Lap KBS 2016

DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESDA / KBS DI PELAYANAN D
PROPINSI : JAWA TENGAH BULAN : Januari

KAB/KOTA : BANYUMAS PUSKESMAS : PUSKESMAS I WANGON
Kepada Yth.
Kepala Dinas Kesehatan Kab. Banyumas
di Tempat
Bersama ini Kami ajukan tagihan Klaim Pelayanan Kesehatan Umum Rawat Jalan Peserta Kartu Banyumas Sehat
Total : 116 Pasien
No Nama Alamat No Asuransi Umur Jenis Kel Tgl Transaksi
1 IKLIL KAFIAH PARUNGKAMAL, 3/7 '1011102001140257 2 P 2/1/2016

2 RANDIF PANDU P WANGON 1/3 '1021072401940156 20 L 2/1/2016
3 SIDAH CIKAKAK 3/9 '1022011607660254 49 P 2/1/2016
4 SUPRIYONO RANDEGAN 5/4 '1051102010800145 35 L 2/1/2016
5 FAIZAL ABDURROHMAN BANTERAN 1/2 '1021013101940243 22 L 4/1/2016
6 SULIYAH RAWAHENG 4/1 '1021061603680152 47 P 4/1/2016
7 ROSIDI JASWAN JAMBU RT 4/10 '1022020709470230 68 L 4/1/2016
8 ADMINI KARANGGAYAM 1/2 '1011073112730135 43 P 5/1/2016
9 ROHYATUN KLAPAGADING 2/10 '1021022308850281 28 P 5/1/2016
10 MUHROJI ROSLAM KLAPAGADING 2/4 '1021023112510273 64 L 5/1/2016
11 FAHRIZAL NUR RANDEGAN 4/2 '1021050411030253 12 L 5/1/2016
12 TUMINAH RANDEGAN 2/11 '1021051608690260 46 P 5/1/2016

13 ROHAYANI RAWAHENG 5/5 '1021061705840161 31 P 5/1/2016
16 RASIYAH BANTERAN 4/2 '1021011409770002 38 P 6/1/2016
17 WASITAH WANGON 3/4 KULON
KLAPAGADING '1021071212770210 38 P 6/1/2016
18 TIRWAN YASMIREJA 2/13 '1021030603840126 68 L 7/1/2016
19 PRASYA ALIF F RAWAHENG 4/2 '1021062201120118 2 L 8/1/2016
20 AKBAR HAINUN MUSTOFA WANGON 1/4 '1021070602130193 2 L 8/1/2016
22 MUH IZHAR SAPUTRA KLAPAGADING 2/8 '102122202130164 2 L 8/1/2016
23 NAKIYAH RANCABANTENG 3/1
KLAPAGADING KULON '1021020312570197 58 P 9/1/2016
24 SUNARTO DIKUN 03/01 '1021033112530182 62 L 9/1/2016
25 KUSTILAH WANGON 1/4 '1021070701730217 42 P 9/1/2016
26 SANROKYAT ANGKAT WANGON 1/7 '1021073112550033 60 L 9/1/2016
28 SAMSUDIN BANTERAN 4/1 '1021010607560218 59 L 11/1/2016
29 AWEN BANTERAN 2/2 '1021012004550114 60 P 11/1/2016
31 TARISEM KLAPAGADING 4/1 '1021020906700010 55 P 11/1/2016
32 SAENDAH KLAPAGADING 5/1 '1021022912980008 37 P 11/1/2016
33 SIGIT RIYANTO WANGON 4/15 '1021070710880041 27 L 11/1/2016
35 ARI SISWATI KLAPAGADING 3/4 '1021023112590042 56 P 12/1/2016
36 KARSIH PENGADEGAN 03/06 '1021041001540271 61 L 12/1/2016
37 RIYATI PENGADEGAN 3/5 '1021041401940219 20 P 12/1/2016
38 WARTAM PENGADEGAN RT 1/2 '1021042407710167 44 L 12/1/2016
39 ROHAYANI RAWAHENG 5/5 '1021061705840161 31 P 12/1/2016
40 ASTUTI NOVI LAELANI WANGON 4/2 '1021071811910220 23 P 12/1/2016
41 MUHAMMAD SEPTIAN ALIF WANGON 4/4 '1021010909150235 L 13-01-2016

42 NASIYAH KLAPAGADING 2/9 '1021023101450172 70 P 13-01-2016
43 KOMARI RAWAHENG 5/2 '1021062810500030 65 L 13-01-2016
44 TARSA SURATMAN PENGADEGAN 1/10 '1021041704720270 44 L 14-01-2016
45 NAURA ARVIANI WANGON 02/12 '1021070909460006 8 P 14-01-2016
46 RANDIF PANDU P WANGON 1/3 '1021072401940156 20 L 14-01-2016
47 MUH IZHAR SAPUTRA KLAPAGADING 2/8 '102122202130164 3 L 14-01-2016
48 ADMINI BANTERAN 2/4 '1021012009760224 45 P 15-01-2016
49 DWI ARIFIANTO CANDUK 1/1 '1011021011050166 10 L 16-01-2016
50 MUHROJI ROSLAM KLAPAGADING 2/4 '1021023112510273 64 L 16-01-2016
51 SUMANTO RANDEGAN 4/5 '1021052606680263 47 L 16-01-2016
52 ISMALIA JAMBU 1/5 '1022021101950169 25 P 16-01-2016
53 WIWIK SUPRIYATI BANTERAN 4/4 '1021011308810229 34 P 18-01-2016
54 SUMIAH BANTERAN 3/4 '1021011408760206 40 P 18-01-2016
55 RASINAH BANTERAN 5/4 KULON
KLAPAGADING '1021012407720080 42 P 18-01-2016
56 NAKIYAH 3/1 '1021020312570197 58 L 18-01-2016
57 WARSINI KLAPAGADING 1/8 '1021022012580190 57 P 18-01-2016
58 ROHYATUN KLAPAGADING 2/10 '1021022308850281 28 P 18-01-2016
59 RUMBIYATI KLAPAGADING 1/10 '1021022505690035 46 P 18-01-2016
60 MUHROJI ROSLAM KLAPAGADING
KLAPAGADING 2/4
KULON '1021023112510273 64 L 18-01-2016
61 SUNARTO DIKUN 03/01 '1021033112530182 62 L 18-01-2016
63 ERNA ASMARANI KLAPAGADING 1/7 '1021021806900137 25 P 19-01-2016
65 SUDARTI RANDEGAN 3/4 '1021050304650217 59 P 19-01-2016
66 FERDI GHANI MAULANA WANGON RT 2/1 '1021071105830200 0 L 19-01-2016
67 MISROJI MISLAM KLAPAGADING 6/5 '1021020204580269 57 L 20-01-2016
68 ROHYATUN KLAPAGADING
KLAPAGADING 2/10
KULON '1021022308850281 28 P 20-01-2016
69 TIRWAN YASMIREJA 2/13 '1021030603840126 68 L 20-01-2016
70 RASINI KLAPAGADING 5/2 '1021033012590216 56 L 20-01-2016
71 ELI SUNINGSIH WANGON 214 '1021070911870222 28 P 20-01-2016
73 SENEN EFENDI WANGON 5/13 KULON
KLAPAGADING '102107606720155 42 L 21-01-2016
74 SENO 3/8 '1021030709700196 40 L 22-01-2016
75 YUNI PRIHATIN RAWAHENG 4/1 '1021060206950149 20 P 22-01-2016
76 SISWANTO WANGON 3/2 '1021070806810032 33 L 22-01-2016
78 SANIS KLAPAGADING RT 4/10 '1021023112540193 61 P 23-01-2016
79 ETI SETIANINGSIH BANTERAN 4/3 KULON
KLAPAGADING '102102711930072 22 P 23-01-2016
80 TUGINI 3/1 '1021031709820153 33 P 23-01-2016
81 PUJIYATI KLAPAGADING 1/10 '1021032908690228 46 P 23-01-2016
82 ASTUTI NOVI LAELANI WANGON 4/2 '1021071811910220 23 P 23-01-2016
83 NAKIYAH RANCABANTENG 3/1 '1021020312570197 58 P 25-01-2016
84 SLAMET KLAPAGADING 4/2 '1021021304480284 68 L 25-01-2016
85 ROHYATUN KLAPAGADING 2/10 '1021022308850281 28 P 25-01-2016
86 KUSMINI KLAPAGADING
KLAPAGADING 3/1
KULON '1021030309810143 29 P 25-01-2016
87 SUNARTO DIKUN 03/01 '1021033112530182 62 L 25-01-2016
88 KARSIH PENGADEGAN 03/06 '1021041001540271 61 L 25-01-2016
89 KANTINI WANGON 6/5 '1021071010690028 46 P 25-01-2016
90 AHMAD BAJURI CANDUK 1/1 '1011020307590138 55 L 26-01-2016
91 MAHFURI BANTERAN 2/2 '1021011603620247 53 L 26-01-2016
92 SUKESIH BANTERAN 3/4 '1021013112630029 52 P 26-01-2016
93 ROPINGAH KLAPAGADING 1/10 '1021021506770278 38 P 26-01-2016

95 ARI SISWATI KLAPAGADING
KLAPAGADING 3/4
KULON '1021023112590042 56 P 26-01-2016
96 AMINAH 3/4 '1021033112610212 48 P 26-01-2016
97 YUNI PRIHATIN RAWAHENG 4/1 '1021060206950149 20 P 26-01-2016
98 ELI SUNINGSIH WANGON 214 '1021070911870222 28 P 26-01-2016
99 NINING PURNINGSIH WANGON RT 2/11 '1021072101890179 25 P 26-01-2016
100 ASTIN NURKHASANAH CANDUK 1/1 '1011020502090142 6 P 27-01-2016
101 DIKAN SUKANDA KLAPAGADING 4/2 '1021020304670272 46 L 27-01-2016
102 SOLINA KLAPAGADING
KLAPAGADING 2/6
KULON '1021021010870285 29 P 27-01-2016
103 EZANI CHOERUL ANAM 1/7 '1021032104850190 0 L 27-01-2016
104 KARSIH PENGADEGAN 03/06 '1021041001540271 62 L 27-01-2016
105 ALMIRA RIZQIYAH LZ. RAWAHENG 5/2 '1021060904930032 23 P 27-01-2016
106 KANTINI WANGON 6/5 KULON
KLAPAGADING '1021071010690028 46 P 27-01-2016
107 AMINAH 3/4 '1021033112610212 48 P 28-01-2016
108 KASWARI RANDEGAN 1/6 '1021051201350264 81 L 28-01-2016
109 SUKIMIN RANDEGAN 02/02 '1021052604670227 48 L 28-01-2016
110 BAMBANG SEPTI WIONO JAMBU RT 01 RW 08 '1022021109860036 29 L 28-01-2016
111 TUTI TUNJUNG 7/3 '1031113112660037 49 P 28-01-2016
112 MAHFURI BANTERAN 2/2 '1021011603620247 53 L 29-01-2016
113 TUMINAH KLAPAGADING RT 5/11 '1021021809740280 41 P 29-01-2016
114 WARTAM PENGADEGAN RT 1/2 '1021042407710167 44 L 29-01-2016
115 SLAMET KLAPAGADING 4/2 '1021021304480284 68 L 30-01-2016
Kepala Puskesmas I Wangon
dr. Tulus Budi Purwanto

NIP. 19820327 200903 1 006
KLAIM-KBS
ALAN JAMKESDA / KBS DI PELAYANAN DASAR
TAHUN : 2016
Diagnosa Tujuan Berobat Karcis + Tindakan
Diare dan gastroenteritis KLINIK UMUM / BP Rp 5,000

KLINIK UMUM / BP Rp 5,000
Demam tifoid dan paratifoid KLINIK UMUM / BP Rp 5,000
TB paru klinis (rontgen +) KLINIK UMUM / BP Rp 5,000
Urtikaria KLINIK UMUM / BP Rp 5,000
Diabetes Mellitus (NIDDM) RUJUKAN Rp 5,000
Gagal jantung RUJUKAN Rp 5,000
Menometrorrhagi KLINIK KIA Rp 5,000
Dispepsia KLINIK UMUM / BP Rp 5,000
Fraktur RUJUKAN Rp 5,000
Vulnus laseratum , punctum RUJUKAN Rp 5,000
Kehamilan (ANC) KLINIK HAMIL Rp 5,000

Vulnus laseratum , punctum KLINIK UMUM / BP Rp 5,000
TB paru BTA + KLINIK UMUM / BP Rp 5,000
Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
Schizophrenia RUJUKAN Rp 5,000
Konjuntivitis
Infeksi Akut lain pada saluran Pernafasan KLINIK UMUM / BP Rp 5,000
bagian atas KLINIK UMUM / BP Rp 5,000
Hipertensi primer KLINIK UMUM / BP Rp 5,000
MYALGIA KLINIK UMUM / BP Rp 5,000
Demam yang tdk diketahui sebabnya KLINIK UMUM / BP Rp 5,000
Dispepsia RUJUKAN Rp 5,000
Luka Terbuka RUJUKAN Rp 5,000
Stroke KLINIK UMUM / BP Rp 5,000
Luka Lecet KLINIK UMUM / BP Rp 5,000
KLINIK KIA Rp 5,000

Vitiligo KLINIK UMUM / BP Rp 5,000
Appendicitis KLINIK UMUM / BP Rp 5,000
Demam yanglain
Infeksi Akut tdkpada
diketahui sebabnya
saluran Pernafasan KLINIK UMUM / BP Rp 5,000
Asma KLINIK UMUM / BP Rp 5,000
Keluarga Berencana (KB) KLINIK KB Rp 5,000
Menometrorrhagi KLINIK KIA Rp 5,000
Nyeri kepala KLINIK UMUM / BP Rp 5,000
STOMATITIS KLINIK UMUM / BP Rp 5,000
Prolaps RUJUKAN Rp 5,000
Konjuntivitis KLINIK UMUM / BP Rp 5,000
KLINIK HAMIL Rp 5,000
Common Cold/Nasopharyngitis Akut KLINIK UMUM / BP Rp 5,000
Pneumonia KLINIK UMUM / BP Rp 5,000
Prolaps RUJUKAN Rp 5,000
Gagal jantung KLINIK UMUM / BP Rp 5,000
Fibro adenoma mammae KLINIK UMUM / BP Rp 5,000
Luka Terbuka KLINIK UMUM / BP Rp 5,000
Anemia Lainnya
Infeksi Akut lain pada saluran Pernafasan RUJUKAN Rp 5,000
Glaukoma RUJUKAN Rp 5,000
Demam yanglain
Infeksi Akut tdkpada
diketahui sebabnya
saluran Pernafasan KLINIK UMUM / BP Rp 5,000
Lipoma RUJUKAN Rp 5,000
Diabetes Mellitus (NIDDM) KLINIK UMUM / BP Rp 5,000
Gastritis RUJUKAN Rp 5,000
Infeksi saluran kemih bagian bawah RUJUKAN Rp 5,000
Keluarga Berencana
COPD (Chronic (KB) Pulmonary
Obstructive KLINIK KB Rp 5,000
Disease) KLINIK UMUM / BP Rp 5,000
Luka Lecet RUJUKAN Rp 5,000
Bronkhitis akut KLINIK UMUM / BP Rp 5,000
Ulkus pada tungkai RUJUKAN Rp 5,000

Nyeri Dada RUJUKAN Rp 5,000
Urtikaria KLINIK UMUM / BP Rp 5,000
Fibro adenoma mammae RUJUKAN Rp 5,000
Dispepsia
KLINIK KIA Rp 5,000
MYALGIA
DECOMP CORDIS KLINIK UMUM / BP Rp 5,000
Hipertensi primer RUJUKAN Rp 5,000
Epilepsi RUJUKAN Rp 5,000
Tonsilitis Akut KLINIK UMUM / BP Rp 5,000
Kehamilan (ANC) KLINIK UMUM / BP Rp 5,000
Stroke KLINIK UMUM / BP Rp 5,000
Hemoroid RUJUKAN Rp 5,000
Rp 580,000
Bendahara Penerima
Sumarno
NIP. 19631011 198603 1 009
DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESDA / KBS DI PELAYANAN
PROPINSI : JAWA TENGAH BULAN : Februari
Kepada Yth.
di Tempat
Total : 95 Pasien

