Data Offline Surveilans PTM berbasis FKTP

IDENTITA
S
Tanggal
No No Rekam Jenis
Pemeriksaan * No KTP * Nama Pasien
Medis Kelamin

1 09 February 2016 0070 3512137012714000 JUHARIATUL P

2 0193 3512130909510002 SUJA'I L
3 0460 3512137006680002 SUNIYA P
4 0092 MATRAWI L
5 0456 3512136507600002 SALAMA P
6 0464 3512131205520003 SANAWI P
7 0381 3512041412820004 MUZAMIL L
8 0389 3512134107760130 NURSIYAMI P
9 10 February 2016 0478 MARTIMI
10 0472 3512137006590005 INDRAWATI P
11 0219 3512130101160009 MANSUR L
12 0243 ULVIRATUS P
13 0475 3512130205540002 SUNAWI L
14 0311 3512134202770017 UMMUNIYANI P
15 11 February 2016 0122 HJ. HILMY P
16 0122 H. SALIM L
17 0482 3512133005520008 MISNI P
18 0368 3512131808770002 AGUS S L
19 12 February 2016 3512130102600135 AKHMAD L
20 0287 3512134906640001 ZAHMA P
21 0501 FAUZAN L
22 0924 3512134107550038 RUKMINA P
23 0499 MATRAWI L
24 0232 3512134101710033 SUSWANI P
25 0005 3512134312560003 HAERANI P
26 0495 3512130107580150 SAIFUL BAHRI L
27 0217 3512130512570002 SANIYA P
28 15 February 2016 0193 3512130909510007 SUJA'I L
29 0510 3512134107410003 MAHYATI P
30 0321 AGUS L
31 0155 3512131506550004 RUSDI L
32 0522 3512134903165004 WINARSIH P
33 0445 3512130107580150 SAIRI L
34 0098 3512132809530001 AMSE P
35 0267 3512135907580002 NURTIMAH P
36 0089 3512135210590002 HERLINA P
37 0525 3512130209600003 HERRY P L
38 0526 3512131207520003 ABDUR RAHMAN L
39 16 February 2016 0232 3512134101710032 SUSWANI P
40 0534 YUNDARI P
41 0533 SUNANDI L
 42 0532 SITI AMINAH P
43 0045 PURWATI P
44 0522 WINARSIH P
45 0527 BETRIYANI P
46 0457 SUYONO L
47
48 0541 HARTATIK P
49 17 February 2016 0067 SUTIK P
50 0554 RUSMIYATI P
xxx xxx xxx xxx xxx xxx
Tempat Lahir Tanggal Lahir Alamat Lengkap No HP

SITUBONDO 09 February 1900 ASEMBAGUS

SITUBONDO 05 March 1900 MOJOSARI
SITUBONDO 16 February 1900 ASEMBAGUS
SITUBONDO 26 February 1900 PERANTE
SITUBONDO 24 February 1900 ASEMBAGUS
SITUBONDO 02 March 1900 WRINGIN ANOM
SITUBONDO 02 February 1900 GUDANG
SITUBONDO 08 February 1900 MOJOSARI

SITUBONDO 19 February 1900 MOJOSARI

SITUBONDO 24 February 1900 GUDANG
SITUBONDO 13 February 1900 KERTOSARI
SITUBONDO 28 February 1900 GUDANG
SITUBONDO 07 February 1900 PERANTE
SITUBONDO 15 February 1900 KERTOSARI
SITUBONDO 20 February 1900 KERTOSARI
SITUBONDO 28 February 1900 PERANTE
SITUBONDO 10 February 1900 ASEMBAGUS
SITUBONDO 23 February 1900 TRIGONCO
SITUBONDO 20 February 1900 MOJOSARI
SITUBONDO 20 February 1900 KERTOSARI
SITUBONDO 18 February 1900 AGEL
SITUBONDO 28 February 1900 PERANTE
SITUBONDO 13 February 1900 MOJOSARI
SITUBONDO 27 February 1900 WRINGIN ANOM
SITUBONDO 26 February 1900 MOJOSARI
SITUBONDO 15 February 1900 KERTOSARI
SITUBONDO 05 March 1900 MOJOSARI
SITUBONDO 15 March 1900 MOJOSARI
SITUBONDO 01 March 1900 MOJOSARI
SITUBONDO 01 March 1900 MOJOSARI
SITUBONDO 18 February 1900 TRIGONCO
SITUBONDO 26 February 1900 MOJOSARI
SITUBONDO 02 March 1900 AWAR-AWAR
SITUBONDO 26 February 1900 MOJOSARI
SITUBONDO 07 March 1900 ASEMBAGUS
SITUBONDO 22 February 1900 MOJOSARI
SITUBONDO 04 March 1900 PERANTE
SITUBONDO 15 February 1900 MOJOSARI
SITUBONDO 16 January 1900 KEDUNGLO
SITUBONDO 10 February 1900 KEDUNGLO
 SITUBONDO 19 March 1900 ASEMBAGUS
SITUBONDO 13 February 1900 PERANTE
SITUBONDO 18 February 1900 TRIGONCO
SITUBONDO 09 February 1900 ASEMBAGUS
SITUBONDO 03 March 1900 BANTAL

SITUBONDO 14 February 1900 TRIGONCO

SITUBONDO 04 March 1900 PERANTE
SITUBONDO 17 February 1900 JANGKAR
xxx xxx xxx xxx
 Golongan
No Telp. Rumah Status Suku Pekerjaan
Darah
xxx xxx xxx xxx xxx
 WAWANCARA IMT Tekanan Darah

