REKAPITULASI PELAY

NAMA FASKES : PUSKESMAS MAMASA

BULAN PELAYANAN :

No. Nama Pasien No. Kartu BPJS Nomor Telepon

1 2 3 4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
TOTAL

Mengetahui,
PLT Kepala Puskesmas Mamasa

YUSUF PUALILLIN
NIP.
TULASI PELAYANAN KB

Besaran Tarif
Tanggal Pelayanan Jenis KB
Paket
5 6 7
TAL

Mamasa, ..

Pengelola JKN

BERTHA M. SALAMANGI, S.Kep,Ns

NIP.
Jumlah
8
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
 -
-
-

..

SALAMANGI, S.Kep,Ns
 REKA
NAMA FASKES : PUSKESMAS MAMASA
BULAN PELAYANAN :

No. Nama Pasien No. Kartu BPJS No. Telepon

1 2 3 4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Mengetahui,
PLT Kepala Puskesmas Mamasa

YUSUF PUALILLIN
NIP.
 REKAPITULASI PELAYANAN PNC

Tanggal
Diagnosa Kunjungan Neonatus Kunjungan N
KN1 KN2 KN3 KF1
5 6 7 8 9
TOTAL
 Besaran Tarif
Kunjungan Nifas Jumlah
Paket
KF2 KF3
10 11 12 13
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
 -
-
-
-

Mamasa, ..

Pengelola JKN

BERTHA M. SALAMANGI, S.Kep,Ns

NIP.
 REKAPITULASI

NAMA FASKES : PUSKESMAS MAMASA

BULAN PELAYANAN :

No. Nama Pasien No.Kartu BPJS No. Telepon

1 2 3 4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
TOTA

Mengetahui,
PLT Kepala Puskesmas Mamasa

YUSUF PUALILLIN
NIP.
REKAPITULASI PELAYANAN PERSALINAN

Tanggal
Diagnosa
Masuk Keluar
5 6 7
TOTAL
Jumlah Hari Besaran Tarif
Jumlah
Rawat Paket
8 9 10
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
 -
-
-

Mamasa, ..

Pengelola JKN

BERTHA M. SALAMANGI, S.Kep,Ns

NIP.
 REKAPITULASI PELA

NAMA FASKES : PUSKESMAS MAMASA

BULAN PELAYANAN :

No. Nama Pasien No.Kartu BPJS No. Telepon

1 2 3 4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
TOTAL

Mengetahui,
PLT Kepala Puskesmas Mamasa

YUSUF PUALILLIN
NIP.
EKAPITULASI PELAYANAN AMBULANCE

Tanggal Rumah Sakit

Diagnosa
Rujukan Tujuan
5 6 7
TOTAL

Mamasa, ..

Pengelola JKN

BERTHA M. SALAMANGI, S.Kep,N

NIP.
Besaran Tarif
Jumlah
Paket
8 9
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
 -
-
-

..

M. SALAMANGI, S.Kep,Ns
 REKAPITULASI

NAMA FASKES : PUSKESMAS MAMASA

BULAN PELAYANAN :

No. Nama Pasien No.Kartu BPJS No. Telepon

1 2 3 4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
TOTA

Mengetahui,
PLT Kepala Puskesmas Mamasa

YUSUF PUALILLIN
NIP.
REKAPITULASI PELAYANAN PRARUJUKAN

Tanggal
Diagnosa
Masuk Keluar
5 6 7
TOTAL
Jumlah Hari Besaran Tarif
Jumlah
Rawat Paket
8 9 10
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
 -
-
-

Mamasa, ..

Pengelola JKN

BERTHA M. SALAMANGI, S.Kep,Ns

NIP.
 REKAPITULAS

NAMA FASKES : PUSKESMAS MAMASA

BULAN PELAYANAN :

No. Nama Pasien No. Kartu BPJS No. Telepon

1 2 3 4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
TOTAL

Mengetahui,
PLT Kepala Puskesmas Mamasa

YUSUF PUALILLIN
NIP.
REKAPITULASI PELAYANAN ANC

Tanggal
Diagnosa
K1 K2 K3 K4
5 6 7 8 9
TOTAL

Mamasa,

Pengelola JKN

BERTHA M. SALAMANGI
NIP.
Besaran Tarif
Jumlah
Paket

10 11
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
 -
-
-
-

..

