FORMAT MONITORING PELAKSANAAN PROGRAM RUJUK BALIK

BPJS KESEHATAN CABANG MEDAN

TAHUN 2019
FKTP KLINIK LAIYSA
NAMA APOTEK SANA BARU
BULAN PELAYANAN AGUSTUS 2019

OBAT Tanda Terima obat

Tanda Terima obat
Oleh Pasien(Paraf Tanda Terima
NO Nama Pasien No. BPJS TANGGAL NO.TELP FKTP (Paraf dan obat Retur
Nama Obat Signa Jumlah dan TGL)
TGL

1 Abd. Mutalib 0000006547577 29-Aug NKF 1x1 30

Aspilet 1x1 30
Bisoprolol 5 mg 1x1 30
Clopidogrel 1x1 30

2 Khor A Giok 0001454583115 29-Aug Amlodipin 5 mg 1x1 30

3 Lukman 0001796183493 29-Aug Amlodipin 5 mg 1x1 30

4 M. Isnen Syafari 0001303148722 29-Aug Amlodipin 5 mg 1x1 30

5 Nazlah Wati 0001817796609 29-Aug Amlodipin 10 mg 1x1 30

6 Selpantina Sibarani 0000008949881 29-Aug Amlodipin 10 mg 1x1 30

Captopril 25 mg 1x1 30
Simvastatin 10 mg 1x1 30
7 Susilawati 0001436884323 29-Aug Amlodipin 5 mg 1x1 30

8 Wagirun 0001830321472 29-Aug Amlodipin 10 mg 1x1 30

9 Suryati 0001273661043 29-Aug Metformin 500 mg 2x1 60

10 Terem Ginting 0000009114737 29-Aug ISDN 2x1 60
Amlodipin 5 mg 1x1 30
11 Jefri Sirait 0001794744887 29-Aug Metformin 500 mg 3x1 90
Glucodex 1x1 30
Amlodipin 5 mg 1x1 30
12 Salbiah 0001851153546 29-Aug Metformin 500 mg 1x1 30
Amlodipin 5 mg 1x1 30
13 Diana Meliana Rumapea 0001467079053 2-Aug Amlodipin 10 mg 1x1 30

14 Djumirah Darsini 0001827881278 2-Aug Amlodipin 5 mg 1x1 30

15 Erliati Purba 0001802456796 29-Aug Amlodipin 5 mg 1x1 30

16 Mulianto 0001801033626 6-Aug Amlodipin 5 mg 1x1 30

17 Aswady 0001805442682 29-Aug Amlodipin 10 mg 1x1 30

18 Lasiono 0001625646407 16-Aug Amlodipin 5 mg 1x1 30

19 Hj. Rohani ZA 0001843637613 29-Aug Amlodipin 5mg 1x1 30

20 Tan Tjoan Nai 0001719044256 3-Aug Amlodipin 10 mg 1x1 30

21 Deli Afridah 0001718869419 29-Aug Metformin 500 mg 1x1 30

22 Ngamini Tarigan 0000165300838 11-Aug Captopril 25 mg 1x1 30

23 Soniah 0001449385661 29-Aug Amlodipin 5 mg 1x1 30

24 Sunardi 0001328407007 29-Aug Metformin 500 mg 1x1 30

Captopril 50 mg 1x1 30

29-Aug
25 Halijah 0000008361628 Metformin 500 mg 1x1 30

26 Bambang Edi Rospianto 0001838983206 20-Aug Amlodipin 5 mg 1x1 30

29-Aug
27 Diah Lesmanasari 0001485086229 Amlodipin 5 mg 1x1 30
Metformin 500 mg 1x1 30
28 Esmida Wati 0001625647871 29-Aug Candesartan 8 mg 1x1 30

29 Ericson Rivaldi 0001303498912 29-Aug Depakote ER 500 mg 2x1 60

30 Rumiati 0000009994533 5-Aug Asetosal 1x1 30
Concor 2,5 mg 1x1 30
NKF 1x1 30
Ramipril 10 mg 1x1 30
31 Panusunan 0000009625364 1-Aug NKF Forte 1x1 30
ISDN 2x1 60
Clopidogrel 1x1 30
Simvastatin 20 mg 1x1 30
Concor 2,5 mg 1x1 30
32 Nurmaisyah Harahap 0001422878861 10-Aug Candesartan 16 mg 1x1 30
Novorapid 1x 10 IU 1