2 KAPSIYAH KLAPAGADING KULON 1/6 '1021032001770122 36 P 2/1/2016
3 KHOTIMAH WANGON 2/1 '1021071105830200 31 P 2/1/2016
4 WARSINI KLAPAGADING 1/8 '1021022012580190 58 P 2/2/2016
6 TIRWAN YASMIREJA KLAPAGADING KULON 2/13 '1021030603840126 68 L 2/2/2016
7 AMINAH KLAPAGADING KULON 3/4 '1021033112610212 48 P 2/3/2016

8 AHMAD MUHTON RAWAHENG 06/03 '1021060705330165 83 L 2/3/2016
9 SISWANTO WANGON 3/2 '1021070806810032 34 L 2/3/2016
11 DULROHMAN PARUNGKAMAL 6/3 '1022203101440101 71 L 2/3/2016
12 MAHFURI BANTERAN 2/2 '1021011603620247 53 L 2/4/2016
13 PATMIATI BANTERAN 1/4 '1021011911790223 36 P 2/4/2016
14 RUMBIYATI KLAPAGADING 1/10 '1021022505690035 46 P 2/4/2016
15 SENO KLAPAGADING KULON 3/8 '1021030709700196 40 L 2/4/2016
16 KARSIH PENGADEGAN 03/06 '1021041001540271 62 L 2/4/2016
17 WATINI RAWAHENG 4/2 '1021060901610122 53 P 2/4/2016
18 HIDAYANISA NUR KAMILA BANTERAN 3/4 '1021010805150249 0 P 2/5/2016
19 AHMAD TURMIDI KLAPAGADING KULON 4/2 '1021033112470120 66 L 2/5/2016
20 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 P 2/6/2016
21 ENI SURYANI KLAPAGADING KULON 1/8 '1021031010850075 30 P 2/6/2016
22 SUNARTO DIKUN KLAPAGADING KULON 03/01 '1021033112530182 62 L 2/6/2016
25 SUWARNI PENGADEGAN RT 1/2 '1021042311680260 47 P 2/9/2016
26 ASTUTI NOVI LAELANI WANGON 4/2 '1021071811910220 23 P 2/9/2016
27 NINING PURNINGSIH WANGON RT 2/11 '1021072101890179 25 P 2/9/2016
28 SATRIO ANGGORO C CANDUK 2/1 '1021022704880032 28 L 2/10/2016
30 NOFIYATI RANDEGAN 3/2 '1021051709890265 26 P 2/10/2016
31 SULIYAH RAWAHENG 4/1 '1021061603680152 47 P 2/10/2016
32 JURIYAH BANTERAN 4/1 '1021011407660182 48 P 2/11/2016
34 AWEN BANTERAN 2/2 '1021012004550114 60 P 2/11/2016
35 MARMI BANTERAN 3/1 '1021013112530244 63 P 2/12/2016
38 KUSTILAH WANGON 1/4 '1021070701730217 42 P 2/13/2016
39 SENEN EFENDI WANGON 5/13 '102107606720155 43 L 2/13/2016
41 SUMIAH BANTERAN 3/4 '1021011408760206 40 P 2/15/2016
42 TURAHMI KLAPAGADING KULON 02/16 '1021032203730165 41 P 2/15/2016

43 JONI WARDADI RAWAHENG 5/2 '1021061606780026 38 L 2/15/2016
44 SITI KHOMARIYAH WANGON 3/2 '1021070502610226 54 P 2/15/2016
45 ASTIN NURKHASANAH CANDUK 1/1 '1011020502090142 6 P 2/16/2016
47 FAHRIZAL NUR RANDEGAN 4/2 '1021050411030253 12 L 2/16/2016
50 TUMIRAH BANTERAN 5/1 '102101170467194 48 P 2/17/2016
53 NOFIYATI RANDEGAN 3/2 '1021051709890265 27 P 2/17/2016
54 ALFINA QALBI NUURAN RANDEGAN 3/2 '1021051709890265 27 P 2/17/2016
55 RENDI RIKO PRATAMA WANGON 02/01 '1021071105830200 9 L 2/17/2016
56 MUH IZHAR SAPUTRA KLAPAGADING 2/8 '102122202130164 3 L 2/17/2016
57 SUGENG SUJARWO JURANGBAHAS 6/1 '1022030504540027 59 L 2/17/2016

59 DIKAN SUKANDA KLAPAGADING 4/2 '1021020304670272 46 L 2/18/2016
60 SLAMET KLAPAGADING 4/2 '1021021304480284 68 L 2/18/2016
63 KASIH RANDEGAN 4/2 '1021052409650267 50 P 2/20/2016
64 HERI SETIAWAN RAWAHENG 5/5 '1021061404690135 47 L 2/20/2016
65 TUMINAH KLAPAGADING RT 5/11 '1021021809740280 41 P 2/22/2016
66 ARI WIJI HASTUTI
HANANDIKA KLAPAGADING KULON 3/4 '1021030801950139 20 P 2/22/2016
67 PRAYATAYASA RANDEGAN 3/8 '1021050906740248 0 L 2/22/2016
68 SUMANTO RANDEGAN 4/5 '1021052606680263 47 L 2/22/2016
69 SUMARNO RANDEGAN 2/9 '1021052802500236 64 L 2/22/2016
70 DIKI DERMAWAN BANTERAN 1/3 '1021011904970228 19 L 2/23/2016
71 ERNA ASMARANI KLAPAGADING 1/7 '1021021806900137 25 P 2/23/2016
72 SANIS KLAPAGADING RT 4/10 '1021023112540193 62 P 2/23/2016
73 WARTEM PENGADEGAN 2/1 '1021040209590162 57 P 2/23/2016
74 SARIKEM RAWAHENG 4/4 '1021062004720158 43 P 2/23/2016
76 AISYAH AILA WANGON 2/4 '1021072911150230 2 P 2/23/2016
77 MUH IMDADUR R KLAPAGADING 2/5 '1021021504130289 3 L 2/24/2016

78 SATRIO ANGGORO C CANDUK 2/1 '1021022704880032 28 L 2/24/2016
81 NAJWAN SAPUTRA RAWAHENG 3/2 '1021061006130163 2 L 2/24/2016
82 FREDI GANI MAULANA WANGON 2/1 '102107115830200 0 L 2/24/2016
85 ADMINI BANTERAN 2/4 '1021012009760224 45 P 2/25/2016
86 AHMAD TURMIDI KLAPAGADING KULON 4/2 '1021033112470120 66 L 2/25/2016

88 DESTA FAJAR ISNANDAR KLAPAGADING 3/1 '1021031812130223 2 L 2/26/2016
89 SUKIMIN RANDEGAN 02/02 '1021052604670227 48 L 2/26/2016
90 OKTA DWI YULIAWAN JAMBU 03/12 '1022020307880057 0 L 2/26/2016

92 HIDAYANISA NUR KAMILA BANTERAN 3/4 '1021010805150249 0 P 2/29/2016
93 SUMIAH BANTERAN 3/4 '1021011408760206 40 P 2/29/2016

94 MUH IMDADUR R KLAPAGADING 2/5 '1021021504130289 3 L 2/29/2016
95 MUJIONO WANGON 3/13 '1021072707820085 36 L 2/29/2016
JUMLAH

NIP. 19820327 200903 1 006
KLAIM-KBS
T JALAN JAMKESDA / KBS DI PELAYANAN DASAR
TAHUN : 2016

bagian atas
Gagal Ginjal Kronis RUJUKAN Rp 5,000

Anemia Lainnya KLINIK UMUM / BP Rp 5,000
Gagal Ginjal Kronis RUJUKAN Rp 5,000
RUJUKAN Rp 5,000
Ulkus Peptikum RUJUKAN Rp 5,000
Anemia Lainnya RUJUKAN Rp 5,000
RUJUKAN Rp 5,000
Bronkhitis akut KLINIK UMUM / BP Rp 5,000
Demam yang tdk diketahui sebabnya RUJUKAN Rp 5,000
Hipertensi
Infeksi Akutprimer
lain pada saluran Pernafasan KLINIK UMUM / BP Rp 5,000
Dispepsia
COPD (Chronic Obstructive Pulmonary KLINIK UMUM / BP Rp 5,000
DECOMP CORDIS RUJUKAN Rp 5,000
Obesitas KLINIK UMUM / BP Rp 5,000
Penyakit mata dan adneksa lain RUJUKAN Rp 5,000
Urtikaria
Demam yang tdk diketahui sebabnya RUJUKAN Rp 5,000
Migraine KLINIK UMUM / BP Rp 5,000
MYALGIA RUJUKAN Rp 5,000
Arthritis lain RUJUKAN Rp 5,000

PERSISTENSI
COPD (ChronicGIGI
Obstructive Pulmonary KLINIK GIGI Rp 5,000
Disease) RUJUKAN Rp 5,000
Preeklamsia KLINIK HAMIL Rp 5,000
Ulkus Peptikum RUJUKAN Rp 5,000
bagian atas
bagian atas

Demam tifoid dan paratifoid KLINIK UMUM / BP Rp 5,000
Nyeri Abdomen RUJUKAN Rp 5,000
Diabetes MellitusObstructive
COPD (Chronic (NIDDM) Pulmonary KLINIK UMUM / BP Rp 5,000
DF (Demam
Infeksi Dengue)
Akut lain pada saluran Pernafasan KLINIK UMUM / BP Rp 5,000
Pyoderma KLINIK UMUM / BP Rp 5,000
bagian atas
Infeksi saluran kemih bagian bawah KLINIK UMUM / BP Rp 5,000

Gangguan Nervus Facial RUJUKAN Rp 5,000
Gagal
Infeksi jantung
Akut lain pada saluran Pernafasan RUJUKAN Rp 5,000
KLINIK KIA Rp 5,000
Gangguan lain pada Kornea RUJUKAN Rp 5,000
Migraine KLINIK UMUM / BP Rp 5,000
bagian atas

Pneumonia KLINIK UMUM / BP Rp 5,000

bagian atas

bagian atas

Hydrocele dan spermatocele RUJUKAN Rp 5,000
Rp 475,000
Bendahara Penerima
Sumarno
NIP. 19631011 198603 1 009
DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESDA / KBS DI PELAYANAN
PROPINSI : JAWA TENGAH BULAN : MARET
Kepada Yth.
di Tempat
Total : 117 Pasien
1 SUKESIH BANTERAN 3/4 '1021013112630029 52 P 3/1/2016

3 ILMAN WANGON 4/11 '1021070612850229 0 L 3/1/2016
4 KANTINI WANGON 6/5 '1021071010690028 46 P 3/1/2016
5 SANDIHARJO KASIM WANGON 2/12 '1021071312440192 74 L 3/1/2016
6 MUJIONO WANGON 3/13 '1021072707820085 36 L 3/1/2016
7 NURULITA APRILIANI KARANGGAYAM 1/1 '1011072004000011 16 P 3/2/2016
8 SOIMAH KLAPAGADING 1/12 '1021021106690087 46 P 3/2/2016

9 ROPINGAH KLAPAGADING 1/10 '1021021506770278 38 P 3/2/2016
10 NANANG SUWANDI KLAPAGADING KULON 1/3 '1021030612620156 53 L 3/2/2016
11 EZANI CHOERUL ANAM KLAPAGADING KULON 1/7 '1021032104850190 0 L 3/2/2016
12 ALFINA QALBI NUURAN RANDEGAN 3/2 '1021051709890265 P 3/2/2016
16 ARI SISWATI KLAPAGADING 3/4 '1021023112590042 56 P 3/3/2016
17 SADAN AHCHMAD S KLAPAGADING KULON 5/12 '1021032609620222 54 L 3/3/2016
18 WARSIAH RAWAHENG 4/3 '1021063112690087 46 P 3/3/2016
20 SISWANTO WANGON 3/2 '1021070806810032 34 L 3/3/2016

21 RIYATI PENGADEGAN 3/5 '1021041401940219 20 P 3/4/2016
24 JONI WARDADI RAWAHENG 5/2 '1021061606780026 38 L 3/5/2016

25 ARTINAH RAWAHENG 6/3 '1021063112620080 53 P 3/5/2016

28 VIKA ARUM MELATI TINGGARJAYA 2/12 '1031102503110253 5 P 3/5/2016
29 AHMAD BAJURI CANDUK 1/1 '1011020307590138 55 L 3/7/2016
32 KARSUN KLAPAGADING KULON 02/04 '1021032205340221 55 L 3/7/2016

34 OBBY FEBRIAN RANDEGAN 02/09 '1021051002930152 23 L 3/7/2016

36 PEPEK PRIHATIN CIKAKAK 03/04 '1022010711630168 53 L 3/7/2016
37 ALVIANSYAH MAULANA S TUNJUNG 2/1 '1031110804140169 1 L 3/7/2016
38 MARMI BANTERAN 3/1 '1021013112530244 63 P 3/8/2016
39 ERNA ASMARANI KLAPAGADING 1/7 '1021021806900137 25 P 3/8/2016

40 SULIMAH WANGON 4/4 '1021070107580231 57 P 3/8/2016
42 RAJIYEM PARUNG KAMAL 04/02 '1011103112610246 45 L 3/10/2016
48 KUSWADI KLAPAGADING RT 3/9 '1021021708750217 40 L 3/11/2016
51 EKAS SANTOSO RANDEGAN 3/9 '1021053010870029 18 L 3/11/2016
52 TUTI TUNJUNG 7/3 '1031113112660037 50 P 3/11/2016
55 YASAERI ASWIN RANDEGAN 2/11 '1021051911470270 60 L 3/12/2016

57 AWEN BANTERAN 2/2 '1021012004550114 60 P 3/14/2016
58 TARISEM KLAPAGADING 4/1 '1021020906700010 55 P 3/14/2016
60 KEN UMIYATI KLAPAGADING KULON 2/9 '1021030310690022 46 P 3/14/2016
61 SITI JULEHA RANDEGAN 3/1 '1021052907750262 41 P 3/14/2016
63 SIGIT RIYANTO WANGON 4/15 '1021070710880041 27 L 3/14/2016
64 KANTINI WANGON 6/5 '1021071010690028 46 P 3/14/2016
65 META MEDIANA WANGON 06/05 '1021071205000201 15 P 3/14/2016
66 ALVIANSYAH MAULANA S TUNJUNG 2/1 '1031110804140169 1 L 3/14/2016
67 SUTIYEM WANGON 2/7 '1021073112350104 78 P 3/15/2016

68 DULROHMAN PARUNGKAMAL 6/3 '1022203101440101 71 L 3/15/2016
69 ROHYATUN KLAPAGADING 2/10 '1021022308850281 28 P 3/16/2016
70 SUSANTI KLAPAGADING KULON 4/2 '1021030405830033 32 P 3/16/2016
72 OKTA DWI YULIAWAN JAMBU 03/12 '1022020307880057 0 L 3/16/2016
75 SAIMAH KLAPAGADING KULON 5/2 '1021030406740223 42 P 3/17/2016
76 ENI SURYANI KLAPAGADING KULON 1/8 '1021031010850075 30 P 3/17/2016
77 AKIKA VAMENIA PUSPITA WANGON RT 6/5 '1021071205000201 0 P 3/17/2016

