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LAPORAN BULANAN DATA KESAKITAN

Bulan :
Tahun :

KODE :
NAMA KLINIK :
ALAMAT :
PENANGGUNGJAWAB KLINIK :
WILAYAH KERJA PUSKESMAS :
NO.TELP KLINIK :
E-MAIL KLINIK :

DATA KESAKITAN

JUMLAH KASUS BARU, LAMA DAN KUNJUNGAN KASUS LAMA GOL UMUR
No Jenis Penyakit < 1 th 1 - 4 th 5 - 14 th 15 - 44 th 45 - 55 th 55 - 64 th >= 65 th
B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L
1 2 3 4 5 6 7 8 9
A KELOMPOK UMUM
1 Tuberkulosis 0 0 0 0 0 0 1 1 1 1 0 0 0 0 1 1 0 0
2 Morbili 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Varisela 0 0 2 2 2 2 1 1 1 1 2 1 2 1 0 0 0 0 0 0 5
4 Malaria 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

5 Demam Dengue dan Demam Berdarah


Dengue 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Leptospirosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Infeksi pada Umbilikus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Kandidiasis Mulut 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Lepra 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Keracunan Makanan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Alergi Makanan 0 0 1 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1
12 Exanthematous Drug Eruption 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Fixed Drug Eruption (FDE) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
14 Reaksi Anafilaktik 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
15 Syok 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0

B DARAH, PEMBENTUKAN DARAH, SISTEM IMUN


1 Anemia 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0
2 HIV/AIDS tanpa Komplikasi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Limfadenitis 0 0 0 0 1 1 0 3 0 3 0 0 0 0 0 0 1

C DIGESTIVE
1 Refluks Gastroesofageal 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0
2 Gastritis 0 0 3 3 3 3 5 3 5 3 8 34 8 34 3 3 3 3 1 2 1 2 3 4 2 7 2 15
3 Intoleransi Makanan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Malabsorbsi Makanan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Demam Tifoid 0 0 1 1 1 1 0 0 2 4 2 4 1 1 0 0 0 0 0 4
6 Gastroenteritis :
a Disentri 1 1 0 1 1 0 1 1 0 1 6 1 6 1 1 0 0 0 1 1 0 6
b Kolera 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
c Giardiasis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Disentri :
a Basiler 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b Amuba 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Apendisitis Akut 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Perdarahan Saluran Makan Bagian Atas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Perdarahan Saluran Makan Bagian
Bawah
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Hemoroid Grade 1-2 0 0 0 0 0 0 4 0 4 1 1 1 1 0 0 1 1 0 0
12 Hepatitis A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Hepatitis B 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0
14 Parotitis 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0
15 Askariasis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
16 Cutaneus Larva Migrans 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
17 Penyakit Cacing Tambang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
18 Skistosomiasis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
19 Strongiloidiasis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
20 Taeniasis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
21 Peritonitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
22 Kolesistitis 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 0 1

D MATA
1 Mata Kering/Dry eye 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Buta Senja 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Hordeolum 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Konjungtivitis 0 0 0 0 0 0 5 0 5 0 0 1 0 1 0 0 0
5 Blefaritis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Perdarahan Subkonjungtiva 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0
7 Benda asing di konjungtiva 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 1
8 Astigmatism 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Hipermetropia 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
JUMLAH KASUS BARU, LAMA DAN KUNJUNGAN KASUS LAMA GOL UMUR
No Jenis Penyakit < 1 th 1 - 4 th 5 - 14 th 15 - 44 th 45 - 55 th 55 - 64 th >= 65 th
B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L
1 2 3 4 5 6 7 8 9
10 Miopia Ringan 0 0 0 0 1 0 1 2 3 2 3 1 1 1 1 0 0 0 0 0
11 Presbiopia 0 0 0 0 0 0 1 1 1 1 2 2 2 2 0 0 1 0 1 0
12 Katarak pada Pasien Dewasa 0 0 0 0 0 0 0 0 0 0 2 0 2 1 1 1 1 0
13 Glaukoma Akut 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0

E TELINGA
1 Otitis Eksterna 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Otitis Media Akut 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Serumen Prop 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

F HIDUNG
1 Benda Asing di Hidung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

