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  • Data Offline Surveilans PTM Berbasis FKTP: Tanggal

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    Uswatun Hasanah
    13 views9 pages
    This document appears to be a template for collecting patient data offline through surveilans based on ID cards. It includes fields for collecting identifying information like name, ID number, date of birth, address, as well as medical information like medical history number, blood pressure, blood sugar, cholesterol, diagnoses, medical tests, and referrals. It also includes dropdown menus for collecting additional details like marital status, occupation, blood type, and medical history responses.

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    formFKTP

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    Print Offline Fktp

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    This document appears to be a template for collecting patient data offline through surveilans based on ID cards. It includes fields for collecting identifying information like name, ID number, date of birth, address, as well as medical information like medical history number, blood pressure, blood sugar, cholesterol, diagnoses, medical tests, and referrals. It also includes dropdown menus for collecting additional details like marital status, occupation, blood type, and medical history responses.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    13 views9 pages

    Data Offline Surveilans PTM Berbasis FKTP: Tanggal

    Uploaded by

    Uswatun Hasanah
    This document appears to be a template for collecting patient data offline through surveilans based on ID cards. It includes fields for collecting identifying information like name, ID number, date of birth, address, as well as medical information like medical history number, blood pressure, blood sugar, cholesterol, diagnoses, medical tests, and referrals. It also includes dropdown menus for collecting additional details like marital status, occupation, blood type, and medical history responses.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 9

    Data Offline Surveilans PTM berbasis FKTP

    IDENTITAS

    No Tanggal* No Rekam JK * Tempat Tanggal Lahir


    No KTP * Nama Pasien * Alamat Lengkap *
    Medis Lahir *

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    xxx xxx xxx xxx xxx xxx xxx xxx xxx
    WAWANCARA IMT Tekanan Darah Gula Darah

    Kura
    Kura ng Kons
    ng Gula Gula
    Gol Mer Aktiv Mak umsi No Tinggi Berat Lingkar
    No HP Status Suku Pekerjaan Sistol Diastol Darah Darah
    Dar okok an Alko Badan Badan Perut
    itas Sayu hol Sewaktu Puasa
    Fisik r

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    xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx
    Kolesterol DIAGNOSA Pemeriksaan Penunjang

    Benjola
    n
    Kolester Trigliseri Abnor Krioter Darah Urin Rutin &
    LDL HDL IVA Diagnosa 1 Diagnosa 2 EKG Radiologi
    ol Total da mal api Lengkap Mikroskopik
    Payuda
    ra
    xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx
    Dirujuk

    id nama kode
    0
    1 Kanker Payudara C50
    2 Diabetes Militus Tipe 2 E11
    3 Asma Bronchiale J45
    4 Hipertensi I10
    5 Jantung Koroner I24.0
    6 Gagal Jantung I50
    7 Obesitas E66
    8 Tiroid E00
    9 Stroke I64
    11 PPOK J44
    12 Osteoporosis M81
    13 Ginjal Kronik N00-N19
    14 Thalasemia D56
    15 Lupus/SLE M32
    16 Retinoblastoma C69
    17 Leukimia C91-C95
    18 Kanker Serviks C53
    19 Cedera Akibat KLL V01-V99
    20 Cedera Akibat Kekerasan X60-Y09
    21 Cedera Akibat Jatuh W00-X59
    22 Diabates Militus Tipe 1 E10
    23 Diabates Militus Gestasional O24
    24 Hipotiroid E03
    25 Hipertiroid E05
    26 Kanker Kolorektal D12
    27 Hipertropi Prostat
    28 Cedera Akibat Terbakar X00-X19
    29 Cedera Akibat Tenggelam W65-W74
    30 Cedera Akibat Keracunan X40-X49
    31 Cedera Akibat Digigit Ular X20-X29
    32 Rematoid Artritis M05.9
    33 Psoriasis Fulgaris L40.0
    34 Glaukoma H40-H.42
    35 OMSK H.66
    36 Gangguan Refraksi H.52
    37 DM-TB
    38 Serumen Prop H.61.2
    39 Katarak H25.2
    40 NIHL H.93
    41 Presbicusis H.93
    42 Tuli Kongenital H.93
    xxx
    Pertanyaan Umum
    No Pilihan Jawaban
    1 Ya Buruk
    2 Tidak Normal

    No Pilihan Jawaban
    1 Positif Ditemukan
    2 Negatif Tidak Ditemukan

    Gol darah
    1 A
    2 B
    3 AB
    4 O
    5

    Status
    1 Menikah
    2 Belum
    3 Janda/Duda
    4

    Pekerjaan
    1 TNI/POLRI
    2 Karyawan Swasta
    3 Pegawai Negeri Sipil
    W74 4 IRT/Tidak Bekerja
    5 Petani
    6 Pedagang
    7 Nelayan
    8 Pendidik
    9 Pengemudi
    10 Buruh
    11 Lainnya
    12

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