82 JURIYAH WANGON 2/7 '1021071808630105 52 P 3/18/2016
83 AJI SUKMA PRAHARA WANGON RT1/12 '1021072903980211 18 L 3/18/2016
84 KUAT SUSENO BANTERAN RT 1/1 '1211013112680040 46 L 3/18/2016
85 KENZOU JULIAN PUTRA RAMA KLAPAGADING 2/3 '1021030905850241 0 L 3/19/2016
86 AFKA UNGGUL PRADIPTA BANTERAN 3/4 '1021011408760206 1 L 3/21/2016
87 KUSMIYATI KLAPAGADING '1021020108650060 51 P 3/21/2016
90 KARSUN KLAPAGADING KULON 02/04 '1021032205340221 55 L 3/22/2016
91 SADAN AHCHMAD SUGITO KLAPAGADING KULON 5/12 '1021032609620222 54 L 3/22/2016
92 WARTEM PENGADEGAN 2/1 '1021040209590162 60 P 3/22/2016

93 WARSIAH RAWAHENG 4/3 '1021063112690087 46 P 3/22/2016
94 SAHIDI KLAPAGADING KULON 2/8 '1021033112590078 55 L 3/23/2016
95 AKIKA VAMENIA PUSPITA WANGON RT 6/5 '1021071205000201 0 P 3/23/2016
97 MUHAMMAD SEPTIAN ALIF WANGON 4/4 '1021010909150235 L 3/24/2016
99 MUHYADI RANDEGAN RT 3/6 '1021052202650272 50 L 3/24/2016
102 RASINAH KLAPAGADING KULON 5/2 '101030407750060 40 P 3/26/2016
103 ASTIN NURKHASANAH CANDUK 1/1 '1011020502090142 7 P 3/26/2016
104 RODIYAH BANTERAN 3/3 '1021012803790254 37 P 3/26/2016
106 ROMINI KLAPAGADING 2/10 '1021020705800292 35 P 3/28/2016

107 ETI SETIANINGSIH BANTERAN 4/3 '102102711930072 22 P 3/28/2016

110 SANIS KLAPAGADING RT 4/10 '1021023112540193 62 P 3/29/2016
112 KARTIEM WANGON 2/11 '1021070508730018 42 P 3/29/2016
113 WASITAH WANGON 3/4 '1021071212770210 38 P 3/29/2016
114 SUKIMIN RANDEGAN 02/02 '1021052604670227 48 L 3/30/2016
116 ILMAN WANGON 4/11 '1021070612850229 0 L 3/30/2016
117 SAHIDI KLAPAGADING KULON 2/8 '1021033112590078 56 L 3/31/2016
JUMLAH


NIP. 19820327 200903 1 006
KLAIM-KBS
JALAN JAMKESDA / KBS DI PELAYANAN DASAR
TAHUN : 2016

BBLR KLINIK KIA Rp 5,000
bagian atas
KLINIK KIA Rp 5,000
KLINIK KIA Rp 5,000
bagian atas
Demam tifoid dan paratifoid RUJUKAN Rp 5,000

Disease)
Dermatitis kontak alergi KLINIK UMUM / BP Rp 5,000

bagian atas
PERIODONTITIS KRONIS KLINIK GIGI Rp 5,000

DF (Demam Dengue) RUJUKAN Rp 5,000
Vertigo KLINIK UMUM / BP Rp 5,000
COPD (Chronic Obstructive Pulmonary RUJUKAN Rp 5,000
Disease)

bagian atas

bagian atas
bagian atas
bagian atas
Anemia Defisiensi Besi RUJUKAN Rp 5,000
Pneumonia RUJUKAN Rp 5,000
Faringitis akut KLINIK UMUM / BP Rp 5,000
Ca Kulit RUJUKAN Rp 5,000
PERIODONTITIS KRONIS KLINIK GIGI Rp 5,000
Migraine RUJUKAN Rp 5,000
Stroke RUJUKAN Rp 5,000
Sindroma Nefrotik RUJUKAN Rp 5,000
Disease)

Sindroma Nefrotik RUJUKAN Rp 5,000
Pneumonia RUJUKAN Rp 5,000
bagian atas

Faringitis akut KLINIK UMUM / BP Rp 5,000
Kandidiasis RUJUKAN Rp 5,000
KLINIK KIA Rp 5,000
Ca lain RUJUKAN Rp 5,000
Menometrorrhagi KLINIK UMUM / BP Rp 5,000
Rheumatoid Arthritis RUJUKAN Rp 5,000

COPD (Chronic Obstructive Pulmonary
Asma RUJUKAN Rp 5,000
TB ANAK (PK TB) KLINIK UMUM / BP Rp 5,000
Arthritis lain KLINIK UMUM / BP Rp 5,000
RUJUKAN Rp 5,000
RUJUKAN Rp 5,000
bagian bawah

Infeksi Akut lain pada saluran Pernafasan
Infeksi Akut lain pada saluran Pernafasan
Nyeri
Infeksikepala
Akut lain pada saluran Pernafasan KLINIK UMUM / BP Rp 5,000
bagian bawah KLINIK UMUM / BP Rp 5,000
bagian atas

Nyeri Dada KLINIK UMUM / BP Rp 5,000
bagian atas
Dermatitis kontak alergi RUJUKAN Rp 5,000

Hemiplegi RUJUKAN Rp 5,000
Stroke RUJUKAN Rp 5,000
KLINIK KIA Rp 5,000
Rp 585,000
Bendahara Penerima
Sumarno
NIP. 19631011 198603 1 009
KLAIM-KBS
DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESDA / KBS DI PELAYANAN DASAR
PROPINSI : JAWA TENGAH BULAN : APRIL TAHUN : 2016

Kepada Yth.
di Tempat
Total : 150 Pasien
No Nama Alamat No Asuransi Umur Jenis Kel Tgl Transaksi Diagnosa Tujuan Berobat Karcis +
Tindakan
1 RODIYAH BANTERAN 3/3 '1021012803790254 37 P 1/4/2016 Dispepsia KLINIK UMUM / BP Rp 5,000
2 ROPINGAH KLAPAGADING 1/10 '1021021506770278 38 P 1/4/2016 MYALGIA KLINIK UMUM / BP Rp 5,000
3 ROSIDI JASWAN JAMBU RT 4/10 '1022020709470230 68 L 1/4/2016 DECOMP CORDIS RUJUKAN Rp 5,000
4 SUMIRAH PARUNG KAMAL 01/01 '1011101204810252 32 P 2/4/2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
5 FAIZAL ABDURROHMAN BANTERAN 1/2 '1021013101940243 22 L 2/4/2016 Limfadenitis KLINIK UMUM / BP Rp 5,000
6 SUWARNI PENGADEGAN RT 1/2 '1021042311680260 48 P 2/4/2016 DECOMP CORDIS KLINIK UMUM / BP Rp 5,000
7 SISWANTO WANGON 3/2 '1021070806810032 34 L 2/4/2016 RUJUKAN Rp 5,000
8 KANTINI WANGON 6/5 '1021071010690028 46 P 2/4/2016 DECOMP CORDIS RUJUKAN Rp 5,000
9 IDA TRIYANI WANGON 2/12 '1021071701830233 33 P 2/4/2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
10 SUMIAH BANTERAN 3/4 '1021011408760206 40 P 4/4/2016 Keluarga Berencana (KB) KLINIK KB Rp 5,000
11 EKO PURNOMO KLAPAGADING 2/8 '1021020701660291 50 L 4/4/2016 Hipertensi primer RUJUKAN Rp 5,000
12 MUHYADI RANDEGAN RT 3/6 '1021052202650272 50 L 4/4/2016 DECOMP CORDIS KLINIK UMUM / BP Rp 5,000
13 SULIYAH RAWAHENG 4/1 '1021061603680152 47 P 4/4/2016 Diabetes Mellitus (NIDDM) RUJUKAN Rp 5,000
Tindakan
14 KARTIEM WANGON 2/11 '1021070508730018 42 P 4/4/2016 KLINIK UMUM / BP Rp 5,000
15 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 P 5/4/2016 Diabetes Mellitus (NIDDM) KLINIK UMUM / BP Rp 5,000
16 ERNA ASMARANI KLAPAGADING 1/7 '1021021806900137 25 P 5/4/2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
17 SUNARTO DIKUN KLAPAGADING KULON 03/01 '1021033112530182 63 L 5/4/2016 COPD (Chronic Obstructive Pulmonary Disease) KLINIK UMUM / BP Rp 5,000
18 SUGENG SUJARWO JURANGBAHAS 6/1 '1022030504540027 59 L 5/4/2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
19 JUMAIYAH JURANGBAHAS RT 6 RW 1 '1022032707530005 63 P 5/4/2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
20 SUSANTI KLAPAGADING KULON 4/2 '1021030405830033 33 P 6/4/2016 MYALGIA KLINIK UMUM / BP Rp 5,000
21 NADIFA KAMELIA BAITIS PENGADEGAN 1/10 '1021042402010275 15 P 6/4/2016 Demam yang tdk diketahui sebabnya KLINIK UMUM / BP Rp 5,000
22 ALFINA QALBI NUURAN RANDEGAN 3/2 '1021051709890265 0 P 6/4/2016 KLINIK KIA Rp 5,000
23 AKIKA VAMENIA PUSPITA WANGON RT 6/5 '1021071205000201 0 P 6/4/2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
24 RAIZAL ASROF SYAHRI RAMADHAN WANGON 4/2 '1021072401820207 0 L 6/4/2016 KLINIK KIA Rp 5,000
25 FAIZAL ASROF SYAHRI ROMADON WANGON 4/2 '102172401820207 L 6/4/2016 KLINIK KIA Rp 5,000
26 MARMI BANTERAN 3/1 '1021013112530244 63 P 7/4/2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
27 SENO KLAPAGADING KULON 3/8 '1021030709700196 40 L 7/4/2016 Gagal jantung KLINIK UMUM / BP Rp 5,000
28 MARGONO BANTERAN 3/5 '1021011212540186 55 L 8/4/2016 Diabetes Mellitus (NIDDM) RUJUKAN Rp 5,000
29 PATMIATI BANTERAN 1/4 '1021011911790223 37 P 8/4/2016 Dispepsia KLINIK UMUM / BP Rp 5,000
30 ROMINI KLAPAGADING 2/10 '1021020705800292 35 P 8/4/2016 Vaginitis KLINIK UMUM / BP Rp 5,000
31 ETI SETIANINGSIH BANTERAN 4/3 '102102711930072 22 P 8/4/2016 Nyeri Dada KLINIK UMUM / BP Rp 5,000
32 JONI WARDADI RAWAHENG 5/2 '1021061606780026 38 L 8/4/2016 Dermatitis kontak alergi KLINIK UMUM / BP Rp 5,000
33 KUSMIYATI KLAPAGADING 2/9 '1021020108650060 51 P 9/4/2016 Arthritis lain KLINIK UMUM / BP Rp 5,000
34 AGUS SULISTIONO WANGON 2/1 '1021072512590235 57 L 9/4/2016 MYALGIA RUJUKAN Rp 5,000
35 DWI WAHYUNI BANTERAN 1/5 '1021010407810251 35 P 11/4/2016 Hipertensi primer RUJUKAN Rp 5,000
36 IWAN SUPRIATNA BANTERAN 4/1 '1021010902930216 22 L 11/4/2016 Dispepsia RUJUKAN Rp 5,000

Tindakan
37 AWEN BANTERAN 2/2 '1021012004550114 60 P 11/4/2016 Diabetes Mellitus (NIDDM) RUJUKAN Rp 5,000
38 RODIYAH BANTERAN 3/3 '1021012803790254 37 P 11/4/2016 Dispepsia KLINIK UMUM / BP Rp 5,000
39 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 P 11/4/2016 Diabetes Mellitus (NIDDM) KLINIK UMUM / BP Rp 5,000
40 SECHUN KLAPAGADING KULON 2/6 '1021031102640225 52 L 11/4/2016 Infark Miokard akut RUJUKAN Rp 5,000
42 SAHIDI KLAPAGADING KULON 2/8 '1021033112590078 57 L 11/4/2016 COPD (Chronic Obstructive Pulmonary Disease) KLINIK UMUM / BP Rp 5,000
43 SUKADI RANDEGAN 2/4 '1021050406470269 60 L 11/4/2016 Gagal jantung RUJUKAN Rp 5,000
44 ALIFIA RACABANTENG RT 2/7 '1021033008140223 1 P 12/4/2016 Asma RUJUKAN Rp 5,000
45 NGATINI KLAPAGADING KULON 2/8 '1021033112720079 44 P 12/4/2016 MYALGIA KLINIK UMUM / BP Rp 5,000
46 KARTIEM WANGON 2/11 '1021070508730018 42 P 12/4/2016 Vertigo KLINIK UMUM / BP Rp 5,000
47 NINING PURNINGSIH WANGON RT 2/11 '1021072101890179 27 P 12/4/2016 Kehamilan Normal KLINIK KIA Rp 5,000
48 ANI ASTUTI WANGON RT 1/8 '1021072609870236 29 P 12/4/2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
49 OKTA DWI YULIAWAN JAMBU 03/12 '1022020307880057 0 L 12/4/2016 Diare dan gastroenteritis KLINIK UMUM / BP Rp 5,000
50 KUSMIATI KLAPAGADING WETAN 2/9 '1021020108650060 50 P 13-04-2016 Arthritis lain RUJUKAN Rp 5,000
51 ZAHER PUTRA PERDANA KLAPAGADING RT1/1 '1021020812120294 4 L 13-04-2016 Diare dan gastroenteritis KLINIK UMUM / BP Rp 5,000
52 SADAN AHCHMAD SUGITO KLAPAGADING KULON 5/12 '1021032609620222 54 L 13-04-2016 Infeksi saluran kemih bagian bawah RUJUKAN Rp 5,000
53 WATINI RAWAHENG 4/2 '1021060901610122 55 P 13-04-2016 Dispepsia KLINIK UMUM / BP Rp 5,000
54 IDA TRIYANI WANGON 2/12 '1021071701830233 33 P 13-04-2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
55 TUTI TUNJUNG 7/3 '1031113112660037 50 P 13-04-2016 MYALGIA RUJUKAN Rp 5,000
56 ALFIAN NUROHMAN BANTERAN 2/5 '1211012502030044 12 L 13-04-2016 Dermatitis kontak alergi KLINIK UMUM / BP Rp 5,000
57 KASINAH BANTERAN 2/3 '1021013112440248 71 P 14-04-2016 Gagal jantung RUJUKAN Rp 5,000
58 TARISEM KLAPAGADING 4/1 '1021020906700010 46 P 14-04-2016 Gagal jantung RUJUKAN Rp 5,000
59 SAENDAH KLAPAGADING 5/1 '1021022912980008 37 P 14-04-2016 DECOMP CORDIS RUJUKAN Rp 5,000

