DAFTAR KLAIM PELAYANAN PASIEN RAWAT JALAN UPT PUSKESMAS NGAWEN

MENURUT JENIS PELAYANAN DAN TINDAKAN

BULAN JANUARI TAHUN 2017

NO KARTU JENIS PENYAKIT /

NO NAMA PASIEN ALAMAT PASIEN NIK JUMLAH KLAIM
JAMKESDA / SKP DIAGNOSA
1 Siti Rodhotul Jannah Ds Gotputuk Rt 05 Rw 01 3316126912820000 Chepalgia
2 Sriyatun Kel.Punggursugih Rt 6 Rw 2 33162001379 Commond Cold
3 Nur Hadi Kel.Ngawen Rt 4 Rw 2 33162001813 Acute Periodontitis
4 Jayusman Kel.Ngawen Rt 4 Rw 1 33161412689 Kontrol Post Op
5 Juminah Kel.Ngawen Rt 1 Rw 3 33162002037 Hipertensi
6 Teguh Andriana Ds.Sambongrejo Rt 3 Rw 3 33162001847 Influenza
7 Muhammad Rendi R Ds.Srigading Rt 1 Rw 1 3316120110080003 Cough
8 Sarti Ds.Ngrambitan Rt 7 Rw 1 Japah 3316165108720001 b Myalgia
9 Eka LamaleaArmiati Ds.Trembulrejo Rt 1 Rw 1 3316104406090001 Cough
10 Sumarno Ds.Srigading Rt1 Rw 1 3316120201740001 Cough
11 Maulana Ahmad T Ds.Sendangmulyo Rt 3 RW 1 3316120710030004 Commond Cold
12 Hartini Kel.Ngawen Rt 2 Rw 5 3316149579 Cough
13 Siti Mutiati Ds.talokwohmojo Rt 2 Rw 2 33161414943 NIDDM
14 Mukminatun Ds.Semawur Rt 7 Rw 1 33161411695 Tremor Resting
15 Juwito Kel.Ngawen Rt 4 rw 6 33161414709 Hematemesis
16 Damiatun Ds.Kebonrejo Rt 4 Rw 3 Banjarejo 33161111713 Cough
17 Warsiti Ds.Berbak Rt 4 Rw 1 33161413375 Psikosomatis
18 Sulasmi Kel.Punggursugih Rt 1 Rw 1 33161411593 NIDDM
19 Sumarno Ds.srigading Rt 1 Rw 1 3316120201740001 Cough
20 Aga Aisha Syafani Kel.Ngawen Rt 2 Rw 1 3316125506080001 Anemia
21 Arzeldan Praja H Kel.Ngawen Rt 1 Rw 5 331612015160001 Obs.Febris
22 Sunari ds.Sendangmulyo Rt 2 Rw 3 33161411708 Cephalgia
23 Sarti Ds.Sambongrejo Rt 3 Rw2 435893000302069 Cephalgia
24 Supartik Ds.Sarimulyo Rt 2 Rw 2 33162001824 NIDDM
25 Sujatmiko Ds.semndangmulyo Rt 3 Rw 2 33161411027 Eksim
26 M Lutfi Nuril H Ds.Nglempung Rt 1 Rw 3 Banjarejo 3316112109140001 Obs.Febris
27 Suwarni Ds.Talokwohmojo Rt 2 Rw 2 3316124102720002 Hipotensi
28 Susmiati Ds.Gotputuk 33162002308 Gangguan Refraksi
29 Sumarni Kel.Punggursugih Rt 7 Rw 3 3316146617 Schizophrenia
30 Budi Suryono Ds.Sumberejo Rt 1 Rw 3 33161414547 TB Paru
31 Sri yatun Kel.Punggursugih Rt 6 Rw 2 33162001379 Depresi
32 Patri Ds.Plumbon Rt 1 Rw 3 3316124107670067 Otitis Eksterna
33 Sumarni Ds.Kedungringin Rt 3 Rw 1 Tunjungan 3316104110770001 Necrosis of pulp
34 Pik Asri Ds.Gondang Rt 1 Rw1 3316125507800005 Obs.Poliuri
35 M.Muhsin Ds.Sarimulyo 33161415103/17 Fraktur Ankebrata
36 Maria Suprapti Kel.Ngawen Rt 1 Rw 3 33162002474 Myalgia
37 Ria Wulaningrum Ds.Semawur 33161414383 Obs.Febris
38 Sujono Ds.Sambongrejo Rt 4 Rw 2 33162002041 Commond Cold
39 Tarni Ds.Sarimulyo 33161415126 Paronichra
40 Ernawati Ds.Srigading 33161414551 Gingival Recession
41 Siti Khomariatun Ds.Bogowanti Rt 2 Rw 1 33161413348 ANC
42 Siti Aminah Ds.Srigading 33161114655 ANC
43 Alif Pratama Putra Kel.Ngawen Rt 1 Rw 6 3316123012100002 Stomatitis
44 Warsini Kel.Ngawen Rt 5 Rw 7 3316127112540004 TB Paru
45 Widodo Ds.Sambongrejo 33161415157/17 Hemoroid
46 Tarni Ds.Sarimulyo 33161415126/17 Paronichra
47 Jastri Ds.Semawur Rt 9 Rw 2 33161412850/16 Asma
48 Habib Maulana A Kel.Punggursugih Rt 1 Rw 1 3316201357 Nefrotic Syndrome
49 Supartik Ds.Sarimulyo Rt 2 Rw 2 33162001824 ISPA
50 Suparjan Ds.Sarimulyo Rt 3 rw 1 33161410007/16 Post Op Tiroid
51 Kunsiah Ds.Semawur Rt 4 Rw 1 3316124208470001 Hipercholesterol
52 Sri Leswati Kel.Ngawen Rt 1 Rw 1 3316126903710001 Abses
