PEMERINTAH KABUPATEN BIAK NUM

RUMAH SAKIT UMUM DAERAH

Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 0981 ) 22

FORM KLAIM PASIEN JAMKES PAPU

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO

:
:
:
:
:
:
:

NAMA

JANUARI 2014
RSUD BIAK

56 PASIEN
dr. IRAS B.P RUMBIAK, M Kes,SpPK
RAWAT JALAN TINGKAT LANJUT

No. MR

UMUR
THN BLN
4
5
28
21
22

P/L

DKTR

6
P
P
P

7
Poli Obgyn
Poli Obgyn
Poli Obgyn

1
1
2
3

2
Ny. Yenny Rumaropen
Ny. Irma Rumbiak
Ny. Eirona Ayomi

3
1/128339/11
1/141852/12
2/192971/14

4
5
6
7

Ny.
Ny.
Ny.
Ny.

2/191636/13
2/194048/14
1/105555/10
2/191638/13

41
35
33
33

P
P
P
P

Poli
Poli
Poli
Poli

Ny. Yuliance Mambobo

1/106768/10

44

Poli Obgyn

By. Gracela Umbara

1/194447/14

Poli Obgyn

10
11
12
13
14

Ny.
Ny.
Ny.
Ny.
Ny.

1/194919/14
1/194876/14
2/124917/11
2/191638/13
2/169084/13

22
21
41
30
25

P
P
P
P
P

Poli
Poli
Poli
Poli
Poli

15
16

Ny. Yuliana Rumbrapuk

Ny. Ruth Rumbiak

1/192574/14
1/109440/12

23

P
P

Poli Obgyn
Poli Obgyn

17
18

Ny. Yuliana Maran

Ny. Ice Rumbrawer

2/146421/12
1/118221/11

29
32

P
P

Poli Obgyn
Poli Obgyn

Silpa Rumbiak
Leni Rumabar
Regina Mansumber
Fransina Wakum

Ida Miokbun
Magdalena Mandibodib
Gloria Rumbarar
Fransina Wakum
Irma Sada

Obgyn
Obgyn
Obgyn
Obgyn

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

19
20
21

Ny. Yeni Marisan

Ny. Dolfin Thenu
Ny. Siti Detepa

2/168559/13
1/140445/12
1/146969/13

32
24
24

P
P
P

Poli Obgyn
Poli Obgyn
Poli Obgyn

22

Ny. Eva Kapisa

1/147833/12

22

Poli Obgyn

23

Ny. Fransina Wakum

2/191638/13

33

Poli Obgyn

24

Ny. Herlina Rumaropen

2/139894/13

37

Poli Obgyn

25

Ny. Silfa Rumbiak

2/175346/13

32

Poli Obgyn

26

Ny. Luciamada Maryen

2/190707/13

33

Poli Obgyn

27

Ny. Herlina Kambubui

2/120978/11

21

Poli Obgyn

28
29

Ny. Marice Kamiraki

Ny. Luciamada Maryen

1/157607/12
2/190707/13

37
33

P
P

Poli Obgyn
Poli Obgyn

30

Ny. Fransina Wakum

2/191638/13

33

Poli Obgyn

31

Ny. Meri Mayor

1/175588/13

24

Poli Obgyn

32

Ny. Fransina Wakum

2/191638/13

33

Poli Obgyn

33
34
35
36
37

Ny.
Ny.
Ny.
Ny.
Ny.

Yudith Mambrasar
Ezra Simbiak
Kristina Awak
Regina Bedes
Silpa Rumbiak

1/176699/13
1/189603/13
2/114706/11
1/170674/13
2/175346/13

31
33
25
32
41

P
P
P
P
P

Poli
Poli
Poli
Poli
Poli

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

38
39
40
41
42
43
44
45
46
47

Ny.
Ny.
Ny.
Ny.
Ny.
Ny.
Ny.
Ny.
Ny.
Ny.

Elisabeth Ojaba
Ezra Simbiak
Tabita Miokbun
Mariana Womsiwor
Herlina Rumaropen
Gloria Rumbarar
Herlina Rumaropen
Gloria Rumbarar
Lina Rumbrawer
Marice Rumbino

1/193874/14
1/189603/13
2/142844/12
1/101899/10
2/139894/12
2/124917/12
2/139894/12
2/124917/11
1/149611/12
1/194500/14

37
31
31
29
32
41
32
41
38
53

P
P
P
P
P
P
P
P
P
P

Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

48
49

Ny. Ice Rumbrawer

By. Rilischa Umbora

1/118221/11

P
P

Poli Obgyn
Poli Obgyn

50

Ny. Leni Rumabar

2/194048/14

Poli Obgyn

51

By. Rilischa Umbora

1/194447/14

Poli Obgyn

52
53
54

Ny. Leni Rumabar

Ny. Ester Rumbarar
Ny. Silpa Rumbiak

2/194048/14
1/194719/14
2/175346/13

35
22
41

P
P
P

Poli Obgyn
Poli Obgyn
Poli Obgyn

55
56

Ny. Levina Rumbino

Ny. Magdalena Mandibidib

1/111187/11
1/194876/14

27
21

P
P

Poli Obgyn
Poli Obgyn

32

1/194447/14

1
35
1

TOTAL

BUPATEN BIAK NUMFOR

KIT UMUM DAERAH

) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

PASIEN JAMKES PAPUA

DIAGNOSA

ICD

8
Infeksi IUD
Gravida+Anemia
Post laparatomi

Post Sc
Post Sc
Anemi
Post Sc
Akseptor KB
Infeksi tali pusat
Gravida
Gravida
Agoils incompleks
Post Sc
Akseptor KB
Ispa
Post PPN+Akseptor KB
Gravida
Post Sc+Luka infeksi

TINDAKAN

ICD

10

11

Kontrol
Kontrol
Kontrol
GV

8908
8908
8908

Kontrol
Kontrol
Kontrol
Kontrol
GV

8908
8908
8908
8908

Kontrol
Inj Depo

8908

Kontrol
GV

8908

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Inj Depo

8908
8908
8908
8908
8908

Kontrol
Kontrol
Inj Depo

8908
8908

Kontrol
Kontrol
GV

8908
8908

BIAYA
12
27,500
27,500
27,500
20,000
27,500
27,500
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
27,500
27,500
27,500
27,500
20,000
27,500
27,500
20,000
27,500
27,500
20,000

JUMLAH
13
27,500
27,500
47,500
27,500
27,500
27,500
47,500
47,500
47,500
27,500
27,500
27,500

47,500
27,500
47,500
27,500
47,500

Gravida
Gravida
Post Sc
Akseptor KB
Post Sc
Post Sc
Post Sc
Post Sc
Post Sc
Adnelitis
Post Sc
Post Sc
Post Sc+Luka infeksi
Post Sc+Luka infeksi
Gravida
Vaginitis+Candiloma
Emesis
Gravida
Post Sc
Gravida
Adnelitis
Akseptor KB
Gravida
Gravida
Metioragic
Anemi
Post Abortus
Gravida
Amenore

Kontrol
Kontrol
Kontrol
GV

8908
8908
8908

Kontrol
Inj Depo

8908

Kontrol
GV

8908

Kontrol
GV

8908

Kontrol
GV

8908

Kontrol
GV

8908

Kontrol
GV

8908

Kontrol
Kontrol
GV

8908
8908

Kontrol
GV

8908

Kontrol
GV

8908

Kontrol
GV

8908

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
GV

8908
8908
8908
8908
8908

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol

8908
8908
8908
8908
8908
8908
8908
8908
8908
8908

27,500
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000

27,500
27,500

27,500
27,500
20,000
27,500
20,000

27,500

47,500
47,500
47,500
47,500
47,500
47,500
47,500

47,500
47,500

27,500
20,000

47,500

27,500
20,000
27,500

47,500
27,500

27,500
27,500
27,500
27,500
20,000
27,500
27,500
27,500
27,500
27,500
27,500

27,500
27,500
27,500

27,500
27,500
27,500
27,500

27,500
27,500
27,500
27,500

47,500
27,500
27,500
27,500
27,500
27,500
27,500

Post Sc+Luka infeksi

Infeksi tali pusat
Post Sc
Infeksi tali pusat
Post Sc
Tumor Abdomen
Post Sc
Adnelitis
Gravida

Kontrol
Kontrol
GV

8908
8908

Kontrol
GV

8908

Kontrol
GV

8908

Kontrol
Kontrol
Kontrol
GV

8908
8908
8908

Kontrol
Kontrol

8908
8908

27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
27,500
27,500
20,000

27,500

27,500
27,500

27,500
27,500

47,500
47,500
47,500
27,500
27,500
47,500

###

Biak, 01 Februari 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

KETERANGAN
14
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry

W,
W,
W,
W,

SpOG
SpOG
SpOG
SpOG

dr. Ferry W, SpOG

dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG

dr. Ferry W, SpOG

dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry

W,
W,
W,
W,
W,

SpOG
SpOG
SpOG
SpOG
SpOG

dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry

W,
W,
W,
W,
W,
W,
W,
W,
W,
W,
W,

SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG

dr. Ferry W, SpOG

dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG
dr. Ferry W, SpOG

PEMERINTAH KABUPATEN BIAK

RUMAH SAKIT UMUM DAE

Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 098

FORM KLAIM PASIEN JAMKES

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO

:
:
:
:
:
:
:

NAMA

FEBRUARI 2014
RSUD BIAK

37 PASIEN
dr. IRAS B.P RUMBIAK, M Kes,SpPK
RAWAT JALAN TINGKAT LANJUT

No. MR

UMUR
THN
BLN
4
5
23
30
24
21

P/L

1
1
2
3
4

2
Ny. Hesti Kbarek
Ny. Yeni Marisan
Nn. Seli Siep
Ny. Magdalena Mandibodibo

3
2/109390/10
2/168559/14
1/196271/14
1/194877/14

Insemina Wanma

2/195259/14

25

Ny. Elisabeth Mofu

1/108702/14

44

Ny. Ester Rumbarar

1/194719/14

17

Ny. Magdalena Mandibodibo

1/194877/14

21

9
10
11
12
13

Ny.
Ny.
Ny.
Ny.
Ny.

