REKAPITULASI PENGAJUAN KLAIM PELAYANAN RAWAT INAP

PESERTA PROGRAM JAMINAN KESEHATAN NASIONAL

NO NAMA PASIEN NO KARTU PESERTA ALAMAT NO TELP DIAGNOSA

1 Ach Sodikin ooooo71210417 Pamokolan gastritis

2 Yeyet oooo440398585 Kertasari febris
3 Juju oooo441807963 Seda kidul dispepsia
4 Oleh solehudin ooooo71543531 Pamokolan arthritis
5 A Rimba oooo441702088 Payung agung heart congestif
6 Ani Rohaeni ooo1089595056 Antralina gastro enteritis
7 Ai Toto oooo440526846 Pamokolan dispepsia
8 Nunus oooo441089829 Pamokolan dispepsia
9 Sri Azkiah oooo441782166 Bojong Hypokalasemia
10 reva ratu natasya oooo441831047 Bojong febris
11 Koniah oooo441393862 Selajasmbe nyeri abdomen
12 Rizki yuliandi lesmana oooo440533192 Pamokolan g.e
kertaharja
Udi nawawi ooo1089599523 panjalu decomp
13
14 Tn. Dede Yunan oooo441630461 Panoongan asma
15 cucu jubaedah oooo441595023 Pasirtamiang obs. Febris
16 Ili Sarhadi oooo440489272 Pasajen decomp
17 Ade Halim oooo441015939 pasajen obs. Febris
18 asep yogi nugraha ooo1444332756 palembang diare
DM anasarka,Susp
19 Ai Yuli oooo440240894 buniasih gastritis
Decomp Cordis, gagal
20 Kusnadi oooo440319464 pamokolan ginjal
21 Rohman oooo441834208 ciawitali asma
22 tn.Suhada oooo440111338 Pasirtamiang decomp Cordis+ KKP
23 Tika oooo440571317 Kersamenak gastritis
24 Ny. Elin herlina oooo440342755 Cioawitali emesis
25 Enah oooo441546142 Jengkol Pandak CHF
NGAJUAN KLAIM PELAYANAN RAWAT INAP
GRAM JAMINAN KESEHATAN NASIONAL

JUMLAH BESARAN JUMLAH JUMLAH

TANGGAL TANGGAL
TINDAKAN YANG DIBERIKAN HARI TAGIHAN SELURUH
MASUK KELUAR RAWAT TARIF PAKET PAKET RITP TAGIHAN
inf RL, O2 3lt/menit, ranitidin injk, 1/14/2015 1/17/2015 3 100,000 300,000 300,000
inf RL, ranitidin injk,ceftriaxone injk, cefotaxime i 1/15/2015 1/19/2015 4 100,000 400,000 400,000
inf RL, ondansetron, 1/19/2015 1/22/2015 3 100,000 300,000 300,000
inf RL, ranitidin,dexametason injk, diazepam injk, 1/19/2015 12/22/2015 3 100,000 300,000 300,000
inf RL, O2 1/20/2015 1/21/2015 1 100,000 100,000 100,000
inf RL, 1/21/2015 1/22/2015 1 100,000 100,000 100,000
inf RL. Ranitidin injk, ondansetron injk 1/22/2015 1/24/2015 3 100,000 300,000 300,000
inf RL,ranitidin, 1/22/2015 1/24/2015 2 100,000 200,000 200,000
inf RL 1/22/2015 1/24/2015 2 100,000 200,000 200,000
inf RL 1/23/2015 1/25/2015 2 100,000 200,000 200,000
inf RL, ranitidin injk, 1/23/2015 1/25/2015 2 100,000 200,000 200,000
inf RL 1/23/2015 1/24/2015 2 100,000 200,000 200,000
inf RL, nebulizer, ranitidin injk, 1/24/2015 1/28/2015 4 100,000 400,000 400,000
inf RL,o2, 1/25/2015 1/26/2015 1 100,000 100,000 100,000
inf RL, cek darah rutin, 1/25/2015 1/28/2015 3 100,000 300,000 300,000
inf RL, o2, ranitidin injk 1/25/2015 1/27/2015 2 100,000 200,000 200,000
inf RL, ranitidin injk, o2, 1/27/2015 1/29/2015 2 100,000 200,000 200,000
inf RL, ranitidin injk, ondansetron injk 1/27/2015 1/29/2015 2 100,000 200,000 200,000
inf RL, ranitidin injk 1/27/2015 1/30/2015 3 100,000 300,000 300,000
inf RL, Dc, cek GDS, O2,furocemid 1/27/2015 1/28/2015 1 100,000 100,000 100,000
inf RL, O2,nebulizer 1/28/2015 1/29/2015 1 100,000 100,000 100,000
inf D5,DC,ranitidin injk, o2, cek GDS, 1/28/2015 1/30/2015 2 100,000 200,000 200,000
inf RL, ranitidin injk, 1/29/2015 1/31/2015 4 100,000 400,000 400,000
inf RL, ranitidin 1/22/2015 1/24/2015 2 100,000 200,000 200,000
inf RL, nebulizer, ranitidin 1/18/2015 1/21/2015 3 100,000 300,000 300,000

Cihaurbeuti, Januari 2015

Kepala UPTD PKM Ciharubeuti

HERMAWAN, SKM
NIP. 19631020 198803 1 003
 DAFTAR PASIEN RAWAT INAP PKM CIHAURBEUTI
PESERTA PROGRAM JAMINAN KESEHATAN NASIONAL
BULAN FERBUARI 2015