53 Audika Pratam Putra Kel.Ngawen Rt 3 Rw 7 3316120301090001 Obs.Febris
54 Bella Graseva Kel.Punggursugih Rt 4 Rw 2 3316149006/16 Influenza
55 Yeni Novitasari Ds.Klokah,Kunduran 33161515172/17 ANC
56 Parti Ds.Sambomgrejo 33162001431 Diare
57 Mubadiah Ds.Sendangmulyo 33161215074/17 ANC
58 Kustinah Kel.Ngawen Rt 2 Rw 6 3316125802540000 Commond Cold
59 Muhammad Naufal F Ds.Pengkolrejo Rt 4 Rw 2 3316161312110001 Alergi
60 Sulasi Ds.Berbak Rt 4 Rw 1 3316124509420002 ISPA
61 Supartik Ds.sarimulyo Rt 2 Rw 2 33162001824 Hipertensi, DM
62 Hartini Kel.Ngawen Rt 2 Rw 5 3316149579/16 Cough
63 Ngasiran Ds.Tawangrejo Rt 7 Rw 1 Tunjungan 3316127525/15 ISPA
64 Yatmi Ds.Tawangrejo Rt 7 Rw 1 Tunjungan 331612000107 CC
65 Nyono Al nyoni Anun N Ds.Sarimulyo Rt 7 Rw 2 33161415045/17 Syndrome dyspepsia
66 Kasmini Ds.Sarimulyo Rt 6 Rw 2 33162014526 TB Paru
67 Sulasih Ds.Wantilgung Rt 2 Rw 1 3316141212/15 Cholesterol
68 Sumardi Ds.Trembulrejo 33161412855/16 Fraktur Femur
69 Zamroni Ds.Srigading 3316122603790003 Vulnus
70 Azza Vikniril Huda Ds.TalokwohmojoRt 6 Rw 4 3316121106140004 Obs.Febris, cough
71 Budi Suryono Ds.Sumberejo Rt 1 Rw 3 33161414547/16 TB Paru
72 Sarti Ds.Sambongrejo Rt3 Rw 2 4358300030206910 Syndrome dyspepsia
73 M.Fachreza M Ds.Sarimulyo Rt 1 Rw 2 3316201872 Commond Cold
74 Djikan Ds.Gondang Rt 3 Rw 2 33161414663/16 Dyspepsia
75 Tarsinah Ds.Bogowanti Rt 1 Rw 2 331614918/15 Anemia
76 Tarni Ds.Sarimulyo 33161415126/17 Paronichra
77 Kasmini Ds.Sarimulyo Rt 6 Rw 2 33162014526 TB Paru
78 Sumiyatun Ds.Wantilgung Rt 3 Rw 2 3316125108690003 Dermatitis
79 Muhammad Anwar N Ds.Sendangagung Rt 4 Rw 2 3316120804120002 Korpus Alienum
80 Rukiyem Ds.Tambahrejo, Tunjungan 3316104708760003 TTH
81 Mirah Ds.sarimulyo Rt 1 Rw 2 3316125404650007 Osteoartritis
82 Baydi Fahrul R Ds.Talokwohmojo Rt 6 Rw 1 3316147551/15 Schizophrenia
83 Sumiyatun Kel.Ngawen Rt 1 Rw 5 3316200146 Atralgia
84 Maryono Ds.Tawangrejo Rt 7 Rw 1 Tunjungan 331612000108 ISPA
85 Sarti Ds.Sambongrejo Rt 43 Rw 2 4358300030206910 Cough
86 Febry Ana Kel.Ngawen rt 3 Rw 6 33162002430 Influenza
87 Supartik Ds.Sarimulyo Rt 2 Rw 2 33162001824 DM, Hipertensi
88 Tarni Ds.Sarimulyo 33161415126/17 Paronichra
89 M. Khairunnizar Kel.Punggursugih Rt 8 Rw 3 3316122407060001 Cough
90 Shofaa Nurus S Ds.Semawur Rt 4 Rw 1 3316126411130002 Obs.Febris
91 Annisa Shobiya F Ds.Semawur Rt 7 Rw 1 3316126702160004 Obs.Febris
92 Mifza Hafiz Al Husain Ds.Kedungsatriyan Rt 6 Rw 1 3316122110160001 Cough
93 Yomi Ds.Kedungringin Rt 3 Rw 1 Tunjungan 3316106401810001 Dermatitis Alergia
94 Sulasi Ds.Berbak Rt 4 Rw 1 3316124509420002 Cough
95 Meindra Rahayu Kel.Ngawen Rt 1 Rw 5 3316126405940002 Influenza
96 Zamroni Ds.Srigading Rt 3 Rw 1 3316122603790003 Vulnus
97 A.Zainul M Ds.sambongrejo Rt 1 Rw 1 33161414813/16 BBP
 98 Siti Supakati Ds.Sambongrejo Rt 4 Rw 2 33162002054 Ischialgia
99 Budi Suryono Ds.Sumberejo Rt 1 Rw 3 33161414547/16 TB Paru
100 Salam Ds.Gotputuk Rt 7 Rw 1 33161415308/17 Dermatitis
101 Sutiah Ds.Bradag Rt 3 Rw 1 3316200371 Dermatitis Atopik
102 Dwi Kader rini Kel.Ngawen Rt 3 Rw 5 3316126209840003 ANC
103 Zuma'inah Kel.Ngawen Rt 1 Rw 6 3316126912650002 Low Back Pain
104 Ahmad Zainul Ammar Ds.Sendangrejo Rt 3 Rw 3 3316122402150002 Cough
105 Rininita Nofianti Kel.Ngawen Rt 1 Rw 1 3316125611110001 Diare
106 Salekun Ds.Adirejo,Tunjungan 331612000234 Obs Prostat BHP
107 Annisa Tri Sunarsih Kel.Ngawen Rt 1 Rw 7 33161415212/17 Anemia