Tindakan
60 HENDRI ALAMSYAH P PENGADEGAN 3/6 '1021040405130216 1 L 14-04-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
61 APRIYANTO RAWAHENG 3/2 '1021060904830007 33 L 14-04-2016 HIV AIDS tanpa komplikasi RUJUKAN Rp 5,000
62 OKTA DWI YULIAWAN JAMBU 03/12 '1022020307880057 0 L 14-04-2016 Demam yang tdk diketahui sebabnya KLINIK UMUM / BP Rp 5,000
63 SETO SUPADI KLAPAGADING 1/12 '102102170630300 40 L 15-04-2016 Lipoma RUJUKAN Rp 5,000
64 SUKIDAH KLAPAGADING KULON 1/7 '1021021707770296 38 P 15-04-2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
65 SEPTI ANISETIYANI KLAPAGADING 6/10 '1021022609910005 24 P 15-04-2016 Dispepsia RUJUKAN Rp 5,000
66 KOMARI RAWAHENG 5/2 '1021062810500030 65 L 15-04-2016 Infeksi saluran kemih bagian bawah KLINIK UMUM / BP Rp 5,000
67 CAHAYA EZA PRAKARTI WANGON 1/14 '1021070304130190 3 P 15-04-2016 Diare dan gastroenteritis KLINIK UMUM / BP Rp 5,000
68 YUDA HARI P WANGON 1/11 '1021071002000234 15 L 15-04-2016 Gangguan Psikotik nonorganik lain RUJUKAN Rp 5,000
69 ALVIANSYAH MAULANA SHALEH TUNJUNG 2/1 '1031110804140169 2 L 15-04-2016 Diare dan gastroenteritis KLINIK UMUM / BP Rp 5,000
70 TUMIRAH BANTERAN 5/1 '102101170467194 49 P 16-04-2016 Arthritis lain RUJUKAN Rp 5,000
71 AMINAH KLAPAGADING KULON 3/4 '1021033112610212 48 P 16-04-2016 DECOMP CORDIS RUJUKAN Rp 5,000
72 SHINTA FADHILLAH WIDRIYANI BANTERAN 4/4 '1021011308810229 14 P 18-04-2016 Otitis Eksterna KLINIK UMUM / BP Rp 5,000
73 ADMINI BANTERAN 2/4 '1021012009760224 45 P 18-04-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
74 SETO SUPADI KLAPAGADING 1/12 '102102170630300 40 L 18-04-2016 Arthritis lain RUJUKAN Rp 5,000
75 SEPTI ANISETIYANI KLAPAGADING 6/10 '1021022609910005 24 P 18-04-2016 Fibro adenoma mammae RUJUKAN Rp 5,000
76 MUHYADI RANDEGAN RT 3/6 '1021052202650272 50 L 18-04-2016 Infark Miokard akut KLINIK UMUM / BP Rp 5,000
77 ARTINAH RAWAHENG 6/3 '1021063112620080 53 P 18-04-2016 Demam tifoid dan paratifoid KLINIK UMUM / BP Rp 5,000
78 ILMAN WANGON 4/11 '1021070612850229 0 L 18-04-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
79 SIGIT RIYANTO WANGON 4/15 '1021070710880041 27 L 18-04-2016 Schizophrenia RUJUKAN Rp 5,000
80 YUDA HARI P WANGON 1/11 '1021071002000234 15 L 18-04-2016 Urtikaria KLINIK UMUM / BP Rp 5,000
81 NINING PURNINGSIH WANGON RT 2/11 '1021072101890179 27 P 18-04-2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
82 ANI ASTUTI WANGON RT 1/8 '1021072609870236 29 P 18-04-2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
Tindakan
83 WATINAH BANTAR 6/3 1031020403820190 34 P 19-04-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
84 SAMSUDIN BANTERAN 4/1 1021010607560218 59 L 19-04-2016 COPD (Chronic Obstructive Pulmonary Disease) KLINIK UMUM / BP Rp 5,000
85 KAMIRAH BANTERAN 6/4 '1021010801700063 45 P 19-04-2016 Gangguan tidur nonorganik KLINIK UMUM / BP Rp 5,000
86 SUTRIYAH KLAPAGADING 1/6 '1021020402880001 33 P 19-04-2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
87 EKO PURNOMO KLAPAGADING 2/8 '1021020701660291 50 L 19-04-2016 Hepatitis Kronik RUJUKAN Rp 5,000
88 UMINAH KLAPAGADING RT 05 RW 10 '1021021201750174 37 P 19-04-2016 Konjuntivitis KLINIK UMUM / BP Rp 5,000
89 ENI SURYANI KLAPAGADING KULON 1/8 '1021031010850075 30 P 19-04-2016 Dispepsia RUJUKAN Rp 5,000
90 TUMINAH RANDEGAN 2/11 '1021051608690260 46 P 19-04-2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
91 WATINI RAWAHENG 4/2 '1021060901610122 55 P 19-04-2016 Bronkhitis akut KLINIK UMUM / BP Rp 5,000
92 SANROKYAT ANGKAT WANGON 1/7 '1021073112550033 60 L 19-04-2016 PERIODONTITIS KRONIS KLINIK GIGI Rp 5,000
93 SUKESIH BANTERAN 3/4 '1021013112630029 52 P 20-04-2016 Diabetes Mellitus (NIDDM) RUJUKAN Rp 5,000
94 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 P 20-04-2016 Dermatitis kontak alergi KLINIK UMUM / BP Rp 5,000
95 AJI SUSWANTO KLAPAGADING RT 1/12 '1021022908720092 44 L 20-04-2016 Stroke KLINIK UMUM / BP Rp 5,000
96 WASITUN SUPRIYADI KLAPAGADING KULON 2.18 '1021032002700228 46 L 20-04-2016 DECOMP CORDIS RUJUKAN Rp 5,000
97 SUNARTO DIKUN KLAPAGADING KULON 03/01 '1021033112530182 63 L 20-04-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
98 SAHIDI KLAPAGADING KULON 2/8 '1021033112590078 57 L 20-04-2016 TB paru klinis (rontgen +) KLINIK UMUM / BP Rp 5,000
99 WARTAM PENGADEGAN RT 1/2 '1021042407710167 44 L 20-04-2016 Stroke RUJUKAN Rp 5,000
100 WARSIAH RAWAHENG 4/3 '1021063112690087 46 P 20-04-2016 DECOMP CORDIS RUJUKAN Rp 5,000
101 KARTIEM WANGON 2/11 '1021070508730018 42 P 20-04-2016 Asma KLINIK UMUM / BP Rp 5,000
102 INDRI SULISTIOWATI KLAPAGADING 1/8 '1021020609820053 32 L 21-04-2016 MYALGIA KLINIK UMUM / BP Rp 5,000
103 WASITUN SUPRIYADI KLAPAGADING KULON 2.18 '1021032002700228 46 L 21-04-2016 Fraktur RUJUKAN Rp 5,000
104 KARSUN KLAPAGADING KULON 02/04 '1021032205340221 55 L 21-04-2016 Batuk RUJUKAN Rp 5,000
105 SIGIT RIYANTO WANGON 4/15 '1021070710880041 27 L 21-04-2016 Schizophrenia KLINIK UMUM / BP Rp 5,000
Tindakan
106 JURIYAH BANTERAN 4/1 '1021114076610182 48 P 21-04-2016 Hemoroid KLINIK UMUM / BP Rp 5,000
107 WATINAH BANTAR 6/3 '1031020403820197 33 P 21-04-2016 Kehamilan serotinus KLINIK HAMIL Rp 5,000
108 ADMINI KARANGGAYAM 1/2 '1011073112730135 43 P 22-04-2016 Hipertensi primer KLINIK UMUM / BP Rp 5,000
109 SAMSUDIN BANTERAN 4/1 '1021010607560218 59 L 22-04-2016 COPD (Chronic Obstructive Pulmonary Disease) KLINIK UMUM / BP Rp 5,000
110 SUWARNI PENGADEGAN RT 1/2 '1021042311680260 48 P 22-04-2016 Gagal jantung RUJUKAN Rp 5,000
111 SUMIRAH BANTERAN 3/6 '1211012510730112 43 P 22-04-2016 Vertigo KLINIK UMUM / BP Rp 5,000
112 SALBIYAH KLAPAGADING 3/1 '1021022610830265 33 P 23-04-2016 Abortus KLINIK KIA Rp 5,000
113 BARIYAH KLAPAGADING 4/2 '1021033012660231 57 P 23-04-2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
114 JURIYAH WANGON 2/7 '1021071808630105 52 P 23-04-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas RUJUKAN Rp 5,000
115 SANROKYAT ANGKAT WANGON 1/7 '1021073112550033 60 L 23-04-2016 Gagal jantung RUJUKAN Rp 5,000
116 MAHARDIKA PARUNG KAMAL 3/3 '1011101303050312 11 L 25-04-2016 STOMATITIS KLINIK UMUM / BP Rp 5,000
117 FAIZAL ABDURROHMAN BANTERAN 1/2 '1021013101940243 23 L 25-04-2016 Limfadenitis KLINIK UMUM / BP Rp 5,000
118 SUKESIH BANTERAN 3/4 '1021013112630029 52 P 25-04-2016 Diabetes Mellitus (NIDDM) RUJUKAN Rp 5,000
119 SETO SUPADI KLAPAGADING 1/12 '102102170630300 40 L 25-04-2016 Limfadenitis RUJUKAN Rp 5,000
120 SATINEM KLAPAGADING 3/3 '1021022512570070 56 P 25-04-2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
121 SEPTI ANISETIYANI KLAPAGADING 6/10 '1021022609910005 24 P 25-04-2016 Fibro adenoma mammae RUJUKAN Rp 5,000
122 MUHYADI RANDEGAN RT 3/6 '1021052202650272 51 L 25-04-2016 Gagal jantung KLINIK UMUM / BP Rp 5,000
123 EKAS SANTOSO RANDEGAN 3/9 '1021053010870029 18 L 25-04-2016 Nyeri kepala RUJUKAN Rp 5,000
124 SURINAH PARUNGKAMAL 3/1 '1011101005850311 31 P 26-04-2016 Dermatitis kontak alergi KLINIK UMUM / BP Rp 5,000
125 KUSMIYATI KLAPAGADING 2/9 '1021020108650060 51 P 26-04-2016 Arthritis lain RUJUKAN Rp 5,000
126 ROMINI KLAPAGADING 2/10 '1021020705800292 35 P 26-04-2016 Dispepsia RUJUKAN Rp 5,000
127 RAWEN KLAPAGADING 4/10 '1021023112540295 62 P 26-04-2016 Hipertensi primer KLINIK UMUM / BP Rp 5,000
128 SUWARNI PENGADEGAN RT 1/2 '1021042311680260 48 P 26-04-2016 Dispepsia RUJUKAN Rp 5,000

Tindakan
129 ASWI RANDEGAN 1/4 '1021050212710276 44 P 26-04-2016 TB paru klinis (rontgen +) RUJUKAN Rp 5,000
130 SUKIMIN RANDEGAN 02/02 '1021052604670227 48 L 26-04-2016 Epilepsi RUJUKAN Rp 5,000
131 SENO KLAPAGADING KULON 3/8 '1021030709700196 40 L 27-04-2016 TB selain Paru (Extra Pulmonner) RUJUKAN Rp 5,000
132 HANANDIKA PRAYATAYASA RANDEGAN 3/8 '1021050906740248 0 L 27-04-2016 KLINIK KIA Rp 5,000
133 TUTI TUNJUNG 7/3 '1031113112660037 50 P 27-04-2016 Gastritis KLINIK UMUM / BP Rp 5,000
134 TUTI TUNJUNG 7/3 '1031113112660037 50 P 27-04-2016 Hipertensi primer RUJUKAN Rp 5,000
135 LASTRIANI KARANGGAYAM 1/1 '1011071210720010 44 P 28-04-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
136 NURULITA APRILIANI KARANGGAYAM 1/1 '1011072004000011 16 P 28-04-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
137 MUHAMMAD SEPTIAN ALIF WANGON 4/4 '1021010909150235 L 28-04-2016 Batuk RUJUKAN Rp 5,000
138 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 P 28-04-2016 Diabetes Mellitus (NIDDM) KLINIK UMUM / BP Rp 5,000
139 ROPINGAH KLAPAGADING 1/10 '1021021506770278 39 P 28-04-2016 Pembesaran kelenjar Tiroid RUJUKAN Rp 5,000
KLAPAGADING 3/4
140 ARI SISWATI 3302027112590017 '1021023112590042 56 P 28-04-2016 Hipertensi primer KLINIK UMUM / BP Rp 5,000
141 SUNARTO DIKUN KLAPAGADING KULON 03/01 '1021033112530182 63 L 28-04-2016 COPD (Chronic Obstructive Pulmonary Disease) KLINIK UMUM / BP Rp 5,000
142 YUDA HARI P WANGON 1/11 '1021071002000234 16 L 28-04-2016 Psikosomatis RUJUKAN Rp 5,000
143 SETO SUPADI KLAPAGADING 1/12 '102102170630300 40 L 29-04-2016 Limfadenitis RUJUKAN Rp 5,000
144 MANISAH WANGON 4/1 '1021073112560082 63 P 29-04-2016 DECOMP CORDIS RUJUKAN Rp 5,000
145 DULROHMAN PARUNGKAMAL 6/3 '1022203101440101 71 L 29-04-2016 DECOMP CORDIS RUJUKAN Rp 5,000
146 SUPRIYONO RANDEGAN 5/4 '1051102010800145 35 L 29-04-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
147 SANIS KLAPAGADING RT 4/10 '1021023112540193 62 P 30-04-2016 Gagal jantung RUJUKAN Rp 5,000
148 JUMIATI KLAPAGADING KULON 4/12 '1021030808780231 36 P 30-04-2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
149 WASITUN SUPRIYADI KLAPAGADING KULON 2.18 '1021032002700228 46 L 30-04-2016 Hernia Inguinal KLINIK UMUM / BP Rp 5,000
150 KOMARI RAWAHENG 5/2 '1021062810500030 65 L 30-04-2016 Infeksi saluran kemih bagian bawah KLINIK UMUM / BP Rp 5,000
Rp 750,000
Tindakan
Kepala Puskesmas I Wangon Bendahara Penerima
dr. Tulus Budi Purwanto Sumarno

NIP. 19820327 200903 1 006 NIP. 19631011 198603 1 009
Laporan Pasien
Rawat Jalan
Jamkesda / KBS
:
Dari 2016/05/0
Tanggal 1
:
Sampai 2016/05/2
Tanggal 7
Total : 127 Pasien
Karcis +
No Tindaka
Asurans Jenis Diagnos Keteran Tujuan n
No Nama Alamat i Umur Kel a gan Berobat
Postpartu
m Care
'1021010 and
DWI BANTER 40781025 Examinati KLINIK
1 WAHYUNI AN 1/5 1 35 P on (PNC) KIA 0
Postpartu
KLAPAG m Care
ADING '1021030 and
KULON 40776023 Examinati KLINIK
2 RATINI 3/18 0 39 P on (PNC) KIA 0
Infeksi
Akut lain
pada
saluran
'1021040 Pernafasa
PENGAD 20959016 n bagian RUJUKA
3 WARTEM EGAN 2/1 2 60 P atas N 0
ERLAN Demam
DWI '1021051 yang tdk KLINIK
ARIYANT RANDEG 20304002 diketahui UMUM /
4 O AN 3/9 2 12 L sebabnya BP 0
KEYLA '1021051
NAFISA RANDEG 30393027 KLINIK
5 ZAHRA AN 6/1 4 0 P BBLR KIA 0
KEYSA '1021051
ANINDITA RANDEG 30393027 KLINIK
6 ZAHRA AN 6/1 4 0 P BBLR KIA 0
HADI '1021051 KLINIK

SISWANT RANDEG 61190027 UMUM /
7 O AN 1/4 5 26 L BP 0
'1021053 Gagal
EKAS RANDEG 01087002 Ginjal RUJUKA
8 SANTOSO AN 3/9 9 18 L Kronis N 0
'1021061 KLINIK
RAWAHE 31254017 UMUM /
9 RATIWAN NG 2/4 3 62 L Fraktur BP 0
'1021073
WANGON 11256008 DECOMP RUJUKA
10 MANISAH 4/1 2 63 P CORDIS N 0
'1022020
ROSIDI JAMBU 70947023 DECOMP RUJUKA
11 JASWAN RT 4/10 0 68 L CORDIS N 0
Postpartu
m Care
'1031020 and
BANTAR 40382019 Examinati KLINIK
12 WATINAH 6/3 7 32 P on (PNC) KIA 0
'1051102
SUPRIYO RANDEG 01080014 TB paru RUJUKA
13 NO AN 5/4 5 35 L BTA + N 0
KLAPAG '1021022 KLINIK
ADING 61262025 UMUM /
14 DASILEM 4/8 8 53 P BP 0
15 SAMINAH 4/9 7 39 P Fraktur BP 0
'1021051
SUSIANT RANDEG 20971017 RUJUKA
16 O DARTO AN 3/6 8 44 L Dispepsia N 0
'1021061 KLINIK
JONI RAWAHE 60678002 UMUM /
17 WARDADI NG 5/2 6 38 L BP 0
'1021070 KLINIK
WANGON 50873001 UMUM /
18 KARTIEM 2/11 8 43 P Asma BP 0
'1021070
SISWANT WANGON 80681003 RUJUKA
19 O 3/2 2 35 L N 0
NADIRA KLAPAG '1021023 KLINIK
AILANI ADING 10316029 Dermatitit UMUM /
20 WIDODO 03/09 9 0 P s atopik BP 0
COPD
(Chronic
Obstructiv
KLAPAG e
ADING '1021033 Pulmonar
SUTARJO KULON 11253022 y RUJUKA
21 SATAR RT 1/7 9 63 L Disease) N 0
Infeksi
Akut lain
pada
saluran
REKHAN '1021052 Pernafasa KLINIK
SATRIA RANDEG 60613027 n bagian UMUM /
22 PUTRA AN 4/6 8 3 L atas BP 0
'1021070
WANGON 61285022 KLINIK
23 ILMAN 4/11 9 0 L KIA 0
ADING 51257007 Nyeri UMUM /
24 SATINEM 3/3 0 59 P kepala BP 0
KLAPAG '1021022
ADING 70377029 RUJUKA
25 SAMINAH 4/9 7 39 P Fraktur N 0
KLAPAG
WASITUN ADING '1021032 KLINIK
SUPRIYAD KULON 00270022 Hernia UMUM /
26 I 2.18 8 46 L Inguinal BP 0
WAHYU '1021051 KLINIK