TINDAKAN YANG TANGGAL

NO NAMA PASIEN NO KARTU PESERTA ALAMAT NO TELP DIAGNOSA DIBERIKAN MASUK

Ahmad HasaN Fauzi oooo195584253 Pamokolan Susp DHF grade II+ Obs 1/29/2015
1 (Fuji) Febris inf RL, LAB
2 Aan Ma'ruf oooo436612689 Palumbungan, o85321634295 inf RL 1/31/2015
kadipaten
3 hasan wirono oooo440538682 cikole,cijulang o85223496948 stroke iskemik inf RL 2/1/2015
4 devi silfiani oooo440953874 pasirtamiang o85624144002 susp typoid inf RL 2/3/2015
5 endang hidayat oooo441839957 seda kaler o87725954428 obs. Febris inf RL 04/02/2015
6 neneng Stiasih oooo441024783 Pamokolan o81322180267 dm inf RL, GDS 2/5/2015
7 tri aldona ooo1427173031 pasirtamiang obs febris inf RL 2/7/2015
8 Cucu Nurmayati ooo1484255755 cihaurbeuti o81322554668 susp.dhf inf RL, LAB 2/9/2015
9 dadang oooo441145574 depok,padamulya o85724054435 diare inf RL 2/9/2015
10 icih oooo440238093 sukahaji o81909755030 diare akut inf RL 2/9/2015
11 deina oooo440777992 cigarunggang o82316631952 obs vomitus inf RL 2/10/2015
12 reisa tri syakirah ooo1424330662 Pamokolan o85289440337 obs febris inf RL, LAB 2/12/2015
13 esih oooo440864346 pasir landak o85222011906 diare akut inf RL,LAB 2/13/2015
14 aminah oooo440382159 desa tengah o82214520097 gastritis inf RL 2/14/2015

15 ade nanan oooo44149264 cigarunggang o87767877348 Hyperlipidemia+syndrom 2/14/2015

dispepsi inf RL, LAB

16 dayat oooo441686384 seda kaler o87888981449 hipertensi inf RL, o2 2/15/2015

17 enih ooo1822739545 sukasetia gastritis inf RL 2/17/2015

18 ae oooo441379787 padamulya gastritis inf RL 2/17/2015
19 nurul amin oooo441058476 padamulya o85962483352 alergi+vomitus inf RL 2/18/2015
20 abi alfitroh ooo1817799434 Pamokolan o81909662179 vomitus inf RL 2/18/2015
21 aah sumirah ooo1006155189 padamulya o97767924445 syndrom dispesia inf RL, O2, EKG 2/18/2015
22 yuningsih oooo158758839 baketrak gastritis inf RL, 2/21/2015
23 vikra nuradam ooo1247422724 pasirtamiang kejang demam inf Rl 2/22/2015
24 dede cahyati oooo196684446 bojong gastritis inf RL, LAB 2/24/2015
25 asep ruhiat oooo441054819 pasajen,pamokolan obs febris inf rl, lab 2/24/2015
26 neni kaniati oooo440828875 desa tengah o82126144574 obs febris inf rl, 2/25/2015
 JUMLAH JUMLAH
TANGGAL BESARAN
KELUAR HARI TARIF PAKET
JUMLAH SELURUH keterangan
RAWAT TAGIHAN TAGIHAN
PAKET RITP

2/3/2015 5 100,000 500,000 500,000

2/1/2015 1 100,000 100,000 100,000 rujuk rsud tasik

06/26/2015 5 100,000 500,000 500,000

2/4/2015 1 100,000 100,000 100,000
2/6/2015 2 100,000 200,000 200,000
2/7/2015 2 100,000 200,000 200,000
2/11/2015 4 100,000 400,000 400,000
2/14/2015 5 100,000 500,000 500,000
2/11/2015 2 100,000 200,000 200,000
2/12/2015 3 100,000 300,000 300,000
2/12/2015 2 100,000 200,000 200,000
2/15/2015 3 100,000 300,000 300,000
2/17/2015 4 100,000 400,000 400,000
2/18/2015 4 100,000 400,000 400,000

2/18/2015 4 100,000 400,000 400,000

2/17/2015 2 100,000 200,000 200,000 rujuk RS Ciamis

2/18/2015 1 100,000 100,000 100,000 rujuk RS Ciamis

2/21/2015 4 100,000 400,000 400,000
2/22/2015 4 100,000 400,000 400,000
2/22/2015 4 100,000 400,000 400,000
2/22/2015 4 100,000 400,000 400,000
2/25/2015 4 100,000 400,000 400,000
2/26/2015 4 100,000 400,000 400,000
2/27/2015 3 100,000 300,000 300,000
2/27/2015 3 100,000 300,000 300,000
2/28/2015 3 100,000 300,000 300,000
83 TOTAL 8,300,000 8,300,000
 DAFTAR PASIEN RAWAT INAP PKM CIHAURBEU
PESERTA PROGRAM JAMINAN KESEHATAN NASIO
BULAN MARET 2015