108 Suwardi Ds.Semawur Rt 3 Rw 1 3316098792/16 Reumatik
109 Siti Marisah Ds.Semawur Rt 10 Rw 2 33161413231/16 HIV
110 Tarni Ds.Sarimulyo 33161415126/17 Paronichra
111 Siti Kartini Ds.Berbak Rt 4 Rw 1 33162002436 Gastritis
112 Ruslan Ds.Sarimulyo Rt 1 Rw 2 33161411162/16 Hipertensi
113 Marni Ds.wantilgung 33161411827/16 DM type II
114 Rumi Ds.Tawangrejo Rt 3 Rw 2 Tunjungan 3316105112590002 Influenza
115 Marsya Desi N Ds.Gondang Rt 1 Rw 1 3316127103070001 Influenza
116 Atsna Bahiya layali Ds.Sendangrejo Rt 1 Rw 4 3316126511120002 Dyspepsia
117 Dwi Santoso Ds.Srigading 33161415315/17 Trauma Mata
118 Suyatmi Ds.Sarimulyo 3316149992/16 Gastritis
119 Supartik Ds.sarimulyo 33162001824 Arthritis
120 Ahamad Zainul M Ds.Sambongrejo Rt 1 Rw 1 33161414813/16 Batuk Bukan pneumonia
121 Deni Maharanti Ds.Sendangrejo Rt 1 Rw 1 3316124603980001 TB Paru
122 Maryono Ds.Sarimulyo Rt 1 Rw 2 3316122909930001 ISPA
123 Ellen Yoga Arnikesari Ds .Ngrambitan Rt 2 Rw 1 Japah 3316165207970001 Karies gigi
124 Musriyati Ds.Semawur Rt 5 Rw 1 33161412231/16 ANC
125 Rusmiyati Ds.Semawur Rt 5 Rw 1 3316143499/16 Hipocolesterol
126 Parsi Ds.Berbak Rt 5 Rw 1 3316149696/16 Sindrom Dyspepsia
127 Sulasri Ds.Srigading Rt 7 Rw 2 33162002446 Cough
128 Painah Ds.Semawur Rt 12 Rw 2 33162001455 Gangguan Refraksi
129 Budi Suryono Ds.sumberejo Rt 1 Rw 3 33161414547/16 Vulnus
130 Siti Uswatun K Ds.Berbak Rt 4 Rw 1 33162002438 Obs.Febris
131 Sumiyatun Ds.Wantilgung Rt 3 Rw 2 3316125108690003 Dermatitis
132 Sri Wahyuni Ds.Sarimulyo Rt 1 Rw 2 3316124203090001 Obs.Febris
133 Siti Musafa'ah Ds.semawur Rt 3 Rw 1 3316124904630002 OMA
134 Siti Miftakhul Jannah Ds.Trembulrejo Rt 3 Rw 2 3316125611100001 Influenza
135 Ahmad Ilham Maulana Ds.Sarimulyo Rt 3 Rw 1 3316141373/16 Obs.Febris
136 Warisah Ds.Sambongrejo Rt 4 Rw 1 33162001893 Myalgia
137 Sudarmini Ds.Semawur 33161415392/17 Commond Cold
138 Muslimin Ds.sendangrejo 33161214993/16 Susp HIV
139 Djumiati Ds.Sarimulyo Rt 1 Rw 2 3316126803870001 Cough
140 Alif Pratama Putra Kel.Ngawen Rt 1 Rw 6 3316123012100002 Pharingitis
141 Sukma Khoiriyah Kel.Ngawen Rt 1 Rw 1 3316126404000001 ISPA
142 Sumarni Ds.Berbak Rt 5 Rw 1 3316125604760002 Hipertensi
143 Fadila Al Manur R Ds.Kedungsatriyan Rt 6 Rw 1 3316127106090001 Cabut gigi desidui
144 Lasiban Ds.Gondang Rt 3 Rw 2 3316120704550003 TB Paru
145 M. Ifza Hafiz Al Husain Ds.Kedungsatriyan Rt 6 Rw 1 3316122110160001 Cough
146 A.Afandi Kel.Ngawen Rt 1 Rw 1 33161414754/16 Kontrol Batu Ginjal
147 Sutarsih Ds.Plumbon Rt 1 Rw 2 33162002609 IDDM
148 Febry Ana Kel Ngawen Rt 3 Rw 6 33162002430 Obs.Febris
149 Saskia M Ds.Sendangrejo Rt 1 Rw 4 33161415433/17 Cough
150 Anisa Tri S Kel.Ngawen Rt 1 Rw 7 33161415212/17 Pharingitis
151 Bella Graseva Kel.Punggursugih Rt 4 Rw 2 3316149006/16 Obs.Febris
152 Lestari Ds.Bogowanti Rt 3 Rw 2 33161412938/16 Kontrol Post Op
153 Gawi Ds.Sarimulyo rt 4 Rw 2 435760040200297 NIDDM
154 Retno Astriani Ds.sarimulyo Rt 5 Rw 2 33161413664/16 ANC
155 Estik F Kel.Punggursugih Rt 8 Rw 3 33161415361/17 ANC
156 M.Royhanul M Ds.Sarimulyo Rt 4 Rw 2 33161200297 Susp.Tb
157 Sumiyatun Kel.Ngawen Rt 1 Rw 5 3316200146 Cough
158 Mulyono Ds.Bradag Rt 1 Rw 1 33161415409/17 Post Trauma Mata
159 Sumiyati Ds.Tengger Rt 4 Rw 2 3316164611620002 Gastritis
160 Raden Ahmad Kholil B Ds.Trembulrejo Rt 3 Rw 3 3522021707150001 Influenza