G KARDIOVASKULAR
1 Angina Pektoris 0 0 0 0 0 0 1 0 1 0 0 0 0 2 2 0 2
2 Infark Miokard 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1
3 Takikardia 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0
4 Gagal Jantung :
a Gagal Jantung Akut 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 1 0
b Gagal Jantung Kronik 0 0 0 0 0 0 0 0 1 0 1 2 2 0 1 1 0 0
5 Cardiorespiratory Arrest 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Hipertensi Esensial 0 0 0 0 0 0 4 2 4 2 9 6 9 6 3 10 3 10 9 17 9 17 0
7 Infark Serebral/Stroke 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

H MUSKULOSKELETAL
1 Fraktur Terbuka 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Fraktur Tertutup 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 1 2
3 Polimialgia Reumatik 0 0 0 0 0 0 1 3 1 3 0 0 0 0 0 0 1
4 Artritis Reumatoid 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Artritis, Osteoartritis 0 0 0 0 0 0 8 5 8 5 4 8 4 8 2 2 2 2 1 3 1 3 15
6 Lipoma 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

I NEUROLOGI
1 Kejang Demam 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Vertigo 0 0 0 0 0 0 7 2 7 2 0 0 1 3 1 3 1 2 1 2 0
3 Delirium 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Tetanus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Rabies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Epilepsi 0 0 0 0 2 2 0 0 0 0 0 0 0 0 0 2
7 Status Epileptikus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Migren 0 0 0 0 0 0 4 4 4 4 3 0 3 2 0 2 2 1 2 1 6
9 Bells’ Palsy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Tension Headache 0 0 0 0 0 0 3 5 3 5 2 0 2 1 1 0 0 0 4

J PSIKOLOGIS
1 Insomnia 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Demensia 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0

3 Gangguan Campuran Anxietas dan


Depresi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

4 Gangguan Psikotik 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

K RESPIRASI
1 Epistaksis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Furunkel Pada Hidung 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faringitis 0 0 2 1 2 1 2 1 2 1 6 14 6 14 5 2 5 2 2 2 0 0 0 17
4 Rhinitis Akut 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 1
5 Rhinitis Alergik 0 0 0 0 1 1 1 1 2 0 2 0 0 0 0 1 0 1 1
6 Rhinitis Vasomotor 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Tonsilitis 0 0 1 1 0 2 1 2 1 1 0 1 3 0 3 0 0 0 0 3
8 Laringitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Bronkitis Akut 0 0 0 0 1 0 1 0 0 2 2 0 0 0 1 3 1 3 3
10 Influenza 1 2 1 2 3 10 3 10 19 10 19 10 27 29 27 29 7 3 7 3 3 1 3 1 5 10 5 10 65
11 Pneumonia Aspirasi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Pneumonia dan Bronkopneumonia :
a Pneumonia 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b Bronkopneumonia 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Pertusis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
14 Asma Bronkial 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0

L KULIT
1 Miliaria 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
2 Veruka Vulgaris 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Reaksi Gigitan Serangga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Herpes Zoster 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Herpes Simpleks 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Skabies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Pedikulosis Kapitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Dermatofitosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
JUMLAH KASUS BARU, LAMA DAN KUNJUNGAN KASUS LAMA GOL UMUR
No Jenis Penyakit < 1 th 1 - 4 th 5 - 14 th 15 - 44 th 45 - 55 th 55 - 64 th >= 65 th
B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B L KKL JKK B
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L
1 2 3 4 5 6 7 8 9
9 Pitiriasis versikolor/ Tinea versikolor 0 0 0 0 0 0 0 0 3 3 0 0 0 0 0 3
10 Pioderma 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Dermatitis Seboroik 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Dermatitis Atopik 0 0 1 0 1 2 1 2 1 5 1 5 1 0 0 0 0 1 1 0 8
13 Dermatitis Numularis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

14 Liken simpleks kronik (neurodermatitis 2


sirkumkripta) 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0

15 Dermatitis Kontak Alergik (DKA) 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 2


16 Dermatitis Kontak Iritan 0 0 0 0 1 0 1 1 1 1 1 1 1 0 0 0 0 0 2
17 Napkin Eczema (dermatitis popok) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
18 Pitiriasis Rosea 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
19 Moluskum Kontagiosum 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
20 Urtikaria 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
21 Filariasis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
22 Luka Bakar :
a Luka Bakar Derajat I 0 0 0 0 1 1 0 2 3 2 3 1 0 1 0 0 1 1 0 4
b Luka Bakar Derajat II 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