NO NAMA PASIEN NO KARTU PESERTA ALAMAT NO TELP DIAGNOSA

1 Silvpi andiyanti ooo1006153132 pasirlandak thypoid, dispepsia

2 ODO oooo441680117 bojong o81317505100 head injury

3 Sandi jamaludin oooo440225943 seda kidul o81219509004 syndroma dispepsy

4 TITA ooooo71394783 dsn tengah, cihaurbeuti o85353155598 syndroma dispepsy
5 AJ ABIDIN oooo437620825 joglo, cibahayu, kadipaten syndroma dispepsy
6 tatang oooo441219914 kertasari combustio grde II
7 uneh oooo440223243 seda kidul o82130776345 gatritis
8 erlangga oooo440512075 seda kaler o85315225620 obs vomitus+febris
9 ASIK ooo1006136364 cianda, cihaurbeuti o82143450071 diare akut, dehidrasi ringan
10 soja ningsih oooo441406945 sukamaju o85721129042 thypoid
11 tatang oooo441219914 kertasari combustio grde II
12 apong oooo440641708 pamokolan o85317035558 dm
13 oyoh ooo1090007831 cihaurbeuti o81220833052 gatritis
14 asih oooo441016097 pamokolan o85321863776 thypoid

15 nani ooo1oo6152243 pasirtamiang o87728159300 syndroma dispepsy

16 nani sumarni oooo440640887 bojong gatritis

lisna oooo441718569 pamokolan o85324574720

17 abses sinistra

18 agustiana oooo440552373 dsn desa, pamokolan o85353488890 vl, kll

19 dedah oooo441511672 pasajen isk
20 een oooo440311768 cigarunggang o85972749104 GEA
21 irman robiana oooo440259849 pasirtamiang o85294403465 ferbris+trombositopenia
22 dede faujan OOOO440704214 pasirlandak thypoid
23 widi oooo440318586 pamokolan syndroma dispepsia
24 cicih oooo440195422 pasirtamiang
25 zumrotul inayah ooo1380856443 desa kaler, cihaurbeuti o81312653332 vertigo
26 udin haerudin oooo439960623 sukamaju o81220607299 diare akut, dehidrasi
27 endang oooo441321603 bojong o82315840998 diare akut, dehidrasi ringan
28 yanto susanto oooo439999751 desa kaler, cihaurbeuti diare akut, dehidrasi ringan

29 apong oooo440641708 pamokolan o85317035558 dm

30 yeni oooo441501963 kersamenak gatritis
ASIEN RAWAT INAP PKM CIHAURBEUTI
OGRAM JAMINAN KESEHATAN NASIONAL
BULAN MARET 2015

JUMLAH JUMLAH
TINDAKAN YANG DIBERIKAN TANGGAL MASUK TANGGAL BESARAN
KELUAR HARI SELURUH keterangan
RAWAT TARIF PAKET JUMLAH TAGIHAN TAGIHAN
PAKET RITP
inf rl. Lab 02/03/2015 06/03/2015 4 100,000 400,000 400,000
gds, infs rl 02/03/2015 07/03/2015 5 100,000 500,000 500,000

inf rl. Lab 02/03/2015 05/03/2015 3 100,000 300,000 300,000

inf Rl 02/03/2015 05/03/2015 3 100,000 300,000 300,000
inf Rl 02/03/2015 05/03/2015 3 100,000 300,000 300,000
inf Rl, perawatan luka 01/03/2015 06/03/2015 5 100,000 500,000 500,000
inf rl. Lab 04/03/2015 07/03/2015 3 100,000 300,000 300,000
infs Rl 05/03/2015 07/03/2015 2 100,000 200,000 200,000
infs rl 07/03/2015 09/03/2015 2 100,000 200,000 200,000
inf rl. Lab 08/03/2015 12/03/2015 4 100,000 400,000 400,000
inf Rl, perawatan luka 10/03/2015 15/03/2015 5 100,000 500,000 500,000
inf rl. Lab 10/03/2015 14/03/2015 4 100,000 400,000 400,000
infs Rl 11/03/2015 14/03/2015 3 100,000 300,000 300,000
inf rl. Lab 12/03/2015 17/03/2015 5 100,000 500,000 500,000

inf Rl 12/03/2015 16/03/2015 4 100,000 400,000 400,000

inf rl. Lab 13/03/2015 17/03/2015 4 100,000 400,000 400,000

13/03/2015 17/03/2015 4 100,000 400,000 400,000

inf RL

inf Rl, perawatan luka 13/03/2015 17/03/2015 4 100,000 400,000 400,000

inf rl. Lab 15/03/2013 18/03/2015 3 100,000 300,000 300,000
inf RL 16/03/2015 19/03/2015 3 100,000 300,000 300,000
inf RL 17/03/2015 19/03/2015 2 100,000 200,000 200,000
inf rl. Lab 17/03/2015 22/03/2015 5 100,000 500,000 500,000
inf RL 17/03/2015 19/03/2015 2 100,000 200,000 200,000
inf RL 18/03/2015 21/03/2015 3 100,000 300,000 300,000
inf RL 18/03/2015 21/03/2015 3 100,000 300,000 300,000
inf RL 23/03/2015 25/03/2015 2 100,000 200,000 200,000
inf RL 23/03/2015 26/03/2015 3 100,000 300,000 300,000
inf RL 24/03/2015 27/03/2015 3 100,000 300,000 300,000

inf rl. Lab 24/03/2015 26/03/2015 2 100,000 200,000 200,000

infs Rl 28/03/2015 30/03/2015 2 100,000 200,000 200,000
100 TOTAL 10,000,000 10,000,000
 DAFTAR PASIEN RAWAT INAP PKM CIHAURBE
PESERTA PROGRAM JAMINAN KESEHATAN NAS
BULAN FERBUARI 2015