161 Reni Wijayanti Ds.Sambongrejo Rt 5 Rw 1 3316165903920002 ANC
162 Latifah Ds.Trembulrejo Rt 1 Rw 1 3316125212460001 Atralgia
163 Siti Maskanah Ds.Sendangagung Rt 1 Rw 2 3316124405760006 Influenza
164 Sutrisno Ds.Pengkolrejo Rt 1 Rw 1 3316161103770001 Commond Cold
165 Supartik Ds.Sarimulyo Rt 2 Rw 2 33162001824 DM
166 Supatmi Kel.Ngawen Rt 3 Rw 2 33161412520/16 Katarak
167 Tarni Ds.sarimulyo 33161415126/17 Atralgia
168 Warjiman Ds.sambongrejo Rt 2 Rw 2 33162011968 Kejang
169 Ngasiran Ds.Tawangrejo Rt 7 Rw 1 Tunjungan 3316127525/15 Bronchitis
170 Mariyono Ds.Tawangrejo Rt 7 Rw 1 Tunjungan 331612000108 Influenza
171 Sugianto Ds.sarimulyo Rt 1 Rw 2 33162002681 Syndrome dyspepsia
172 Jarum Ds.Gotputuk Rt 7 Rw 2 3316123112550069 35 Luxasi O3
173 A.Nizam Al Fatqi Ds.Sendangrejo Rt 1 Rw 1 3316147504/15 Obs.Febris
174 Karni Ds.Sarimulyo Rt 8 Rw 2 33162002010 DM
175 Maysaroh Ds.Trembulrejo 33161412531/16 Chepalgia
176 Siti Nur Halimah Ds.Semawur Rt 4 Rw 1 3316125808960003 ANC
177 Kenta Gista Kel.Ngawen Rt 1 Rw 6 3316126409010004 Obs.Febris
178 Deni Maharanti Ds.Sendangrejo Rt 1 Rw 1 3316124603980001 TB Paru
179 Warsini Kel.Ngawen Rt 5 Rw 7 3316127112540004 TB Paru
180 Hilda Zahrotul Ds. Trembulrejo Rt 2 Rw 1 331612002225 ISPA
181 Irma Noviana Kel Ngawen Rt 4 Rw 6 33161412841/16 Kontrol post Op Mandibula
182 Budi Suryono Ds.Sumberejo Rt 1 Rw 3 3316144547/16 TB Paru
183 Diyah Setiyorini Ngawen 33161414562/16 ANC
184 Sumiyatun Ds.Wantilgung Rt 1 Rw 5 3316125108690003 Dermatitis
185 Jofinka Emmanuella Kel.Ngawen Rt 2 Rw 5 3316127103090001 Myalgia
186 Caila Oktiva Ds.Sambongrejo Rt 5 Rw 2 3316127010060004 Scabies
187 Sumiyatun Kel.NgawenRt 3R w2 3316200146 Cerumen prop
188 Parsi Ds.Berbak Rt 5 Rw 1 3316149696/16 Gastritis
189 Hartini kel.Ngawen Rt 2 Rw 5 3316149579/16 Cough
190 Rachel P Ds.Trembul Rt 4 Rw 3 33161410272/16 Cough
191 Zanuba Ds.Semawur Rt 6 Rw 1 3316126404990001 Obs.Febris
192 Parwati Ds.Dologan Rt 2 Rw 1 Japah 3316166908900005 Karies gigi
193 M. Sobirin Ds.Dologan Rt 2 Rw 1 Japah 3316161202940005 Karies gigi
194 Parwi Ds.Berbak Rt 5 Rw 1 3316125507830005 Gastritis
195 Rawijah Ds.Kendayaan Rt 6 Rw 1 3316125207630003 Atralgia
196 Supuryati Ds.Berbak Rt 3 Rw 1 3316124201710004 Cephalgia
197 Aga Bachtiar Kel.Ngawen Rt 2 Rw 1 3316122208150002 Obs.Febris
198 Warjiman Ds.Sambongrejo Rt 2 Rw 2 33162011968 Bronchitis
199 Parti Ds.Sambongrejo Rt 13 Rw 2 33162001431 Bronchitis
200 Mariyono Ds.Tawangrejo Rt 7 Rw 1 Tunjungan 331612000108 Commond Cold
201 Ngasiran Ds.Tawangrejo Rt 7 Rw 1 Tunjungan 3316127525/15 Influenza
202 Suhartanto Ds.Semawur Rt 9 Rw 2 33162002633 Hernia
203 Vita Anggraeni Ds.Sarimulyo Rt 2 Rw 2 3316126606100001
204 Untari Ds.Ngrambitan Rt 1 Rw 1 Japah 331616640179000 Karies gigi
205 Marindawati Ds.Semawur 3316125712740001 ISPA
206 Margiyati Ds.Berbak Rt 1 Rw 1 3316126010730001 Influenza
207 Siti Marpuah Ds.Berbak Rt 4 Rw 1 3316124612700004 Influenza
208 Wagiman Ds.Berbak Rt 1 Rw 1 3316121701470001 Atralgia
209 Supatmi Ds.Berbak Rt 4 Rw 1 3316124905370001 Atralgia
210 Sugiarti Ds.Berbak Rt 2 rw 1 3316125203520001 Atralgia
211 Siti Nurkhayati Ds.Berbak Rt 5 Rw 1 3316125704890005 ANC
212 Suparmi Ds.Berbak Rt 5 Rw 1 3316127112570070 Hipertensi
213 Ahmad Johan Ds.Berbak Rt 5 Rw 1 3316122212130001 Cough
214 Gariyah Ds.Berbak Rt 5 Rw 1 3316127112610041 Influenza
215 Kamirah Ds.Berbak Rt 3 Rw 1 3316127112520050 Influenza
JUMLAH