M. SALAMANGI, S.Kep,Ns
 REKAPITULASI PELAYANAN

NAMA FASKES : PUSKESMAS MAMASA

BULAN PELAYANAN : APRIL TAHUN 2017

No. Nama Pasien No. Kartu BPJS No. Telepon

1 2 3 4
1 0001076588998
2 0002059000255 082187644799
3 0000131496639 085256131305
4 000096554812
5 0000963692763 085242165822
6 0001889657392 082292323888
7 0001884165164
8 0001076565982
9 0000131541805 085242248654
10 0000131463189
11 0001076566757 081356499241
12 0001885632851 085242762604
13 0000964133864 082196576924
14 0001076563247 082348059259
15 000123252872 082349472137
16 000107655696
17 0000131516291
18 0001886150046 081241841626
19 0000207103274
20 0000131535101
21 00001314866692
22 0002203187714 081342122115
23 0000963610738
24 0000131503217
25 0001884165164
26 0001076567411
27 0001836672568
28 0000131514412
29 0000171273565 081241381388
30 0000131540771
31 0002230707194
32 0000963696238
33 0001886552054 085255242755
34 0002084066256 082191052951
35 0000131526461
36 0000963692763
37 0002195685189
38 0001076616145
39 0002050542268
40 000031479222 081342508582
41 0001886958112
42 0000963889132 085256163352
43 0001896102011
44 0000963692965 085340702004
45 0000963736986
46 0001903162476
47 0001076612051
48 0001239273279
49 0000964629393 081343940144
50 0000964607534 082293577188
51 0001239273279
52 0002009727448
53 0001232460628
54 0001232460742
55 0000964101374
56 0002009746991 085396912087
57 0001076566972
58 0000131549264 082292885775
59 0001076619251
60 0000131520611
61 0009965954812
62 000096124199
63 0000964124199
64 0000131550996
65
66
67 0853971694
68 0000964500715
69 0001900923085
70 0001312356003
71 0000964118960
72 0000963852805
73 0000962924635
74 0000962926479
75 0001076611274
76 0000131461806 085242359249
77 0000963953739
78 0000976540522
79 0001076557353
80 0002218067561 082187675649
81 0001076619881
82 0001076611678
83 0001076565475 085251794904
84 0000131496491 082192213813
85 0000131468376
86 0001232414201 085255318800
87 0000130841109
88 0000964666383
89 0000963962842
90 0000964423877 085340396605
91 0000131496491
92 0000964666383 085146247739
93 0000963962842 085342707873
94 0000131467735
95 0000131467735 085255337795
96 00000131515075
97 0001426075277
98 0001890890673 081343749572
99 0000130841109
100 0001076565982 082291034233
101 0000964124897 082348994114
102 000108146039
103 0001076564474 082393054006
104 0000152580161
105 0000131541838
106 0001811675687
107 0001076614356
108
109
110
TOTAL

