LAPORAN RUJUK BALIK

UPT PUSKESMAS WATUBELAH

BULAN : FEBRUARI Tahun 2019
Surat Rujukan Balik Kelengkapan Surat Rujukan Balik
Jumlah
No Nama Rumah Sakit Alamat RS Ada
Rujukan ADA TIDAK Ada Tindak Lanjut
diagnosa Pengobatan
1 RSUD Gunung Djat Kota Cirebon 13 -

2 RS Permata Kab Cirebon 11 3 -

3 RS Mitra Plumbon Kab Cirebon 76 14 -

4 RSJ Hasna Medika Kab Cirebon 10 2 -

BADAN RSUD
5 Kab Cirebon 17 -
ARJAWINANGUN

7 RS Sumber Hurip Kab Cirebon 61 10 -

13 RS PARU 2

Mengtahui

Kepala UPT Puskesmas Watubelah

drg. Hj. RETNO WIDOWATI

NIP :19661025 200112 2 001
BALIK
UBELAH

Surat Rujukan Balik Ditandatangi dr Spesialis poliklinik yang

Kontrol rujuk balik tidak
Kembali ke Ya Tidak Tidak ada lengkap
RS keterangan
- - - -

- 3 - - -

- 14 - - -

- 2 - - -

- - - -

- 10 - - -

Cirebon, 04 MARET 2019

Pengelola Kesehatan Rujukan

AGUNG HERMANTO, AMKG

 LAPORAN BULANAN RUJUKAN
UPT PUSKESMAS WATUBELAH
Bulan/Tahun : FEBRUARI 2019

No Nama Pasien Diagnosa

1 MULYANI ( D649 ) Anaemia, unspecified

2 AAS SOLEHATI ( O029 ) Abnormal product of concepton, unspecified

3 NENGSI MILASARI ( O48 ) Prolonged pregnancy

4 ABIYYU ( S82.2 ) Fracture of shaft of tbia

5 ( i63 ) Alopecia areata

NAJIB NURHALIM
6 TUKIYYAH ( N18 ) Chronic kidney disease

7 DONI SETIAWAN ( G40 ) Epilepsy

8 CALVIENE APRILIYANTO ( O029 ) Kitasehat2019@

9 AZFAR RABBANI ( K58 ) Irritable bowel syndrome

10 DIDI DARMADI ( K27 ) Peptc ulcer, site unspecified

11 DARSINI ( O13) Gestatonal [pregnancy-induced] hypertension without significant proteinuri

12 SARENI ( I10 ) Essental (primary) hypertension

13 KAPSAH ( E14) Unspecified diabetes mellitus

14 DEDE ( I11 ) Hypertensive heart disease

15 ACHMAD MUKMIN ( E11.8 ) Non-insulin-dependent diabetes mellitus with unspecified complicatons

16 KURNIASIH ( O42) Premature rupture of membranes

17 ENI APRILIYANI ( H62.1 ) Otts externa in viral diseases classified elsewhere

18 ASEP RIDWAN NULHAKIM ( M50.2 ) Other cervical disc displacement

19 NANGWAR ( R03.8 ) Other symptoms and signs concerning food and fluid intake

20 MASRINI ( M54.1 ) Radiculopathy

21 JUMALI ( A15 ) Respiratory tuberculosis, bacteriologically and histologically confirmed

22 SURIAH ( E11.8 ) Non-insulin-dependent diabetes mellitus with unspecified complicatons

23 NADILAH ( K04.1 ) Necrosis of pulp

24 DEDI S ( K04 ) Diseases of pulp and periapical tssues

25 SANUSI ( D64 ) Other anaemias

26 MINA ( O14.1 ) Severe pre-eclampsia

27 TEMU ( I61.9 ) Intracerebral haemorrhage, unspecified

27 SHODIQ MUHAMAD ( H72 ) Perforaton of tympanic membrane

28 MARFUAH ( N92 ) Excessive, frequent and irregular menstruaton

29 ATIKAH ( O42.0 ) Premature rupture of membranes, onset of labour within 24 hours

30 MUHAMMAD NUR KHALID ( A01.4 ) Paratyphoid fever, unspecified

31 ELLY SUMARNI ( O80.0 ) Twin pregnancy

32 TATI ( O10.0 ) Pre-existng essental hypertension complicatng pregnancy, childbirth an

33 ASTUTI ( H54.2 ) Low vision, both eyes

34 MUADAH ( L04.2 ) Acute lymphadenits of upper limb

35 ASTUTI ( H54.2 ) Low vision, both eyes

36 MUADAH ( L04.2 ) Acute lymphadenits of upper limb

37 MURTI ( N81 ) Female genital prolapse

38 IKA SETIAWATI ( E11.8 ) Non-insulin-dependent diabetes mellitus with other specified complicaton

39 WARSI ( H52.7 ) Disorder of refracton, unspecified

40 SANIYA ( E11.4 ) Non-insulin-dependent diabetes mellitus with neurological complicatons

41 CICI LIAWATI ( H52.7 ) Disorder of refracton, unspecified

42 NUNG HARTUTI ( H66 ) Suppuratve and unspecified otts media

43 JUWITA ( H93.1 ) Tinnitus

44 RADIJA ( I45.1 ) Other and unspecified right bundle-branch block

45 SAIRAH ( E04 ) Other nontoxic goitre

46 KASAN ( N40 ) Hyperplasia of prostate

47 UMAMAH ( R38 ) Unspecified haematuria

48 HELMI ZAKI ERDIANSYAH ( F80.9 ) Developmental disorder of speech and language, unspecified

49 SUSILOWATY ( E04.9 ) Nontoxic goitre, unspecified

50 BAYI NYONYA RAHMAWATI ( P07.3 ) Other preterm infants

51 MOHAMAD AFIF FACHRI ( H01 ) Other hearing loss

52 AMINAH ( I11 ) Hypertensive heart disease

53 BAYI NYONYA NINING R ( P03.4 ) Fetus and newborn affected by caesarean delivery

54 ELA MELAWATI FAZRIN ( K35.8 ) Acute appendicits, other and unspecified

55 JULEKA ( d21 ) Other benign neoplasms of connectve and other soft tssue

56 JUMILA ( G81 ) Hemiplegia

57 KUSNIA ( O10.0 ) Pre-existng essental hypertension complicatng pregnancy, childbirth an

58 MARNI ( I11 ) Hypertensive heart disease

59 SANIRI ( M54.1 ) Radiculopathy, cervical region

60 LINA MAULINA ( O32.U) Maternal care for other malpresentaton of fetus

61 H. RAKHMAT ( D21 ) Other benign neoplasms of connectve and other soft tssue
62 SUGIARTO ( K04 ) Diseases of pulp and periapical tssues