M METABOLIK ENDOKRIN DAN NUTRISI


1 Obesitas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Tirotoksikosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Hiperglikemia Hiperosmolar Non 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Ketotik
4 Hipoglikemia 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Diabetes Melitus 0 0 0 0 0 0 5 4 5 4 3 6 3 6 2 6 2 6 2 8 2 8 0
6 Malnutrisi Energi Protein (MEP) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Hiperuricemia-Gout Arthritis 0 0 0 0 0 0 0 0 0 0 2 1 2 1 1 0 1 2
8 Dislipidemia 0 0 0 0 0 0 5 2 5 2 1 4 1 4 3 0 3 3 0 3 0

N SALURAN KEMIH
1 Infeksi Saluran Kemih 0 0 0 0 1 1 0 1 5 1 5 1 1 0 0 0 0 0 3

O KESEHATAN WANITA
1 Hiperemesis Gravidarum 0 0 0 0 0 0 1 1 0 2 0 0 0 0 0 0 0
2 Kehamilan Normal 0 0 0 0 0 0 1 7 0 8 0 0 0 0 0 0 0
3 Pre-eklampsia 0 0 0 0 0 0 2 0 2 0 0 0 0 0 0 0
4 Eklampsi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Abortus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

6 Anemia Defisiensi Besi pada Kehamilan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

7 Ketuban Pecah Dini (KPD) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0


8 Persalinan Lama 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Perdarahan Post Partum 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Ruptur Perineum Tingkat 1-2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Mastitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

P PENYAKIT KELAMIN
1 Fluor Albus / Vaginal discharge Non
Gonore 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Sifilis:
a Stadium I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b Stadium II 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
c Stadium III 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Gonore 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1
4 Vaginitis 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0
5 Vulvitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Q TINDAKAN
1 KIA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 KB: 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0
a Suntik 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b Pil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
c Lainnya ................ 0 0 0 0 0 0 3 0 3 0 0 0 0 0 0 0

R PENYAKIT RONGGA MULUT


1 Caries gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Peny. Pulpa & jar periapikal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Peny gusi & jar periodontal 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 1

4 Kelainan dento fasial termasuk


Maloklusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Stomatitis 0 0 1 0 1 2 2 0 1 1 1 1 0 0 0 0 0 0 3
6 Moniliasis 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
7 Scalling 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

JUMLAH 2 3 0 0 0 0 2 3 14 22 0 0 0 0 14 22 41 22 0 2 0 0 41 24 68 101 35 68 0 0 103 169 31 28 17 21 0 0 48 49 11 11 8 25 0 0 19 36 19 21 20 35 0 0 39 56 186


LAH KASUS BARU, LAMA DAN KUNJUNGAN KASUS LAMA GOL UMUR
Jumlah
B L KKL JKK
P L P L P L P Total
10

0 2 1 0 0 2 1 3
0 0 0 0 0 0 0 0
4 0 0 0 0 5 4 9
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
2 0 0 0 0 1 2 3
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
1 0 0 0 0 0 1 1

1 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0
0 0 3 0 0 1 3 4

1 0 0 0 0 0 1 1
11 12 36 0 0 27 47 74
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
5 0 0 0 0 4 5 9

6 0 0 0 0 6 6 12
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 2 5 0 0 2 5 7
0 0 0 0 0 0 0 0
0 1 0 0 0 1 0 1
1 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
1 0 0 0 0 1 1 2

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
6 0 0 0 0 0 6 6
0 0 0 0 0 0 0 0
1 0 0 0 0 0 1 1
0 0 0 0 0 1 0 1
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
LAH KASUS BARU, LAMA DAN KUNJUNGAN KASUS LAMA GOL UMUR
Jumlah
B L KKL JKK
P L P L P L P Total
10
0 3 5 0 0 3 5 8
0 3 4 0 0 3 4 7
0 1 3 0 0 1 3 4
0 0 1 0 0 0 1 1