2/195708/14
2/154412/12
1/197158/14
1/197170/14
1/197104/14

20
29
28
26
35

P
P
P
P
P

14
15

Ny. Martince Maryen

Ny. Insemina Wanma

1/197104/14
2/195269/14

36
25

P
P

16
17
18
19

Ny. Erna Krey

Ny. Yuliana Kabak
Nn. Ester Rumbarar
Ny. Yeni Marisan

1/195613/13
2/180339/13
1/194719/14
2/168559/13

25
25
18
30

P
P
P
P

Atika Ayemi
Eferdina Rumbarar
Martha Makmaker
Ema Rumkorem
Martince Maran

6
P
P
P
P

20
21

Ny. Stevani Warumi

Ny. Etha Sanadi

1/196104/14
2/177201/14

23
31

P
P

22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37

Ny. Elisabeth Rumawak

Ny. Elsa Bonggoibo
Ny. Yuliana Kobak
Ny. Yuliana Kaize
Ny. Magdalena Mandibodibo
Ny. Marsela Kapitarauw
Ny. Regina Mansumber
Ny. Dora Wamafma
Ny. Feronika Arfayai
Ny. Dorkas Wabiser
Nn. Elisabeth Rumawak
Ny. Marice Rumbino
Nn. Ester Rumbarar
Ny. Iryani Rumbewas
Ny. Elisabeth Mofu
Ny. Debora Kurni

2/128566/13
1/195396/14
2/180399/13
1/139851/12
1/194877/14
1/129015/12
1/105555/10
1/134994/12
2/123543/14
1/151443/12
2/128566/12
1/194500/14
1/194719/14
1/195296/14
1/108702/10
1/195911/14

22
17
25
27
21
34
33
34
19
35
22
54
18
25
44
36

P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P

TOTAL

INTAH KABUPATEN BIAK NUMFOR

MAH SAKIT UMUM DAERAH

I Tlp ( 0981 ) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

M KLAIM PASIEN JAMKES PAPUA

DKTR

Poli
Poli
Poli
Poli

7
Obgyn
Obgyn
Obgyn
Obgyn

DIAGNOSA

ICD

8
Akseptor KB
Gravida
Gravida
Post Sc

TINDAKAN

ICD

10

11

Kontrol
Kontrol
Kontrol
Kontrol
GV

8908
8908
8908
8908

Poli Obgyn

Post partus

Kontrol
GV

8908

Poli Obgyn

Adneksiti

Kontrol
Tindakan

8908

Poli Obgyn

Adneksiti

Kontrol
Tindakan

8908

Poli Obgyn

Post Sc

Kontrol
GV

8908

Adneksiti
Gravida
Aminorhae
Gravida
Gravida

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
USG

8908
8908
8908
8908
8908

Gravida
Post partus+Anemi

Kontrol
Kontrol
GV

8908
8908

Kontrol
Kontrol
Kontrol
Kontrol

8908
8908
8908
8908

Poli
Poli
Poli
Poli
Poli

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

Poli Obgyn
Poli Obgyn
Poli
Poli
Poli
Poli

Obgyn
Gravida
Obgyn
Adneksiti
Obgyn Kista ovarium+Anemi
Obgyn
Gravida

BIAYA
12
27,500
27,500
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
27,500
27,500
27,500
27,500
53,000
27,500
27,500
20,000
27,500
27,500
27,500
27,500

Poli Obgyn
Poli Obgyn
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli

Gravida
Gravida

Obgyn
Susp kista
Obgyn
Gravida
Obgyn
Adnecitis
Obgyn
Gravida
Obgyn
Post Sc+B20
Obgyn
Gravida
Obgyn
Metroragis
Obgyn
Apseptor KB
Obgyn
Gravida+ISK
Obgyn
Gravida+Ketuban merembes
Obgyn
Kista ovarium
Obgyn
Adnecitis
Obgyn
Kista ovarium
Obgyn
Gravida
Obgyn
Adnecitis
Obgyn
Gravida

Kontrol
Kontrol
USG

8908
8908

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Lab

8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908

27,500
27,500
53,000
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
18,000

TOTAL

Biak, 01 Maret 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

JUMLAH

KETERANGAN

13
27,500
27,500
27,500

14
dr. Darien
dr. Ferry W, SpOG
dr. Ferry W, SpOG

47,500

dr. Ferry W, SpOG

47,500

dr. Ferry W, SpOG

47,500

dr. Ferry W, SpOG

47,500

dr. Ferry W, SpOG

47,500
27,500
27,500
27,500
27,500

dr.
dr.
dr.
dr.
dr.

80,500
27,500

dr. Ferry W, SpOG

dr. Ferry W, SpOG

47,500
27,500
27,500
27,500
27,500

dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry

Ferry
Ferry
Ferry
Ferry
Ferry

W,
W,
W,
W,
W,

W,
W,
W,
W,
W,

SpOG
SpOG
SpOG
SpOG
SpOG

SpOG
SpOG
SpOG
SpOG
SpOG

27,500

dr. Ferry W, SpOG

80,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500

dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.

45,500

dr. Ferry W, SpOG

1,261,500.00

aret 2014
SUD Biak

iak,M.Kes,SpPK
200012 2 002

Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry

W,
W,
W,
W,
W,
W,
W,
W,
W,
W,
W,
W,
W,
W,
W,
W,

SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG

PEMERINTAH KABUPATEN BIAK NUM

RUMAH SAKIT UMUM DAERAH

Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 0981 ) 22

FORM KLAIM PASIEN JAMKES PAPU

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO

NAMA

:
:
:
:
:
:
:

MARET 2014
RSUD BIAK

30 PASIEN
dr. IRAS B.P RUMBIAK, M Kes,SpPK
RAWAT JALAN TINGKAT LANJUT

No. MR

1
1
2
3
4
5
6
7
8
9
10

2
Ny. Penina Wanggi
Ny. Morensa Wakum
Ny. Yuliance Mambobo
Ny. Yunita Wanma
Ny. Marensa Wakum
An. Ester Kapitarauw
Ny. Sara Dasem
Ny. Sara Dasem
Ny. Natalia Thibo
Ny. Ros Ayorbaba

3
1/158892/14
1/198934/14
1/106768/10
1/111910/11
1/198934/14
1/198964/14
1/198765/14
1/198765/15
1/198789/14
1/197934/14

11
12
13
14

Ny.
Ny.
Ny.
Ny.

1/101578/10
1/197934/14
2/168559/14
2/197561/14

15 Ny. Fani Mayor

16
17
18
19
20
21
22
23

Mia Msen
Ros Ayorbaba
Yeni Marisan
Sofice Rumakeuw

Ny.
Ny.
Ny.
Ny.

Sarce Mandosir
Ester Miokbun
Irma Simbiak
Fani Mayor

Ny.
Ny.
Ny.
Ny.

Dorkas Wabiser
Tina Farwas
Sofice Rumaikeu
Lenny Rumbrapuk

UMUR
THN
BLN
4
5
27
20
44
25
21
22
39
40
27
45

P/L

DKTR

6
P
P
P
P
P
P
P
P
P
P

Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli

7
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

23
45
30
32

P
P
P
P

Poli
Poli
Poli
Poli

Obgyn
Obgyn
Obgyn
Obgyn

1/198001/14

30

Poli Obgyn

1/146810/14
2/154505/13
2/119281/11
1/198001/14
1/151443/12
1/163642/13
2/197561/14
1/137144/12

32
20
34
31

P
P
P
P
P
P
P
P

Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli

35
20
32
42

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

24
25
26
27
28
29
30

Ny.
Ny.
Ny.
Ny.
Ny.
Ny.
Ny.