NO NAMA PASIEN NO KARTU PESERTA ALAMAT NO TELP DIAGNOSA

1 IRSA LESTARI oooo440408002 PASIRTAMIANG DECOMP CORDIS

2 RUDI HIDAYAT oooo441326979 PADAMULYA THYPOID

3 IJAH oooo440552834 KERSAMENAK HIPERTENSI GRADE II

4 AMAD ooo SOMPOK
5 ROSIDAH oooo440645444 NANGGELA
6 SANTI NURAENI oooo440563724 DUSUN DESA KALER
7 NURUL HIKMAH oooo440707735 NANGGELA HEADACH
8 E LILI HARYADI oooo439872716 DESA TENGAH

9 IING SOLIHIN ooo1247422544 PASAJEN THYPOID

10 LAILATUL SADIAH oooo441046631 PASIRTAMIANG THYPOID
11 EUIS FATIMAH ooo1089581692 PADAMULYA CHF+ HIPERTENSI
12 HESTI NURLATIFAH oooo440416214 KERTASARI THYPOID
13 AI DASITI oooo441097154 PADAMULYA ANEMIA+MELENA+GASTRITIS
14 NINGRUM oooo440530479 KERSAMENAK HIPERTENSI
15 SOPIAH oooo440693212 CIGOROWONG
16 IWA oooo442020532 NANGGELA SINDROMA DISPEPSI
17 DIAN ROSDIANA oooo440777979 PASIRTAMIANG LANDEUH THYPOID
18 UHA ooooo70994801 PASIRTAMIANG LANDEUH HIPERTENSI GRADE III+ VOMITUS
19 ETE YAYAT oooo441829045 PADAMULYA VERTIGO
20 A RIMBA oooo441702088 PAMEKARAN, PANUMBANGAN CHF
21 CUCU oooo440759103 CIPEUCEUK GEA
22 CICIH ooo1006155527 KERSAMENAK DM+ANEMIA
23
24
25
26
IEN RAWAT INAP PKM CIHAURBEUTI
RAM JAMINAN KESEHATAN NASIONAL
BULAN FERBUARI 2015

TANGGAL TANGGAL JUMLAH BESARAN JUMLAH

TINDAKAN YANG DIBERIKAN MASUK KELUAR HARI RAWAT TARIF PAKET JUMLAH SELURUH keterangan
TAGIHAN TAGIHAN
PAKET RITP
inf RL, LAB, O2 12/04/2015 15/04/2015 3 100,000 300,000 300,000

INFS RL, HEMRUT+WIDAL 13/04/2015 15/04/2015 2 100,000 200,000 200,000 rujuk

tasik
rsud

INF RL, 16/04/2015 19/04/2015 3 100,000 300,000 300,000

inf RL 100,000 - -
inf RL 100,000 - -
inf RL, GDS 100,000 - -
INF RL 12/04/2015 14/04/2015 2 100,000 200,000 200,000
INF RL, LAB, CEK DAHAK 15/04/2015 18/04/2015 3 100,000 300,000 300,000

INF RL, HEMRUT, WIDAL,NEBU, O2 20/04/2015 2 100,000 200,000 200,000

18/04/2015
INFS RL, CEK HEMRUT+ WIDAL, O2 30/03/2015 02/04/2015 3 100,000 300,000 300,000 RUJUK RS CIAMIS
INFS RL, O2 02/04/2015 06/04/2015 4 100,000 400,000 400,000
INF RL, CEK HEMRUT+WIDAL 02/04/2015 06/04/2015 4 100,000 400,000 400,000
INF RL, CEK HB 31/04/2015 04/04/2015 4 100,000 400,000 400,000
INF RL 08/04/2015 11/04/2015 3 100,000 300,000 300,000
inf RL, LAB 100,000 - -
INF RL 09/04/2015 13/04/2015 4 100,000 400,000 400,000
INFS RL, CEK HEMRUT+ WIDAL, O2 03/04/2015 06/04/2015 3 100,000 300,000 300,000
inf RL 31/03/2015 04/03/2015 3 100,000 300,000 300,000
INFS RL 31/03/2015 04/03/2015 3 100,000 300,000 300,000
INFRL, O2 09/04/2015 13/04/2015 4 100,000 400,000 400,000
INF RL 18/04/2015 20/04/2015 2 100,000 200,000 200,000
INF RL, O2, HB,GDS,ASAM URAT 13/04/2015 15/04/2015 2 100,000 200,000 200,000
100,000 - -
100,000 - -
100,000 - -
100,000 - -
54 TOTAL 5,400,000 5,400,000

Cihaurbeuti, Januari 2015

Kepala UPTD PKM Ciharubeuti
 HERMAWAN, SKM
NIP. 19631020 198803 1 003
RUJUK RS CIAMIS
 DAFTAR PASIEN RAWAT INAP PKM
PESERTA PROGRAM JAMINAN KESEH
BULAN MEI 2015

NO NAMA PASIEN NO KARTU PESERTA ALAMAT NO TELP DIAGNOSA

1 DEDE SAEPUDIN oooo441752916 CIAWITALI o85221032257 CHF

2 ALINA ANJANI ooo1247422972 PASIRTAMIANG KEJANG DEMAM
3 HAIDAR ALI AS SHIDIQ ooo1300196632 SUMBERJAYA DIARE+ DEHIDRASI
5 POPON oooo440026536 CIGOROWONG o87888274004 GEA
6 ICIH oooo440948542 PASIRTAMIANG LANDEUH o85793722690 HIPERTENSI GRADE II+ SD
7 ENAH MAEMUNAH oooo441738786 PAMOKOLAN o87710331910 DIARE AKUT
8 ELI MARLINA oooo440918886 PAMOKOLAN DIABETES MILETUS
9 WARDI ooooo71032937 SUKAHURIP o85223027126 HIPERTENSI+STROKE RINGAN