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

1 0 0 0 0 2 1 3
0 0 0 0 0 1 0 1
1 0 0 0 0 0 1 1

0 1 1 0 0 1 1 2
0 3 1 0 0 3 1 4
0 0 0 0 0 0 0 0
0 25 35 0 0 25 35 60
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
1 0 0 0 0 2 1 3
3 0 0 0 0 1 3 4
0 0 0 0 0 0 0 0
18 0 0 0 0 15 18 33
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 9 7 0 0 9 7 16
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 2 0 2
0 0 0 0 0 0 0 0
10 0 0 0 0 6 10 16
0 0 0 0 0 0 0 0
7 0 0 0 0 4 7 11

0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 1

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
1 0 0 0 0 0 1 1
18 0 0 0 0 17 18 35
1 0 0 0 0 1 1 2
4 0 0 0 0 1 4 5
0 0 0 0 0 0 0 0
5 0 0 0 0 3 5 8
0 0 0 0 0 0 0 0
4 0 0 0 0 3 4 7
65 0 0 0 0 65 65 130
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 1

1 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
LAH KASUS BARU, LAMA DAN KUNJUNGAN KASUS LAMA GOL UMUR
Jumlah
B L KKL JKK
P L P L P L P Total
10
0 0 0 0 0 3 0 3
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
3 0 0 0 0 8 3 11
0 0 0 0 0 0 0 0

2 0 0 0 0 0 2 2

0 0 0 0 0 2 0 2
2 0 0 0 0 2 2 4
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

4 0 0 0 0 4 4 8
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 12 24 0 0 12 24 36
0 0 0 0 0 0 0 0
2 0 0 0 0 2 2 4
0 6 12 0 0 6 12 18

5 0 0 0 0 3 5 8

1 0 1 0 0 0 2 2
1 0 7 0 0 0 8 8
0 0 2 0 0 0 2 2
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 1
1 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
3 0 0 0 0 0 3 3

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
1 0 0 0 0 1 1 2

0 0 0 0 0 0 0 0
2 0 0 0 0 3 2 5
1 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0

208 80 151 0 0 266 359 625


LAPORAN BULANAN DATA KUNJUNGAN PASIEN

Tahun : 2018

KODE : 0
NAMA : 0
ALAMAT : 0
PENANGGUNGJAWAB KLINIK : 0
WILAYAH KERJA PUSKESMAS : 0
NO.TELP KLINIK : 0
E-MAIL KLINIK : 0

JUMLAH KUNJUNGAN KUNJUNGAN GANGGUAN JIWA


NO BULAN KUNJUNGAN RAWAT JALAN RAWAT INAP JUMLAH
L P L+P L P L+P L P L+P
1 2 3 4 5 6 7 8 9 10 11
1 JANUARI 227 244 471 0 0
2 FEBRUARI 221 208 429 0 0
3 MARET 260 327 587 0 0
4 APRIL 237 330 567 0 0
5 MEI 268 349 617 0 0
6 JUNI 178 248 426 0 0
7 JULI 238 279 517 0 0
8 AGUSTUS 217 354 571 0 0
9 SEPTEMBER 278 363 641 0 0
10 OKTOBER 266 359 625 0 0
11 NOVEMBER 0 0 0
12 DESEMBER 0 0 0
JUMLAH 2,390 3,061 5,451 0 0 0 0 0 0
LAPORAN BULANAN DATA RUJUKAN PASIEN

Bulan : 0
Tahun : 0

KODE : 0
NAMA KLINIK : 0
ALAMAT : 0
PENANGGUNGJAWAB KLINIK : 0
WILAYAH KERJA PUSKESMAS : 0
NO.TELP KLINIK : 0
E-MAIL KLINIK : 0