Mengetahui,
PLT Kepala Puskesmas Mamasa

YUSUF PUALILLIN
NIP.19691110200312 1 008
PITULASI PELAYANAN RAWAT INAP

Tanggal Jumlah Besaran Tarif

Diagnosa
Masuk Keluar Hari Rawat Paket
5 6 7 8 9
REAKSI ALERGI 27/02/2017 04/03/2017 5 HARI 120,000
TCR 27/02/2017 02/03/2017 3 HARI 120,000
HIPERTENSI 27/02/2017 03/03/2017 4 HARI 120,000
HIPERTENSI 27/02/2017 13/03/2017 14 HARI 120,000
KOLIC ABDOMEN 28/02/2017 09/03/2017 9 HARI 120,000
DIARE AKUT 28/02/2017 02/03/2017 2 HARI 120,000
HIPERTENSI 28/02/2017 02/03/2017 2 HARI 120,000
CHEPALGIA 28/02/2017 02/03/2017 2 HARI 120,000
DYSPEPSIA 28/02/2017 04/03/2017 3 HARI 120,000
ISK + DEMAM TYPOID 28/02/2017 05/03/2017 5 HARI 120,000
HIPERTENSI 28/02/2017 03/03/2017 5 HARI 120,000
FEBRIS ISPA 01/03/2017 04/03/2017 3 HARI 120,000
DYSPEPSIA 01/03/2017 09/03/2017 8 HARI 120,000
DYSPEPSIA 01/03/2017 04/03/2017 3 HARI 120,000
HIPERTENSI 01/03/2017 03/03/2017 2 HARI 120,000
HIPERTROPI PROSTAT 01/03/2017 09/03/2017 8 HARI 120,000
ASMA BRONCHIALE 02/03/2017 06/03/2017 4 HARI 120,000
DYSPEPSIA 02/03/2017 04/03/2017 2 HARI 120,000
FEBRIS 02/03/2017 06/03/2017 4 HARI 120,000
HIPERTENSI 02/03/2017 10/03/2017 8 HARI 120,000
HIPERTENSI + CHEPALGIA 02/03/2017 07/03/2017 5 HARI 120,000
SUSP.COLITIS 02/03/2017 07/03/2017 5 HARI 120,000
GASTRITIS 02/03/2017 04/03/2017 2 HARI 120,000
NEUROPATI N.RADIALIS 03/03/2017 06/03/2017 3 HARI 120,000
DYSPEPSIA 04/03/2017 10/03/2017 6 HARI 120,000
DISMENORHEA 04/03/2017 07/03/2017 3 HARI 120,000
BRONCHITIS CRONIK 05/03/2017 07/03/2017 2 HARI 120,000
ANTENATAL SCREENING 06/03/2017 07/03/2017 1 HARI 120,000
GASTROENTERITIS AKUT 06/03/2017 10/03/2017 4 HARI 120,000
HIPERTENSI 06/03/2017 10/03/2017 4 HARI 120,000
FEBRIS 06/03/2017 10/03/2017 4 HARI 120,000
 BELL'PALSY 06/03/2017 11/03/2017 5 HARI 120,000
DEMAM TYPOID 06/03/2017 13/03/2017 7 HARI 120,000
PPOM 06/03/2017 09/03/2017 3 HARI 120,000
PNEUMONIA 06/03/2017 07/03/2017 1 HARI 120,000
COLIC ABDOMEN 06/03/2017 09/03/2017 3 HARI 120,000
FEBRIS + HIPERTENSI 07/03/2017 10/03/2017 3 HARI 120,000
CEPHALGIA 07/03/2017 11/03/2017 4 HARI 120,000
DIARE AKUT 07/03/2017 13/03/2017 6 HARI 120,000
SUSP.PIELONEFRITIS 07/03/2017 11/03/2017 4 HARI 120,000
SUSP.APPENDICITIS 08/03/2017 10/03/2017 2 HARI 120,000
FEBRIS 08/03/2017 11/03/2017 3 HARI 120,000
ASTHMA AKUT 08/03/2017 09/03/2017 1 HARI 120,000
DYSPEPSIA 08/03/2017 10/03/2017 2 HARI 120,000
KOLIC ABDOMEN 08/03/2017 09/03/2017 1 HARI 120,000
GEA 08/03/2017 10/03/2017 3 HARI 120,000
FEBRIS PRO EVOLUSI 09/03/2017 12/03/2017 3 HARI 120,000
PPOM 09/03/2017 13/03/2017 4 HARI 120,000
TRAUMA CAPITIS 08/03/2017 10/03/2017 2 HARI 120,000
DYSMENORHEA 08/03/2017 10/03/2017 2 HARI 120,000
PPOM 09/03/2017 13/03/2017 4 HARI 120,000
ABORTUS INSPIENS 10/03/2017 14/03/2017 4 HARI 120,000
DYSPEPSIA 10/03/2017 14/03/2017 4 HARI 120,000
SUSP.NHS 10/03/2017 17/03/2017 7 HARI 120,000
ASMA BRONCHIALE 04/03/2017 06/03/2017 2 HARI 120,000
SUSP.TYIPOD 10/03/2017 13/03/2017 3 HARI 120,000
GASTRITIS 11/03/2017 13/03/2017 2 HARI 120,000
HIPERTENSI 11/03/2017 18/03/2017 7 HARI 120,000
SUSP.DEMAM TYPOID 11/03/2017 17/03/2017 6 HARI 120,000