33 Asba Sinaga 0001303498959 6-Aug Depakote ER 500 mg 2x1 60

34 Alindan Harahap 0001866522148 29-Aug Amlodipin 10 mg 1x1 30
Aptor 1x1 30
35 Jenni Agustina 0001303486918 16-Aug Metformin 500 mg 3x1 90
36 Yusdi 0001274804155 29-Aug NKF Forte 1x1 30
Amlodipin 5 mg 1x1 30
Concor 2,5 mg 1x1 30
37 Rosmini 0000168667402 25-Aug Micardis 80 mg 1x1 30
Furosemid 1x1 30
Concor 2,5 mg 1x1 30
38 Nurlimpah 0001294214894 sudah ambil di sufina aziz Salbutamol 1x1 30
Retapyl SR 1x1 30
39 Faridahani Hsb 0001475379279 29-Aug Micardis 80 mg 1x1 30
Amlodipin 10 mg 1x1 30
40 Anggiat Girsang 0001302120123 16-Aug Candesartan 8 mg 1x1 30
Bisoprolol 5 mg 1x1 30
Metformin 500 mg 3x1 90
Glikuidon 2x1 60
41 Sujudin 0002034885778 29-Aug Candesartan 16 mg 1x1 30
42 Syamsudin 0000009490432 11-Aug Valsartan 80 mg 1x1 30
Simvastatin 10 mg 1x1 30
Amlodipin 10 mg 1x1 30
43 Darwis 0001261068759 29-Aug Captopril 25 mg 1x1 30
Amlodipin 10 mg 1x1 30
Bisoprolol 2,5 mg 1x1 30
44 Darwan Batubara 0001179800267 29-Aug Amlodipin 10 mg 1x1 30
Irbesartan 150 mg 1x1 30
45 Agustina Lbs 0000008777979 8-Aug Valsartan 80 mg 1x1 30
46 Hj. Nurdiani 0000009957407 29-Aug Amlodipin 10 mg 1x1 30
Metformin 500 mg 3x1 90
Valsartan 80 mg 1x1 30
47 H. Erjan Fillen 0000009956338 29-Aug Amlodipin 10 mg 1x1 30
Lantus 2x10 IU 2
48 Suparman 0001478293762 4-Aug Symbicort 160 spn.puff 1
Retapyl SR 1x1 30
49 Arnisah 0001462829231 24-Aug Clopidogrel 1x1 30
Aspilet 1x1 30
NKF 1x1 30
Concor 2,5 mg 1x1 30
50 Syahrul Hidayat 0001963443508 29-Aug Metformin 500 mg 2x1 60
Lantus 1x30 IU 3
51 Siti Syarifah 0000008597722 5-Aug Concor 2,5 mg 1x1 30
NKF 1x1 30
52 Tjioe Kong Fe 0001807669989 24-Aug Amlodipin 10 mg 1x1 30
Clopidogrel 1x1 30
53 Yamilianto 0001899657628 14-Aug Lantus 2x10 IU 2
Glimepirid 2 mg 1x2 60

54 Erlinda Br. Sitepu 0002224921522 29-Aug Symbicort 60 spn puff 1

55 Edi Sunarto 0002199741041 16-Aug Glibenklamid 1x1 30
Metformin 500 mg 2x1 60
56 Zahara Erli 0001267070229 16-Aug Glibenklamid 1x1 30
Metformin 500 mg 2x1 60

57 Isyah 0001479071002 29-Aug Metformin 500 mg 2x1 60

58 Sulastri 0000007515279 11-Aug Amlodipin 10 mg 1x1 30
Captopril 12,5 mg 2x1 60
Simvastatin 10 mg 1x1 30
59 Poniah 0001257121225 8-Aug Metformin 500 mg 2x1 60
Glibenklamid 1x1 30

60 Sri Bint 0002427072074 18-Aug Metformin 500 mg 1x1 30

61 Binsar Amlodipin 1x1 30

 Telmisartan 80 1x1 30
62 Robby Septa 0002771616385 glikazide 1x1 30
Metformin 500 mg 2x1 60
63 lasmaria 0000011552646 Amlodipin 10 mg 1x1 30
aptor 1x1 30
bisosprolol 1x1 30
Candesartan 8 mg 1x1 30
Simvastatin 20 mg 1x1 30
FORMAT MONITORING PELAKSANAAN PROGRAM RUJUK BALIK
BPJS KESEHATAN CABANG MEDAN
TAHUN 2019
FKTP PUSKESMAS SEI AGUL
NAMA APOTEK SANA BARU
BULAN PELAYANAN AGUSTUS 2019

OBAT Tanda Terima Tanda Terima

obat FKTP obat Oleh Tanda Terima
NO Nama Pasien No. BPJS TANGGAL NO.TELP
Nama Obat Signa Jumlah (Paraf dan Pasien(Paraf obat Retur
TGL dan TGL)