Yermina Kawer
Dorkas Wabiser
Lenny Rumbrapuk
Yermina Kamer
Tresia Wanma
Puri Warnary
Ruth Maryen

1/197585/14
1/151443/12
1/137144/12
1/197585/14
1/136432/12
2/119918/14
2/191789/12

38
35
42
38
29
25
26

P
P
P
P
P
P
P

Poli
Poli
Poli
Poli
Poli
Poli
Poli

TOTAL

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

BUPATEN BIAK NUMFOR

IT UMUM DAERAH
21294 Fax ( 0981 ) 22747 BIAK PAPUA

ASIEN JAMKES PAPUA

DIAGNOSA

ICD

8
Post partus
Gravida
Adnecitis
Mastitis
Gravida
Gravida
Gravida
Gravida
Gravida
Adnecitis

TINDAKAN

ICD

10

11

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
USG

8908
8908
8908
8908
8908
8908
8908
8908
8908
8908

Adnecitis
Adnecitis
Gravida
Post SCTP

Kontrol
Kontrol
Kontrol
Kontrol
GV

8908
8908
8908
8908

Post SCTP

Kontrol
GV

8908

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol

8908
8908
8908
8908
8908
8908
8908
8908

Abseptor KB
Gravida
Gravida
Adnecitis
Gravida
Adnecitis
Post SCTP
Gravida

BIAYA
12
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
53,000
27,500
27,500
27,500
27,500
20,000
27,500
20,000
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500

JUMLAH
13
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
80,500
27,500
27,500
27,500
47,500
47,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500

Gravida
Gravida
Gravida
Gravida
Gravida
Gravida
Post SCTP

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol

8908
8908
8908
8908
8908
8908
8908

27,500
27,500
27,500
27,500
27,500
27,500
27,500

27,500
27,500
27,500
27,500
27,500
27,500
27,500
918,000.00

Biak, 01 April 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

KETERANGAN

dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.

14
Ferry W.
Ferry W.
Ferry W.
Ferry W.
Ferry W.
Ferry W.
Ferry W.
Ferry W.
Ferry W.

SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG

dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry

SpOG
SpOG
SpOG
SpOG

W.
W.
W.
W.

dr. Ferry W. SpOG

dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.
W.
W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG

dr.
dr.
dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG

PEMERINTAH KABUPATEN BIAK

RUMAH SAKIT UMUM DAE

Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 098

FORM KLAIM PASIEN JAMKES

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO

:
:
:
:
:
:
:

NAMA

APRIL 2014
RSUD BIAK

34 PASIEN
dr. IRAS B.P RUMBIAK, M Kes,SpPK
RAWAT JALAN TINGKAT LANJUT

No. MR

UMUR
THN
BLN
4
5
69

P/L

DKTR

6
P

7
Poli Obgyn

1
1

2
Ny Sermina Inggamer

3
1/201536/14

Ny desy mambrasar

2/200879/14

36

Poli Obgyn

Nn Dorkas Mnsnandifu

2/120553/13

16

Poli Obgyn

4
5

Ny Lodia yarangga
Ny Yemima sroyer

1/130321/13
1/201357/14

35
49

P
P

Poli Obgyn
Poli Obgyn

Ny Dorkas Mansnandifu

2/120553/14

16

Poli Obgyn

Ny Ayu rahayu Rumbiak

1/198921/14

39

Poli Obgyn

Nn Dorkas Mnsnandifu

2/120553/13

16

Poli Obgyn

Ny Yuliance Mambobo

1/106768/10

45

Poli Obgyn

10

Ny Ayu rahayu Rumbiak

1/198921/14

39

Poli Obgyn

11

Ny Yuliana Simbiak

1/129346/14

56

Poli Obgyn

12
13

Ny Marlinda Insyur
Ny Ayu rahayu Rumbiak

2/200643/14
1/198921/14

25
39

P
P

Poli Obgyn
Poli Obgyn

14

Nn Dorkas Mnsnandifu

2/120553/13

16

Poli Obgyn

15
16

Ny Marlinda Insyur
Ny Ayu rahayu Rumbiak

2/200643/14
1/198921/14

25
39

P
P

Poli Obgyn
Poli Obgyn

17
18
19

Ny Ester P D Insyur
Ny Ayu rahayu Rumbiak
Ny Ayu rahayu Rumbiak

1/153166/12
1/198921/14
1/198921/14

27
39
39

P
P
P

Poli Obgyn
Poli Obgyn
Poli Obgyn

20
21
22
23
24

Ny
Ny
Ny
Ny
Ny

Dorkas wabiser
lina Krey
Tabita Miokbun
Amelia P Kbarek
Ayu rahayu Rumbiak

1/151443/12
195717/14
2/142844/12
1/199875/14
1/198921/14

35
24
30
31
39

P
P
P
P
P

Poli
Poli
Poli
Poli
Poli

25

Ny Ayu rahayu Rumbiak

1/198921/14

39

Poli Obgyn

26
27

Ny Agustina Faknik
Ny Ayu rahayu Rumbiak

1/199367/14
1/198921/14

17
39

P
P

Poli Obgyn
Poli Obgyn

28
29

Ny Mia Msen
Ny Ayu rahayu Rumbiak

1/101578/10
1/198921/14

22
39

P
P

Poli Obgyn
Poli Obgyn

30
31
32
33

Ny
Ny
Ny
Ny

2/1996889/14
1/199875/14
1/137144/11
1/198921/14

39
31
41
39

P
P
P
P

Poli
Poli
Poli
Poli

34

Ny Ester Kapitarauw

1/198964/14

22

Poli Obgyn

Vera Warikar
Amelia P Kbarek
Leni Rumbrapuk
Ayu rahayu Rumbiak

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

Obgyn
Obgyn
Obgyn
Obgyn

TOTAL

KABUPATEN BIAK NUMFOR

AKIT UMUM DAERAH

81 ) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

M PASIEN JAMKES PAPUA

DIAGNOSA

ICD

TINDAKAN

ICD

8
Prolaps uteri

10

11

Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
Kontrol
GV
Kontrol
GV

8908

Kontrol
GV
Kontrol
GV

8908

Kontrol
GV

8908

Kontrol
GV
Kontrol
GV
Kontrol
Kontrol
GV
Kontrol
GV

8908

Post SCTP
Post SC + Infeksi
adonetis
Mioma Uteri
Post SC
Post SCTP
Post SC + Infeksi
akseptor KB
Post SCTP
Post masektomi
Kista Ovarium + dsipepsia
Post SCTP
Post SC + Infeksi

8908
8908
8908
8908
8908

8908

8908
8908
8908
8908

BIAYA
12
27,500
20,000
27,500
20,000
27,500
20,000
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
27,500
20,000
27,500
20,000

JUMLAH
13
47,500
47,500
47,500
27,500
47,500
47,500
47,500
47,500
47,500
47,500
47,500
27,500
47,500
47,500

Kista Ovarium + dsipepsia

Post SCTP
Gravid
Post SCTP
Post SCTP
Gravid
Gravid
septor KB
Gravid
Post SCTP
Post SCTP
Gravid
Post SCTP
Gravid + dispepsia
Post SCTP
Gravid
Gravid
Gravid
Post SCTP
Gravid

Kontrol
Kontrol
GV
Kontrol
Kontrol
Kontrol
GV
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
GV
Kontrol
GV
Kontrol
Kontrol
GV
Kontrol
Kontrol
GV
Kontrol
Kontrol
Kontrol
Kontrol
GV
Kontrol
USG

8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908

27,500
27,500
20,000
27,500
27,500
27,500
20,000
27,500
27,500
27,500
27,500
27,500
20,000
27,500
20,000
27,500
27,500
20,000
27,500
27,500
20,000
27,500
27,500
27,500
27,500
20,000
27,500
53,000

AL

27,500
47,500
27,500
27,500
47,500
27,500
27,500
27,500
27,500
47,500
47,500
27,500
47,500
27,500
47,500
27,500
27,500
27,500
47,500
80,500
1,368,000.00

Biak, 01 Mei 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

KETERANGAN
14
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG

dr. Ferry W. SpOG

dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG
SpOG

dr. Ferry W. SpOG

dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG

dr. Ferry W. SpOG

PEMERINTAH KABUPATEN BIA

RUMAH SAKIT UMUM DA

Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 09

FORM KLAIM PASIEN JAMKE

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO

: MEI 2014
: RSUD BIAK
:
:
28 PASIEN
: dr. IRAS B.P RUMBIAK, M Kes,SpPK
: RAWAT JALAN TINGKAT LANJUT

NAMA

No. MR

UMUR
THN
BLN
4
5
45

P/L

1
1

2
Ny yemima sroyer

3
1/201357/14

Ny marlinda insyur

2/200643/14

25

3
4
5
6

Ny
Ny
Ny
Ny

2/200643/14
1/106701/13
1/146364/12
2/120553/14

25
32
24
16

P
P
P
P

Ny yemima sroyer

1/201357/14

45

Ny Sarah Mandosir

2/144840/14

36

10
11
12
13
14

Ny
Ny
Ny
Ny
Ny

1/202575/14
1/168914/13
1/182960/13
1/137144/11
2/200643/14

19
22
29
41
25

P
P
p
P
P

15

Ny marlinda insyur

2/200643/14

25

16

Ny rahel Arwam

1/202984/14

21

17
18

Ny marensa wakum
Ny marlinda insyur

1/198934/14
2/200643/14

20
25

P
P

marlinda insyur
selfi rumbarar
magrice Morin
Dorkas mansnandifu

Everdina Mnusefer
Josepina Korwa
selli suruan
Leni M Rumbrapuk
marlinda insyur

6
P

19

Ny Antomina Faidiban

1/110900/14

35

20
21
22

Ny Pilha Silak
Ny yemima sroyer
Ny kristina mandosir

1/203067/14
1/201357/14
1/193841/14

21
45
23

P
P
P

23
24

Ny Alfonsina kbarek
Ny marlinda insyur

2/104439/14
2/200643/14

63
25

P
P

25

Ny marlinda insyur

2/200643/14

25

26

Ny Leni M Rumbrapuk

1/137144/11

41

27
28

Ny Elsabeth Rumaropen
Ny marlinda insyur

1/203544/14
2/200643/14

28
25

P
P

TOTAL

ERINTAH KABUPATEN BIAK NUMFOR

RUMAH SAKIT UMUM DAERAH

ge I Tlp ( 0981 ) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

ORM KLAIM PASIEN JAMKES PAPUA

DKTR

DIAGNOSA

ICD

TINDAKAN

ICD

7
Poli Obgyn

8
Inseptor

10

11
8908

Poli Obgyn

Kista ovarium

Poli
Poli
Poli
Poli

Kista ovarium
Gravida
Gravida
Post SCTP

Kontrol
USG
Kontrol
Lab
Kontrol
Kontrol
Kontrol
Kontrol
GV
Kontrol
USG
Kontrol
GV
Kontrol
Kontrol
Kontrol

