LAMPIRAN 1

FORM SELF ASSESSMENT

Diagnosa Non Spesialistik Kompetensi 4A
Nama FKTP :
Alamat :
Jenis FKTP : Puskesmas/Klinik Pratama/DPP/RS D Pratama (lingkari salah satu)
Waktu Assessment :
KC BPJS Kesehatan :

Dapat Tuntas Ditangani

di Faskes Saudara
(*mohon di checklist)
No Kode ICD 10 Nama Diagnosa Non Spesialistik Tidak
Ya
Kompetensi Obat Alat Laboratorium

1 A01.0 Typhoid fever

2 A06.0 Acute amoebic dysentery
Other and unspecified gastroeteritis and colitis of
3 A09.0
infectious origin
Respiratory tuberculosis, bacteriologically and
4 A15.0
histologically confirmed
5 A27.9 Leptospirosis, unspecified
6 A30.0 Indeterminate leprosy
7 A35 Other tetanus
8 A54.9 Gonococcal infection, unspecified
9 A90 Dengue fever [classical dengue]
10 A91 Dengue haemorrhagic fever
11 B00.9 Herpesviral infection, unspecified
12 B01.9 Varicella without complication
13 B02.9 Zoster without complication
14 B05.9 Measles without complication
15 B07 Viral warts
16 B08.1 Molluscum contagiosum
17 B15 Acute hepatitis A
18 B26.0 Mumps orchitis
19 B35 Dermatophytosis
20 B35.0 Tinea barbae and tinea capitis
21 B35.1 Tinea unguium
22 B35.2 Tinea manuum
23 B35.3 Tinea pedis
24 B35.4 Tinea corporis
25 B35.6 Tinea cruris
26 B35.8 Other Dermatophytosis
27 B36.0 Pityriasis versicolor
28 B37.9 Candidiasis, unspecified
29 B54 Unspecified malaria
Schistosomiasis due to Schistosoma haematobium
30 B65.0
[urinary schistosomiasis]

31 B65.2 Schistosomiasis due to Schistosoma japonicum

32 B65.9 Schistosomiasis, unspecifed

33 B68.0 Taenia solium taeniasis
34 B68.9 Taeniasis, unspecified
35 B74.0 Filariasis due to Wuchereria bancrofti
36 B76.0 Ancylostomiasis
37 B76.9 Hookworm disease, unspecified
38 B77.9 Ascariasis, unspecified
39 B78.0 Intestinal strongyloidiasis
40 B78.9 Strongyloidiasis, unspecified
41 B85.0 Pediculosis due to Pediculus humanus capitis
42 B85.3 Phthiriasis
43 B86 Scabies
44 D17.9 Benign lipomatous neoplasm, unspecified
Iron deficiency anaemia secondary to blood loss
45 D50.0
(chronic)
46 D50.9 Iron deficiency anaemia, unspecified
Non-insulin-dependent diabetes mellitus without
47 E11.9
complication
48 E16.2 Hypoglycaemia, unspecified
49 E46 Unspecified protein-energy malnutrition
50 E66.9 Obesity, unspecified
51 E78.5 Hyperlipidaemia, unspecified
Hyperuricemia without signs of inflammatory arthritis
52 E79.0
and tophaceous disease
53 F45.0 Somatization disorder
 Dapat Tuntas Ditangani
di Faskes Saudara
(*mohon di checklist)
No Kode ICD 10 Nama Diagnosa Non Spesialistik Tidak
Ya
Kompetensi Obat Alat Laboratorium

54 F51.0 Non organic insomnia

55 G43.0 Migraine without aura [common migraine]
56 G43.9 Migraine, unspecified
57 G44.2 Tension-type headache
58 G51.0 Bell's palsy

59 H00.0 Hordeolum and other deep inflammation of eyelid

60 H01.0 Blepharitis
61 H02.0 Entropion and trichiasis of eyelid
62 H04.1 Other disorders of lacrimal gland
63 H10.1 Acute atopic conjunctivitis
64 H10.9 Unspecified conjunctivitis
65 H15.1 Episcleritis
66 H52.0 Hypermetropia