SRI RANDEG 60592025 UMUM /
27 LESTARI AN 2/11 8 24 P Dispepsia BP 0
RANDEG '1021052
AN RT 20265027 Gagal RUJUKA
28 MUHYADI 3/6 2 51 L jantung N 0
Demam
AKBAR '1021070 yang tdk KLINIK
HAINUN WANGON 60213019 diketahui UMUM /
29 MUSTOFA 1/4 3 3 L sebabnya BP 0
Infeksi
Akut lain
pada
saluran
'1021071 Pernafasa
EMI PASA WANGON 90586003 n bagian RUJUKA
30 NURAINI 1/3 5 29 P atas N 0
ACHMAD CANDUK KLINIK

BAJURI RT 01 '1011020 UMUM /
31 JUMAH RW 01 37590138 54 L Dispepsia BP 0
NURULIT KARANG '1011072 KLINIK
A GAYAM 00400001 Luka UMUM /
32 APRILIANI 1/1 1 16 P Lecet BP 0
'1021010
PUJI BANTER 80982018 LABORA
33 RAHAYU AN 2/5 4 34 P TORIUM 58,000
AFKA '1021011 KLINIK

UNGGUL BANTER 40876020 STOMATI UMUM /
34 PRADIPTA AN 3/4 6 1 L TIS BP 0
'1021012 Diabetes
BANTER 00455011 Mellitus RUJUKA
35 AWEN AN 2/2 4 60 P (NIDDM) N 0
KLAPAG
ADING '1021030 KLINIK
NANANG KULON 61262015 Hipertensi UMUM /
36 SUWANDI 1/3 6 53 L primer BP 0
'1021071
WANGON 01069002 RUJUKA
37 KANTINI 6/5 8 46 P Dispepsia N 0
Postpartu
m Care
'1031020 and
GERDUR 40382019 Examinati KLINIK
38 WATINAH EN 6/3 7 33 P on (PNC) KIA 0
Demam
'1021013 yang tdk
BANTER 11253024 diketahui RUJUKA
39 MARMI AN 3/1 4 63 P sebabnya N 0
BPH
(Benigna
KLAPAG '1021020 Prostate KLINIK
ADING 10733030 Hyperthro UMUM /
40 MAJERI 1/10 4 83 L phy) BP 0
'1021061 Diabetes
RAWAHE 60368015 Mellitus RUJUKA
41 SULIYAH NG 4/1 2 47 P (NIDDM) N 0
AKBAR '1021070
HAINUN WANGON 60213019 Pneumoni RUJUKA
42 MUSTOFA 1/4 3 3 L a N 0
'1021013
BANTER 11248025 RUJUKA
43 NARTEM AN 2/3 3 67 P Stroke N 0
KLAPAG '1021020
44 MAJERI 1/10 4 83 L N 0
KLAPAG '1021021 Rheumat KLINIK
ADING 50960030 oid UMUM /
45 SUMINAH 6/10 5 55 P Arthritis BP 0
KLAPAG
KULON 70777029 UMUM /
46 SUKIDAH 1/7 6 38 P MYALGIA BP 0
KLAPAG
ADING '1021021
ELBARCA KULON 70777029 KLINIK
47 AFTANIA 1/7 6 0 P KIA 0
DESTA
FAJAR KLAPAG '1021031 Dermatitis KLINIK
ISNANDA ADING 81213022 kontak UMUM /
48 R 3/1 3 2 L alergi BP 0
KLAPAG
ADING '1021033 Diabetes
KULON 01237023 Mellitus RUJUKA
49 SUPARTI 2/15 2 55 P (NIDDM) N 0
PENGAD '1021042
EGAN RT 31168026 DECOMP RUJUKA
50 SUWARNI 1/2 0 48 P CORDIS N 0
HIV AIDS
'1021060 tanpa
APRIYANT RAWAHE 90483000 komplikas RUJUKA
51 O NG 3/2 7 33 L i N 0
KLAPAG '1021021
ADING 11095030 Hepatitis RUJUKA
52 RIYANI 2/9 3 20 P virus N 0
RACABA '1021033 KLINIK
NTENG 00814022 Konjuntivi UMUM /
53 ALIFIA RT 2/7 3 2 P tis BP 0
'1021041 KLINIK
PENGAD 50363026 UMUM /
54 KAISEM EGAN 1/2 1 53 P MYALGIA BP 0
'1021050 KLINIK
PAWIT RANDEG 80416027 UMUM /
55 APRILIO AN 5/5 3 L BP 0
'1021052 KLINIK
RANDEG 30196028 UMUM /
56 MARYANI AN 4/3 0 32 P Dispepsia BP 0
'1021011 Rheumat
MARGON BANTER 21254018 oid RUJUKA
57 O AN 3/5 6 60 L Arthritis N 0
DIKI '1021011 PERIOD

DERMAW BANTER 90497022 ONTITIS KLINIK
58 AN AN 1/3 8 19 L KRONIS GIGI 0
RANCAB '1021020 KLINIK
ANTENG 31257019 Arthritis UMUM /
59 NAKIYAH 3/1 7 59 P lain BP 0
Postpartu
m Care
KLAPAG '1021021 and
ADING 10685030 Examinati KLINIK
60 YUNIATI 1/12 6 31 P on (PNC) KIA 0
KLAPAG
SUNARTO KULON 11253018 Pneumoni UMUM /
61 DIKUN 03/01 2 63 L a BP 0
YAYAS '1021070 KLINIK

FIMAULID WANGON 50992000 UMUM /
62 A 4/2 8 24 P MYALGIA BP 0
Postpartu
m Care
'1031020 and
GERDUR 40382019 Examinati KLINIK
63 WATINAH EN 6/3 7 34 P on (PNC) KIA 0
BANTER '1021011 DECOMP RUJUKA
64 TUMIRAH AN 5/1 70467194 49 P CORDIS N 0
Infeksi
Akut lain
pada
saluran
LINDA KLAPAG '1021022 Pernafasa KLINIK
DWI ADING 50495030 n bagian UMUM /
65 FAOZIAH 01/11 4 20 P atas BP 0
Infeksi
Akut lain
pada
KLAPAG saluran
ADING '1021031 Pernafasa KLINIK
KULON 70982015 n bagian UMUM /
66 TUGINI 3/1 3 34 P atas BP 0
RANDEG '1021052 KLINIK
AN RT 20265027 DECOMP UMUM /
67 MUHYADI 3/6 2 51 L CORDIS BP 0
'1021053 Gagal
'1021114 Anemia KLINIK
BANTER 07661018 Defisiensi UMUM /
69 JURIYAH AN 4/1 2 48 P Besi BP 0
Postpartu
m Care
'1022021 and
JAMBU 10872028 Examinati KLINIK
70 ADMINAH 2/4 0 44 P on (PNC) KIA 0
'1021013
BANTER 11244024 DECOMP RUJUKA
71 KASINAH AN 2/3 8 71 P CORDIS N 0
Postpartu
m Care
LINDA KLAPAG '1021022 and
DWI ADING 50495030 Examinati KLINIK
72 FAOZIAH 01/11 4 20 P on (PNC) KIA 0
Postpartu
m Care
KLAPAG '1021022 and
KEISHA ADING 50495030 Examinati KLINIK
73 VIOLA A 1/11 4 0 P on (PNC) KIA 0
KLAPAG '1021022
ADING 91298000 DECOMP RUJUKA
74 SAENDAH 5/1 8 37 P CORDIS N 0
ADING 11254029 Hipertensi UMUM /
75 RAWEN 4/10 5 62 P primer BP 0
Infeksi
Akut lain
KLAPAG pada
ADING saluran
3/4 '1021023 Pernafasa KLINIK
ARI 33020271 11259004 n bagian UMUM /
76 SISWATI 12590017 2 56 P atas BP 0
HADI '1021051 KLINIK

SISWANT RANDEG 61190027 UMUM /
77 O AN 1/4 5 26 L MYALGIA BP 0
RAWAHE '1021060
NG RT 20204017 Schizophr RUJUKA
78 LILI AULIA 1/3 1 22 P enia N 0
'1022020 KLINIK
JAMBU 30788005 Konjuntivi UMUM /
79 YULIATUN 6/4 7 27 P tis BP 0
'1021010
BANTER 30374004 Hipertensi RUJUKA
80 ADIRAH AN 2/2 6 41 P primer N 0
Infeksi
Akut lain
pada
saluran
GURUH '1021011 Pernafasa KLINIK
PRASETY BANTER 20291021 n bagian UMUM /
81 O AN 2/4 2 25 L atas BP 0
Infeksi
Akut lain
pada
saluran
SUGENG '1021021 Pernafasa KLINIK
ROMADO CITOMO 21201008 n bagian UMUM /
82 N 1/12 9 14 L atas BP 0
KLAPAG
TIRWAN ADING '1021030 Dermatitis KLINIK
YASMIREJ KULON 60384012 kontak UMUM /
83 A 2/13 6 69 L alergi BP 0
'1021061 KLINIK
JONI RAWAHE 60678002 UMUM /
84 WARDADI NG 5/2 6 38 L MYALGIA BP 0
'1021070 KLINIK
SIGIT WANGON 71088004 Schizophr UMUM /
85 RIYANTO 4/15 1 28 L enia BP 0
SANROKY '1021073 KLINIK

AT WANGON 11255003 Gagal UMUM /
86 ANGKAT 1/7 3 60 L jantung BP 0
'1011020 KLINIK
AHMAD CANDUK 30759013 UMUM /
87 BAJURI 1/1 8 55 L Dispepsia BP 0
'1021012
SRI BANTER 10499025 KLINIK
88 HARTINI AN 5/5 7 18 P Abortus KIA 0
Postpartu
m Care
KLAPAG '1021021 and
ADING 10685030 Examinati KLINIK
89 YUNIATI 1/12 6 31 P on (PNC) KIA 0
'1021070 KLINIK
SIGIT WANGON 71088004 Schizophr UMUM /
90 RIYANTO 4/15 1 28 L enia BP 0
'1021010 KLINIK
DWI BANTER 40781025 Otitis UMUM /
91 WAHYUNI AN 1/5 1 35 P Eksterna BP 0
Infeksi
Akut lain
pada
KLAPAG saluran
TIRWAN ADING '1021030 Pernafasa KLINIK
YASMIREJ KULON 60384012 n bagian UMUM /
92 A 2/13 6 69 L atas BP 0
KLAPAG
AHMAD KULON 11247012 UMUM /
93 TURMIDI 4/2 0 66 L Batuk BP 0
Ganggua
'1021061 n KLINIK
JONI RAWAHE 60678002 Kecemas UMUM /
94 WARDADI NG 5/2 6 38 L an BP 0
KLAPAG '1021022
RUMBIYA ADING 50569003 RUJUKA
95 TI 1/10 5 47 P MYALGIA N 0
96 RAWEN 4/10 5 62 P MYALGIA BP 0
KENZOU
JULIAN
PUTRA KLAPAG '1021030 Dermatitis KLINIK
RAMADH ADING 90585024 kontak UMUM /
97 AN 2/3 1 0 L alergi BP 0
KLAPAG
ADING '1021033
AHMAD KULON 11247012 Hipertensi RUJUKA
98 TURMIDI 4/2 0 66 L primer N 0
RANDEG '1021052
AN RT 20265027 DECOMP RUJUKA
99 MUHYADI 3/6 2 51 L CORDIS N 0
RANDEG '1021052
AN RT 20265027 DECOMP RUJUKA
100 MUHYADI 3/6 2 51 L CORDIS N 0
SANROKY '1021073 KLINIK

AT WANGON 11255003 DECOMP UMUM /
101 ANGKAT 1/7 3 61 L CORDIS BP 0
Vulnus KLINIK
WANGON '0001015 laseratum UMUM /
102 RINAH RT 4/11 759708 54 P , punctum BP 0
RANCAB '1021020 Diabetes KLINIK
ANTENG 31257019 Mellitus UMUM /
103 NAKIYAH 3/1 7 59 P (NIDDM) BP 0
KLAPAG '1021023
104 SURYONO 2/10 7 38 L Batuk N 0
KLAPAG
ADING '1021032
KULON 20534022 DECOMP RUJUKA
105 KARSUN 02/04 1 55 L CORDIS N 0
KLAPAG
SUNARTO KULON 11253018 Craced UMUM /
106 DIKUN 03/01 2 63 L nipple BP 0
'1021050
PAWIT RANDEG 80416027 RUJUKA
107 APRILIO AN 5/5 3 L BBLR N 0
'1021061
RAWAHE 31254017 RUJUKA
108 RATIWAN NG 2/4 3 62 L Fraktur N 0
'1021061 Diabetes
RAWAHE 60368015 Mellitus RUJUKA
109 SULIYAH NG 4/1 2 47 P (NIDDM) N 0
Infeksi
Akut lain
pada
saluran
KARANG '1011071 Pernafasa KLINIK
LASTRIAN GAYAM 21072001 n bagian UMUM /
110 I 1/1 0 44 P atas BP 0
Infeksi
Akut lain
pada
saluran
NURULIT KARANG '1011072 Pernafasa KLINIK
A GAYAM 00400001 n bagian UMUM /
111 APRILIANI 1/1 1 16 P atas BP 0
PENGAD '1021042
EGAN RT 40771016 RUJUKA
112 WARTAM 1/2 7 44 L Stroke N 0
'1021050 Diabetes
RANDEG 21271027 Mellitus RUJUKA
113 ASWI AN 1/4 6 45 P (NIDDM) N 0
Infeksi
Akut lain
pada
saluran
'1021050 Pernafasa KLINIK
RANDEG 50672001 n bagian UMUM /
114 JEMIATI AN 4/1 6 43 P atas BP 0
BPH
(Benigna
'1021062 Prostate
RAWAHE 81050003 Hyperthro RUJUKA
115 KOMARI NG 5/2 0 65 L phy) N 0
BPH
(Benigna
'1021062 Prostate
RAWAHE 81050003 Hyperthro RUJUKA
116 KOMARI NG 5/2 0 65 L phy) N 0
'1021052
RANDEG 60467022 RUJUKA
117 SUKIMIN AN 02/02 7 49 L Epilepsi N 0
RAWAHE '1021060
NG RT 20204017 Schizophr RUJUKA
118 LILI AULIA 1/3 1 22 P enia N 0
'1021062 Hordeolu KLINIK
PRASYA RAWAHE 20112011 m dan UMUM /
119 ALIF F NG 4/2 6 4 L Chalazion BP 0
Common
'1021071 Cold/Nas
YUDHA WANGON 00200023 opharyngi RUJUKA
120 HARI P 1/11 4 16 L tis Akut N 0
121 RASWEN 2/9 3 74 P Batuk BP 0
'1021053 Gagal
Infeksi
Akut lain
pada
saluran
'1021072 Pernafasa KLINIK
INDRAWA WANGON 00792016 n bagian UMUM /
123 NTI 6/13 7 24 P atas BP 0
SUPARNI WANGON '1010710 Schizophr RUJUKA
124 O 3/17 04720007 41 L enia N 0
PENGAD '1021042 KLINIK
EGAN RT 31168026 Menometr UMUM /
125 SUWARNI 1/2 0 48 P orrhagi BP 0
'1021070 KLINIK
WANGON 50873001 UMUM /
126 KARTIEM 2/11 8 43 P Dispepsia BP 0
'1031113 KLINIK
TUNJUN 11266003 DECOMP UMUM /
127 TUTI G 7/3 7 50 P CORDIS BP 0
PROPINSI : JAWA TENGAH BULAN : JULI TAHUN : 2016