NB. 1. untuk semua pasien dilampiri bukti dan tagihan tiap pasien berdasarkan tindakan
2. untuk pasien dengan persalinan dilengkapi data-data dan kelengkapan kemiskinan serta buku KIA
......................,............
Kepala UPT Puskesmas Ngawen Bendahara Pene
UPT Puskesmas N

dr. Nur Istifah Tety Susiand

NIP. 19660212 200212 2001 NIP. 19871211 201
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...,.......................20......
hara Penerimaan
uskesmas Ngawen

ty Susiandari
71211 201101 2016
 DAFTAR NAMA PASIEN RAWAT INAP UPT PUSKESMAS NGAWEN
BULAN ......................... TAHUN ..................

TANGGAL BANYAK BIAYA

UMUR NO JAMKESDA /
NO NAMA PASIEN PISA DIAGNOSA HARI Ttd Pasien
(Th) SKP MASUK KELUAR (Rp.)
RAWAT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
JUMLAH

Yang Menerima Penanggungjawab Rawat Inap

Bendahara Penerimaan
UPT Puskesmas Ngawen

Tety Susiandari Catur Hendro Yunianto

NIP. 19871211 201101 2016 NIP. 19720605 199403 1005
Kepala UPT Puskesmas Ngawen

dr. Nur Istifah

NIP. 19660212 200212 2001
 DAFTAR NAMA PASIEN PONED UPT PUSKESMAS NGAWEN
BULAN ......................... TAHUN ..................
TANGGAL BANYAK BIAYA
UMUR NO JAMKESDA /
NO NAMA PASIEN PISA DIAGNOSA HARI Ttd Pasien
(Th) SKP MASUK KELUAR RAWAT (Rp.)
1
2
3
4
5
6
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12
JUMLAH

Ngawen, ..................2017
Yang Menerima Penanggungjawab PONED
Bendahara Penerimaan
UPT Puskesmas Ngawen

Tety Susiandari Retno Sri Hayati

NIP. 19871211 201101 2016 NIP. 19720627 199310 2001
Kepala UPT Puskesmas Ngawen

dr. Nur Istifah

NIP. 19660212 200212 2001
DAFTAR REKAPITULASI TAGIHAN KLAIM PELAYANAN RAWAT JALAN DI PUSKESMAS

BULAN : JANUARI TAHUN : 2017

PUSKESMAS : UPT PUSKESMAS NGAWEN

Pelayanan Kes dan Besaran Tarif sesuai dengan PERBUP (Rp)

JENIS
No. KARTU PESERTA UMUR KELAMIN TANGGAL
NO NAMA PASIEN DIAGNOSA/GEJALA
JAMKESDA (Thn) KUNJUNGAN
(L/P)
Pemeriksaan
Poli Umum IGD Poli Gigi KIA
Penunjang