JENIS
NAMA PASIEN
NO KELAMIN (L/P) TANGGAL DIRUJUK

1 2 3 4

JENIS
NAMA PASIEN
NO KELAMIN (L/P) TANGGAL DIRUJUK

1 2 3 4

1 ANNISA ISTIQOMAH P 1/10/2018

2 SITI DJAZILAH KSITI DJAZILAH K P 1/10/2018

3 JIHADIAH NUR IKROMAH P 1/10/2018

4 DANIEL SAPUTRA L 1/10/2018

5 PUNARDI SURYAJAYA, DRS. L 1/10/2018

6 PRINCESS AZEEZAH SALSABEELA P 1/10/2018

7 CHRISTANTI YULIA ANGGRAENI P 1/10/2018

8 GEORGEO AUBERON L 1/10/2018

9 WAHYUDI SETIAWAN L 1/10/2018

10 CARMEN GLORIELLA SETIO P 2/10/2018

11 ROY NOTO HAMDANI L 4/10/2018

12 RAHAYU AGUSTINA P 4/10/2018

13 ANIWATI SATYAGRAHA P 4/10/2018

14 FEEI FEEI KARTIKA, SE P 5/10/2018


15 GO NATALIA P 5/1012018

16 SUSENO L 5/10/2018

17 DJUN KEK P 5/10/2018

18 SOEWITO L 5/10/2018

19 ELLA NOVITA P 6/10/2018

20 TJOA FENNY S P 6/10/2018

21 EVI KRISTIANA P 6/10/2018

22 MUDJIJANTO L 6/10/2018

23 DIANA WULANDARIE P 6/10/2018

24 KESI INDRAWATI P 6/10/2018

25 TJAHJONO L 8/10/2018

26 DIDIK IRIYANTO L 8/10/2018

27 SURATI P 8/10/2018

28 MOCH. SYAIFUL ROZIE L 8/10/2018

29 GRACE LIDYA P 8/10/2018

30 HANIFAH L P 8/10/2018

31 MOCHAMMAD AMIEN L 8/10/2018

32 LINDAWATI P 9/10/2018

33 SISWATI IR P 9/10/2018

34 PAULA ERFINA P 9/10/2018

35 GRACE WIDYANTI P 9/10/2018

36 OEING THING THING P 9/10/2018

37 IVANA RIANA P 9/10/2018

38 KISMAWATI P 9/10/2018

39 RATIH EKA P 9/10/2018

40 DJAELAN L 9/10/2018
41 P 10/10/2018
SITI DJAZILAH K

42 P 10/10/2018
RINA BANARSARI, DRG

43 P 10/10/2018
ENDANG SRI WAHYUNI

44 RATIH SULISTYOWATI P 11/10/2018

45 WIILY WIBISONO L 11/10/2018

46 WIDIYANA(GO KA GOEI) P 11/10/2018

47 LIDYAWATI P 11/10/2018

48 CINDERASMI AMEPUTRI P 11/10/2018

49 DIVA HAIRIANNISA P 11/10/2018

50 MIARTI RESPIM P 11/10/2018

MEI KUSMIATI P 11/10/2018


51

DR ELITA HALIMSETIONO P 12/10/2018


52

GINA LYDIAWATI P 12/10/2018


53

JOBPI P L 12/10/2018
54

YUSUF ARWANDY L 12/10/2018


55

P 12/10/2018
56 LIEM WAN ING

LUKI MARIANA P 12/10/2018


57

FIRDA AYU WAHYUNI P 13/10/2018


58

GO GIOK LIAN P 13/10/2018


59

TJAHJONO L 15/10/2018
60

NATHASA RUTH P 15/10/2018


61

NURI ASIFA P 15/10/2018


62

TANIMAN L 15/10/2018
63

YOHANA P 15/10/2018
64
FAJRI NURRASYID L 15/10/2018
65

TJIA LIE ING P 15/10/2018


66

MA'IN L 15/10/2018
67

BAMBANG HENRYANTO L 15/10/2018


68

TAN SHINDUNATA L 16/10/2018


69

INDRAWATI SOEGIANTO P 17/10/2018


70

IRENE MAGDALENA P 17/10/2018


71

ALVIN WIJAYANTI SARI P 17/10/2018


72

ANNISA ISTIQOMAH P 18/10/2018


73

FRANSISKUS FILDO toni L 18/10/2018


74

KENZIE ATHARAYYHAN L 18/10/2018


75

MASMARIANI P 18/10/2018
76

DANIN L 19/10/2018
77

MUKODIMATUR ROHMA P 19/10/2018


78

DAVID ALEXANDER L 19/10/2018


79

JENNIFER ALEXANDER P 19/10/2018


80

TANIMAN L 20/10/2018
81