8908

Obgyn
Obgyn
Obgyn
Obgyn

Poli Obgyn

Inseptor

Poli Obgyn

Post SCTP

Poli
Poli
Poli
Poli
Poli

Aminorehe
anemia
P/V
Gravida
Laparatomi

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

Poli Obgyn

Post Laparascopi

Poli Obgyn

lepas IUD

Poli Obgyn
Poli Obgyn

Gravida
Post Laparascopi

Kontrol
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
Kontrol
GV

8908
8908
8908
8908
8908
8908

8908
8908
8908
8908
8908
8908
8908
8908
8908

BIAYA
12
27,500
53,000
27,500
36,000
27,500
27,500
27,500
27,500
20,000
27,500
53,000
27,500
20,000
27,500
27,500
27,500
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
27,500
20,000

Poli Obgyn

Abortua

Poli Obgyn
Poli Obgyn
Poli Obgyn

Aminore
Kista + mioma
P/V

Poli Obgyn
Poli Obgyn

Prolaps uteri
post Laparatomi

Poli Obgyn

post Laparatomi

Poli Obgyn

Post MOW

Poli Obgyn
Poli Obgyn

Gravid
post Laparatomi

Kontrol
GV
USG
Kontrol
Kontrol
Kontrol
GV
Kontrol
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
Kontrol
GV

8908

8908
8908
8908
8908
8908
8908
8908
8908
8908

27,500
20,000
53,000
27,500
27,500
27,500
20,000
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
27,500
20,000

TOTAL

Biak, 01 Juni 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

JUMLAH

KETERANGAN

13

14
dr. Ferry W. SpOG

80,500
dr. Ferry W. SpOG
63,500
27,500
27,500
27,500

dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG

47,500
80,500
47,500
27,500
27,500
27,500
27,500

dr. Ferry W. SpOG

dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG
SpOG

47,500
dr. Ferry W. SpOG
47,500
dr. Ferry W. SpOG
47,500
27,500
47,500

dr. Ferry W. SpOG

dr. Ferry W. SpOG

dr. Ferry W. SpOG

100,500
27,500
27,500
47,500
27,500
27,500
47,500

dr. Ferry W. SpOG

dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG

47,500
dr. Ferry W. SpOG
47,500
27,500
47,500
1,205,000.00

i 2014
UD Biak

k,M.Kes,SpPK
00012 2 002

dr. Ferry W. SpOG

dr. Ferry W. SpOG

PEMERINTAH KABUPATEN BIAK N

RUMAH SAKIT UMUM DAER
Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 0981

FORM KLAIM PASIEN JAMKES P

Bulan Pelayanan
Nama RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan
NO

NAMA

: JUNI 2014
: RSUD BIAK
19 PASIEN
: dr. IRAS B.P RUMBIAK, M Kes,SpPK
: RAWAT JALAN TINGKAT LANJUT
UMUR
No. MR
P/L
THN
BLN
3
4
5
6
2/185568/14
39
P

DKTR

1
1

2
Ny Delila Miokbun

2
3

Ny Yudith yanggoseray
Ny Delila Miokbun

2/178201/13
2/185568/14

30
39

P
P

Poli Obgyn
Poli Obgyn

Ny Delila Miokbun

2/185568/14

39

Poli Obgyn

5
6

Ny yuliance Mambobo
Ny Martha Wanggori

1/106768/10
2/204776/14

45
22

P
P

Poli Obgyn
Poli Obgyn

Ny
Ny
Ny
Ny
Ny
Ny
Ny
Ny
Ny
Ny
Ny
Ny

1/204936/14
1/205203/14
1/201357/14
1/125725/13
1/182960/14
2/178972/14
1/201357/14
2/100463/14
1/163642/14
1/205027/14
1/180427/12
1/169136/14
1/205812/14

20
37
45
31
29
33
45
28
31
37
29
27

P
P
P
P
P
p
P
P
P
P
P
P
P

Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli

7
8
9
10
11
12
13
14
15
16
17
18
19

dorsila Mnadowen
korina Rumere
yemima sroyer
mina farwas
Seli suruan
Dolli Rumkorem
yemima sroyer
maya Dimara
mina farwas
desi Horota
Maria Pariaribo
Imelda Womsiwor

Ny seli Opi Rumbiak

35

7
Poli Obgyn

TOTAL

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

UPATEN BIAK NUMFOR

T UMUM DAERAH

21294 Fax ( 0981 ) 22747 BIAK PAPUA

ASIEN JAMKES PAPUA

DIAGNOSA

ICD

TINDAKAN

ICD

8
Pos SC

10

11

Kontrol
GV
Kontrol
Kontrol
GV
Kontrol
GV
Kontrol
Kontrol
GV
Kontrol

8908

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol

8908
8908
8908
8908
8908
8908

Gravida
Pos SC
Pos SC
Adnecitis
Post Curetase
Gravida
Gravida
mioma uteri
Adnecitis
Metroragia
aminore
mioma uteri
mioma uteri
Adnecitis
Medioragis
Gravida
Gravida
Prolaps

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol

8908
8908
8908
8908
8908

8908
8908
8908
8908
8908

BIAYA
12
27,500
20,000
27,500
27,500
20,000
27,500
20,000
27,500
27,500
20,000
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500

JUMLAH
13
47,500
27,500
47,500
47,500
27,500
47,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
602,500.00

Biak, 01 Juli 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

KETERANGAN
14
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.
W.
W.
W.
W.
W.
W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG

PEMERINTAH KABUPAT
RUMAH SAKIT UM

Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 098

FORM KLAIM PASIEN JAMKES

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO

: JULI 2014
: RSUD BIAK
:
:
38 PASIEN
: dr. IRAS B.P RUMBIAK, M Kes,SpPK
: RAWAT JALAN TINGKAT LANJUT

NAMA

No. MR

UMUR
THN
BLN
4
5
30

P/L

1
1

2
Ny Diana mambiuw

3
1/205876/14

6
P

2
3
4
5
6
7
8
9

Ny
Ny
Ny
Ny
Ny
Ny
Ny
Ny

Tabita Miokbun
Marthina Kafiar
Dorkas Maker
Yemima mambobo
Rosina mambobo
Yuliance Mambobo
Yuliana Eti Benu
Erna A Wabdaron

2/142844/12
1/145375/12
1/140949/12
1/144401/12
1/159338/14
1/106768/11
1/150897/12
1/206728/14

31
24
64
38
34
45
35
32

P
p
P
p
P
P
p
P

10
11
12

Ny selviana kambuaya
Ny diana Brabar
Ny diana Brabar

2/206327/14
2/158128/14
2/158128/14

34
21
21

P
P
P

13

Ny Fonny Rumbino

1/100921/10

28

14
15

Ny Mieke D Rumere
Ny Erna Wabdaron

1/206829/14
1/206728/14

27
32

P
P

16
17
18
19
20

Ny evelyn Korwa
Ny Yemima sroyer
Ny Alfonsina Kbarek
Ny evelyn Korwa
NY Elona Bab

1/207153/14
1/201357/14
2/104439/14
1/207153/14
1/207213/14

37
45
63
37
28

P
P
P
P
P

21
22
23
24

Ny
Ny
Ny
Ny

25
26

Ferdinanda sarewo
Imelda Fatubun
sanderina sawen
Agustina Ansek

2/207233/14
2/169136/13
1/154221/12
1/207565/14

28
33
36
29

P
P
P
P

Ny Juliana Rumbino
Ny Korina Rumere

1/151538/12
1/205203/14

22
37

P
P

27
28
29
30

Ny
Ny
Ny
Ny

1/205203/14
2/207233/14
1/206832/14
1/190094/14

37
28
61
34

P
P
P
P

31

Ny Yosina Mayor

1/190094/14

34

32

Ny Yosina Mayor

1/190094/14

34

33

Ny Yosina Mayor

1/190094/14

34

34

Ny Yosina Mayor

1/190094/14

34

35

Ny Yosina Mayor

1/190094/14

34

36

Ny Yosina Mayor

1/190094/14

34

37

Ny Yosina Mayor

1/190094/14

34

38

Ny Yosina Mayor

1/190094/14

34

Korina Rumere
Ferdinanda sarewo
freda Yafdas
Yosina Mayor

TOTAL

EMERINTAH KABUPATEN BIAK NUMFOR

RUMAH SAKIT UMUM DAERAH

lp ( 0981 ) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

KLAIM PASIEN JAMKES PAPUA

DKTR

DIAGNOSA

ICD

7
Poli Obgyn

8
Gravida

Poli
Poli
Poli
Poli
Poli
Poli
Poli
Poli

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

Aseptor
Vaginitis
Vaginitis
Vaginitis
Adnecitis
Aseptor KB
Endometritits
Gravida

Poli Obgyn
Poli Obgyn
Poli Obgyn

Post partum
susp Abortus
Gravida

Poli Obgyn

Gravida

Poli Obgyn
Poli Obgyn

Gravida
Gravida

Poli
Poli
Poli
Poli
Poli

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

Kista
Kista Ovarium
prolaps Uteri
Mioma uteri
Gravida

TINDAKAN

ICD

10

11

Kontrol
Lab
USG
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol

8908

USG
Kontrol
Kontrol
Kontrol
USG
Kontrol
Lab
Kontrol
Kontrol
Lab
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol

8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908

BIAYA
12
27,500
54,000
53,000
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
53,000
27,500
27,500
27,500
53,000
27,500
18,000
27,500
27,500
54,000
27,500
27,500
27,500
27,500
27,500

Poli
Poli
Poli
Poli

Obgyn
Obgyn
Obgyn
Obgyn

Poli Obgyn
Poli Obgyn
Poli
Poli
Poli
Poli

Obgyn
Obgyn
Obgyn
Obgyn

Gravida
vaginitis
vaginitis
Amenore
Anemia
Gravid
Gravid
Gravida
Kista ovarium
Post SCTP

Poli Obgyn

Post SCTP

Poli Obgyn

Post SCTP

Poli Obgyn

Post SCTP

Poli Obgyn

Post SCTP

Poli Obgyn

Post SCTP

Poli Obgyn

Post SCTP

Poli Obgyn

Post SCTP

Poli Obgyn

Post SCTP

Kontrol
Kontrol
Kontrol
Kontrol
USG
Kontrol
Kontrol
Lab
Kontrol
Kontrol
Kontrol
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
GV

8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908

27,500
27,500
27,500
27,500
53,000
27,500
27,500
18,000
27,500
27,500
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000

TOTAL

Biak, 01 Agustus 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

JUMLAH

KETERANGAN

13

14
dr. Ferry W. SpOG

134,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
80,500
27,500
27,500

dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.
W.
W.
W.
W.
W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG

80,500
dr. Ferry W. SpOG
45,500
27,500
27,500
81,500
27,500
27,500
27,500
27,500
27,500

dr. Ferry W. SpOG

dr. Ferry W. SpOG
dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG
SpOG

27,500
27,500
27,500
80,500
27,500
45,500
27,500
27,500
27,500

dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG

dr. Ferry W. SpOG

dr. Ferry W. SpOG
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG

47,500
dr. Ferry W. SpOG
47,500
dr. Ferry W. SpOG
47,500
dr. Ferry W. SpOG
47,500
dr. Ferry W. SpOG
47,500
dr. Ferry W. SpOG
47,500
dr. Ferry W. SpOG
47,500
dr. Ferry W. SpOG
47,500
dr. Ferry W. SpOG
47,500
1,608,500.00

stus 2014
UD Biak

ak,M.Kes,SpPK
200012 2 002

PEMERINTAH KABUPATEN BIAK N

RUMAH SAKIT UMUM DAER

Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 0981

FORM KLAIM PASIEN JAMKES P

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

:
:
:
:
:
:
:

AGUSTUS 2014
RSUD BIAK

35 PASIEN
dr. IRAS B.P RUMBIAK, M Kes,SpPK
RAWAT JALAN TINGKAT LANJUT

NO

NAMA

No. MR

1
1
2
3
4

2
Ny
Ny
Ny
Ny

3
2/122569/14
2/208052/14
1/129379/14
2/108441/14

Ny Anike asso

6
7

NY Nelce Rumere
Ny Anike asso

8
9
10

UMUR
THN
BLN
4
5
19
30
19
17

P/L

DKTR

6
P
p
P
P

Poli
Poli
Poli
Poli

17

Poli Obgyn

2/108441/14

17

P
P

Poli Obgyn
Poli Obgyn

Ny Linda Rumpaidus
Ny elisabeth yawan
Ny Elisabeth Sarewo

1/118555/10
2/169716/14
1/209221/14

30
29
29

P
P
P

Poli Obgyn
Poli Obgyn
Poli Obgyn

11

Ny Yeni lussi

2/182636/13

22

Poli Obgyn

12
13
14
15
16
17
18

Ny Ema Yewun
NY Dominika Maryar
Ny Novela Mambobo
Ny Yuliance Mambobo
Ny Marthina Kafiar
Ny yemimam F Mambobo
Ny Anike asso

1/209084/14
1/168767/13
1/159335/13
1/106768/10
1/145375/12
1/14401/12
2/108441/14

30
23
26
45
25
38
17

p
p
P
p
P
P
P

Poli
Poli
Poli
Poli
Poli
Poli
Poli

Henny w
Mariam Antaribaba
Merry Mandowen
Anike asso

2/108441/14

7
Obgyn
Obgyn
Obgyn
Obgyn

Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn
Obgyn

19

Ny Anike asso

2/108441/14

17

Poli Obgyn

20

Ny Linda Rumpaidus

1/118555/14

20

Poli Obgyn

21
22
23

Ny Magdalena Mandibodib
Ny Antoneta Komboy
Ny Anike asso

2/195255/14
1/209571/14
2/108441/14

21
31
17

P
p
P

Poli Obgyn
Poli Obgyn
Poli Obgyn

24
25

Ny Antoneta Komboy
Ny Grasela Ayomi

1/209571/14
1/209801/14

31
16

p
P

Poli Obgyn
Poli Obgyn

26

Ny Lea Kmur

1/209822/14

24

Poli Obgyn

27
28
29

Ny Hermelina Kafiar
Ny Novera Wambaruw
Ny Anike asso

2/153384/12
1/144415/14
2/108441/14

20
27
17

P
P
P

Poli Obgyn
Poli Obgyn
Poli Obgyn

30

Ny Yosina Mayor

1/190094/14

34

Poli Obgyn

31

Ny Yosina Mayor

1/190094/14

34

Poli Obgyn

32

Ny Yosina Mayor

1/190094/14

34

Poli Obgyn

33

Ny Yosina Mayor

1/190094/14

34

Poli Obgyn

34

Ny Yosina Mayor

1/190094/14

34

Poli Obgyn

35

Ny Yosina Mayor

1/190094/14

34

Poli Obgyn

TOTAL

UPATEN BIAK NUMFOR

T UMUM DAERAH

21294 Fax ( 0981 ) 22747 BIAK PAPUA

SIEN JAMKES PAPUA

DIAGNOSA

ICD

TINDAKAN

ICD

8
Gravida
Post partum
Vaginitis
Post SCTP

10

11

Kontrol
Kontrol
Kontrol
Kontrol
GV
Kontrol
GV
Kontrol
Kontrol
GV
Kontrol

8908
8908
8908
8908

Post SCTP
Vagivitis
Post SCTP
Vaginitis
Post PPM
Gravida

Admecilin
Admecilin
Vaginalis
Admecilin
Admecilin
Vaginalis
Admecilin
Post SCTP

Kontrol
Kontrol
Lab
USG
Kontrol
Lab
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
GV

8908
8908
8908
8908
8908
8908

8908
8908
8908
8908
8908
8908
8908
8908

BIAYA
12
27,500
27,500
27,500
27,500
20,000
27,500
20,000
27,500
27,500
20,000
27,500
27,500
27,500
72,000
53,000
27,500
36,000
27,500
27,500
27,500
27,500
27,500
27,500
27,500
20,000

JUMLAH
13
27,500
27,500
27,500
47,500
47,500
27,500
47,500
27,500
27,500

152,500
63,500
27,500
27,500
27,500
27,500
27,500
27,500
47,500

Post SCTP
Gangguan haids
Vaginalis
Gravid
Post SCTP
Gravid
Gravid
Gravid
Amenore
Gravid
Post SCTP
Post SCTP
Post SCTP
Post SCTP
Post SCTP
Post SCTP
Post SCTP

Kontrol
GV
Kontrol
USG
Kontrol
Kontrol
Kontrol
GV
Kontrol
Kontrol
USG
Kontrol
USG
Kontrol
Kontrol
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
GV

8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908
8908

27,500
20,000
27,500
53,000
27,500
27,500
27,500
20,000
27,500
27,500
53,000
27,500
53,000
27,500
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000

47,500
80,500
27,500
27,500
47,500
27,500
27,500
80,500
80,500
27,500
27,500
47,500
47,500
47,500
47,500
47,500
47,500
47,500
1,570,000.00

Biak, 01 September 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

KETERANGAN

dr.
dr.
dr.
dr.

14
Ferry W.
Ferry W.
Ferry W.
Ferry W.

SpOG
SpOG
SpOG
SpOG

dr. Ferry W. SpOG

dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG

dr. Ferry W. SpOG

dr.
dr.
dr.
dr.
dr.
dr.
dr.