1 2 3 4 5 6 7 8 9 10 11 12
1 Siti Rodhotul Jannah 3316126912820000 55 P 1/2/2017 Chepalgia Rp 10,000 Rp - Rp - Rp - Rp -
2 Muhammad Rendi R 3316120110080003 17 L 1/3/2017 Cough Rp 10,000 Rp - Rp - Rp - Rp -
3 Sarti 3316165108720001 45 P 1/3/2017 Myalgia Rp 10,000 Rp - Rp - Rp - Rp -
4 Sumarno 3316120201740001 43 L 1/3/2017 Cough Rp 10,000 Rp - Rp - Rp - Rp -
5 Maulana Ahmad T 3316120710030004 14 L 1/3/2017 Commond Cold Rp 10,000 Rp - Rp - Rp - Rp -
6 Eka Lamalea Armiati 3316104406090001 8 P 1/3/2017 Cough Rp 10,000 Rp - Rp - Rp - Rp -
7 Supartik 33162001824 52 P 1/4/2017 NIDDM Rp 10,000 Rp - Rp - Rp 30,000 Rp -
8 Sumarno 3316120201740001 43 L 1/4/2017 Cough Rp 10,000 Rp - Rp - Rp - Rp -
9 Aga Aisha Syafani 3316125506080001 9 P 1/4/2017 Anemia Rp 10,000 Rp - Rp - Rp - Rp -
10 Arzeldan Praja H 331612015160001 7 L 1/4/2017 Obs. Febris Rp 10,000 Rp - Rp - Rp - Rp -
11 M Lutfi Nuril H 3316112109140001 3 L 1/5/2017 Obs. Febris Rp - Rp - Rp - Rp - Rp 10,000
12 Suwarni 3316124102720002 45 P 1/6/2017 Hipotensi Rp 10,000 Rp - Rp - Rp - Rp -
13 Tarni 33161415126 59 P 1/7/2017 Paronichra Rp 10,000 Rp - Rp - Rp - Rp -
14 Patri 3316124107670067 50 P 1/7/2017 Otitis eksterna Rp 10,000 Rp - Rp - Rp - Rp -
15 Pik Asri 3316125507800005 37 P 1/7/2017 Obs. Poliuri Rp 10,000 Rp - Rp - Rp - Rp -
16 Sumarni 3316104110770001 30 P 1/7/2017 Necrosis of pulp Rp - Rp - Rp 70,000 Rp - Rp -
17 Tarni 33161415126/17 59 P 1/9/2017 Paronichra Rp 10,000 Rp - Rp - Rp - Rp -
18 Alif Pratama Putra 3316123012100002 7 L 1/9/2017 Stomatitis Rp 10,000 Rp - Rp - Rp - Rp -
19 Warsini 3316127112540004 63 p 1/9/2017 TB. Paru Rp 10,000 Rp - Rp - Rp - Rp -
20 Supartik 33162001824 52 p 1/9/2017 Hipertensi, DM Rp 10,000 Rp - Rp - Rp - Rp -
21 Yeni Novitasari 33161515172/17 24 P 1/10/2017 ANC Rp - Rp - Rp - Rp - Rp 10,000
22 Kunsiah 3316124208470001 69 P 1/10/2017 Hypercholesterol Rp 10,000 Rp - Rp - Rp 20,000 Rp -
23 Sri Leswati 3316126903710001 17 P 1/10/2017 Abses Rp - Rp - Rp 20,000 Rp - Rp -
24 Andika Pratam Putra 3316120301090001 8 L 1/10/2017 Obs. Febris Rp 10,000 Rp - Rp - Rp - Rp -
25 Yatmi 331612000107 54 P 1/11/2017 Commond Cold Rp 10,000 Rp - Rp - Rp - Rp -
26 Ngasiran 3316127525/15 23 L 1/11/2017 ISPA Rp 10,000 Rp - Rp - Rp - Rp -
27 Supartik 33162001824 52 P 1/11/2017 ISPA Rp 10,000 Rp - Rp - Rp - Rp -
28 Sulasi 3316124509420002 72 P 1/11/2017 ISPA Rp 10,000 Rp - Rp - Rp - Rp -
29 Muhammad Naufal F 3316161312110001 6 L 1/11/2017 Alergi Rp 10,000 Rp - Rp - Rp - Rp -
30 Tarsinah 331614918/15 58 P 1/12/2017 Anemia Rp 10,000 Rp - Rp - Rp 20,000 Rp -
31 Tarni 33161415126/17 59 P 1/12/2017 Paronichra Rp 10,000 Rp - Rp - Rp - Rp -
32 Zamroni 3316122603790003 28 L 1/12/2017 Vulnus Rp 10,000 Rp - Rp - Rp - Rp -
33 Azza Vikniril Huda 3316121106140004 3 P 1/12/2017 Obs. Febris, Cough Rp - Rp - Rp - Rp - Rp 10,000
34 Baydi Fahrul R 3316147551/15 19 L 1/13/2017 Schizophrenia Rp 10,000 Rp - Rp - Rp - Rp -
35 Muhammad Anwar N 3316120804120002 38 L 1/13/2017 Korpus Alienum Rp 10,000 Rp - Rp - Rp - Rp -
36 Sumiyatun 3316125108690003 48 P 1/13/2017 Dermatitis Rp 10,000 Rp - Rp - Rp - Rp -
37 Rukiyem 3316104708760003 41 P 1/13/2017 TTH Rp 10,000 Rp - Rp - Rp - Rp -
38 Mirah 3316125404650007 52 P 1/13/2017 Osteortritis Rp 10,000 Rp - Rp - Rp - Rp -
39 Maryono 331612000108 23 L 1/14/2017 ISPA Rp 10,000 Rp - Rp - Rp - Rp -
40 Supartik 33162001824 52 P 1/14/2017 DM, Hipertensi Rp 10,000 Rp - Rp - Rp - Rp -
41 Tarni 33161415126/17 59 P 1/14/2017 Paronichra Rp 10,000 Rp - Rp - Rp - Rp -
42 M. Khairunnizar 3316122407060001 12 L 1/14/2017 Cough Rp 10,000 Rp - Rp - Rp - Rp -