YOHANES CHRISTIAN L 20/10/2018


82

HARITS MEDIPTYAN INDRASTATA L 22/10/2018


83

VENNY SUJANI P 22/10/2018


84

WILFRY SIMATAUW L 22/10/2018


85

ANGGORO KASIH SETYAWAN L 23/10/2018


86

ACHMAD JUNAIDI L 23/10/2018


87

KURNIAWATI P 23/10/2018
88
VAREL ALFARIZY L 23/10/2018
89

P 24/10/2018
90 LILIANA VERONICA RUSDIAH

ROY NOTO HAMDANI L 24/10/2018


91
LILIANA VERONICA RUSDIAH P 25/10/2018
92

P 25/10/2018
93 DIAN SUBEKTI

FOE YENNY FRANSISCA P 25/10/2018


94

95 ANITA MARDIANA P 25/10/2018

ANWAR SIEDARTA L 26/10/2018


96

NISSAM TIMOTHY SUNJATA L 26/10/2018


97
LINDAWATI P 26/10/2018
98

HERU SUJATMIKO P 26/10/2018


99

DESA RAI AJU KONI TRISNOWATI, S.PD P 27/10/2018


100

L 27/10/2018
101 LUCKY SUSANDJI,IR

WAHYUDI SUBIANTO L 27/10/2018


102
MIMIK SUSINAWATI P 27/10/2018
103

P 28/10/2018
104 LIES NOVIANTI

DRS,. M. SOKA ,SH,MH (SOKA HUTOMO) L 28/10/2018


105
L 28/10/2018
106 BAMBANG PURWANTO
FITRI APRILIANA P 28/10/2018
107

DJUN KEK P 29/10/2018


108

ANWAR SIEDARTA L 29/10/2018


109

P 29/10/2018
110 RUSMIATI

JUNAIDI A. GANI L 29/10/2018


111
L 30/10/2018
112 DAVE ANDERASON
TAN SING TJAY L 30/10/2018
113

P 30/10/2018
114 RATIH EKA RACHMAWATI

115 ANISAK SUVY P 30/10/2018

L 30/10/2018
116 FAKHRI DEVANUS RAMADHAN

ANDY HERMAWAN L 31/10/2018


117

MAYESHA YUMMA KHAIRA P 30/10/2018


118

HENY RISMAWATI P 30/10/2018


119

HENY RISMAWATI P 30/10/2018


120

121 GILBERT WIIBISONO L 31/10/2018

ANWAR SIEDARTA L 31/10/2018


122

123

124

125

126

127

128

129

130

131

132

133

134

135

136

137
138

139

140

141

142

143

144

145

146

147

148

149

150

151

152
153
154
155
156
OKTOBER
2018

Klinik Pratama Mitra Medicare


jl dharmahusada utara no 36-38 blok G-J
Dr. Hardy Soetanto
Mojoarum
031-5978180
mitramedicare.klinik.dhusby@gmail.com

DIAGNOSA

DIAGNOSA

M51.4

I11.0

I88.9

H52.1

H25.1+H25.2

J42

Z35

Z28

A15

H52.1

M54.5

E88.3

H25

H25
M25.5

F31

D24

I44.2

Z35.8

I20

L53

I25.9

O32.1

H52

I64

B16

M65.4

H35.2

T78.4

I88.9

I20

H52.1

C50

H36.0

H52.1

H49+I10

H04.1

C20

N60.2

S82.1
G20

E14

E14

M65.4

I25.1

I10

O14.9

Z32.0

R59.9

N93.9

R51.9

D06.9

E11

E11

I15.9

H52.4

H40

K35.9

M54.5

H53.4

F41.2

J32

M54.5

I11
D56.9

I48

C18.1

K58.0

I25.1

I11

H52.4

J01

H16.9

C43.9

J03.9

H52.4

B16

I84.9

H25

H52.1

M54.5

D21

D21

J42

E14

D29.1

N18

H35.6
J32.0

H25

H52.1

I87.2+I11+E78.5

Z35

S32.0+S22.0

Z35

K80

J39.0

M54.5

G54.2

L28.0

L28.0

H52.4

H52.4

S82.1+S83

H25.9

I24.0

J35.0

D36

I48

H26.9

C96.2

F90.0
H52.1+H52.2

N60.2

H52.4

H35.1

D29.1

K30

I11

E14

G40.9

I48
NAMA FASYANKES RUJUKAN

NAMA FASYANKES RUJUKAN

POLI PENYAKIT DALAM (RSIA PURA RAHARJA)