63 MULYANI ( N60 ) Benign mammary dysplasia

64 MULYATI ( D25 ) Leiomyoma of uterus

65 ISAH ( B90.9 ) Sequelae of respiratory and unspecified tuberculosis

66 ANDINI RAHMADIANTI ( G44.0 ) Cluster headache syndrome

67 ELANG PRAPANCA ( G93.4 ) Encephalopathy, unspecified

68 SANTI ( O42 ) Premature rupture of membranes

69 SITI KUNAENI ( E11.0 ) Non-insulin-dependent diabetes mellitus with other specified complicaton

70 UNZHURNA RIZQAN D. PUTR ( I84 ) Haemorrhoids

71 SUPRIYATIN ( O30.0) Twin pregnancy

72 TUTI SETIAWATI ( G44 ) Other headache syndromes

73 AYEP JOHANSYAH ( E14 ) Unspecified diabetes mellitus

74 ELIS ( H52.4 ) Presbyopia

75 SARJONO ( G50.0 ) Trigeminal neuralgia

76 UMAMAH ( n20.9 ) Urinary calculus, unspecified

77 DISA ( F80.9 ) Developmental disorder of speech and language, unspecified

78 SISWO ( H25 ) Senile cataract

79 ZAHIRA FAIRUZ ( J18.9 ) Pneumonia, unspecified

80 DULADI ( E78 ) Disorders of lipoprotein metabolism and other lipidaemias

81 NURHAYATI ( O10.9 ) Unspecified pre-existng hypertension complicatng pregnancy, childbirth

82 SRI RAHAYU ( N91.2 ) Amenorrhoea, unspecified

83 IIS ROHAYATI ( D22 ) Melanocytc naevi

84 TATANG SUHENDI ( K01.1 ) Impacted teeth

85 NURVIAN ( K01.1 ) Impacted teeth

86 INTAN ( F80.9 ) Developmental disorder of speech and language, unspecified

87 MASHUDI ( h25 ) Senile cataract

88 RAMA AINUN NASRULLAH ( F80.9 ) Developmental disorder of speech and language, unspecified

89 SITI KUNAENI ( Z09.0 ) Follow-up examinaton after surgery for other conditons

90 DAMAYANTI ( R07 ) Pain in throat and chest

91 JOHAR MAKNUN ( H52.7 ) Disorder of refracton, unspecified

92 RETNO T ( L02 ) Cutaneous abscess, furuncle and carbuncle

93 SUDARJI ( I11.0 ) Hypertensive heart disease with (congestve) heart failure

94 MUKHSIN ( I63 ) Intracerebral haemorrhage

95 SAENAH ( M21.5 ) Acquired clawhand, clubhand, clawfoot and clubfoot

96 MASRIYAH ( M54.5 ) Low back pain

97 LUCKY NURROCHMAN ( K01.1) Impacted teeth

98 SITI AMINAH ( I25 ) Chronic ischaemic heart disease

99 RUMINI ( M51.5 ) Other intervertebral disc disorders

100 KADIJO ( N18 ) Chronic kidney disease

101 YANTO SUPRIYANTO ( J44 ) Other chronic obstructve pulmonary disease

102 NENTI ( N73.9 ) Female pelvic inflammatory disease, unspecified

103 EDI SUPRIADI ( K40.9 ) Unilateral or unspecified inguinal hernia, without obstructon or gangrene

104 SITI SETIAMAH ( M13 ) Other arthrits

105 SUWARDI ( G44.3 ) Chronic post-traumatc headache

106 KASNITI ( A15 ) Respiratory tuberculosis, bacteriologically and histologically confirmed

107 TITIN RATINI ( H81.4 ) Vertgo of central origin

108 SAIRAH ( F20.9 ) Schizophrenia, unspecified

109 INDAH SEFTIANTY ( K21 ) Gastro-oesophageal reflux disease

110 ANDI SUBANDI ( I11 ) Hypertensive heart disease

111 AJIZAH ( H70 ) Mastoidits and related conditons