43 Shofaa Nurus S 3316126411130002 4 P 1/14/2017 Obs. Febris Rp - Rp - Rp - Rp - Rp 10,000
44 Annisa Shobiya F 3316126702160004 2 P 1/14/2017 Obs. Febris Rp - Rp - Rp - Rp - Rp 10,000
45 Mifza Hafiz Al Husain 3316122110160001 8 L 1/16/2017 Cough Rp 10,000 Rp - Rp - Rp - Rp -
46 Yomi 3316106401810001 36 P 1/16/2017 Dermatitis alergia Rp 10,000 Rp - Rp - Rp - Rp -
47 Sulasi 3316124509420002 75 P 1/16/2017 Cough Rp 10,000 Rp - Rp - Rp - Rp -
48 Zamroni 3316122603790003 38 L 1/16/2017 Fulnus Rp 10,000 Rp - Rp - Rp - Rp -
49 Meindra Rahayu 3316126405940002 23 P 1/16/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
50 Tarni 33161415126/17 59 P 1/17/2017 Paronichra Rp 10,000 Rp - Rp - Rp - Rp -
51 Rininita Nofianti 3316125611110001 46 P 1/17/2017 Diare Rp 10,000 Rp - Rp - Rp - Rp -
52 Ahmad Zainul Ammar 3316122402150002 2 L 1/17/2017 Cough Rp - Rp - Rp - Rp - Rp 10,000
53 Zuma'inah 3316126912650002 52 P 1/17/2017 Low Back Pain Rp 10,000 Rp - Rp - Rp - Rp -
54 Dwi Kader rini 3316126209840003 21 P 1/17/2017 ANC Rp - Rp - Rp - Rp - Rp 10,000
55 Supartik 33162001824 52 P 1/18/2017 Arthritis Rp 10,000 Rp - Rp - Rp - Rp -
56 Atsna Bahiya layali 3316126511120002 5 P 1/18/2017 Dispepsia Rp - Rp - Rp - Rp - Rp 10,000
57 Marsya Desi N 3316127103070001 10 P 1/18/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
58 Rumi 3316105112590002 58 P 1/18/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
59 Parsi 3316149696/16 52 P 1/19/2017 Syndrome Dyspepsia Rp 10,000 Rp - Rp - Rp - Rp -
60 Deni Maharanti 3316124603980001 18 L 1/19/2017 TB. Paru Rp 10,000 Rp - Rp - Rp - Rp -
61 Maryono 3316122909930001 24 L 1/19/2017 ISPA Rp 10,000 Rp - Rp - Rp - Rp -
62 Ellen Yoga Arnikesari 3316165207970001 20 P 1/19/2017 Karies gigi Rp - Rp - Rp - Rp 70,000 Rp -
63 Sri Wahyuni 3316124203090001 8 P 1/19/2017 Obs. Febris Rp 10,000 Rp - Rp - Rp - Rp -
64 Sumiyatun 3316125108690003 48 P 1/20/2017 Dermatitis Rp 10,000 Rp - Rp - Rp - Rp -
65 Siti Musafa'ah 3316124904630002 54 p 1/20/2017 OMA Rp 10,000 Rp - Rp - Rp - Rp -
66 Siti Miftakhul Jannah 3316125611100001 7 P 1/20/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
67 Djumiati 3316126803870001 30 P 1/21/2017 Cough Rp 10,000 Rp - Rp - Rp - Rp -
68 Alif Pratama Putra 3316123012100002 7 L 1/21/2017 Pharingitis Rp 10,000 Rp - Rp - Rp - Rp -
69 Sumarni 3316125604760002 39 P 1/23/2017 Hipertensi Rp 10,000 Rp - Rp - Rp - Rp -
70 Fadila Al Manur R 3316127106090001 7 P 1/23/2017 Cabut gigi desidui Rp - Rp - Rp 30,000 Rp - Rp -
71 M. Ifza Hafiz Al Husain 3316122110160001 1 L 1/23/2017 Cough Rp - Rp - Rp - Rp - Rp 10,000
72 Sukma Khoiriyah 3316126404000001 17 P 1/23/2017 ISPA Rp 10,000 Rp - Rp - Rp - Rp -
73 Lasiban 3316120704550003 59 L 1/23/2017 TB. Paru Rp 10,000 Rp - Rp - Rp - Rp -
74 Supartik 33162001824 52 P 1/24/2017 DM Rp 10,000 Rp - Rp - Rp - Rp -
75 Tarni 33161415126/17 59 P 1/24/2017 Atralgia Rp 10,000 Rp - Rp - Rp - Rp -
76 Mariyono 331612000108 23 L 1/24/2017 Commond Cold Rp 10,000 Rp - Rp - Rp - Rp -
77 Ngasiran 3316127525/15 53 L 1/24/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
78 Sumiyati 3316164611620002 55 P 1/24/2017 Gastritis Rp 10,000 Rp - Rp - Rp - Rp -
79 Raden Ahmad Kholil B 3522021707150001 2 L 1/24/2017 Influenza Rp - Rp - Rp - Rp - Rp 10,000
80 Reni Wijayanti 3316165903920002 25 P 1/24/2017 ANC Rp - Rp - Rp - Rp - Rp 10,000
81 Latifah 3316125212460001 71 P 1/24/2017 Atralgia Rp 10,000 Rp - Rp - Rp - Rp -
82 Siti Maskanah 3316124405760006 47 P 1/24/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
83 Sutrisno 3316161103770001 40 L 1/24/2017 Commond Cold Rp 10,000 Rp - Rp - Rp - Rp -