POLI PENYAKIT DALAM (RSI A YANI)

POLI BEDAH (RS WILLIAM BOOTH)

POLI MATA (KLINIK MATA TRITYA)

POLI MATA (KLINIK MATA DR SJAMSOE)

POLI ANAK (RS ADI HUSADA KAPASARI)

POLI OBGYN (RSIA PUTRI)

POLI ANAK (RS MITRA KELUARGA KENJERAN)

POLI PARU (RS HUSADA UTAMA SURABAYA)

POLI MATA (RS ADI HUSADA KAPASARI)

POLI SYARAF (RS ADI HUSADA KAPASARI)

POLI BEDAH (RSI A YANI)

POLI MATA (RS ADI HUSADA KAPASARI)

POLI MATA (KLINIK MATA DR SJAMSOE)


POLI PENYAKIT DALAM (RS WILLIAM BOOTH)

POLI JIWA (RSJ MENUR)

POLI BEDAH (RS ADI HUSADA KAPASARI)

POLI JANTUNG (RSUD DR SOETOMO)

POLI OBGYN (RSIA PURA RAHARJA)

POLI JANTUNG (ADI HUSADA KAPASARI)

POLI PENYAKIT DALAM (RS SOEMITRO)

POLI JANTUNG (RS ADI HUSADA KAPASARI)

POLI OBGYN (RSIA PUTRI)

POLI MATA (RS HUSADA UTAMA)

POLI SYARAF (RS ADI HUSADA KAPASARI)

POLI PENYAKIT DALAM (RSI A YANI)

POLI SYARAF (RS ADI HUSADA KAPASARI)

POLI MATA (KLINIK MATA DR SJAMSOE)

POLI KULIT (RS ADI HUSADA KAPASARI)

POLI BEDAH (RS UNAIR/AIRLANGGA)

POLI JANTUNG (RS HUSADA UTAMA)

POLI MATA (KLINIK MATA DR SJAMSOE)

SARANA KEMOTERAPI (RSUD DR SOETOMO)

POLI MATA (KLINIK MATA TRITYA)

POLI MATA (KLINIK MATA TRITYA)

POLI MATA (KLINIK MATA DR SJAMSOE)

POLI MATA (KLINIK MATA DR SJAMSOE)

POLI BEDAH DIGENSIF (RS PHC)

POLI BEDAH (RS ADI HUSADA KAPASARI)

POLI ORTHOPEDI (RS ADI HUSADA KAPASARI)


POLI SYARAF (RSI A YANI)

PENYAKIT DALAM (KLINIK UTAMA WELAS ASIH)

POLI PENYAKIT DALAM (RSI JEMURSARI)

POLI ORTHOPEDI (RS ADI HUSADA KAPASARI)

POLI JANTUNG (RS ADI HUSADA KAPASARI)

POLI PENYAKIT DALAM (RS ADI HUSADA KAPASARI)

POLI OBGYN (RSIA PUTRI)

POLI OBGYN (RS MITRA KELUARGA KENJERAN)

POLI BEDAH (RS HUSADA UTAMA)

POLI OBGYN (RS HUSADA UTAMA)

POLI SYARAF (RS HUSADA UTAMA)

POLI OBGYN (RS HUSADA UTAMA)

POLI PENYAKIT DALAM (RS ROYAL)

POLI PENYAKIT DALAM (RS ROYAL)

POLI JANTUNG (RSI A YANI)

POLI MATA (RS ADI HUSADA KAPASARI)

POLI MATA (KLINIK MATA DR TRITYA)

POLI BEDAH ( RS ADI HUSADA KAPASARI)

POLI SYARAF(RS ADI HUSADA KAPASARI)

POLI MTA (KLINIK MATA TRITYA)

POLI JIWA (RS WILLIAM BOOTH)

POLI THT (RS SILOAM)

POLI SYARAF (RS HUSADA UTAMA)

POLI JANTUNG (RSU HAJI)


SARANA KEMOTERAPI (RSUD DR SOETOMO)