Ferry
Ferry
Ferry
Ferry
Ferry
Ferry
Ferry

W.
W.
W.
W.
W.
W.
W.

SpOG
SpOG
SpOG
SpOG
SpOG
SpOG
SpOG

dr. Ferry W. SpOG

dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG
dr. Ferry W. SpOG

PEMERINTAH KABUPATEN BIAK NUMFOR

RUMAH SAKIT UMUM DAERAH
Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

FORM KLAIM KARTU PAPUA SEHAT

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO

NAMA

:
:
:
:
:
:
:

SEPTEMBER 2014
RSUD BIAK

51 PASIEN
dr. IRAS B.P RUMBIAK, M Kes,SpPK
RAWAT JALAN TINGKAT LANJUT

TANGGAL

No. MR

THN
4
20
24

UMUR
BLN HARI
5

P/L

DKTR

DIAGNOSA

ICD

TINDAKAN

ICD

6
P
P

7
dr. Fery Wijaya
dr. Fery Wijaya

8
Gravida
Gravida

10

11

1
1
2

2
Ny. Yuli Rumbrawer
Ny.Yulina Pariaribo

03 Sept 2014
03 Sept 2014

3
2/210342/14
2/156776/14

Ny.Sindi Rumere

03 Sept 2014

1/208995/14

33

dr. Fery Wijaya

post Laparascopi

Usg
Kontrol

4
5

Ny.Maryangke Bleskadit
Ny.Ningsih Obinaru

01 Sept 2014
03 Sept 2014

2/206111/14
2/209867/14

25
19

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Gravida,Diare
Post Sc

kontrol
kontrol

6
7

Ny.Feronika Womsiwor
Ny.Anike Asso

04 Sept 2014
05 Sept 2014

1/102648/10
2/208441/14

24
17

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Mastitis,Post Partum
Akseptor,Post Sc

Kontrol
Kontrol
Gv

Ny.Maryangke Bleskadit
Ny.Anita I Pondagintan
Ny.Neli Mandowen
Ny.Yohana Aibekob
Ny.Nelce Waiberi

08
09
10
11
11

2/195864/14
1/161704/13
2/106019/14
2/136738/14
2/240984/14

25
37
38
55
19

P
P
P
P
P

dr.
dr.
dr.
dr.
dr.

Gravida
Amenothoe
Gravida
Agnesitis

Kontrol
Kontrol
Kontrol

8
9
10
11
12

Sept
Sept
Sept
Sept
Sept

2014
2014
2014
2014
2014

Fery
Fery
Fery
Fery
Fery

Wijaya
Wijaya
Wijaya
Wijaya
Wijaya

Gravida

Kontrol
Kontrol

Kontrol
Kontrol

13
14
15

Ny.Delan M S Ulayananan
Ny.Grasela Ayomi
Ny.Fawelda Sada

11 Sept 2014
12 Sept 2014
12 Sept 2014

1/210938/14
1/209801/14
1/211109/14

26
19
24

P
P
P

dr. Fery Wijaya

dr. Fery Wijaya
dr. Fery Wijaya

Gravida
Gravida
Gravida

Kontrol
Kontrol
Kontrol

16
17

Ny.Ernita Monim
Ny.Maryangke Bleskadit

12 Sept 2014
15 Sept 2014

1/146483/14
2/195864/14

40
25

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Adnesitis
Gravida

Kontrol
Kontrol

18

Ny. Keterina Manufandu

15 Sept 2014

1/211227/14

32

dr. Fery Wijaya

Gravida+Dyspepsia

19
20

Ny. Orpa Prawar

Ny. Hernia Kabes

15 Sept 2014
18 Sept 2014

1/116531/11
2/211129/14

34
22

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Gravida
Post Sc

Kontrol
Lab
Kontrol
Kontrol

21

Ny. Naomi Mansmor

18 Sept 2014

1/210938/14

36

dr. Fery Wijaya

Gravida+Anamia

Kontrol
Lab
Kontrol

22

Ny. Delan Ms. Uluyanan

19 Sept 2014

1/210938/14

26

dr. Fery Wijaya

Gravida

23

Ny. Hernia Kabes

20 Sept 2014

2/211129/14

19

dr. Fery Wijaya

Post Sc

24

Ny. Hernia Kabes

22 Sept 2014

2/211129/14

19

dr. Fery Wijaya

Post Sc

25
26

Ny. Oktovina Rumbewas

Ny. Ester Meokbun

22 Sept 2014
22 Sept 2014

1/211702/14
2/154505/13

24
22

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Apseptor KB Implant
Gravida

27

Ny. Grasela Ayomi

23 Sept 2014

1/209801/14

18

dr. Fery Wijaya

Post Sc

28

Ny. Hernia Kabes

23 Sept 2014

2/211129/14

19

dr. Fery Wijaya

Post Sc

29
30

Ny. Elisabeth Kayoi

Ny. Grasela Ayomi

23 Sept 2014
24 Sept 2014

2/208545/14
1/209801/14

44
18

P
P

dr. Tjendono H
dr. Fery Wijaya

Amonorhoe
Post Sc

31

Ny. Orpa Prawar

24 Sept 2014

1/116531/11

34

dr. Fery Wijaya

Gravida

Usg
Kontrol
Gv
Kontrol
Gv
Kontrol
Kontrol
Usg
Kontrol
Gv
Kontrol
Gv
Kontrol
Kontrol
Gv
Kontrol

32
33

Nn. Yemima Kararbo

Ny. Hernia Kabes

25 Sept 2014
25 Sept 2014

1/211953/14
2/211129/14

18
19

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Gravida
Post Sc

Kontrol
Kontrol
Gv

34

Ny. Juliana Rumbino

25 Sept 2014

1/151538/12

22

dr. Fery Wijaya

Ad Kontraksi

Kontrol

35

Tn. Darius Kiin

25 Sept 2014

1/199107/14

43

dr. Fery Wijaya

Gonorhoe

36

Ny. Grasela Ayomi

22 Sept 2014

1/209801/14

18

dr. Fery Wijaya

Post Sc

37

Tn. Darius Kiin

23 Sept 2014

1/199107/14

43

dr. Fery Wijaya

Gonorhoe

38

Ny. Grasela Ayomi

26 Sept 2014

1/209801/14

18

dr. Fery Wijaya

Post Sc

39

Ny. Juliana Rumbino

26 Sept 2014

1/151538/12

28

dr. Fery Wijaya

Ad Kontraksi

Usg
Kontrol
Gv
Kontrol
Gv
Kontrol
Gv
Kontrol
Gv
Kontrol

40

Ny. Novela Korwa

26 Sept 2014

1/177524/14

25

dr. Fery Wijaya

Gravida

Kontrol

41
42
43

Ny. Rosalina Prawar

Ny. Elisabeth Kayoi
Ny. Grasela Ayomi

27 Sept 2014
27 Sept 2014
29 Sept 2014

1/212147/14
2/208545/14
1/209801/14

24
44
18

P
P
P

dr. Fery Wijaya

dr. Fery Wijaya
dr. Fery Wijaya

Gravida
Ad Kontraksi
Post Sc

44
45
46

Ny. Marianke Bleskadit

Ny. Alfonsina Asyerem
Ny. Anike Asso

29 Sept 2014
29 Sept 2014
29 Sept 2014

2/195864/14
1/212351/14
2/208441/14

25
31
17

P
P
P

dr. Fery Wijaya

dr. Fery Wijaya
dr. Fery Wijaya

Gravida
Gravida
Post Sc

47

Ny. Hernia Kabes

29 Sept 2014

2/211129/14

19

dr. Fery Wijaya

Post Sc

48
49

Ny. Sonya Mandowen

Ny. Novela Rumainum

29 Sept 2014
29 Sept 2014

2/100274/10
2/187922/14

35
23

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Gravida
Kista Ovarium

Usg
Kontrol
Kontrol
Kontrol
Gv
Kontrol
Kontrol
Kontrol
Gv
Kontrol
Gv
Kontrol
Kontrol

Apseptor KB

Usg
Kontrol

50

Ny. Tuksi N. Wanma

30 Sept 2014

2/161952/14

23

dr. Fery Wijaya

51

Ny. Elisabeth Kayoi

30 Sept 2014

2/208545/14

44

P
dr. Fery Wijaya
TOTAL

Amonorhoe

Kontrol

Biak, 01 Oktober 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

BIAYA
12
27,500
###
53,000
27,500
20,000
20,000
27,500
27,500
###
20,000
27,500
###
###
###
25,700

JUMLAH

KETERANGAN

13

14
27,500
80,500
47,500
47,500
27,500
47,500
27,500
27,500
27,500
27,500
27,500

27,500
###
###

27,500
27,500
27,500

###
###

27,500
27,500

###
18,000
27,500
###

45,500
27,500
27,500

###
18,000
27,500
53,000
27,500
20,000
27,500
20,000
27,500
###
53,000
27,500
20,000
27,500
20,000
27,500
###
20,000
27,500

45,500
80,500
47,500
47,500
27,500
80,500
47,500
47,500
27,500
47,500
27,500

27,500
###
20,000
27,500
53,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500
20,000
27,500

###
53,000
27,500
###
###
20,000
27,500
###
###
20,000
27,500
20,000
27,500
###
53,000
27,500

27,500
47,500
80,500
47,500
47,500
47,500
47,500
27,500

80,500
27,500
27,500
47,500
27,500
27,500
47,500
47,500
27,500
80,500
27,500

27,500

27,500
2,049,000

PEMERINTAH KABUPATEN BIAK NUMFOR

RUMAH SAKIT UMUM DAERAH
Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

FORM KLAIM KARTU PAPUA SEHAT

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO

NAMA

:
:
:
:
:
:
:

OKTOBER 2014
RSUD BIAK

51 PASIEN
dr. IRAS B.P RUMBIAK, M Kes,SpPK
RAWAT JALAN TINGKAT LANJUT

TANGGAL

No. MR

UMUR
THN BLN HARI
5
6
7
29
45
19

P/L

DKTR

DIAGNOSA

ICD

TINDAKAN

ICD

8
P
P
P

9
dr. Fery Wijaya
dr. Fery Wijaya
dr. Fery Wijaya

10
Adnecitis
Vaginitis
Post SCTP

11

12

13

Post SC

1
1
2
3

2
Ny. Fransina Krey
Ny. Yuliance Mambobo
Ny. Hernia Kabes

3
01 Okt 2014
01 Okt 2014
01 Okt 2014

4
1/212451/14
1/106768/10
2/211129/14

Ny. Grasela Ayomi

01 Okt 2014

1/209801/14

19

dr. Fery Wijaya

5
6
7
8

Ny.
Ny.
Ny.
Ny.

