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FORMULIR PENGAJUAN JAMKESDA RAWAT JALAN UPT PUSKESMAS KECAMATAN RAAS PONKESDES DESA POTERAN Bulan Februari 2018 No

FORMULIR PENGAJUAN JAMKESDA RAWAT JALAN UPT PUSKESMAS KECAMATAN RAAS PONKESDES DESA POTERAN Bulan Februari 2018

FORMULIR PENGAJUAN JAMKESDA RAWAT JALAN UPT PUSKESMAS KECAMATAN RAAS PONKESDES DESA POTERAN Bulan Februari 2018 No

No

Tanggal

No.KTP/KK/SPM

Nama Penderita

Jenis Kelamin

Umur

Alamat

Diagnosa

Code ICD

Tindakan

Karcis

Biaya

Total

X

Masuk

Tindakan

 
  • 1 1/2/2018

3529220606700000

Qosim

L

 
  • 47 Rematoid

Poteran

 

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 2 1/2/2018

3529224208880000

Radiya

p

 
  • 23 Ispa

Poteran

 

J 06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 3 2/2/2018

3529225610860000

Rafika

p

 

Guru

  • 24 Rematoid

 

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 4 3/2/2018

3529222003670000

Rahman

L

 
  • 38 Rematoid

Poteran

 

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 5 5/2/2018

3529224211450000

Sumaena

P

 

Lembena

  • 53 Rematoid

 

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 6 6/2/2018

3529224105520000

Mohra

L

 
  • 47 Rematoid

Poteran

 

M

07

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 7 7/2/2018

3529224107600080

Asnami

P

 

Guru

  • 43 HT

 

I109

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 8 7/2/2018

3529225005850000

Nur aini

p

 

Guru

  • 56 Batuk

 

R06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 9 8/2/2018

3529226103880000

Nur halima

p

 

Lembena

  • 53 Rematoid

 

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 10 9/2/2018

3529225012810000

Puaton

p

 

Lembena

  • 44 GEA

 

A 09

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 11 10/2/2018

3529221412620000

Sawiha

P

 

Mantok

  • 37 Rematoid

 

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 12 10/2/2018

3529225309560000

Muhliya

P

 
  • 28 Gastritis

Poteran

 

K 29

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 13 12/2/2018

3529225502750000

Nariya

P

 
  • 43 Gastritis

Poteran

 

K 29

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 14 13/2/2018

3529225906470000

Hj.suhyani

P

 

Guru

  • 45 HT

 

I109

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 15 15/2/2018

3529226204780000

rahmat

L

 

Guru

  • 53 Ispa

 

J 06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 16 16/2/2018

3529224409560000

marhamah

p

 
  • 47 Gastritis

Poteran

 

K 29

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 17 17/2/2018

3529225809760000

apsani

p

 

Mantok

  • 43 Batuk

 

R05

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 18 17/2/2018

3529221208900000

misnari

L

 

Guru

  • 56 Rematoid

 

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 19 19/2/2018

3529224508720000

masyuni

p

 
  • 53 Rematoid

Poteran

 

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 20 19/2/2018

3529225302650000

rahmani

p

 

Lembena

  • 42 Rematoid

 

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 21 20/2/2018

3529224846900000

suna

p

 

Guru

  • 36 Gastritis

 

K 29

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 22 20/2/2018

3529224211450000

Sumaena

P

 

Lembena

  • 42 Gastritis

 

K 29

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 23 21/2/2018

3529224105520000

Mohra

L

 
  • 38 Rematoid

Poteran

 

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 24 22/2/2018

3529224107600080

Asnami

P

 
  • 42 Karang

Rematoid

M

07

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 25 23/2/2018

3529225807660000

Akma

P

 
  • 48 Karang

Asma

J450

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 26 23/2/2018

3529225411650000

Mesna

P

 
  • 47 Guru

Gastritis

K 29

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 27 24/2/2018

3529226204780000

rahayu

p

 
  • 41 Poteran

Rematoid

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 28 25/2/2018

3529225108670000

juhairia

p

 
  • 53 Guru

Gastritis

K 29

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 29 25/2/2018

3529221408600000

nawar

L

 
  • 42 Mantok

Gastritis

K 30

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 30 26/2/2018

3529220405680000

akmo

L

 
  • 45 Poteran

Gastritis

K 29

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 31 27/2/2018

3529224311750000

misri

L

 
  • 20 Karang

Rematoid

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 32 28/2/2018

3529222008660000

aksan

L

 
  • 43 Guru

Rematoid

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 33 28/2/2018

3529225309560000

Muhliya

p

 
  • 30 Poteran

Rematoid

M

06

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

 
  • 34 31/1/2018

3529224510830000

asmani

p

 
  • 43 Poteran

Rematoid

M

81

Injeksi, obat oral

Rp7,500

Rp1,000

Rp8,500

Mengetahui Kepala Puskesmas Raas

H.Hermanto.S.Kep NIP 19690717 199003 1 007

Raas, 28 Februari 2018 Penanggung jawab Ponkesdes

Retno Joni Heri Andika Amd.Kep

NITKA : 35290410099