POLI SYARAF (RS ADI HUSADA KAPASARI

POLI BEDAH (RS ADI HUSADA KAPASARI)

POLI PENYAKIT DALAM (RS SILOAM HOSPITAL)

POLI JANTUNG (RS HUSADA UTAMA)

POLI JANTUNG (RS HUSADA UTAMA)

POLI MATA RS MITRA KELUARGA KENJERAN

POLI THT (RS HUSADA UTAMA)

POLI MATA (RS UNAIR/AIRLANGGA)

POLI BEDAH SYARAF (RS UNAIR/AIRLANGGA)

POLI THT(RS UNAIR/AIRLANGGA)

POLI MATA (RS MATA UNDAAN)

POLI PENYAKIT DALAM (RS HUSADA UTAMA)

POLI BEDAH (RSI JEMURSARI)

POLI MATA (RS MATA UNDAAN)

POLI MATA (RS MATA UNDAAN)

POLI SYARAF (RS HUSADA UTAMA)

POLI BEDAH (RSK BEDAH SURABAYA)

POLI BEDAH (RS ADI HUSADA KAPASARI)

POLI PARU (RS ADI HUSADA KAPASARI)

POLI PENYAKIT DALAM (RS ADI HUSADA KAPASARI)

POLI UROLOGI (RS ADI HUSADA KAPASARI)

POLI PENYAKIT DALAM (RS ROYAL)

POLI MATA (KLINIK MATA TRITYA)


POLI THT (RS WILLIAM BOOTH)

POLI MATA (KLINIK MATA JAVA CATARACT)

POLI MATA (KLINIK MATA DR SJAMSOE)

POLI PENYAKIT DALAM (RS ADI HUSADA KAPASARI)

POLI OBGYN (RS ROYAL)

POLI ORTHOPEDI (RS ADI HUSADA KAPASARI)

POLI OBGYN (RS ISLAM SURABAYA)

POLI PENYAKIT DALAM (RS ADI HUSADA KAPASARI)

POLI THT (RS ADI HUSADA KAPASARI)

POLI SYARAF (RS ADI HUSADA KAPASARI)

POLI SYARAF (RS ISLAM SURABAYA)

POLI KULIT (RS ADI HUSADA KAPASARI)

POLI KULIT (RS ADI HUSADA KAPASARI)

POII MATA (RS MITRA KELUARGA KENJERAN)

POLI MATA RS MITRA KELUARGA KENJERAN)

POLI ORTHOPEDI (RS ROYAL)

POLI MATA (KLINIK MATA JAVA CATARACT)

POLI JANTUNG (RS ADI HUSADA KAPASARI)

POLI THT (RS HUSADA UTAMA)

SARANA KEMOTERAPI (RSUD DR SOETOMO)

POLI JANTUNG DAN PEMBULUH DARAH (RS ADI HUSADA KAPASARI)

POLI MATA (KLINIK MATA TRITYA)

POLI PENYAKIT DALAM (RS HUSADA UTAMA)

POLI JIWA (RS WILLIAM BOOTH)


POLI MATA (KLINIK MATA TRITYA)

POLI BEDAH (RS ADI HUSADA KAPASARI)

POLI MATA (KLINIK MATA TRITYA)

POLI MATA (RS MATA MASYARAKAT SURABAYA)

POLI UROLOGI (RS ADI HUSADA KAPASARI)

POLI ANAK (RS MITRA KELUARGA KENJERAN)

POLI JANTUNG (RS HUSADA UTAMA)

POLI PENYAKIT DALAM (RS HUSADA UTAMA)

POLI ANAK (RS ADI HUSADA KAPASARI)

POLI JANTUNG DAN PEMBULUH DARAH (RS ADI HUSADA KAPASARI)


PERUBAHAN TENAGA SDM KLINIK

TENAGA BARU TENAGA LAMA MASA BERLAKU STR MASA BERLAKU SIP
NO
NAMA JABATAN NAMA JABATAN TENAGA BARU TENAGA BARU
1 ..........s/d.......... ..........s/d..........
2
3
4
5
6
7

Ket : Jika tenaga yg bersangkutan bukan tenaga medis dan paramedis maka kolom Masa Berlaku STR dan SIP di Kosongi