112 ROHILAILI ( D21 ) Other benign neoplasms of connectve and other soft tssue

113 ARIS ISKANDAR ( F20) Schizophrenia

114 ISNAENI ( K04 ) Diseases of pulp and periapical tssues

115 FENI LESTARI ( O14.1 ) Severe pre-eclampsia

116 CL BAYI NY SUPRIYATIN A ( P03.4 ) Fetus and newborn affected by caesarean delivery

117 BAYI NY RATINI ( D18 ) Haemangioma and lymphangioma, any site

118 ADAM RIFQI DHARMAWAN ( N62 ) Hypertrophy of breast

119 MISA ( O99 ) Other maternal diseases classifiable elsewhere but complicatng pregnancy,

120 FITRIA ( D24 ) Benign neoplasm of breast

121 ANDI SUBANDI ( I11 ) Hypertensive heart disease

123 SITI KHODIJAH ( E05.9 ) Thyrotoxicosis, unspecified

124 JERI GUTAWA ( M25.7 ) Osteophyte

125 ROKIYAH ( M17 ) Gonarthrosis [arthrosis of knee]

126 NAPIAH ( R33 ) Retenton of urine

127 IKA OKTAVIANI ( F31 ) Bipolar affectve disorder

128 Nurul Habibah ( O60.1 ) Preterm labour with preterm delivery

129 IWING BARA ( T18.9 ) Foreign body in alimentary tract, part unspecified

130 SAENA ( H25 ) Senile cataract

131 SALAMUN ( S72 ) Fracture of femur

132 SARMA ( K74 ) Fibrosis and cirrhosis of liver

133 SUKI ( R06 ) Abnormalites of breathing

134 KOMARIYAH ( I11 ) Hypertensive heart disease

135 JABAR ASYAMIE ( R50 ) Fever of other and unknown origin

136 RENY ASRILIANI ( O13 ) Gestatonal [pregnancy-induced] hypertension without significant proteinuri

137 MEGA ESTIANA SHEILAHET ( O02 ) Other abnormal products of concepton

138 YANTO ( R06 ) Abnormalites of breathing

139 BAYI NYONYA ENSARI ( P24.8 ) Other neonatal aspiraton syndromes

141 WAHYU MUSTIKA RAHMAD ( B35.9 ) Dermatophytosis, unspecified

142 SAERAH ( G58.9 ) Mononeuropathy, unspecified

143 MUNAWAN ( A15 ) Respiratory tuberculosis, bacteriologically and histologically confirmed

144 LINTANG ( D21 ) Other benign neoplasms of connectve and other soft tssue

145 KARMINI ( O42.0 ) Premature rupture of membranes, onset of labour within 24 hours

146 RUBEAH ( H02 ) Other disorders of eyelid

147 RINA ( E11.8 ) Non-insulin-dependent diabetes mellitus with unspecified complicatons

148 ISWATUN KHASANAH ( Z35 ) Supervision of high-risk pregnancy

149 TAMRIN SM ( I25 ) Chronic ischaemic heart disease

150 AGUS MACHRUS ( N18 ) Chronic kidney disease

151 KURSAN ( K04 ) Diseases of pulp and periapical tssues

152 AYU NURHAENI ( A18.2 ) Tuberculous peripheral lymphadenopathy

153 KAENI ( E11.8 ) Non-insulin-dependent diabetes mellitus with unspecified complicatons

154 ROIYAH ( M54.5 ) Low back pain

155 DAMAYANTI (S29 ) Other and unspecified injuries of thorax

156 ANAH ROHANAH DARYANTO ( E10.2 ) Insulin-dependent diabetes mellitus with renal complicatons
158 SHAfiRA HANI MARI INDA ( K04 ) Diseases of pulp and periapical tssues
159 ALLYZA RAHMA ( I08 ) Other local infectons of skin and subcutaneous tssue