84 Karni 33162002010 47 P 1/25/2017 DM Rp 10,000 Rp - Rp - Rp 20,000 Rp -
85 Jarum 3316123112550069 62 L 1/25/2017 35 Luxasi O3 Rp - Rp - Rp 10,000 Rp - Rp -
86 Warsini 3316127112540004 63 P 1/26/2017 TB. Paru Rp 10,000 Rp - Rp - Rp - Rp -
87 Deni Maharanti 3316124603980001 19 P 1/26/2017 TB. Paru Rp 10,000 Rp - Rp - Rp - Rp -
88 Kenta Gista 3316126409010004 16 L 1/26/2017 Obs. Febris Rp 10,000 Rp - Rp - Rp - Rp -
89 Siti Nur Halimah 3316125808960003 21 P 1/26/2017 ANC Rp - Rp - Rp - Rp - Rp 10,000
90 Parsi 3316149696/16 52 P 1/27/2017 Gastritis Rp 10,000 Rp - Rp - Rp - Rp -
91 Caila Oktiva 3316127010060004 11 P 1/27/2017 Scabies Rp 10,000 Rp - Rp - Rp - Rp -
92 Jofinka Emmanuella 3316127103090001 8 L 1/27/2017 Myalgia Rp 10,000 Rp - Rp - Rp - Rp -
93 Sumiyatun 3316200146 51 P 1/27/2017 Cerumen prop Rp 10,000 Rp - Rp - Rp - Rp -
94 Ngasiran 3316127525/15 23 L 1/30/2017 Bronchitis Rp 10,000 Rp - Rp - Rp - Rp -
95 Mariyono 331612000108 23 L 1/30/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
96 Parti 33162001431 37 P 1/30/2017 Bronchitis Rp 10,000 Rp - Rp - Rp - Rp -
97 Aga Bachtiar 3316122208150002 2 L 1/30/2017 Obs. Febris Rp - Rp - Rp - Rp - Rp 10,000
98 Supuryati 3316124201710004 46 P 1/30/2017 Chepalgia Rp 10,000 Rp - Rp - Rp - Rp -
99 Rawijah 3316125207630003 54 P 1/30/2017 Atralgia Rp 10,000 Rp - Rp - Rp - Rp -
100 Parwi 3316125507830005 34 P 1/30/2017 Gastritis Rp 10,000 Rp - Rp - Rp - Rp -
101 Zanuba 3316126404990001 18 P 1/30/2017 Obs. Febris Rp 10,000 Rp - Rp - Rp - Rp -
102 M. Sobirin 3316161202940005 23 L 1/30/2017 Karies gigi Rp - Rp - Rp 70,000 Rp - Rp -
103 Parwati 3316166908900005 27 P 1/30/2017 Karies gigi Rp - Rp - Rp 70,000 Rp - Rp -
104 Untari 331616640179000 38 P 1/31/2017 Karies gigi Rp - Rp - Rp 20,000 Rp - Rp -
105 Marindawati 3316125712740001 43 P 1/31/2017 ISPA Rp 10,000 Rp - Rp - Rp - Rp -
106 Margiyati 3316126010730001 44 P 1/31/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
107 Vita Anggraeni 3316126606100001 7 P 1/31/2017 Obs. Febris Rp 10,000 Rp - Rp - Rp - Rp -
108 Kamirah 3316127112520050 65 P 1/31/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
109 Gariyah 3316127112610041 56 P 1/31/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
110 Ahmad Johan 3316122212130001 4 L 1/31/2017 BBP Rp - Rp - Rp - Rp - Rp 10,000
111 Suparmi 3316127112570070 60 P 1/31/2017 Hipertensi Rp 10,000 Rp - Rp - Rp - Rp -
112 Siti Nurkhayati 3316125704890005 28 P 1/31/2017 ANC Rp - Rp - Rp - Rp - Rp 10,000
113 Sugiarti 3316125203520001 65 P 1/31/2017 Atralgia Rp 10,000 Rp - Rp - Rp - Rp -
114 Supatmi 3316124905370001 80 P 1/31/2017 Atralgia Rp 10,000 Rp - Rp - Rp - Rp -
115 Wagiman 3316121701470001 70 L 1/31/2017 Atralgia Rp 10,000 Rp - Rp - Rp - Rp -
116 Siti Marpuah 3316124612700004 47 P 1/31/2017 Influenza Rp 10,000 Rp - Rp - Rp - Rp -
JUMLAH Rp 930,000 Rp - Rp 290,000 Rp 160,000 Rp 150,000

Mengetahui
Kepala UPT Puskesmas Ngawen Pj.Pelayanan
UPT Puskesmas Ngawen

dr. Nur Istifah Catur Hendro Yunianto

NIP. 19660212 200212 2001 NIP. 19871211 201101 2016
 TOTAL BIAYA

13=(8+9+10+11+12)
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 40,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 70,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 30,000
Rp 20,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 30,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 70,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 30,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 30,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 70,000
Rp 70,000
Rp 20,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 1,530,000