Kurang Kurang Konsumsi Tinggi Berat Lingkar

Keterangan Merokok Aktivitas Makan Sistol
Alkohol Badan Badan Perut
Fisik Sayur
xxx xxx xxx xxx xxx xxx xxx xxx xxx
Tekanan Darah Gula Darah Kolesterol

Arus Kadar
Gula Darah Gula Darah Kolesterol Puncak
Diastol Trigliserida LDL HDL Alkohol
Sewaktu Puasa Total Ekspirasi Pernafasan
(APE)
xxx xxx xxx xxx xxx xxx xxx xxx xxx
 DIAGNOSA

Tes Benjolan Hasil

Amfetamin Abnormal Pap Smear Periksa Krioterapi Diagnosa 1 Diagnosa 2
Urin Payudara IVA
xxx xxx xxx xxx xxx xxx xxx
DIAGNOSA Pemeriksaan Penunjang

Urin Rutin
Darah &
Diagnosa 3 Diagnosa 4 Diagnosa 5 EKG Radiologi Lengkap Mikroskop
ik
xxx xxx xxx xxx xxx xxx xxx
Dirujuk
xxx
 tgl_periksa rekam_medis nik nama tgl_lahir alamat gender
2016-02-09 0070 3512137012714000 JUHARIATUL 1900-02-09 ASEMBAGUS P
0193 3512130909510002 SUJA'I 1900-03-05 MOJOSARI L
0460 3512137006680002 SUNIYA 1900-02-16 ASEMBAGUS P
0092 MATRAWI 1900-02-26 PERANTE L
0456 3512136507600002 SALAMA 1900-02-24 ASEMBAGUS P
0464 3512131205520003 SANAWI 1900-03-02 WRINGIN ANOM P
0381 3512041412820004 MUZAMIL 1900-02-02 GUDANG L
0389 3512134107760130 NURSIYAMI 1900-02-08 MOJOSARI P
2016-02-10 0478 MARTIMI
0472 3512137006590005 INDRAWATI 1900-02-19 MOJOSARI P
0219 3512130101160009 MANSUR 1900-02-24 GUDANG L
0243 ULVIRATUS 1900-02-13 KERTOSARI P
0475 3512130205540002 SUNAWI 1900-02-28 GUDANG L
0311 3512134202770017 UMMUNIYANI 1900-02-07 PERANTE P
2016-02-11 0122 HJ. HILMY 1900-02-15 KERTOSARI P
0122 H. SALIM 1900-02-20 KERTOSARI L
0482 3512133005520008 MISNI 1900-02-28 PERANTE P
0368 3512131808770002 AGUS S 1900-02-10 ASEMBAGUS L
2016-02-12 3512130102600135 AKHMAD 1900-02-23 TRIGONCO L
0287 3512134906640001 ZAHMA 1900-02-20 MOJOSARI P
0501 FAUZAN 1900-02-20 KERTOSARI L
0924 3512134107550038 RUKMINA 1900-02-18 AGEL P
0499 MATRAWI 1900-02-28 PERANTE L
0232 3512134101710033 SUSWANI 1900-02-13 MOJOSARI P
0005 3512134312560003 HAERANI 1900-02-27 WRINGIN ANOM P
0495 3512130107580150 SAIFUL BAHRI 1900-02-26 MOJOSARI L
0217 3512130512570002 SANIYA 1900-02-15 KERTOSARI P
2016-02-15 0193 3512130909510007 SUJA'I 1900-03-05 MOJOSARI L
0510 3512134107410003 MAHYATI 1900-03-15 MOJOSARI P
0321 AGUS 1900-03-01 MOJOSARI L
0155 3512131506550004 RUSDI 1900-03-01 MOJOSARI L
0522 3512134903165004 WINARSIH 1900-02-18 TRIGONCO P
0445 3512130107580150 SAIRI 1900-02-26 MOJOSARI L
0098 3512132809530001 AMSE 1900-03-02 AWAR-AWAR P
0267 3512135907580002 NURTIMAH 1900-02-26 MOJOSARI P
0089 3512135210590002 HERLINA 1900-03-07 ASEMBAGUS P
0525 3512130209600003 HERRY P 1900-02-22 MOJOSARI L
0526 3512131207520003 ABDUR RAHMAN 1900-03-04 PERANTE L
2016-02-16 0232 3512134101710032 SUSWANI 1900-02-15 MOJOSARI P
0534 YUNDARI 1900-01-16 KEDUNGLO P
0533 SUNANDI 1900-02-10 KEDUNGLO L
0532 SITI AMINAH 1900-03-19 ASEMBAGUS P
0045 PURWATI 1900-02-13 PERANTE P
0522 WINARSIH 1900-02-18 TRIGONCO P
0527 BETRIYANI 1900-02-09 ASEMBAGUS P
Err:509 Err:509 SUYONO 1900-03-03 BANTAL L
0457
 0541 HARTATIK 1900-02-14 TRIGONCO P
2016-02-17 0067 SUTIK 1900-03-04 PERANTE P
0554 RUSMIYATI 1900-02-17 JANGKAR P
telp diagnosa1 diagnosa2 diagnosa3 diagnosa4 diagnosa5 merokok kurang_aktifitas
kurang_sayur
konsumsi_alkohol tb bb lp sistol diastol gds gdp
apebenjolan_payudara
positif_iva krioterapi papsmear tempat_lahirno_telprum golongan_dastatus
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suku pekerjaan keterangan kolesterol_totrigliserida ldl hdl kadar_alko
tesamfetamekg radiologi darah_lengurin_rutin dirujuk
2 fktp