Kepada Yth.
di Tempat
Total : 128 Pasien
Jenis Tgl Karcis +

No Nama Alamat No Asuransi Umur Diagnosa Tujuan Berobat
Kel Transaksi Tindakan
1 KUSMIATI KLAPAGADING WETAN 2/9 '1021020108650060 50 P 1/7/2016 Migraine KLINIK UMUM / BP Rp 5,000
2 MUJABUL KAFI KLAPAGADING 3/7 '1021022910150276 0 L 1/7/2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
3 WAHYUNI KLAPAGADING KULON 1/3 '1021030204720186 43 P 1/7/2016 Dermatitis kontak alergi KLINIK UMUM / BP Rp 5,000
5 SUKADI PENGADEGAN 3/3 '1021040904810280 35 L 1/7/2016 Orchitis dan epididymitis RUJUKAN Rp 5,000
6 KOMARI RAWAHENG 5/2 '1021062810500030 65 L 1/7/2016 Cystitis RUJUKAN Rp 5,000
7 KARTIEM WANGON 2/11 '1021070508730018 43 P 1/7/2016 Sinusitis RUJUKAN Rp 5,000
8 ROSIDI JASWAN JAMBU RT 4/10 '1022020709470230 69 L 1/7/2016 DECOMP CORDIS RUJUKAN Rp 5,000
9 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 P 2/7/2016 Diare dan gastroenteritis KLINIK UMUM / BP Rp 5,000
10 RASIYEM WANGON 4/1 '1021070903520045 64 P 2/7/2016 Dispepsia RUJUKAN Rp 5,000
11 SIKIN CANDUK 2/8 '1011023009650095 51 L 11/7/2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
12 RAWEN KLAPAGADING 4/10 '1021023112540295 62 P 11/7/2016 MYALGIA KLINIK UMUM / BP Rp 5,000
13 MOEHAMMAD HAFIZI KLAPAGADING KULON 4/10 '1021030505770025 3 L 11/7/2016 Diare dan gastroenteritis RUJUKAN Rp 5,000
Jenis Tgl Karcis +
14 MISEM KLAPAGADING KULON 1/7 '1021033112590236 57 P 11/7/2016 Katarak RUJUKAN Rp 5,000
15 SUWARNI PENGADEGAN RT 1/2 '1021042311680260 48 P 11/7/2016 Gagal jantung RUJUKAN Rp 5,000
16 YATIMAH RANDEGAN 6/5 '1021053105490290 66 P 11/7/2016 Katarak RUJUKAN Rp 5,000
17 NOVY WIDYAWATI RAWAHENG 03/05 '1021062811860025 20 P 11/7/2016 HIV AIDS tanpa komplikasi RUJUKAN Rp 5,000
18 RASIYEM WANGON 4/1 '1021070903520045 64 P 11/7/2016 Herpes Zoster RUJUKAN Rp 5,000
19 ESTI WIJAYANTI WANGON 2/12 '1021071408810239 35 P 11/7/2016 Ca Payudara RUJUKAN Rp 5,000
20 SANROKYAT ANGKAT WANGON 1/7 '1021073112550033 61 L 11/7/2016 Gagal jantung RUJUKAN Rp 5,000
21 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 P 12/7/2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
22 RASWEN KLAPAGADING 2/9 '1021023112420143 74 P 12/7/2016 TB paru klinis (rontgen +) RUJUKAN Rp 5,000
23 PURWATI KLAPAGADING 4/2 '1021031206860238 30 P 12/7/2016 Keluarga Berencana (KB) KLINIK KIA Rp 5,000
24 SUTINI RANDEGAN 02/05 '1021051505520277 64 P 12/7/2016 Gagal jantung RUJUKAN Rp 5,000
25 MARYANI RANDEGAN 4/3 '1021052301960280 32 P 12/7/2016 Dispepsia RUJUKAN Rp 5,000
26 YUDHA HARI P WANGON 1/11 '1021071002000234 16 L 12/7/2016 Diare dan gastroenteritis KLINIK UMUM / BP Rp 5,000
27 ALFIAN NUROHMAN BANTERAN 2/5 '1211012502030044 13 L 12/7/2016 TB paru klinis (rontgen +) KLINIK UMUM / BP Rp 5,000
28 ROHYATUN KLAPAGADING 2/10 '1021022308850281 31 P 13-07-2016 Diare dan gastroenteritis KLINIK UMUM / BP Rp 5,000
29 NADIRA AILANI WIDODO KLAPAGADING 03/09 '1021023103160299 0 P 13-07-2016 KLINIK KIA Rp 5,000
30 SURYONO KLAPAGADING 2/10 '1021023108770307 38 L 13-07-2016 TB paru klinis (rontgen +) KLINIK UMUM / BP Rp 5,000
31 TIRWAN YASMIREJA KLAPAGADING KULON 2/13 '1021030603840126 32 L 13-07-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
32 HENDRI ALAMSYAH P PENGADEGAN 3/6 '1021040405130216 1 L 13-07-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
33 ALFIAN NUROHMAN BANTERAN 2/5 '1211012502030044 13 L 13-07-2016 Nail Disorders KLINIK UMUM / BP Rp 5,000
34 MUJABUL KAFI KLAPAGADING 3/7 '1021022910150276 0 L 14-07-2016 Bibir Sumbing RUJUKAN Rp 5,000
35 SANIS KLAPAGADING RT 4/10 '1021023112540193 62 P 14-07-2016 Stroke KLINIK UMUM / BP Rp 5,000
36 KENZOU JULIAN PUTRA RAMADHAN KLAPAGADING 2/3 '1021030905850241 0 L 14-07-2016 Common Cold/Nasopharyngitis Akut KLINIK UMUM / BP Rp 5,000
Jenis Tgl Karcis +
37 DEVIN ANGGER JOVANCA PUTRI KLAPAGADING 2/3 '1021030905850241 13 P 14-07-2016 Dermatitits Seboroik KLINIK UMUM / BP Rp 5,000
38 FINA SUSANTI RANDEGAN RT 1/8 '1021051301960014 20 P 14-07-2016 Demam yang tdk diketahui sebabnya KLINIK UMUM / BP Rp 5,000
39 RUSMINI JAMBU 1/3 '102202100670295 37 P 14-07-2016 KLINIK HAMIL Rp 5,000
40 WATINAH BANTAR 6/3 '1031020403820197 34 P 14-07-2016 Asma RUJUKAN Rp 5,000
41 NARSO KLAPAGADING 2/10 '1021021403790321 37 L 15-07-2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
42 SARIKEM RAWAHENG 4/4 '1021062004720158 44 P 15-07-2016 Diabetes Mellitus (NIDDM) RUJUKAN Rp 5,000
43 KOMARI RAWAHENG 5/2 '1021062810500030 65 L 15-07-2016 BPH (Benigna Prostate Hyperthrophy) RUJUKAN Rp 5,000
44 ASTUTI NOVI LAELANI WANGON 4/2 '1021071811910220 25 P 15-07-2016 Asma KLINIK UMUM / BP Rp 5,000
45 ALFIAN NUROHMAN BANTERAN 2/5 '1211012502030044 13 L 15-07-2016 Nail Disorders KLINIK UMUM / BP Rp 5,000
46 TARISEM KLAPAGADING 4/1 '1021020906700010 46 P 16-07-2016 DECOMP CORDIS RUJUKAN Rp 5,000
47 SAENDAH KLAPAGADING 5/1 '1021022912980008 38 P 16-07-2016 DECOMP CORDIS RUJUKAN Rp 5,000
48 SUPARTI KLAPAGADING KULON 2/15 '1021033012370232 55 P 16-07-2016 Dispepsia RUJUKAN Rp 5,000
49 JURIYAH WANGON 2/7 '1021071808630105 52 P 16-07-2016 MYALGIA RUJUKAN Rp 5,000
50 AWEN BANTERAN 2/2 '1021012004550114 61 P 18-07-2016 Gastritis RUJUKAN Rp 5,000
51 KASINAH BANTERAN 2/3 '1021013112440248 74 P 18-07-2016 Gagal jantung RUJUKAN Rp 5,000
52 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 P 18-07-2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
53 NARSO KLAPAGADING 2/10 '1021021403790321 37 L 18-07-2016 Migraine RUJUKAN Rp 5,000
54 KARSEM WANGON 3/15 '1021070903570244 59 P 18-07-2016 Dislokasi KLINIK UMUM / BP Rp 5,000
55 KANTINI WANGON 6/5 '1021071010690028 48 P 18-07-2016 DECOMP CORDIS RUJUKAN Rp 5,000
56 ANI SETIANINGSIH JAMBU RT 1/4 '1022021209920290 24 P 18-07-2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
57 ACHMAD BAJURI CANDUK 1/1 '1011020307590138 56 L 19-07-2016 Pneumonia RUJUKAN Rp 5,000
58 FEBBY OCTAVIANA KLAPAGADING KULON 5/13 '1021020210930320 22 P 19-07-2016 Luka Lecet RUJUKAN Rp 5,000
59 RASWEN KLAPAGADING 2/9 '102102311242014 74 P 19-07-2016 TB paru klinis (rontgen +) KLINIK UMUM / BP Rp 5,000
Jenis Tgl Karcis +
60 ARI SISWATI KLAPAGADING 3/4 '1021023112590042 56 P 19-07-2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
61 KENZOU JULIAN PUTRA RAMADHAN KLAPAGADING 2/3 '1021030905850241 1 L 19-07-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
62 KENZIE JULIAN PUTRA RAMADHAN KLAPAGADING 2/3 '1021030905850241 1 L 19-07-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
63 AKBAR HAINUN MUSTOFA WANGON 1/4 '1021070602130193 3 L 19-07-2016 Hordeolum dan Chalazion KLINIK UMUM / BP Rp 5,000
64 NY RASINI WANGON 2/7 '1021070606750107 41 P 19-07-2016 Kehamilan (ANC) KLINIK HAMIL Rp 5,000
65 SUKINI KLAPAGADING 4/5 '1021020901770319 40 P 20-07-2016 Salpingitis KLINIK KIA Rp 5,000
66 CINTIA LAELATUL MAGFIROH PENGADEGAN 3/5 '1021041507100051 6 P 20-07-2016 PERSISTENSI GIGI KLINIK GIGI Rp 5,000
67 MAULANA LUCKI HABIBI RAWAHENG 1/1 '1021061502760175 0 L 20-07-2016 KLINIK KIA Rp 5,000
68 AFIA ZARA KAUSAR WANGON 1/5 '1021072609870236 0 P 20-07-2016 KLINIK KIA Rp 5,000
69 SANROKYAT ANGKAT WANGON 1/7 '1021073112550033 61 L 20-07-2016 Gagal jantung KLINIK UMUM / BP Rp 5,000
70 GALUH IMAM M JAMBU 6/4 '1022020909050058 11 L 20-07-2016 Diare dan gastroenteritis KLINIK UMUM / BP Rp 5,000
71 SATRIO ANGGORO C CANDUK 2/1 '1021022704880032 28 L 21-07-2016 Schizophrenia RUJUKAN Rp 5,000
72 SUTRISNO KLAPAGADING KULON 3/14 '1021031006780179 37 L 21-07-2016 RUJUKAN Rp 5,000
73 KARSUN KLAPAGADING KULON 02/04 '1021032205340221 61 L 21-07-2016 COPD (Chronic Obstructive Pulmonary Disease) RUJUKAN Rp 5,000
74 SUBANDI RANDEGAN 2/4 '1021050911810283 35 L 21-07-2016 Diare dan gastroenteritis RUJUKAN Rp 5,000
75 AHMAD MUHTON RAWAHENG 06/03 '1021060705330165 83 L 21-07-2016 RUJUKAN Rp 5,000
76 KARSEM WANGON 3/15 '1021070903570244 59 P 21-07-2016 KLINIK UMUM / BP Rp 5,000
77 SUKIYEM WANGON 5/15 '1021073007760240 40 P 21-07-2016 Kehamilan (ANC) KLINIK HAMIL Rp 5,000
78 NURUL KHOERIYAH KLAPAGADING KULON 3/13 '1021031705900238 26 P 22-07-2016 Postpartum Care and Examination (PNC) KLINIK KIA Rp 5,000
79 SALIMAH PENGADEGAN RT 4/5 '102104311260004 50 P 22-07-2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
80 SUKIMIN RANDEGAN 02/02 '1021052604670227 49 L 22-07-2016 Epilepsi RUJUKAN Rp 5,000
81 EKAS SANTOSO RANDEGAN 3/9 '1021053010870029 19 L 22-07-2016 Sindroma Nefrotik RUJUKAN Rp 5,000
82 AHMAD MUHTON RAWAHENG 06/03 '1021060705330165 83 L 22-07-2016 Penyakit mata dan adneksa lain RUJUKAN Rp 5,000
Jenis Tgl Karcis +
83 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 P 23-07-2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
84 LINDA DWI FAOZIAH KLAPAGADING 01/11 '1021022504950304 21 P 23-07-2016 Gagal jantung RUJUKAN Rp 5,000
85 SUTRISNO KLAPAGADING KULON 3/14 '1021031006780179 38 L 23-07-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas RUJUKAN Rp 5,000
86 SITI NASIATI KLAPAGADING KULON 02/04 '1021032307830215 33 P 23-07-2016 Kehamilan (ANC) KLINIK HAMIL Rp 5,000
87 SUNARTO DIKUN KLAPAGADING KULON 03/01 '1021033112530182 63 L 23-07-2016 COPD (Chronic Obstructive Pulmonary Disease) KLINIK UMUM / BP Rp 5,000
88 URIP MUHIDI JAMBU 3/4 '1022021209580306 58 L 23-07-2016 Abses, Furunkel dan Karbunkel KLINIK UMUM / BP Rp 5,000
90 RASINAH KLAPAGADING KULON 5/2 '101030407750060 41 P 25-07-2016 KLINIK KIA Rp 5,000
91 TUMIRAH BANTERAN 5/1 '102101170467194 49 P 25-07-2016 Asma RUJUKAN Rp 5,000
92 GESANG PRIAYATNI BANTERAN 1/6 '1021012209790261 17 P 25-07-2016 Otitis media akut RUJUKAN Rp 5,000
93 SIGIT RIYANTO WANGON 4/15 '1021070710880041 28 L 25-07-2016 Dermatopolymyositis RUJUKAN Rp 5,000
94 KARSEM WANGON 3/15 '1021070903570244 59 P 25-07-2016 Dislokasi KLINIK UMUM / BP Rp 5,000
95 WASITAH WANGON 3/4 '1021071212770210 38 P 25-07-2016 Schizophrenia RUJUKAN Rp 5,000
96 ANI ASTUTI WANGON RT 1/8 '1021072609870236 29 P 25-07-2016 Keluarga Berencana (KB) KLINIK KB Rp 5,000
97 SUWARNI WANGON 3/3 '1021073112450144 70 P 25-07-2016 Gangguan lain pada Kornea RUJUKAN Rp 5,000
99 TUTI TUNJUNG 7/3 '1031113112660037 50 P 25-07-2016 Dispepsia RUJUKAN Rp 5,000
100 SUMIAH BANTERAN 3/4 '1021011408760206 40 P 26-07-2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
101 DWI ARIYANI KLAPAGADING KULON 5/2 '1021031204950132 21 P 26-07-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
102 ABDULLOH PENGADEGAN 3/6 '1021042709960283 21 L 26-07-2016 Appendicitis RUJUKAN Rp 5,000
103 YULIATUN JAMBU 6/4 '1022020307880057 28 P 26-07-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
104 AHMAD BAJURI CANDUK 1/1 '1011020307590138 55 L 27-07-2016 Asma KLINIK UMUM / BP Rp 5,000
105 KEVIN VANESA KLAPAGADING 2/3 '1021030905850241 10 L 27-07-2016 Hernia Inguinal RUJUKAN Rp 5,000
Jenis Tgl Karcis +
106 KENZOU JULIAN PUTRA RAMADHAN KLAPAGADING 2/3 '1021030905850241 1 L 27-07-2016 Batuk RUJUKAN Rp 5,000
107 KENZIE JULIAN PUTRA RAMADHAN KLAPAGADING 2/3 '1021030905850241 1 L 27-07-2016 Asma RUJUKAN Rp 5,000
108 ARLIFAH KLAPAGADING KULON 2/11 '1021031309870239 29 P 27-07-2016 Kehamilan kembar KLINIK HAMIL Rp 5,000
109 SUKADI RANDEGAN RT 1/4 '1021050406470269 67 L 27-07-2016 DECOMP CORDIS RUJUKAN Rp 5,000
110 URIP MUHIDI JAMBU 3/4 '1022021209580306 58 L 27-07-2016 Hemoroid KLINIK UMUM / BP Rp 5,000
111 MARSITI BANTERAN 2/4 '1021010801690263 44 P 28-07-2016 Diabetes Mellitus (NIDDM) RUJUKAN Rp 5,000
112 TURYATI KLAPAGADING RT 4/8 '1021021011670308 49 P 28-07-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
113 NARSO KLAPAGADING 2/10 '1021021403790321 37 L 28-07-2016 Nyeri kepala RUJUKAN Rp 5,000
114 RASWEN KLAPAGADING 2/9 '102102311242014 74 P 28-07-2016 Dispepsia KLINIK UMUM / BP Rp 5,000
115 KARSEM WANGON 3/15 '1021070903570244 59 P 28-07-2016 Luka Lecet KLINIK UMUM / BP Rp 5,000
116 MANISAH WANGON 4/1 '1021073112560082 60 P 28-07-2016 Gagal jantung RUJUKAN Rp 5,000
117 YUSIATI BANTERAN 2/4 '1021012901740262 42 P 29-07-2016 Gagal jantung KLINIK UMUM / BP Rp 5,000
118 ARI SISWATI KLAPAGADING 3/4 '1021023112590042 56 P 29-07-2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
119 ARLIFAH KLAPAGADING KULON 2/11 '1021031309870239 29 P 29-07-2016 Kehamilan (ANC) KLINIK HAMIL Rp 5,000
120 DESTA FAJAR ISNANDAR KLAPAGADING 3/1 '1021031812130223 2 L 29-07-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
121 RASINI KLAPAGADING KULON 2/13 '1021033112550240 61 P 29-07-2016 Stroke KLINIK UMUM / BP Rp 5,000
122 MOH. RAFI WIJAYA SAPUTRA PENGADEGAN 4/5 '1021040105010060 15 L 29-07-2016 Nyeri kepala KLINIK UMUM / BP Rp 5,000
123 AKBAR HAINUN MUSTOFA WANGON 1/4 '1021070602130193 3 L 29-07-2016 Urtikaria KLINIK UMUM / BP Rp 5,000
124 SISWANTO WANGON 3/2 '1021070806810032 35 L 29-07-2016 Pembesaran kelenjar Tiroid RUJUKAN Rp 5,000
126 SURYONO KLAPAGADING 2/10 '1021023108770307 38 L 30-07-2016 Infeksi Akut lain pada saluran Pernafasan bagian atas KLINIK UMUM / BP Rp 5,000
127 JONI WARDADI RAWAHENG 5/2 '1021061606780026 38 L 30-07-2016 Gangguan Kecemasan RUJUKAN Rp 5,000
Jenis Tgl Karcis +
JUMLAH Rp 640,000
Kepala Puskesmas I Wangon Bendahara Penerima
dr. Tulus Budi Purwanto Sumarno