10 SITI FATIMAH oooo441094241 CIKALAPA o87826732621 THYPOID

11 OJO SUTARJO oooo440461271 SUKAMAJU STROKE+HIPERTENSI GRADE II
12 AHMAD oooo441171393 CIAWITALI o82316068322 DIARE AKUT+ DEHIDRASI
13 KUSTIWA oooo440496404 KERSAMENAK o85321827775 GEA
14 E. JAELANI ooo1247423354 CIJULANG o8962470006 THALASEMIA+CEPHALGIA
15 TOTO oooo440982279 SUKAHURIP SYNDROMA DISPEPSIA
16 TUTI ooooo70331984 BEBEDAHAN, RAJAPOLAH o81909747480 GEA
17 NANI SYABANIAH oooo172887232 DESA TENGAH HIPERTENSI GRADE II
19 EDI SUHENDRAWAN oooo440859273 NANGGELA KIDUL o82320145411 SINDROMA DISPEPSIA+TB PA
20 WAWAN oooo441606969 PADAMULYA THYPOID
21 M ALGHIFFARY PUTRA ooo1310014912 DESA TENGAH o81221468365 THYPOID
AR PASIEN RAWAT INAP PKM CIHAURBEUTI
A PROGRAM JAMINAN KESEHATAN NASIONAL
BULAN MEI 2015

JUMLAH BESARAN JUMLAH

TANGGAL JUMLAH
TINDAKAN YANG DIBERIKAN TANGGAL KELUAR HARI TARIF SELURUH
MASUK TAGIHAN
RAWAT PAKET TAGIHAN
PAKET RITP
O2, INF RL, 30/04/2015 05/05/2015 5 100,000 500,000 500,000
O2, INF RL, 07/05/2015 09/05/2015 2 100,000 200,000 200,000
INF RL 14/05/2015 16/05/2015 2 100,000 200,000 200,000
INF RL 04/05/2015 07/05/2015 3 100,000 300,000 300,000
inf rl 02/05/2015 05/05/2015 3 100,000 300,000 300,000
INF RL, 30/04/2015 03/05/2015 3 100,000 300,000 300,000
INF RL, CEK LAB (HB,) COLESTROL, 27/04/2015 02/05/2015 5 100,000 500,000 500,000

INF RL, O2, GDS 13/05/2015 18/05/2015 5 100,000 500,000 500,000

INF RL 18/05/2015 23/05/2015 5 100,000 500,000 500,000

INF RL,O2 26/05/2015 26/05/2015 0 100,000 - -
INF RL, 27/05/2015 30/05/2015 3 100,000 300,000 300,000
INF RL 10/05/2015 12/05/2015 2 100,000 200,000 200,000
INF RL, 07/05/2015 10/05/2015 3 100,000 300,000 300,000
INF RL, 09/05/2015 12/05/2015 3 100,000 300,000 300,000
INF RL 08/05/2015 12/05/2015 4 100,000 400,000 400,000
INF RL 18/05/2015 19/05/2015 1 100,000 100,000 100,000
INF RL 28/05/2015 31/05/2015 3 100,000 300,000 300,000
INF RL, CEK LAB (HEMRUT), WIDAL 28/05/2015 31/05/2015 3 100,000 300,000 300,000
INF RL 26/05/2015 27/052015 1 100,000 100,000 100,000
56 TOTAL 5,600,000 5,600,000

Cihaurbeuti, Januari 2015

Kepala UPTD PKM Ciharubeuti

HERMAWAN, SKM
NIP. 19631020 198803 1 003
 keterangan

rujuk RSU Ciamis

 DAFTAR PASIEN RAWAT INAP PKM CIHA
PESERTA PROGRAM JAMINAN KESEHATA
BULAN MEI 2015

NO NAMA PASIEN NO KARTU PESERTA ALAMAT NO TELP DIAGNOSA

1 DEDE SAEPUDIN oooo441752916 CIAWITALI o85221032257 CHF

2 ALINA ANJANI ooo1247422972 PASIRTAMIANG KEJANG DEMAM
3 HAIDAR ALI AS SHIDIQ ooo1300196632 SUMBERJAYA DIARE+ DEHIDRASI
4 KIYAN DARMAWAN oooo440391374 BOJONG
5 POPON oooo440026536 CIGOROWONG o87888274004 GEA
6 ICIH oooo440948542 PASIRTAMIANG LANDEUH o85793722690 HIPERTENSI GRADE II+ SD
7 ENAH MAEMUNAH oooo441738786 PAMOKOLAN o87710331910 DIARE AKUT
8 ELI MARLINA oooo440918886 PAMOKOLAN DIABETES MILETUS
9 WARDI ooooo71032937 SUKAHURIP o85223027126 HIPERTENSI+STROKE RINGAN