67 H52.1 Myopia
68 H52.2 Astigmatism
69 H52.4 Presbyopia
70 H53.6 Night blindness
71 H57.8 Other specified disorders of eye and adnexa
72 H60.9 Otitis externa, unspecified
73 H61.2 Impacted cerumen
74 H65.0 Acute serous otitis media
75 H65.1 Other acute nonsuppurative otitis media
76 H66.0 Acute suppurative otitis media
77 I10 Essential (primary) hypertension
Varicose veins of lower extremities without ulcer or
78 I83.9
inflammation
79 I84.0 Internal thrombosed haemorrhoids
80 I84.2 Internal haemorrhoids without complication
81 I84.9 Unspecified haemorrhoids without complication
82 J00 Acute nasopharyngitis [common cold]
83 J02 Acute pharyngitis
84 J02.9 Acute pharyngitis, unspecified
85 J03 Acute tonsillitis
86 J03.9 Acute tonsillitis, unspecified
87 J04.0 Acute laryngitis
88 J11.0 Influenza with pneumonia, virus not identified
89 J18.0 Bronchopneumonia, unspecified
90 J18.9 Pneumonia, unspecified
91 J20.9 Acute bronchitis, unspecified
92 J30.0 Vasomotor rhinitis
93 J30.4 Allergic rhinitis, unspecified
94 J34.0 Abscess, furuncle and carbuncle of nose
95 J35.0 Chronic tonsillitis
96 J45.9 Asthma, unspecified
97 K12 Stomatitis and related lesions
Gastro-oesophageal reflux disease without
98 K21.9
oesophagitis
99 K29.7 Gastritis, unspecified
Malabsorption due to intolerance, not elsewhere
100 K90.4
classified
101 L01.0 Impetigo [any organism] [any site]
102 L02.0 Cutaneous abscess, furuncle and carbuncle of face

103 L02.2 Cutaneous abscess, furuncle and carbuncle of trunk

Cutaneous abscess, furuncle and carbuncle of other

104 L02.8
sites
105 L04.9 Acute lymphadenitis, unspecified
106 L08.0 Pyoderma
107 L08.1 Erythrasma
108 L20.8 Other atopic dermatitis
 Dapat Tuntas Ditangani
di Faskes Saudara
(*mohon di checklist)
No Kode ICD 10 Nama Diagnosa Non Spesialistik Tidak
Ya
Kompetensi Obat Alat Laboratorium

109 L21.0 Seborrhoea capitis

110 L22 Diaper [napkin] dermatitis
111 L24.0 Irritant contact dermatitis due to detergents
Generalized skin eruption due to drugs and
112 L27.0
medicaments
113 L27.2 Dermatitis due to ingested food
114 L42 Pityriasis rosea
115 L50.0 Allergic urticaria
116 L50.9 Urticaria, unspecified
117 L70.0 Acne vulgaris
118 L71.0 Perioral dermatitis
119 L73.2 Hidradenitis suppurativa
120 L74.3 Miliaria, unspecified
121 L97 Ulcer of lower limb, not elsewhere classified
122 M10 Gout
123 N10 Acute tubulo-interstitial nephritis
124 N39.0 Urinary tract infection, site not specified
125 N47 Redundant prepuce, phimosis and paraphimosis

126 N61 Inflammatory disorders of breast

127 N76.0 Acute vaginitis
Complication associated with artificial fertilization,
128 N98.9
unspecified
Spontaneous abortion: Complete or unspecified,
129 O03.9
without complication
130 O70.0 First degree perineal laceration during delivery
131 O80.9 Single spontaneous delivery, unspecified
132 O92.0 Retracted nipple associated with childbirth
Omphalitis of newborn with or without mild
133 P38
haemorrhage
134 R04.0 Epistaxis
135 R42 Dizziness and giddiness
136 R56.0 Febrile convulsions
137 T14 Injury of unspecified body region
138 T14.1 Open wound of unspecified body region
139 T15.9 Foreign body on external eye, part unspecified
140 T17.1 Foreign body in nostril
141 T30.1 Burn of first degree, body region unspecified
142 T30.2 Burn of second degree, body region unspecified
143 T63.4 Toxic effect: Venom of other arthropods
144 T78.2 Anaphylactic shock, unspecified
Asymptomatic human immunodeficiency virus [HIV]
145 Z21
infection status
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