02
02
03
03

2014
2014
2014
2014

1/187610/13
1/212554/14
1/212646/14
1/157865/12

36
25
53
30

P
P
P
P

dr.
dr.
dr.
dr.

Ny. Ice Pusop

03 Okt 2014

1/212636/14

19

dr. Fery Wijaya

Gravida

10

Ny. Grasela Ayomi

04 Okt 2014

1/209801/14

19

dr. Fery Wijaya

Post SC

11

Ny. Hernia Kabes

07 Okt 2014

2/211129/14

19

dr. Fery Wijaya

Post SC

Launike Wambrauw
Maria Rumabar
Yuliana Ronsumbre
Yulce Saflembolo

Okt
Okt
Okt
Okt

Fery
Fery
Fery
Fery

Wijaya
Wijaya
Wijaya
Wijaya

Post Partum
Gravida
Prolap Uteri
Post SC

Kontrol
Kontrol
Kontrol
Gv
Kontrol
Gv
Kontrol
Kontrol
Kontrol
Kontrol
Gv
Kontrol
USG
Kontrol
Gv
Kontrol

12
13

Ny. Maryanke Bleskadit

Ny. Yulce Saflembolo

07 Okt 2014
07 Okt 2014

2/195864/14
1/157865/12

25
30

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Post Partum
Post SC

Gv
Kontrol
Kontrol
Gv
Kontrol
USG

14

Ny. Oce Yawan

08 Okt 2014

1/169426/13

30

dr. Fery Wijaya

Adnecitis

15

Ny. Weldemina Ayomi

08 Okt 2014

2/212602/14

26

dr. Fery Wijaya

Post SCTP

16
17

Ny. Ester Miokbun

Ny. Grasela Ayomi

08 Okt 2014
08 Okt 2014

2/154505/12
1/209801/14

21
19

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Gravida
Post SCTP

18
19
20

Ny. Fenny Swabra

Ny. Merry Saday
Ny. Hernia Kabes

08 Okt 2014
09 Okt 2014
09 Okt 2014

1/209846/14
2/130432/12
2/211129/14

31
33
19

P
P
P

dr. Fery Wijaya

dr. Fery Wijaya
dr. Fery Wijaya

Vaginitis
Hidronefrosis
Post SCTP

Kontrol
Kontrol

21

Ny. Nita Kbarek

09 Okt 2014

2/212719/14

20

dr. Fery Wijaya

Post SCTP

Kontrol
Gv

22

Ny. Yulce Saflembolo

10 Okt 2014

1/157865/12

30

dr. Fery Wijaya

Post SCTP

23
24

Ny. Anita Pondagitan

Ny. Lia Yunita Yewun

10 Okt 2014
10 Okt 2014

1/161704/12
2/143564/12

37
22

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Apseptor KB
Gravida

25

Ny. Meral A. A. Runaweri

10 Okt 2014

1/104882/10

29

dr. Fery Wijaya

Post Sc

Kontrol
Gv
Kontrol
Kontrol
USG
Kontrol
Lab
Lab

26

Ny. Yulce Saflembolo

13 Okt 2014

1/157865/12

30

dr. Fery Wijaya

Post SCTP

27
28

Ny. Rawelda Sada

Ny. Yanti Adadikam

13 Okt 2014
13 Okt 2014

1/211109/14
2/190964/14

24
19

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Post Partum
Post SCTP

Kontrol
Gv
Kontrol
Kontrol
Gv

Kontrol
Gv

Kontrol
Gv
Kontrol
Kontrol
Gv

29

Ny. Nita Kbarek

13 Okt 2014

2/212719/14

20

dr. Fery Wijaya

Post SCTP

30

Ny. Nita Kbarek

14 Okt 2014

2/212719/14

20

dr. Fery Wijaya

Post Sc

Kontrol
Gv
Kontrol

31

Ny. Yulce Saflembolo

14 Okt 2014

1/157865/12

30

dr. Fery Wijaya

Post Sc

32

Ny. Yanti Adadikam

15 Okt 2014

2/190964/14

19

dr. Fery Wijaya

Post Sc

33
34

Ny. Leonora Raprap

Ny. Yanti Adadikam

15 Okt 2014
17 Okt 2014

1/210850/14
2/190964/14

37
19

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Aminorhoe
Post Sc

35
36

Ny. Ester Miokbun

Ny. Nova Silak

17 Okt 2014
17 Okt 2014

2/154505/12
2/119110/11

20
21

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Gravida
Gravida

Lab
Kontrol
Gv
USG
Kontrol
Gv
Kontrol
Kontrol
Gv
Kontrol
Kontrol

37

Ny. Dormina Yapen

17 Okt 2014

1/213318/14

41

dr. Fery Wijaya

Gravida

Kontrol
Usg
Kontrol
Gv
Kontrol
Kontrol

38

Ny. Nita Kbarek

17 Okt 2014

2/212719/14

20

dr. Fery Wijaya

Post Sc

39
40
41

Ny. Merry Sroyer

Ny. Lusiana B. Bonwefer
Ny. Yanti Adadikam

21 Okt 2014
22 Okt 2014
22 Okt 2014

1/192537/14
1/146146/12
2/190964/14

27
21
19

P
P
P

dr. Fery Wijaya

dr. Fery Wijaya
dr. Fery Wijaya

Aminorhoe
Menomefroragia
Post SCTP

42

Ny. Anita Kbarek

20 Okt 2014

2/212719/14

20

dr. Fery Wijaya

Post SCTP

Kontrol
Gv

43

Ny. Nita Kbarek

23 Okt 2014

2/212719/14

20

dr. Fery Wijaya

Post Sc

Kontrol
Gv

44
45

Ny. Marsita Wabiser

Ny. Dessy A. Kafiar

23 Okt 2014
24 Okt 2014

2/106125/10
1/135530/12

24
29

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Aminorhoe
Gravida

Kontrol
Kontrol

PID

Usg
Kontrol

46

Nn. Ina Wambrauw

24 Okt 2014

2/213368/14

19

dr. Fery Wijaya

Kontrol
Gv

Usg
Kontrol
Gv

47

Ny. Nita Kbarek

28 Okt 2014

2/212719/14

20

dr. Fery Wijaya

Post SCTP

48

Ny. Ningsih Obinaru

29 Okt 2014

2/179105/13

19

dr. Fery Wijaya

Post SCTP

Kontrol
Gv

49

Ny. Irene Rumbrawer

30 Okt 2014

2/140666/12

27

dr. Fery Wijaya

Gravida

50

Nn. Dessi Miokbun

31 Okt 2014

1/213122/14

17

dr. Fery Wijaya

Adnecitis

Kontrol
Lab
Lab
Kontrol

51

Ny. Damares Rejauw

31 Okt 2014

1/214487/14

45

dr. Fery Wijaya

Adnecitis

Usg
Kontrol

TOTAL

Biak, 01 November 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

BIAYA
14
27,500
27,500
27,500
20,000
27,500
20,000
27,500
27,500
27,500
27,500
20,000
27,500
53,000
27,500
20,000
27,500

JUMLAH

KETERANGAN

15

16
27,500
27,500
47,500
47,500
27,500
27,500
27,500
47,500
80,500
47,500

20,000
27,500
27,500

47,500
27,500

20,000
27,500
53,000

47,500

27,500
20,000
27,500
27,500
20,000
27,500
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
27,500
53,000
27,500
18,000
18,000
27,500
20,000
27,500
27,500
20,000

80,500

47,500
27,500
47,500
27,500
27,500
47,500
47,500
47,500
27,500
80,500

63,500
47,500
27,500
47,500

27,500
20,000
27,500
20,000
27,500
20,000
53,000
27,500
20,000
27,500
###
20,000
27,500
27,500

27,500
53,000
27,500
20,000
27,500
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
27,500
53,000
27,500

47,500
47,500

100,500
47,500
27,500
47,500
27,500
27,500

80,500
47,500
27,500
27,500
47,500
47,500
47,500
27,500
80,500

53,000
27,500
20,000
27,500
20,000
27,500
18,000
18,000
27,500
53,000
27,500

80,500
47,500
47,500

63,500
80,500
27,500
2,378,500

PEMERINTAH KABUPATEN BIAK NUMFOR

RUMAH SAKIT UMUM DAERAH
Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

FORM KLAIM KARTU PAPUA SEHAT

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO

NAMA

1
1
2
3
4
5
6
7

Ny.
Ny.
Ny.
Ny.
Ny.
Ny.
Ny.