10 SITI FATIMAH oooo441094241 CIKALAPA o87826732621 THYPOID

11 OJO SUTARJO oooo440461271 SUKAMAJU STROKE+HIPERTENSI GRADE II
12 AHMAD oooo441171393 CIAWITALI o82316068322 DIARE AKUT+ DEHIDRASI
13 KUSTIWA oooo440496404 KERSAMENAK o85321827775 GEA
14 E. JAELANI ooo1247423354 CIJULANG o8962470006 THALASEMIA+CEPHALGIA
15 TOTO oooo440982279 SUKAHURIP SYNDROMA DISPEPSIA
16 TUTI ooooo70331984 BEBEDAHAN, RAJAPOLAH o81909747480 GEA
17 NANI SYABANIAH oooo172887232 DESA TENGAH HIPERTENSI GRADE II
18 ENCE WASLI oooo440730911
19 EDI SUHENDRAWAN oooo440859273 NANGGELA KIDUL o82320145411 SINDROMA DISPEPSIA+TB PA
20 WAWAN oooo441606969 PADAMULYA THYPOID
21 M ALGHIFFARY PUTRA ooo1310014912 DESA TENGAH o81221468365 THYPOID
PASIEN RAWAT INAP PKM CIHAURBEUTI
OGRAM JAMINAN KESEHATAN NASIONAL
BULAN MEI 2015

JUMLAH BESARAN JUMLAH

TANGGAL TANGGAL JUMLAH
TINDAKAN YANG DIBERIKAN HARI TARIF SELURUH
MASUK KELUAR TAGIHAN
RAWAT PAKET TAGIHAN
PAKET RITP
O2, INF RL, 30/04/2015 05/05/2015 5 100,000 500,000 500,000
O2, INF RL, 07/05/2015 09/05/2015 2 100,000 200,000 200,000
INF RL 14/05/2015 16/05/2015 2 100,000 200,000 200,000
INF RL 18/05/2015 20/05/2015 2 100,000 200,000 200,000
INF RL 04/05/2015 07/05/2015 3 100,000 300,000 300,000
inf rl 02/05/2015 05/05/2015 3 100,000 300,000 300,000
INF RL, 30/04/2015 03/05/2015 3 100,000 300,000 300,000
INF RL, CEK LAB (HB,) COLESTROL, 27/04/2015 02/05/2015 5 100,000 500,000 500,000

INF RL, O2, GDS 13/05/2015 18/05/2015 5 100,000 500,000 500,000

INF RL 18/05/2015 23/05/2015 5 100,000 500,000 500,000

INF RL,O2 26/05/2015 26/05/2015 0 100,000 - -
INF RL, 27/05/2015 30/05/2015 3 100,000 300,000 300,000
INF RL 10/05/2015 12/05/2015 2 100,000 200,000 200,000
INF RL, 07/05/2015 10/05/2015 3 100,000 300,000 300,000
INF RL, 09/05/2015 12/05/2015 3 100,000 300,000 300,000
INF RL 08/05/2015 12/05/2015 4 100,000 400,000 400,000
INF RL 18/05/2015 19/05/2015 1 100,000 100,000 100,000
100,000 - -
INF RL 28/05/2015 31/05/2015 3 100,000 300,000 300,000
INF RL, CEK LAB (HEMRUT), WIDAL 28/05/2015 31/05/2015 3 100,000 300,000 300,000
INF RL 100,000 - -
57 TOTAL 5,700,000 5,700,000

Cihaurbeuti, Januari 2015

Kepala UPTD PKM Ciharubeuti

HERMAWAN, SKM
NIP. 19631020 198803 1 003
 keterangan

rujuk RSU Ciamis

 DAFTAR PASIEN RAWAT INAP PKM CIHA
PESERTA PROGRAM JAMINAN KESEHATA
BULAN JUNI 2015

NO NAMA PASIEN NO KARTU PESERTA ALAMAT NO TELP DIAGNOSA

1 AMAD oooo440330321 SOMPOK CHF

2 AGUS EMAN oooo439514199 BUNIASIH LANDEUH o8568548838 HIPERTENSI GRADE II
3 ESIH ooo1006155246 CIAWITALI o87826878791 SYNDROMA DISPEPSIA
4 SIDIQ ALI MUQRAM oooo440243436 SUKAHURIP o85323588502 SYNDROMA DISPEPSIA + ISPA
5 AZIS oooo440172674 PASIRTAMIANG SYNDROMA DISPEPSIA
6 AE oooo441379787 CIAWITALI o87767924430 GEA
7 YUNINGSIH oooo158758839 BAKETRAK
8 RIKI CAHYANA oooo435987617 TANJUNG JAYA o85939595031
9 UAS oooo440169614 CITUNGKU o87826361448
10 YULI LEVI HERAWATI ooooo70971827 SINDANGRASA o85210791073
11 AI JUHROH oooo441575897 KERTASARI o85353087727
12 YATI oooo440511568 KERTASARI o85222386765
13 DEDAH oooo440314727 DUSUN DESA o81312932436
14 ELON oooo440851781 NANGGELA o82240289006
15 H ADE MUBAROK ooo1080338747 CIKALAPA
16 NANI ooo1006152243 PASIRTAMIANG
17
18
19
20
21
PASIEN RAWAT INAP PKM CIHAURBEUTI
OGRAM JAMINAN KESEHATAN NASIONAL
BULAN JUNI 2015

