 24 87.4 4.61 18.96
3504091909940001 24 76 5.58 13.62