160 ARUM PUSPANINGSIH ( K04 ) Diseases of pulp and periapical tssues

161 AIRA MECCA DINSA ( G40 ) Epilepsy

162 WIFA KAFITRI ( J18.0 ) Bronchopneumonia, unspecified

163 IQBAL MAULANA ( J18.0) Bronchopneumonia, unspecified

164 MUKHLISIN HADI ( A18 ) Tuberculosis of other organs

165 tka tneke ( O48 ) Prolonged pregnancy

166 MARDIYAH MUTMAINAH ( O32.8 ) Maternal care for other malpresentaton of fetus

167 YATI OTOVIA ( O04.4 ) Medical aborton, incomplete, without complicaton

168 MAENA ( O42.0 ) Premature rupture of membranes, onset of labour within 24 hours

169 MADIRA ( L89.99 ) Decubitus ulcer and pressure area, unspecified

170 ROBEAH ( H25 ) Senile cataract

171 ANIS ( C64 ) Malignant neoplasm of kidney, except renal pelvis

172 KARNESIH ( I25) Chronic ischaemiAc heart disease

173 ADE LIZIA ( O34.2 ) Maternal care due to uterine scar from previous surgery

174 SANIYA ( E11.4 ) Non-insulin-dependent diabetes mellitus with neurological complicatons

175 SETI ( I84 ) Haemorrhoids

176 RUKINA ( M54.5 ) Low back pain

177 RUDI NURANI ( K40 ) Inguinal hernia

178 YANA ( I51.7 ) Cardiomegaly

179 SRI HAYATUN ( G80 ) Cerebral palsy

180 ANAH ROHANAH D ( N18 ) Chronic kidney disease

181 ULFATUL QOLBIYAH ( O42.0 ) Premature rupture of membranes, onset of labour within 24 hours

182 VARISSA ( H52.7 ) Disorder of refracton, unspecified

183 DIDIN SAEPUDIN ( I69.4 ) Sequelae of stroke, not specified as haemorrhage or infarcton

184 MULYANI ( M54.5 ) Low back pain

185 DIDI DARMADI ( J05 ) Acute obstructve laryngits [croup] and epiglottits

186 SODIKIN ( A15 ) Respiratory tuberculosis, bacteriologically and histologically confirmed

187 AYU NURHeni ( O029 ) Tuberculous peripheral lymphadenopathy

188 ABDULLAH FIKRI ( A15 ) Respiratory tuberculosis, bacteriologically and histologically confirmed

189 masiri ( H25 ) Senile cataract

190 abdul aziz ( I74.0 ) Miliaria rubra

191 ETI YULIARTI ( E14 ) Unspecified diabetes mellitus

192 JAJULI ( I10 ) Essental (primary) hypertension

193 ENI SAENI ( M54.1 ) Radiculopathy, lumbar region

194 WATIMAH ( R13 ) Dysphagia

195 SUWANI ( M54.1 ) Radiculopathy, cervical region

196 ZAHRA ASILA TASYA ( A01 ) Typhoid and paratyphoid fevers

197 KAPSAH ( M75.9 ) Shoulder lesion, unspecified

198 KIRA ( I64 ) Stroke, not specified as haemorrhage or infarcton

199 NIA ROSLIANA DEWI ( M75.9 ) Shoulder lesion, unspecified

200 JUMENI ( E11.5 ) Non-insulin-dependent diabetes mellitus with peripheral circulatory compl

201 KARMILA ( O99.0 ) Anaemia complicatng pregnancy, childbirth and the puerperium

202 SARIKO ( F20 ) Schizophrenia

203 ACHMAD SHOBIHIN ( A30.9 ) Leprosy, unspecified

204 MOH YASIN ( A15 ) Respiratory tuberculosis, bacteriologically and histologically confirmed
205 NADIA SRI BUDI N ( Z35.9 ) Supervision of high-risk pregnancy, unspecified