JUMLAH BESARAN JUMLAH

TANGGAL TANGGAL JUMLAH
TINDAKAN YANG DIBERIKAN HARI TARIF SELURUH
MASUK KELUAR TAGIHAN
RAWAT PAKET TAGIHAN
PAKET RITP
INF RL, 30/06/2015 03/06/2015 4 100,000 400,000 400,000
INF RL, 31/05/2015 04/06/2015 4 100,000 400,000 400,000
INF RL, 09/05/2015 10/06/2015 1 100,000 100,000 100,000
INF RL, 09/06/2015 12/06/2015 3 100,000 300,000 300,000
INF RL, 10/06/2015 11/06/2015 1 100,000 100,000 100,000
INF RL, 08/06/2015 10/06/2015 2 100,000 200,000 200,000
INF RL, 03/06/2015 04/06/2015 1 100,000 100,000 100,000
INF RL, 12/06/2015 13/06/2015 1 100,000 100,000 100,000
INF RL, 09/06/2015 12/06/2015 3 100,000 300,000 300,000
INF RL, 03/06/2015 06/06/2015 3 100,000 300,000 300,000
INF RL, 05/06/2015 06/06/2015 1 100,000 100,000 100,000
INF RL, 02/06/2015 03/06/2015 1 100,000 100,000 100,000
INF RL, 30/06/2015 01/06/2015 2 100,000 200,000 200,000
INF RL, 05/06/2015 07/06/2015 2 100,000 200,000 200,000
INF RL, 05/06/2015 05/06/2015 0 100,000 - -
01/06/2015 06/06/2015 5 100,000 500,000 500,000
100,000 - -
100,000 - -
100,000 - -
100,000 - -
100,000 - -
34 TOTAL 3,400,000 3,400,000

Cihaurbeuti, Januari 2015

Kepala UPTD PKM Ciharubeuti

HERMAWAN, SKM
NIP. 19631020 198803 1 003
keterangan
 DAFTAR PASIEN RAWAT INAP PKM CIHAURBEUTI
PESERTA PROGRAM JAMINAN KESEHATAN NASIONAL
BULAN JULI 2017

