Data Offline Surveilans PTM berbasis FKTP

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

1 18 February 2016 0568 ARSITO L

2 0184 KUSNANTO L
3 0451 SUYONO L
4 0143 SUJA'I L
5 19 February 2016 0584 3512136302070032 AYUDIA P
6 0579 ERNI P
7 0582 3512131104590001 FATHOLLAH L
8 0525 3512130209600009 HERRY L
9 0576 3512135212620001 UMMI P
10 20 February 2016 SOFIYATI P
11 NUR HASANAH P
12 TOTOK P
13 AMINATES P
14 RATNA P
15 HJ. TUN P
16 ENDANG P
17 TOTOK L
18 YULIS P
19 AMINARTO L
20 HJ. TATIK P
21 MAHLAWI L
22 PONIYEM P
23 SAMSIYAH P
24 SONI L
25 NUR WATI P
26 SUPARTI
27 SUSRIYATI
28 22 February 2016 0609 3512132912770001 ISKANDAR L
29 0605 3512164504470066 SUMIATIN P
30 0223 3512133061264002 NY. SUN P
31 0220 3512135407580002 MARSIYANA P
32 0596 SUTIJO L
33 0057 ABD. HALIM L
34 0671 3512135108750001 ASMOJO L
35 0085 3512130209600003 ANHAR L
36 0403 FADILATUS P
37 0525 3512130209600003 HERRY L
38 0001 3512134202750017
39 23 February 2016 0019 AMINARTO L
40 0134 AHMAD L
41 0028 3512134906640024 ZAHMA P
 42 0615 3512132707590002 SUDARSONO L
43 0617 SAIMAN L
44 0217 MUJIONO L
45 0625 3512136507810001 WIWIK P
46 24 February 2016 0427 AGUS TEGUH L
47
48 0633 3512130101630032
49 0122 3512134605670003 HJ. HELMI L
50
xxx xxx xxx xxx xxx xxx
Tempat Lahir Tanggal Lahir Alamat Lengkap No HP

SITUBONDO 25 February 1900 TRIGONCO

SITUBONDO 18 February 1900 TRIGONCO
SITUBONDO 03 March 1900 BANTAL
SITUBONDO 05 March 1900 MOJOSARI
SITUBONDO 08 January 1900 ASEMBAGUS
SITUBONDO 16 February 1900 ASEMBAGUS
SITUBONDO 24 February 1900 MOJOSARI
SITUBONDO 22 February 1900 MOJOSARI
SITUBONDO 21 February 1900 WRINGIN ANOM
SITUBONDO 24 February 1900
SITUBONDO 14 February 1900
SITUBONDO 13 February 1900
SITUBONDO 09 February 1900
SITUBONDO 03 March 1900
SITUBONDO 28 February 1900
SITUBONDO 24 February 1900
SITUBONDO 27 February 1900
SITUBONDO 07 February 1900
SITUBONDO 12 February 1900

06 February 1900
14 February 1900
15 February 1900
26 February 1900
16 February 1900
28 February 1900
10 March 1900
04 March 1900
08 January 1900
22 February 1900
07 February 1900
28 February 1900
03 February 1900 GUDANG
20 February 1900 MOJOSARI
 25 February 1900 TRIGONCO
03 February 1900 WRINGIN ANOM
24 February 1900 GUDANG
03 February 1900 PERANTE
28 February 1900 ASEMBAGUS

13 February 1900 KERTOSARI

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
2016-02-18 0568 ARSITO 1900-02-25 TRIGONCO L
0184 KUSNANTO 1900-02-18 TRIGONCO L
0451 SUYONO 1900-03-03 BANTAL L
0143 SUJA'I 1900-03-05 MOJOSARI L
2016-02-19 0584 3512136302070032 AYUDIA 1900-01-08 ASEMBAGUS P
0579 ERNI 1900-02-16 ASEMBAGUS P
0582 3512131104590001 FATHOLLAH 1900-02-24 MOJOSARI L
0525 3512130209600009 HERRY 1900-02-22 MOJOSARI L
0576 3512135212620001 UMMI 1900-02-21 WRINGIN ANOM P
2016-02-20 SOFIYATI 1900-02-24 P
NUR HASANAH 1900-02-14 P
TOTOK 1900-02-13 P
AMINATES 1900-02-09 P
RATNA 1900-03-03 P
HJ. TUN 1900-02-28 P
ENDANG 1900-02-24 P
TOTOK 1900-02-27 L
YULIS 1900-02-07 P
AMINARTO 1900-02-12 L
HJ. TATIK P
MAHLAWI L
PONIYEM P
SAMSIYAH P
SONI L
NUR WATI P
SUPARTI
SUSRIYATI
2016-02-22 0609 3512132912770001 ISKANDAR 1900-02-06 L
0605 3512164504470066 SUMIATIN 1900-02-14 P
0223 3512133061264002 NY. SUN 1900-02-15 P
0220 3512135407580002 MARSIYANA 1900-02-26 P
0596 SUTIJO 1900-02-16 L
0057 ABD. HALIM 1900-02-28 L
0671 3512135108750001 ASMOJO 1900-03-10 L
0085 3512130209600003 ANHAR 1900-03-04 L
0403 FADILATUS 1900-01-08 P
0525 3512130209600003 HERRY 1900-02-22 L
0001 3512134202750017 1900-02-07
2016-02-23 0019 AMINARTO 1900-02-28 L
0134 AHMAD 1900-02-03 GUDANG L
0028 3512134906640024 ZAHMA 1900-02-20 MOJOSARI P
0615 3512132707590002 SUDARSONO 1900-02-25 TRIGONCO L
0617 SAIMAN 1900-02-03 WRINGIN ANOM L
0217 MUJIONO 1900-02-24 GUDANG L
0625 3512136507810001 WIWIK 1900-02-03 PERANTE P
2016-02-24 Err:509 Err:509 AGUS TEGUH 1900-02-28 ASEMBAGUS L
0427
0633 3512130101630032
0122 3512134605670003 HJ. HELMI 1900-02-13 KERTOSARI L
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
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
SITUBONDO
suku pekerjaan keterangan kolesterol_totrigliserida ldl hdl kadar_alko
tesamfetamekg radiologi darah_lengurin_rutin dirujuk
2 fktp