NIP. 19820327 200903 1 006 NIP. 19631011 198603 1 009
PROPINSI : JAWA TENGAH BULAN : DESEMBER

Kepada Yth.
di Tempat
Total : 153
No Nama Alamat No Asuransi Umur Jenis Kel Tgl Trans Diagnosa
Acute upper respiratory infection,
1 TUMINAH BANTERAN 1/5 '1021011404460034 70 Th 7 Bln 18 Hr P 12/1/2016 unspecified
2 PARWANTO RAWAHENG 3/1 '1021060712820188 33 Th 11 Bln 25 Hr L 12/1/2016 Scrotal varices
3 KENZOU JULIAN PUTRA RAMADHAN KLAPAGADING 2/3 '1021030905850241 1 Th 4 Bln 25 Hr L 12/1/2016 unspecified
4 MUHYADI RANDEGAN RT 3/6 '1021052202650272 51 Th 9 Bln 8 Hr L 12/1/2016 Heart
Acute disease, unspecified
upper respiratory infection,
5 ILHAM FADIL AKBAR RANDEGAN 1/1 '1021051005160282 0 Th 6 Bln 22 Hr L 12/1/2016 unspecified
6 DASILEM KLAPAGADING 3/11 '1021023112560322 59 Th 11 Bln 1 Hr P 12/2/2016 Heart failure, unspecified
7 SITEM RAWAHENG 4/1 '1021060809450184 66 Th 2 Bln 24 Hr P 12/2/2016 Cataract, unspecified
8 HIDAYANISA NUR KAMILA BANTERAN 3/4 '1021010805150249 1 Th 6 Bln 26 Hr P 12/2/2016 Febrile convulsions
9 KUSMIATI KLAPAGADING 2/9 '1021020108650060 51 Th 4 Bln 2 Hr P 12/3/2016 Allergic contact dermatitis, unspecified cause
10 KANTINI WANGON 6/5 '1021071010690028 47 Th 1 Bln 23 Hr P 12/3/2016 Congestive heart failure
11 KARTIEM WANGON 2/11 '1021070508730018 43 Th 3 Bln 29 Hr P 12/3/2016 Urinary tract infection, site
Non-insulin-dependent not specified
diabetes mellitus
12 MISWATI PARUNGKAMAL 3/3 '1011101409660008 50 Th 2 Bln 19 Hr P 12/3/2016 without complications
14 SUKADI RANDEGAN RT 1/4 '1021050406470269 69 Th 6 Bln 0 Hr L 12/3/2016 Heart failure, unspecified
15 MANISAH RANDEGAN 4/3 '1021051503820309 34 Th 8 Bln 20 Hr P 12/3/2016 Dyspepsia
16 ILHAM FADIL AKBAR RANDEGAN 1/1 '1021051005160282 0 Th 6 Bln 24 Hr L 12/3/2016 Fever, unspecified
Non-insulin-dependent diabetes mellitus
17 TUMINAH BANTERAN 1/5 '1021011404460034 70 Th 7 Bln 22 Hr P 12/5/2016 without complications
18 AKBAR HAINUN MUSTOFA WANGON 1/4 '1021070602130193 3 Th 9 Bln 28 Hr L 12/5/2016 unspecified
Syndrome of inappropriate secretion of
19 EKAS SANTOSO RANDEGAN 3/9 '1021053010870029 29 Th 1 Bln 6 Hr L 12/5/2016 antidiuretic hormone
20 LASEM RAWAHENG 3/4 '1021061005550176 61 Th 6 Bln 27 Hr P 12/5/2016 Benign paroxysmal vertigo
21 SAANY SANDRINA LANING BANTERAN RT01/05 '1021012203130001 3 Th 8 Bln 14 Hr P 12/5/2016 Bronchitis, not specified as acute or chronic
22 HIDAYANISA NUR KAMILA BANTERAN 3/4 '1021010805150249 1 Th 6 Bln 29 Hr P 12/5/2016 Epilepsy, unspecified
Respiratory tuberculosis unspecified, without
23 LILI AULIA RAWAHENG RT 1/3 '1021060202040171 22 Th 10 Bln 2 Hr P 12/5/2016 Schizophrenia, unspecified or histological
mention of bacteriological
24 PUJIONO WANGON 5/17 '1021071005870254 29 Th 6 Bln 27 Hr L 12/5/2016 confirmation
25 RUSMINI JAMBU 1/3 '1022021006760295 40 Th 5 Bln 26 Hr P 12/6/2016 Supervision of other normal pregnancy
26 SATINEM KLAPAGADING 2/12 '1021021210490323 67 Th 2 Bln 24 Hr P 12/6/2016 Asthma, unspecified
27 MAELANI AMALIA BANTERAN 1/3 '1021013005920205 24 Th 6 Bln 7 Hr P 12/6/2016 Fibroadenosis of breast diabetes mellitus
Non-insulin-dependent
28 JURIYAH BANTERAN 4/1 '1021114076610182 50 Th 4 Bln 23 Hr P 12/6/2016 without complications
Diarrhoea and gastroenteritis of presumed
29 RADITYA AFANDI KLAPAGADING 1/1 '1021021011150329 1 Th 0 Bln 26 Hr L 12/6/2016 infectious origin
Care and examination immediately after
30 NURUL OKVANTI KLAPAGADING 1/12 '1021031010930252 23 Th 1 Bln 26 Hr P 12/6/2016 delivery
31 ASIFA GUSPRIATIN KLAPAGADING 05/01 '1021020908160327 0 Th 3 Bln 27 Hr P 12/6/2016 Febrile convulsions
32 KOMARI RAWAHENG 5/2 '1021062810500030 66 Th 1 Bln 10 Hr L 12/7/2016 Acute tubulo-interstitial nephritis
33 JONI WARDADI RAWAHENG 5/2 '1021061606780026 38 Th 5 Bln 22 Hr L 12/7/2016 Depressive episode, unspecified
34 INDRAWANTI WANGON 6/13 '1021072007920167 24 Th 4 Bln 18 Hr P 12/7/2016 Dyspepsia
35 MUJIZAT BAHRUL PEKIH KLAPAGADING KULON 3/7 '1021031302000011 16 Th 9 Bln 24 Hr L 12/7/2016 Myalgia
Chronic obstructive pulmonary disease,
36 SUNARTO DIKUN KLAPAGADING KULON 03/01 '1021033112530182 62 Th 11 Bln 6 Hr L 12/7/2016 unspecified
37 SUWARNI PENGADEGAN RT 1/2 '1021042311680260 48 Th 0 Bln 14 Hr P 12/7/2016 Essential (primary) hypertension
38 YANUAR RAMADHANI KLAPAGADING 3/1 '1021020201000334 16 Th 11 Bln 5 Hr L 12/7/2016 Allergic rhinitis,
Unilateral unspecified
or unspecified inguinal hernia,
39 MARDIYAT TURYAT BANTERAN 1/4 '1021010707510269 65 Th 5 Bln 1 Hr L 12/7/2016 without obstruction or gangrene
40 RUMBIYATI KLAPAGADING 1/10 '1021022505690035 47 Th 6 Bln 14 Hr P 12/8/2016 Cord compression, unspecified
41 RAWEN KLAPAGADING 4/10 '1021023112540295 62 Th 10 Bln 6 Hr P 12/8/2016 Essential (primary)
Sacrococcygeal hypertension
disorders, not elsewhere
42 NARTIAH RAWAHENG RT 2/3 '1021063112770091 38 Th 11 Bln 7 Hr P 12/8/2016 classified
43 YUNI PRIHATIN RAWAHENG 4/1 '1021060206950149 21 Th 6 Bln 7 Hr P 12/8/2016 Tension-type
Tuberculosis of headache
lung, confirmed by sputum
44 MUSLIM HIDAYAT KLAPAGADING 5/7 '1021022404860335 30 Th 7 Bln 15 Hr L 12/8/2016 microscopy with or without culture
45 SATINEM KLAPAGADING 2/12 '1021021210490323 67 Th 2 Bln 27 Hr P 12/9/2016 Gastritis, unspecified diabetes mellitus
46 SULIYAH RAWAHENG 4/1 '1021061603680152 48 Th 8 Bln 24 Hr P 12/9/2016 without complications
47 SUBANDI KLAPAGADING 2/1 '1021020808840049 32 Th 4 Bln 2 Hr L 12/10/2016 Fracture of shaft of tibia, closed
48 RASIYEM WANGON 4/1 '1021070903520045 64 Th 9 Bln 2 Hr P 12/10/2016 Gastritis, unspecified
49 SUMARNI RAWAHENG 3/5 '1021060109470001 42 Th 3 Bln 9 Hr P 12/10/2016 Supervision
Sacrococcygealof other high-risk
disorders, not pregnancies
elsewhere
50 TIRWAN YASMIREJA KLAPAGADING KULON 2/13 '1021030603840126 68 Th 11 Bln 10 Hr L 12/10/2016 classified
51 MAELANI AMALIA BANTERAN 1/3 '1021013005920205 24 Th 6 Bln 11 Hr P 12/10/2016 Fibroadenosis
Sacrococcygealofdisorders,
breast not elsewhere
52 MARDIYAH KLAPAGADING RT 2/8 '1021021511650336 60 Th 0 Bln 25 Hr P 12/10/2016 classified
Influenza with other respiratory
53 LINDA DWI FAOZIAH KLAPAGADING 01/11 '1021022504950304 21 Th 7 Bln 16 Hr P 12/10/2016 manifestations, virus not identified
54 ILHAM FADIL AKBAR RANDEGAN 1/1 '1021051005160282 0 Th 7 Bln 1 Hr L 12/10/2016 Bronchitis, not specified as acute or chronic
55 RASINAH KLAPAGADING 2/9 '1021023112630345 52 Th 11 Bln 10 Hr L 12/10/2016 Essential (primary) hypertension
56 KUSMIATI KLAPAGADING 2/9 '1021020108650060 51 Th 4 Bln 12 Hr P 12/13/2016 Pyoderma
57 AKBAR HAINUN MUSTOFA WANGON 1/4 '1021070602130193 3 Th 10 Bln 6 Hr L 12/13/2016 manifestations, virus not identified
58 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 Th 0 Bln 10 Hr P 12/13/2016 Arthritis in lyme disease, hand
59 ANDIYAH KLAPAGADING 4/3 '1021020309760343 40 Th 3 Bln 9 Hr P 12/13/2016 Fracture of first metacarpal
Chronic obstructive pulmonarybone , closed
disease,
61 NURUL OKVANTI KLAPAGADING 1/12 '1021031010930252 23 Th 2 Bln 3 Hr P 12/13/2016 Routine postpartum follow-up
62 AKSEL BARIQ AROHIM BANTERAN 5/4 '1021012707160274 0 Th 4 Bln 17 Hr L 12/13/2016 Pneumonia, unspecified
63 SALVA NUR ARSYIFA BOJONG 4/12 '1021031010930252 0 Th 0 Bln 13 Hr P 12/13/2016 General medical examination
64 MARDIYAH KLAPAGADING RT 2/8 '1021021511650336 60 Th 0 Bln 29 Hr P 12/14/2016 Arthritis, unspecified
65 DULROHMAN PARUNGKAMAL 6/3 '1022203101440101 72 Th 10 Bln 13 Hr L 12/14/2016 Congestive heart failurediabetes mellitus
66 DARSIH WANGON RT 4/6 '1021070807630246 53 Th 5 Bln 7 Hr P 12/14/2016 without complications
67 KENZOU JULIAN PUTRA RAMADHAN KLAPAGADING 2/3 '1021030905850241 1 Th 5 Bln 7 Hr L 12/14/2016 manifestations, virus notinfection,
Acute upper respiratory identified
68 KENZIE JULIAN PUTRA RAMADHAN KLAPAGADING 2/3 '1021030905850241 1 Th 5 Bln 7 Hr L 12/14/2016 unspecified
69 SAMSUDIN BANTERAN 4/1 '1021010607560218 60 Th 5 Bln 8 Hr L 12/14/2016 Congestive heart failure
70 ESTI WIJAYANTI WANGON 2/12 '1021071408810239 35 Th 4 Bln 0 Hr P 12/14/2016 Malignant neoplasm of breast, unspecified
71 RIDEM RANDEGAN 1/1 '1021052304550312 61 Th 7 Bln 22 Hr P 12/14/2016 Fracture of lower end of tibia
72 ANDIYAH KLAPAGADING WETAN RT 4/3 '1021020309760343 40 Th 3 Bln 11 Hr P 12/15/2016 Fracture of other toe
73 MARYANI RANDEGAN 4/3 '1021052301960280 20 Th 10 Bln 22 Hr P 12/15/2016 Supervision of normal first
Continuing pregnancy afterpregnancy
abortion of one
74 SITI NASIATI KLAPAGADING KULON 02/04 '1021032307830215 33 Th 4 Bln 24 Hr P 12/15/2016 fetus or more
75 GESANG PRIAYATNI BANTERAN 1/6 '1021012209790261 17 Th 11 Bln 6 Hr P 12/15/2016 Otitis externa,
Continuing unspecified
pregnancy after abortion of one
76 MURTIANI WANGON 2/13 '0001694534185 33 Th 1 Bln 14 Hr P 12/15/2016 fetus or more
77 SUKESIH BANTERAN 3/4 '1021013112630029 52 Th 11 Bln 16 Hr P 12/16/2016 without complications
Sacrococcygeal disorders, not elsewhere
78 INDRAWANTI WANGON 6/13 '1021072007920167 24 Th 4 Bln 27 Hr P 12/16/2016 classified
79 AWEN BANTERAN 2/2 '1021012004550114 61 Th 7 Bln 27 Hr P 12/16/2016 without complications
Sacrococcygeal disorders, not elsewhere
80 TURYAMI KLAPAGADING 3/1 '0001694484336 35 Th 2 Bln 8 Hr P 12/16/2016 classified
Supervision of pregnancy with grand
81 MUSTOLIAH KLAPAGADING 1/10 '1021022707760192 40 Th 4 Bln 20 Hr P 12/16/2016 multiparity
82 DESTA FAJAR ISNANDAR KLAPAGADING 3/1 '1021031812130223 2 Th 11 Bln 28 Hr L 12/16/2016 manifestations, virus not identified
83 ROJIKIN KLAPAGADING, 1/10 '1021023112620208 53 Th 11 Bln 16 Hr L 12/16/2016 Acute
mention pharyngitis, unspecified
of bacteriological or histological