TINDAKAN YANG TANGGAL TANGGAL BESARAN TARIF JUMLAH JUMLAH SELURUH

NO NAMA PASIEN NO KARTU PESERTA ALAMAT NO TELP DIAGNOSA keterangan
DIBERIKAN MASUK KELUAR PAKET TAGIHAN PAKET TAGIHAN
RITP
1 EMEN OOOO435440992 CISAYONG MELENA + ANEMIA INFUS RL 7/30/2017 7/31/2017 1 200,000 200,000 200,000
2 DEZAN MUHAMMAD S OOOO440895047 SINDANGKASIH DIARE INFUS RL, 7/30/2017 7/31/2017 1 200,000 200,000 200,000
3 RENA RUSMAYANTI OOO1006150026 SUMBERJAYA GASTRITIS INFUS RL 7/28/2017 7/30/2017 2 400,000 400,000 400,000
4 NANI SUMARNI OOOO440640887 BOJONG GASTRITIS INFUS RL, 7/26/2017 7/31/2017 5 1,000,000 1,000,000 1,000,000
5 PATIMAH OOOO440496459 KERSAMENAK GASTRITIS INFUS RL, 7/25/2017 7/27/2017 2 400,000 400,000 400,000
6 DEDAH OOOO441511672 PASAJEN DIARE (GEA) INFUS RL, 7/25/2017 7/27/2017 2 400,000 400,000 400,000
7 AISAH OOOO199433171 PASIRTAMIANG PAIN/ABDOMEN INFUS RL, 7/24/2017 7/25/2017 1 200,000 200,000 200,000
8 NESIH OOOO441152807 TANJUNG ASIH GEA INFUS RL, 7/24/2017 7/26/2017 2 400,000 400,000 400,000
9 EUIS SRININGSIH OOOOO70214499 MANGUNJAYA HIPERTENSI INFUS RL, 7/23/2017 7/25/2017 2 400,000 400,000 400,000
10 TOMO OOOOO71660935 PAMOKOLAN HIPERTENSI INFUS RL, 7/23/2017 7/25/2017 2 400,000 400,000 400,000
11 ACAH OOOO441399846 DESA KIDUL HIPERTENSI INFUS RL, 7/22/2017 7/24/2017 2 400,000 400,000 400,000
12 ENAH OOOO441522595 TENJOLAYA GASTRITIS INFUS RL, 7/22/2017 7/24/2017 2 400,000 400,000 400,000
13 JOJO OOO1006139125 LENGKOB HEADCH INFUS RL, 7/22/2017 7/25/2017 3 600,000 600,000 600,000
14 REHANA MAHADEWI OOO1247422926 PASIRTAMIANG THYPOID INFUS RL, 7/22/2017 7/24/2017 2 400,000 400,000 400,000
15 LINDA BAHTIAR OOO1872529266 SUKASETIA GASTRITIS INFUS RL, 7/22/2017 7/24/2017 2 400,000 400,000 400,000
16 MUMUN CAMUN OOOO440038394 KERTASARI DM INFUS RL, 7/21/2017 7/23/2017 2 400,000 400,000 400,000
17 NENENG SETIASIH OOOO441024783 DUSUN DESA DM INFUS RL, 7/18/2017 7/19/2017 1 200,000 200,000 200,000
18 AMAD OOOO440285984 BUNIASIH FEVER INFUS RL, 7/17/2017 7/18/2017 1 200,000 200,000 200,000
19 ISAH OOOO439949619 SELAJAMBE VERTIGO INFUS RL, 7/15/2017 7/17/2017 2 400,000 400,000 400,000
20 KOKOY OOOO441312581 CIGARUNGGANG GEA INFUS RL, 7/15/2017 7/17/2017 2 400,000 400,000 400,000
21 DHIKA ANGGA RN OOOO440691838 PASIRTAMIANG THYPOID INFUS RL, 7/14/2017 7/17/2017 3 600,000 600,000 600,000
22 OON NURAIDAH OOOO441645309 BOJONG GEA INFUS RL, 14/17/2017 7/17/2017 3 600,000 600,000 600,000
23 IPAH PATIMAH OOOO441773504 PASIRTAMIANG GEA INFUS RL, 7/14/2017 7/16/2017 2 400,000 400,000 400,000
24 ESIH OOO1006155246 CIAWITALI DIARE AKUT INFUS RL, 7/14/2017 7/16/2017 2 400,000 400,000 400,000
25 ENTIN SURYANI OOOO440777114 KERTASARI GASTRITIS INFUS RL, 7/13/2017 7/17/2017 4 800,000 800,000 800,000
26 ACENG OOOO436536167 PETEUY NUNGGAL GEA INFUS RL, 7/12/2017 7/15/2017 3 600,000 600,000 600,000
27 SUKMI OOOO441500122 JENGKOL PANDAK FEVER INFUS RL, O9/O7/2O17 11/O7/2O17 2 400,000 400,000 400,000
28 SITI ALISA OOOO44OO21667 PASIR LANDAK PEBRIS INFUS RL, 7/6/2017 7/11/2017 3 600,000 600,000 600,000
29 DINI INAYAH OOOO44O762488 KERTANASARI PEBRIS INFUS RL, 7/8/2017 7/12/2017 4 800,000 800,000 800,000
30 OHAN OOOO44O528635 PASIR LANDAK HIPERTENSI,DISPEPSIA INFUS RL, 7/7/2017 7/10/2017 3 600,000 600,000 600,000
31 MARFU PURNAMA OOO2214000700 CIJOHO DEMAM,THYPOID INFUS RL, 7/7/2017 7/10/2017 4 800,000 800,000 800,000
32 YURIMAWANTI OOOO44O226415 DEPOK FEVER INFUS RL, 7/6/2017 7/10/2017 4 800,000 800,000 800,000
33 AAN GUNAWAN OOO2080341721 CIAWITALI ASMA INFUS RL, 7/6/2017 7/7/2017 1 200,000 200,000 200,000
34 ROSID OOOO440524034 PAMOKOLAN ASTHMA INFUS RL, 7/5/2017 7/7/2017 1 200,000 200,000 200,000
35 RESTI SANIYATI OOO1006152581 PASIRTAMIANG ISPA INFUS RL, 7/5/2017 7/8/2017 3 600,000 600,000 600,000
36 ENTIN HERNAWATI OOO1855867037 DESA KIDUL CARDIVAS,ASMA INFUS RL, 7/5/2017 7/7/2017 2 400,000 400,000 400,000
37 INEN NENGSIH OOO191231O662 CIJULANG GASTRITIS INFUS RL, 7/5/2017 7/7/2017 2 400,000 400,000 400,000
38 NANI SUMARNI OOOO44O64O887 BOJONG GASTRITIS INFUS RL, 7/4/2017 7/6/2017 2 400,000 400,000 400,000
39 TENI OOO22O2414748 PAMOKOLAN GASTRITIS,VERTIGO INFUS RL, 7/4/2017 7/6/2017 2 400,000 400,000 400,000
40 EEN DANIATI AM KEP OOOOO71492253 CIJAMBAN GATRITIS INFUS RL, 7/3/2017 7/5/2017 2 400,000 400,000 400,000
41 BADRUN OOOO44O642125 PASIRTAMIANG FEBRIS INFUS RL, 7/3/2017 7/5/2017 2 400,000 400,000 400,000
42 UBED ISKANDAR OOO167O5O2431 NANGGELA HIPERTENSI INFUS RL, 7/3/2017 7/7/2017 4 800,000 800,000 800,000
43 WARTI OOOO44O478887 CIPEUCEUK GASTRITIS INFUS RL, 7/2/2017 7/4/2017 2 400,000 400,000 400,000
44 FIRDAWATI OOO16666379958 SUMBERJAYA VERTIGO INFUS RL, 7/2/2017 7/4/2017 2 400,000 400,000 400,000
45 RASTI RIYADUL BADIAH OOO2231195253 PAMOKOLAN VOMITUS INFUS RL, 7/2/2017 7/4/2017 2 400,000 400,000 400,000
46 ENTING OOOO44O531368 BUNIASIH GASTRITIS INFUS RL, 7/1/2017 7/3/2017 2 400,000 400,000 400,000
47 DENI RAMDANI OOOO4417227OO PADAMULYA FEVER INFUS RL, 7/1/2017 7/5/2017 4 800,000 800,000 800,000
48 SAADAH OOOO441154146 DUSUN DESA GASTRITIS INFUS RL 7/28/2017 7/30/2017 2 400,000 400,000 400,000
49 EUIS KOMARIAH OOOO44635239 PAMOKOLAN GRAVIDARUM INFUS RL 7/19/2017 7/23/2017 4 800,000 800,000 800,000
50 SRI RAHAYU OOOO43993418 DESA KALER GRAVIDARUM INFUS RL 7/23/2017 7/25/2017 2 400,000 400,000 400,000
51 ELSA NURHAYATI OOOO435865678 TONJONG GASTRITIS INFUS RL 7/30/2017 7/31/2017 1 200,000 200,000 200,000
52 JUMLAH 118 23,600,000 23,600,000 23,600,000
53
54
55
56
57
58
59
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