1 Jaka Permana Sembiring 0002036449113 6-Aug Phenitoin 100 mg 3x1 90

Carbamazepin 200 mg 3x1 90
2 Mujianto 0002145542141 11-Aug Metformin 500 mg 3x1 90
Glimipiride 4 mg 1x1 30
3 Berliani 0000168630827 11-Aug Valsartan 80 mg 1x1 30
0 Amlodipin 10 mg 1x1 30
4 Asima Rumapea 0000009107987 10-Aug Candesartan 16 mg 1x1 30
Concor 2,5 mg 1x1 30
Furusemide 40 mg 1x1 30
5 Raja Basir Barus 0001864534735 28-Aug Amlodipin 10 mg 1x1 30
Micardis 80 mg 1x1 30
Simvastatin 20 mg 1x1 30
Metformin 500 mg 3x1 90
Glimipiride 2 mg 1x1 30
6 Lazuardi 0001486529649 7-Aug Symbicort 160/4,5 2 x 1 Puff 1
Berotec 1x1 1
Retapyl 300 2x1 60
7 Amirullah 0000266877448 6-Aug Candesartan 8 mg 1x1 30
Nitrokap Retart 2,5 mg1x1 30
8 Mianna Saragih 0001905202001 22-Aug 082167615105 Glimipiride 2 mg 1x1 30
Metformin 500 mg 2x1 60
9 Nurmala Siagian 0001486530516 21-Aug 082370099356 ISDN 5 mg 3x1 90
 Aptor 1x1 30
Bisosprolol 5 mg 1 x 1/2 15
Candesartan 16 mg 1x1 30
10 Jumia 0000266871835 10-Aug 081375454092 Candesartan 8 mg 1x1 30
Aptor 1x1 30
11 Nuraini 0000266755689 23-Aug 082360513143 Amlodipin 10 mg 1x1 30
Glibenklamide 5 mg 2x1 60
12 Erfi Harlina hsb 0000009368921 14-Aug 085360115736 Novorapide 26-26-26 8
lanrtus 0-0-26 3
13 Ivano Syahputra 0001455652449 14-Aug 081375312390 candesartan 8 mg 1x1 30
Novorapide 16-16-16 5
14 Sahat Marulitua Sihaan 0000013426648 15-Aug 08126598019 ISDN 5 MG 3x1 90
candesartan 8 mg 1x1 30
Furusemide 40 mg 1x1 30
Concor 2,5 mg 1x1 30
Spironolaktone 25 mg 1x1 30
15 Razali 0001273925643 12-Aug 018361503300 candesartan 8 mg 1x1 30
Concor 2,5 mg 1x1 30
Nitrokraf 2,5 mg 1x1 30
Aptor 1x1 30
Amlodipin 10 mg 1x1 30
16 Nursamsinar 00014864544657 14-Aug 082364213157 Candesartan 16 mg 1x1 30
082164637005 Bisosprolol 5 mg 1x1 30
Aptor 1x1 30
ISDN 5 MG 3x1 90
17 Saur TPM Amin Huta 0001278534047 13-Aug 085275926921 Retapyl 300 1x1 30
Symbicort 1x Puff 1
18 Sumiaty 0000267141565 10-Aug 085270299233 Acarbose 100 mg 3x1 90
Glimipiride 3 mg 2x1 60
Micardis 80 mg 1x1 30
Amlodipin 5 mg 1x1 30
19 Djamarsen Sipayung 0001905201066 29-Aug 08216761505 Amlodipin 5mg 1x1 30
Bisosprolol 5 mg 1x1 30
Furusemide 40 mg 1x1 30
Spironolaktone 25 mg 1x1 30
Simvastatin 10 1x1 30
20 Afniati 0000009366827 19-Aug Amlodipin 10 mg 1x1 30
Candaesartan 16 mg 1x1 30
Novomix 26-0-26 6
Simvastatin 10 1x1 30
21 Tiawan Klara 0001486534015 13-Aug 08126449988 Aptor 1x1 30
Micardis 80 mg 1x1 30
Bisosprolol 5 mg 1x1 30
Spironolaktone 25 mg 1x1 30
22 Merna Masrida HRP 0000009491218 30-Aug 085261917014 Concor 2,5 mg 1x1 30
candesartan 8 mg 1x1 30
23 Naimah Nst 0000009691277 29-Aug 082160873773 Glimipiride 1 mg 1x1 30
Metformin 500 mg 3x1 90
Acarbose 100 mg 1x1 30
24 Valeria Emma R.Purba 0000009114985 13-Aug 081370300141 candesartan 16 mg 1x1 30
25 Sumarni Rajagukguk 0001279641227 13-Aug 081263277378 Adalat Oros 30 mg 1x1 30
candesartan 8 mg 1x1 30
26 Rosni Lubis 0000009994465 1-Aug Amlodipin 5 mg 1x1 30
candesartan 8 mg 1x1 30
27 Ali Nafiah HSB .0002070154484 15-Aug Amlodipin 10 mg 1x1 30
Aptor 1x1 30
Captopril 25 mg 2x1 60