206 JAENAH ( C50 ) Malignant neoplasm of breast

drg. Hj. RETNO WIDOWATI

NIP. 19661025 200112 2 001
N BULANAN RUJUKAN
SKESMAS WATUBELAH

Tujuan Melalui Call

Rujukan Center Nama
Tanggal dirujuk Asuransi Pendamping
Rawat Rawat Rujukan
Ya Tidak
Jalan Inap
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√ 2/27/2019 PBI (APBN) √
√ 2/27/2019 PEKERJA MANDIRI √
√ 2/27/2019 PBI (APBN) √
√ 2/27/2019 PEKERJA MANDIRI √
√ 2/27/2019 PEKERJA MANDIRI √
√ 2/28/2019 PNS DAERAH √
√ 2/28/2019 PBI (APBN) √
√ 2/28/2019 PBI (APBN) √ BIDAN

√ 2/28/2019 PEKERJA MANDIRI √

√ 2/28/2019 PEGAWAI SWASTA √
√ 2/28/2019 PEKERJA MANDIRI √
√ 2/28/2019 PEKERJA MANDIRI √ BIDAN

√ 2/28/2019 PEKERJA MANDIRI √

AGUNG HERMANTO, AMKG

 LAPORAN REKAPITULASI RUJUKAN
UPT PUSKESMAS WATUBELAH

NO Tempat Rujukan Alamat

BADAN RSUD ARJAWINANGUN Jl. By Pass Palimanan-Jakarta Km. 2 No.1, Kebonturi

1 Cirebon Jawa Barat

2 RSUD Gunung Djat Jl Kesambi Raya No 56 Drajat Kesambi Kota Cirebon

3 RS Permata Jl. Tuparev No. 117 Pilangsari Cirebon

4 RS Mitra Plumbon Jl Raya Plumbon Km 11 Palimanan Cirebon

5 RS Jantung Hasna Medika Jl Kiageng Tepak No 8 palimanan Timur Palimanan

Cirebon
Jl. Dewi Sartka No.15, Tukmudal, Sumber, Cirebon,
6 RS Sumber Hurip Jawa Barat

7 RS PARU

Mengtahui
Kepala UPT Puskesmas Watubelah

drg. Hj. RETNO WIDOWATI

NIP :19661025 200112 2 001

0
REKAPITULASI RUJUKAN
SKESMAS WATUBELAH

KEPESERTAAN
Jumlah Rujukan Ket
BPJS/PBI BPJS/Non PBI

17 16 1

13 8 5

11 2 9

76 40 36

10 7 3

61 45 16

2 2
 LAPORAN PERMASALAHAN PELAYANAN KESEHATAN RU
UPT PUSKESMAS WATUBELAH
BULAN FEBRUARI 2019
Tidak ditangani oleh dr Special di poliklinik Tidak diterima/Di tolak Rawat Ina

No Nama Rumah Sakit

Nama poliklinik dan dokter Tanggal
yang menangani Alasan
Identitas pasien rujukan
diagnosa
BADAN RSUD
1 ARJAWINANGUN
RSUD Gunung jat
2
RS Permata
3
RS Mitra Plumbon
4
RS Jantung Hasna Medika
5
RS Sumber Hurip
6
RSP Sidawangi
7

Mengtahui
Kepala UPT Puskesmas Watubelah

drg. Hj. RETNO WIDOWATI

NIP :19661025 200112 2 001
LAYANAN KESEHATAN RUJUKAN
AS WATUBELAH

Tidak diterima/Di tolak Rawat Inap Permasalahan lainnya

Identitas Pasien tanggal Jenis Identitas pasien Tanggal

Diagnosa Rujukan permasalahan Diagnosa dirujuk

Cirebon, 4 MARET 2019

Pengelola Kesehatan Rujukan

AGUNG HERMANTO, AMKG