BRONCHITIS 11/03/2017 17/03/2017 6 HARI 120,000
GASTRITIS 11/03/2017 13/03/2017 2 HARI 120,000
KOLIC ABDOMEN 11/03/2017 18/03.2017 7 HARI 120,000
KOLIC ABDOMEN 11/03/2017 18/03/2017 7 HARI 120,000
PPOK EKS AKUT 12/03/2017 18/03/2017 6 HARI 120,000
GASTRITIS 12/03/2017 19/03/2017 7 HARI 120,000
HIPERTENSI 13/03/2017 16/03/2017 3 HARI 120,000
HIPERTENSI 13/03/2017 20/03/2017 7 HARI 120,000
EPITAXIS 13/03/2017 17/03/2017 4 HARI 120,000
HIPERTENSI 14/03/2017 16/03/2017 2 HARI 120,000
 DYSPEPSIA 14/03/2017 17/03/2017 3 HARI 120,000
FARINGITIS 14/03/2017 19/03/2017 5 HARI 120,000
SUSP.DEMAM TYPOID 14/03/2017 17/03/2017 3 HARI 120,000
ISK 15/03/2017 27/03/2017 12 HARI 120,000
GEA 15/03/2017 26/03/2017 11 HARI 120,000
GASTRITIS 15/03/2017 18/03/2017 3 HARI 120,000
DIARE 15/03/2017 18/03/2017 3 HARI 120,000
GASTRITIS 15/03/2017 16/03/2017 1 HARI 120,000
SUSP.PJK 15/03/2017 16/03/2017 1 HARI 120,000
TONSILITIS 17/03/2017 22/03/2017 5 HARI 120,000
FARINGITIS AKUT 18/03/2017 20/03/2017 2 HARI 120,000
DYSPEPSIA 19/03/2017 21/03/2017 2 HARI 120,000
KOLIC ABDOMEN 19/03/2017 21/03/2017 2 HARI 120,000
DYSPEPSIA 21/03/2017 22/03/2017 1 HARI 120,000
DYSPEPSIA,HIPERTENSI 21/02/2017 01/03/2017 8 HARI 120,000
CHEST PAIN 21/03/2017 22/03/2017 1 HARI 120,000
HIPERTENSI 22/03/2017 23/03/2017 1 HARI 120,000
DIARE AKUT 22/03/2017 23/03/2017 1 HARI 120,000
DYSPEPSIA 22/03/2017 27/03/2017 5 HARI 120,000
SUSP.HAEMORAGIC 23/03/2017 26/03/2017 3 HARI 120,000
DISFALGIA 19/03/2017 22/03/2017 2 HARI 120,000
HIPERTENSI 23/03/2017 26/03/2017 2 HARI 120,000
DYSPEPSIA 24/03/2017 28/03/2017 4 HARI 120,000
TRAUMA ABDOMEN 24/03/2017 28/03/2017 4 HARI 120,000
DEMAM TYPOID 24/03/2017 27/03/2017 3 HARI 120,000
FEBRIS PRO EVOLUSI 24/03/2017 25/03/2017 1 HARI 120,000
DYSPEPSIA 24/03/2017 28/03/2017 4 HARI 120,000
PAROTITIS,DIARE AKUT 24/03/2017 30/03/2017 6 HARI 120,000
CEFALGIA, DYSPEPSIA 24/03/2017 26/03/2017 2 HARI 120,000
DYSPEPSIA 24/03/2017 28/03/2017 4 HARI 120,000
PSIKOMATIK 24/03/2017 25/03/2017 1 HARI 120,000
TONSILITIS 28/02/2017 03/03/2017 3 HARI 120,000
SUSP.APPENDICITIS 28/03/2017 30/03/2017 2 HARI 120,000
TRAUMA TUMPUL 28/03/2017 30/03/2017 2 HARI 120,000
HIPERTENSI 27/03/2017 29/03/2017 2 HARI 120,000
CHEST PAIN 29/03/2017 29/03/2017 2 HARI 120,000
HIPERTENSI 30/03/2017 31/03/2017 1 HARI 120,000
VULNUM LASETARUM 30/03/2017 31/03/2017 1 HARI 200,000
TOTAL

Mamasa, 17 April 2017

Pengelola JKN

RAHEL,SKM
NIP.19750521200502 2 005
Jumlah
10

600,000
360,000
960,000
360,000
240,000
960,000
480,000
240,000
480,000
960,000
600,000
600,000
240,000
360,000
720,000
360,000
240,000
120,000
480,000
480,000
480,000
600,000
840,000
360,000
120,000
360,000
360,000
480,000
720,000
480,000
240,000
360,000
120,000
240,000
120,000
360,000
360,000
480,000
240,000
240,000
480,000
480,000
480,000
840,000
240,000
360,000
240,000
840,000
720,000
720,000
240,000
840,000
840,000
720,000
840,000
360,000
840,000
480,000
240,000
 360,000
600,000
360,000
1,440,000
1,320,000
360,000
360,000
120,000
120,000
600,000
240,000
240,000
240,000
120,000
960,000
120,000
120,000
120,000
600,000
360,000
240,000
240,000
480,000
 -
-
-
37,920,000