28 Ghito Arriyanto 00000008920383 10-Aug Concor 2,5 mg 1x1 30
Spironolaktone 25 mg 1x1 30
29 STN Inayah r.Htgl 00001489081151 10-Aug 085275482778 Spironolaktone 25 mg 1x1 30
Micardis 80 mg 1x1 30
Glimipiride 2 mg 1x1 30
 Novorapide 16-16-16 5
Lantus 0-0-14 2
30 Harmon Koto 0001486530573 1-Aug 081361620772 Candesartan 16 mg 1x1 30
Amlodipin 10 mg 1x1 30
31 Nurdini Lbs 0001323342134 2-Aug 082161639271 Seretide 250 2 x Puff 1
32 Etty Herawati 0000008963515 8-Aug 081219317371 Concor 2,5 mg 1x1 30
Valsartan 80 mg 1x1 30
33 Suyati 0001088797331 8-Aug 085362488755 Amlodipin 10 mg 1x1 30
0001088797331 15-Aug 085362488755 Seretide 250 2 x Puff 1
34 Gustina Siregar 0000139614662 30-Dec 081318425066 Amlodipin 10 mg 3x1 90
Candesartan 16 mg
ISDN
35 Ramses Ricardo 0000211442793 8-Aug 081318425066 Depakote 500 mg 2x1 60
Phentoin 3x1 90
36 Jana Sujana 0000008963504 8-Aug 0811612327 Apidra 16-16-16 5
37 Jumadi 0000985607976 5-Aug 085385833493 Salbutamol 2 mg 1x1 30
Symbicort 2 x Puff 1
Aptor 1x1 10
Retapyl SR 2x1 60
38 Willy Permana Kosasih 0001724026689 11-Aug 081264404315 Lantus 0-0-20 2
Apidra 18-18-18 5
39 Redili lase 0002071316057 7-Aug 085361098997 Symbicort 2 x Puff 1
40 Djamintan Simanjuntak 0000198116065 8-Aug 085361717875 Novomix 36-0-34 7
41 latifah Hanum 0001467897355 1-Aug Simvastatin 20 mg 1x1 30
Concor 2,5 mg 1x1 30
42 Amrul Irsan 0001467897341 1-Aug Simvastatin 20 mg 1x1 30
Aptor 1x1 30
Concor 2,5 mg 1x1 30
43 Ridhayanti Nauli 0002033981965 3-Aug Depakote 500 mg 2x1 60
Fenitoin 3x1 90
B1 3x1 90
44 Sapari 0000265995922 11-Aug Retapyl 300 2x1 60
Symbicort 2 x Puff 1
45 Benedicta FM 0001486544231 16-Aug 082276682668 Depokote 250 mg 1x1 30
46 Chairul Lely 0000009108459 16-Aug 081260400886 Gliquidon 30 mg 2x1 60
Metformin 500 mg 3x1 90
47 Lisnawaty 0001272247986 25-Aug 082368231793 Symbicort 2 x Puff 1
Retapyl 1x1 30
Aptor 1x1 10
48 Tasnim 0000009107908 24-Aug 081376653582 Bisosprolol 5 mg 1x1 30
Amlodipin 10 mg 1x1 30
Ramipril 5 1x1 30
49 Hasbullah Chan 0000007207323 16-Aug 08126582448 Furusemide 40 mg 1x1 30
Micardis 80 mg 1x1 30
Concor 2,5 mg 1x1 30
clopidogrel 1x1 30
ISDN 3x1 90
50 Drs Zubair lubis 0000158978507 19-Aug 082165958547 Apidra 26-0-26 6
Lantus 0-0-20 2
51 Yusmai Alinasih 0000265556169 19-Aug 081394122149 Glimipiriide 2 2x1 60
52 Masriani Siregar 0000168778181 19-Aug 085361243664 Concor 2,5 mg 1x1 30
Candesartab 8 1x1 30
53 Benedicta FM Wirong 0001486544231 9-Aug 082276682668 Depakote 250 1x1 30
54 Saut Anthony 0000009544465 23-Aug 081293306501 Apidra 30-30-30 9
Lantus 0-0-30 3
55 Marwin 0000266731018 24-Aug 085361840583 Amlodipin 5 1x1 30
belum antar Glibenklamide 5 mg 1x1 30
Metformin 500 mg 1x1 30
56 Mahadi Lubis 0000157947052 20-Aug 085261663445 Candesartan 8 mg 1x1 30
belum antar Amlodipin 10 mg 1x1 30
57 Hj.Yusnani 0001438351964 20-Aug 081376996605 Concor 2,5 mg 1x1 30
belum antar candesartan 8 mg 1x1 30
 1,664,520
2,174,997
617,997
2,450,426

4,350,000

8,290,800

214,500

2,922,689

4,159,500
235,000
234,000
11,020,800

4,913,997

43,249,226
13,450,801
2,648,100
59,348,127