8
9

2
Antomina Sanadi
Fawelda Sada
Erna A. Wabdaron
Ice Pusop
Selina Korwa
Andi M. O. Boseren
Agnes Marandof

:
:
:
:
:
:
:

NOVEMBER 2014
RSUD BIAK

52 PASIEN
dr. IRAS B.P RUMBIAK, M Kes,SpPK
RAWAT JALAN TINGKAT LANJUT

TANGGAL
3
Nov
Nov
Nov
Nov
Nov
Nov
Nov

No. MR

UMUR
THN BLN HARI
5
6
7
25
24
32
17
31
27
29

P/L

DKTR

dr.
dr.
dr.
dr.
dr.
dr.
dr.

9
Fery Wijaya
Fery Wijaya
Fery Wijaya
Fery Wijaya
Fery Wijaya
Fery Wijaya
Fery Wijaya

ICD

TINDAKAN

ICD

10
ISK
Post Partum
Gravida
Gravida
Adnecitis
Gravida
Post Laparatomi

11
N39,9

12

13

2014
2014
2014
2014
2014
2014
2014

4
2/118255/11
1/211109/14
1/206728/14
1/212636/14
1/214711/14
1/214714/14
1/129058/12

Ny. Tabita Miokbun

Ny. Beatriks Rawar

05 Nov 2014
06 Nov 2014

2/142844/12
2/175157/13

31
26

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Adnecitis
Post SCTP

10 Ny. Maria Arfayan

11 Ny. Andi M. O. Boseren

06 Nov 2014
07 Nov 2014

1/214827/14
1/214714/14

28
27

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Post Sc
Adnecitis

12 Ny. Ros Dimara

07 Nov 2014

1/189467/13

34

dr. Fery Wijaya

Post SCTP

01
03
04
04
04
04
05

8
P
P
P
P
P
P
P

DIAGNOSA

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
GV
Kontrol
Kontrol
GV
Kontrol
Kontrol
USG
Kontrol
GV

13 Ny. Erna A. Wabdaron

07 Nov 2014

1/206728/14

32

dr. Fery Wijaya

Gravida

14 Ny. Andi M. O. Boseren

08 Nov 2014

1/214714/14

27

dr. Fery Wijaya

Gravida

Kontrol
USG
Kontrol

15 Ny. Beatriks Rawar

16 Maryanke Bleskadit

08 Nov 2014
08 Nov 2014

2/175157/13
2/20611/14

26
25

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Post SCTP
Post Partum

Kontrol
Kontrol

17 Ny. Beatriks Rawar

11 Nov 2014

2/175157/13

26

dr. Fery Wijaya

Post Sc

18
19
20
21
22
23

11
12
12
12
12
13

2014
2014
2014
2014
2014
2014

1/150293/12
2/125705/12
2/187738/12
1/213122/14
1/215198/14
2/101474/10

35
25
27
17
36
19

P
P
P
P
P
P

dr.
dr.
dr.
dr.
dr.
dr.

24 Ny. Maria Arfayan

13 Nov 2014

1/214827/14

28

dr. Fery Wijaya

Post SCTP

25 Ny. Beatriks Rawar

13 Nov 2014

2/175157/13

26

dr. Fery Wijaya

Post SCTP

26 Ny. Insos Randongkir

14 Nov 2014

2/101474/10

20

dr. Fery Wijaya

Gravida

27 Ny. Margaretha Rumbrapuk

14 Nov 2014

1/134068/12

41

dr. Fery Wijaya

Post Mow

28 Ny. Andi Miryam O. Boseren

15 Nov 2014

1/214714/14

27

dr. Fery Wijaya

Post Mow

29 Ny. Margaretha Rumbrapuk

15 Nov 2014

1/134068/12

41

dr. Fery Wijaya

Post Mow

Kontrol
GV
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Lab
Lab
Lab
Lab
Kontrol
GV
Kontrol
GV
Kontrol
Lab
Lab
Kontrol
GV
Kontrol
GV
Kontrol
GV

Ny. Yubelina M. Rumbrawer

Ny. Shintia Olla
Ny. Conny A. Rumbiak
Nn. Dessi Miokbun
Ny. Merry Adur
Nn. Insos Randongkir

Nov
Nov
Nov
Nov
Nov
Nov

Fery
Fery
Fery
Fery
Fery
Fery

Wijaya
Wijaya
Wijaya
Wijaya
Wijaya
Wijaya

Adnecitis
Post Curetase
Gravida
Adnecitis
Gravida
Gravida

30 Ny. Rosita Orbay

17 Nov 2014

2/198661/14

34

dr. Fery Wijaya

Post SC

32 Ny. Ice Pusop

17 Nov 2014

1/212636/14

17

dr. Fery Wijaya

Adnecitis

33 Ny. Insos Randongkir

34 Ny. Andi Miryam O. Boseren

18 Nov 2014
18 Nov 2014

2/101474/10
1/214714/14

20
27

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Gravida
Post SC

35 Ny. Margaretha Rumbrapuk

18 Nov 2014

1/134068/12

41

dr. Fery Wijaya

Post Mow
Gravida

36 Ny. Insos Randongkir

19 Nov 2014

2/101474/10

37 Ny. Maria Hungan

19 Nov 2014

2/152491/12

38 Ny. Margaretha Rumbrapuk

20 Nov 2014

1/134068/12

39 Ny. Erna A. Wabdaron

40 Ny. Adolina Fairyo
41 Ny. Beatriks Rawar

20 Nov 2014
21 Nov 2014
21 Nov 2014

42 Ny. Ramadona Simbiak

dr. Fery Wijaya

Gravida

dr. Fery Wijaya

Gravida

41

dr. Fery Wijaya

Post. Mow

1/206728/14
1/142793/12
2/175157/12

32
22
26

P
P
P

dr. Fery Wijaya

dr. Fery Wijaya
dr. Fery Wijaya

Post SC
Adnecitis
Post SC

22 Nov 2014

1/105533/10

24

dr. Fery Wijaya

Post SC

43 Ny. Ramadona Simbiak

24 Nov 2014

1/105533/10

24

dr. Fery Wijaya

Post SC

44
45
46
47

25
25
26
26

2014
2014
2014
2014

1/161704/12
1/145748/12
2/175157/12
1/206728/14

37
76
26
32

P
P
P
P

dr.
dr.
dr.
dr.

26 Nov 2014

1/105533/10

24

dr. Fery Wijaya

Ny.
Ny.
Ny.
Ny.

Anita I. Pondagitan
Hendrika Rumaropen
Beatriks Rawar
Erna Agustina Wabdaron

48 Ny. Ramadona Simbiak

Nov
Nov
Nov
Nov

20

Fery
Fery
Fery
Fery

Wijaya
Wijaya
Wijaya
Wijaya

Adnecitis
Prolaps Ut
Post SCTP
Post SC
Post SC

Kontrol
GV
Kontrol
Kontrol
Kontrol
GV
Kontrol
GV
Kontrol
Lab
Lab
Kontrol
Lab 2x

Kontrol
USG
Kontrol
GV
Kontrol
Kontrol
Kontrol
GV
Kontrol
GV
Kontrol
GV
Kontrol
Kontrol
Kontrol
Kontrol
GV
Kontrol

49 Ny. Bache Obinaru

50 Nn. Dessi Miokbun

26 Nov 2014
26 Nov 2014

1/216474/14
1/213122/14

22
17

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Dispmenorae
Vaginitis

GV
Kontrol
Kontrol

51 Ny. Ramadona Simbiak

52 Ny. Feny Swabra

28 Nov 2014
28 Nov 2014

1/105533/10
1/209846/14

24
31

P
P

dr. Fery Wijaya

dr. Fery Wijaya

Post SCTP
Metnoragia

Kontrol
Kontrol

TOTAL

Biak, 01 November 2014

Direktur RSUD Biak

dr. Iras B.P Rumbiak,M.Kes,SpPK

NIP : 19681014 200012 2 002

BIAYA
14
27,500
27,500
27,500
###
###
27,500
27,500
20,000
27,500
27,500
20,000
27,500
27,500
53,000
27,500
20,000

JUMLAH

KETERANGAN

15
16
27,500 P. Obgyn
27,500
27,500
27,500
27,500
27,500
47,500

47,500

80,500
47,500

27,500
53,000
27,500

80,500
27,500

27,500
27,500

27,500

27,500
20,000
27,500
27,500
27,500
27,500
27,500
###
18,000
18,000
18,000
18,000
27,500
20,000
27,500
20,000
27,500
18,000
18,000
27,500
20,000
27,500
20,000
27,500
20,000

47,500
27,500
27,500

27,500

99,500
47,500
47,500

63,500
47,500
47,500
47,500

27,500
20,000
27,500
27,500
27,500
20,000
27,500
20,000
27,500
18,000
18,000
27,500
36,000

27,500
53,000
27,500
20,000
27,500
27,500
27,500
20,000
27,500
20,000
27,500
20,000
27,500
27,500
27,500
27,500
20,000
27,500

47,500
27,500
27,500
47,500
47,500

63,500
63,500

80,500
47,500
27,500
27,500
47,500
47,500
47,500
27,500
27,500
27,500
47,500

20,000
27,500
27,500

47,500
27,500
27,500

27,500
27,500

27,500
27,500
1,991,500

Total Pasien Polik Obgyn tahun 2014

Januari
Februari
Maret
April
Mei
Juni
Juli
Agustus
September
Oktober
November
Desember
Total >>>>>>>

:
:
:
:
:
:
:
:
:
:
:
:

56

37
30
34
28
19
38
35
51

328