84 BADRUN ASYAKIRI BANTERAN RT 1/2 '1021011208640272 52 Th 4 Bln 4 Hr L 12/16/2016 confirmation
85 KANTINI WANGON 6/5 '1021071010690028 47 Th 2 Bln 7 Hr P 12/17/2016 Scabies
86 RIDEM RANDEGAN 1/1 '1021052304550312 61 Th 7 Bln 25 Hr P 12/17/2016 Fracture of lower end of tibia
87 JAMINGUN JAMBU 3/3 '1022022907780344 38 Th 4 Bln 19 Hr L 12/17/2016 Dengue fever [classical dengue]
88 RAGIL WIASTUTI KLAPAGADING KULON 3/1 '1021031811810002 35 Th 1 Bln 1 Hr P 12/19/2016 Ventricular
Sacrococcygealseptal defect not elsewhere
disorders,
89 MARDIYAH KLAPAGADING RT 2/8 '1021021511650336 60 Th 1 Bln 3 Hr P 12/19/2016 classified
90 DWI WAHYUNI BANTERAN 1/5 '1021010407810251 35 Th 5 Bln 16 Hr P 12/19/2016 Supervision of other high-risk
Stroke, not specified pregnancies
as haemorrhage or
91 SARTIM PANGADEGAN '1021041004520161 64 Th 8 Bln 9 Hr L 12/19/2016 infarction
92 KUSMIATI KLAPAGADING 2/9 '1021020108650060 51 Th 4 Bln 19 Hr P 12/20/2016 Pyoderma
93 SUBANDI KLAPAGADING 2/1 '1021020808840049 32 Th 4 Bln 12 Hr L 12/20/2016 Fracture of lower end of tibia
94 AKBAR HAINUN MUSTOFA WANGON 1/4 '1021070602130193 3 Th 10 Bln 12 Hr L 12/20/2016 Scabies
95 SUMINAH KLAPAGADING 6/10 '1021021509600305 56 Th 3 Bln 4 Hr P 12/20/2016 Polymyalgia rheumaticadiabetes mellitus
96 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 Th 0 Bln 17 Hr P 12/20/2016 without complications
97 SATRIO ANGGORO C CANDUK 2/1 '1021022704880032 28 Th 0 Bln 0 Hr L 12/20/2016 Schizophrenia, unspecified
98 NURHAYATI CANDUK 1/1 '1021021906680039 48 Th 6 Bln 1 Hr P 12/20/2016 Arthritis, unspecified
99 ADMIRAH JAMBU 4/7 '10220229080323 38 Th 3 Bln 22 Hr P 12/20/2016 Supervision of other normal pregnancy
100 ANDIYAH KLAPAGADING WETAN RT 4/3 '1021020309760343 40 Th 3 Bln 16 Hr P 12/20/2016 Fracture of shaft of femur
Chronic obstructive pulmonary disease,
General counselling and advice on
102 SUWARNI RANDEGAN 2/5 '1021050804810308 35 Th 8 Bln 12 Hr P 12/20/2016 contraception
103 TUWIYAH RANDEGAN 2/10 '1021052106800037 36 Th 6 Bln 0 Hr P 12/21/2016 Schizophrenia, unspecified
104 ALFIAN NUROHMAN BANTERAN 2/5 '1211012502030044 13 Th 9 Bln 25 Hr L 12/21/2016 Open wound of unspecified body region
105 EMI PASA NURAINI WANGON 1/3 '1021071905860035 30 Th 7 Bln 3 Hr P 12/21/2016 Gingival recession
Stroke, not specified as haemorrhage or
106 MAHROJI KLAPAGADING KULON 4/15 '1021031409300185 86 Th 3 Bln 7 Hr L 12/21/2016 infarction
107 KENZIE JULIAN PUTRA RAMADHAN KLAPAGADING 2/3 '1021030905850241 1 Th 5 Bln 14 Hr L 12/21/2016 Open wound
mention of unspecifiedorbody
of bacteriological region
histological
108 RADITYA AFANDI KLAPAGADING 1/1 '1021021011150329 1 Th 1 Bln 11 Hr L 12/21/2016 confirmation
109 SATINEM KLAPAGADING 3/3 '1021022512570070 58 Th 11 Bln 27 Hr P 12/22/2016 Headache
110 SUKIMIN RANDEGAN 02/02 '1021052604670227 49 Th 7 Bln 27 Hr L 12/22/2016 Epilepsy, unspecified
111 ANDIYAH KLAPAGADING WETAN RT 4/3 '1021020309760343 40 Th 3 Bln 18 Hr P 12/22/2016 Fracture of foot, unspecified , open
112 SIRAN SUGIARTO BANTERAN 5/5 '1021012904620276 54 Th 7 Bln 24 Hr L 12/22/2016 Benign
Care andneoplasm of prostate
examination immediately after
113 MARYANI RANDEGAN 4/3 '1021052301960280 20 Th 10 Bln 29 Hr P 12/22/2016 delivery
114 AGUS SISWANTO KLAPAGADING, 3/3 '1021021608940071 22 Th 4 Bln 6 Hr L 12/22/2016 manifestations, virusrespiratory
Influenza with other not identified
115 AMIR NURYANTO BESUKI 3/2 '101011101790190 37 Th 11 Bln 11 Hr L 12/22/2016 manifestations, virus not identified
116 TURINAH KLAPAGADING KULON 2/9 '1021030708570093 59 Th 4 Bln 15 Hr P 12/22/2016 Observation for suspected tuberculosis
117 RAWEN KLAPAGADING 4/10 '1021023112540295 62 Th 10 Bln 21 Hr P 12/23/2016 Acute pharyngitis, unspecified
118 MARGONO BANTERAN 3/5 '1021011212540186 62 Th 0 Bln 11 Hr L 12/23/2016 without complications
119 TUSILAH KLAPAGADING KULON RT 3/10 '1021032006740243 42 Th 6 Bln 3 Hr P 12/23/2016 Thyrotoxicosis, unspecified
120 SUWARNI RANDEGAN 2/5 '1021050804810308 35 Th 8 Bln 15 Hr P 12/23/2016 Surgical follow-up care, unspecified
121 MISEM KLAPAGADING KULON 1/7 '1021033112590236 56 Th 11 Bln 23 Hr P 12/23/2016 Contusion of thorax
122 SUDIYAH BANTERAN 4/1 '1021011204650277 51 Th 8 Bln 11 Hr P 12/23/2016 Myalgia
mention of bacteriological or histological
123 PUJIONO WANGON 5/17 '1021071005870254 29 Th 7 Bln 14 Hr L 12/23/2016 confirmation
124 ANISAH LIFTI JIANTI GERDUREN 04/02 '1131011407050114 11 Th 5 Bln 10 Hr P 12/23/2016 Acute pharyngitis,
Supervision unspecified
of pregnancy with grand
125 SUMARNI RAWAHENG 3/5 '1021060109470001 42 Th 3 Bln 23 Hr P 12/24/2016 multiparity
126 ANDIYAH KLAPAGADING WETAN RT 4/3 '1021020309760343 40 Th 3 Bln 20 Hr P 12/24/2016 Superficial injury of unspecified body region
127 ELING RINJANI RANDEGAN 1/2 '1021051507980313 18 Th 5 Bln 10 Hr P 12/24/2016 Ingrowing nail
128 SITAH BANTERAN 4/1 '1021010107560275 60 Th 5 Bln 23 Hr P 12/24/2016 Ischaemic
Stroke, notinfarction
specified of
asmuscle, other or
haemorrhage
129 ASIYAH KLAPA GADING KULOON 3/ 10 '0001694482806 54 Th 7 Bln 8 Hr L 12/24/2016 infarction
130 ALFIAN NUROHMAN BANTERAN 2/5 '1211012502030044 13 Th 10 Bln 1 Hr L 12/27/2016 Scabies
131 AJI SATRIANTO KLAPAGADING 4/8 '1021021011120340 4 Th 1 Bln 16 Hr L 12/27/2016 Epilepsy, unspecified
132 WARSINI KLAPAGADING 1/8 '1021022012580190 58 Th 0 Bln 7 Hr P 12/27/2016 Urticaria, unspecified
133 ANDIYAH KLAPAGADING WETAN RT 4/3 '1021020309760343 40 Th 3 Bln 23 Hr P 12/27/2016 Fracture of metatarsal bone
134 KASINAH BANTERAN 2/3 '1021013112440248 71 Th 11 Bln 26 Hr P 12/27/2016 Congestive heart failure
135 TUTI KLAPAGADING 2/8 '1031113112660037 49 Th 11 Bln 27 Hr P 12/27/2016 Congestive heart failure
136 MUKSIN WANGON 2/2 '1021071201530259 63 Th 11 Bln 14 Hr L 12/27/2016 Unspecified appendicitis
137 SATINEM KLAPAGADING 3/3 '1021022512570070 59 Th 0 Bln 3 Hr P 12/28/2016 Tension-type headache diabetes mellitus
138 SUWARNI KARANGJENGKOL 3/3 '1021073112450144 70 Th 11 Bln 27 Hr P 12/28/2016 without complications
139 NASIYAH KLAPAGADING 2/9 '1021023101450172 71 Th 10 Bln 27 Hr P 12/28/2016 Benign paroxysmal
Supervision vertigowith grand
of pregnancy
140 MUSTOLIAH KLAPAGADING 1/10 '1021022707760192 40 Th 5 Bln 2 Hr P 12/28/2016 multiparity
141 AGUS SISWANTO KLAPAGADING, 3/3 '1021021608940071 22 Th 4 Bln 12 Hr L 12/28/2016 External haemorrhoids without complication
142 SUWARNI RANDEGAN 2/5 '1021050804810308 35 Th 8 Bln 20 Hr P 12/28/2016 Surgical follow-up care, unspecified
143 LISTIYOWATI RAWAHENG 1/4 '1021061606900189 26 Th 6 Bln 12 Hr P 12/28/2016 Surgical follow-up care, unspecified
144 SUDIYAH BANTERAN 4/1 '1021011204650277 51 Th 8 Bln 16 Hr P 12/28/2016 Acute pharyngitis, unspecified
145 SOIMAH KLAPAGADING 1/12 '1021021106690087 47 Th 6 Bln 18 Hr P 12/29/2016 Tension-type headache
146 SISWANTO WANGON 3/2 '1021070806810032 35 Th 6 Bln 21 Hr L 12/29/2016 Thyrotoxicosis, unspecified
147 WARISEM GERDUREN 1/3 '1131010304550107 52 Th 0 Bln 0 Hr P 12/29/2016 Dyspepsia
Continuing pregnancy after abortion of one
148 SITI NASIATI KLAPAGADING KULON 02/04 '1021032307830215 33 Th 5 Bln 7 Hr P 12/29/2016 fetus or more
149 TUSILAH KLAPAGADING KULON RT 3/10 '1021032006740243 42 Th 6 Bln 10 Hr P 12/29/2016 Thyrotoxicosis, unspecified
150 NGATINI KLAPAGADING KULON 2/8 '1021033112720079 43 Th 11 Bln 29 Hr P 12/30/2016 Otitis media, unspecified
151 RAWEN KLAPAGADING 4/10 '1021023112540295 62 Th 10 Bln 28 Hr P 12/30/2016 Essential (primary) hypertension
152 SUGENG SUJARWO JURANGBAHAS 6/1 '1022030504540027 62 Th 7 Bln 28 Hr L 12/31/2016 Soft tissue disorder, unspecified, lower leg
153 JUMAIYAH JURANGBAHAS 6/1 '1022032707530005 63 Th 5 Bln 5 Hr P 12/31/2016 Dengue fever [classical dengue]
TAHUN : 2016
Karcis +
Tindaka
KLINIK
Tujuan
UMUM / n
KLINIK
BP
UMUM Rp.5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM / Rp. 5000
KLINIK
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM / Rp. 5000
KLINIK
BP
UMUM / Rp. 5000
BP Rp. 5000
KLINIK
UMUM
KLINIK /
BP
UMUM / Rp. 5000
BP
KLINIK Rp. 5000
KLINIK
HAMIL
UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM / Rp. 5000
BP Rp. 5000
KLINIK
KLINIK
UMUMKIA/ Rp. 5000
KLINIK
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UMUM Rp. 5000
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UMUM Rp. 5000
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UMUM Rp. 5000
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UMUM Rp. 5000
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UMUM Rp. 5000
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KLINIK /
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UMUM / Rp. 5000
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KLINIK Rp. 5000
KLINIK
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UMUM Rp. 5000
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UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
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UMUM Rp. 5000
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UMUM Rp. 5000
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UMUM / Rp. 5000
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UMUM / Rp. 5000
BP Rp. 5000
KLINIK
UMUM
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM / Rp. 5000
BP Rp. 5000
KLINIK
KLINIK
UMUM / Rp. 5000
KIA
BP Rp. 5000
KLINIK
KLINIK
UMUM KIA Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
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UMUM / Rp. 5000
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UMUM / Rp. 5000
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KLINIK Rp. 5000
HAMIL
KLINIK Rp. 5000
KLINIK
HAMIL
UMUM / Rp. 5000
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KLINIK Rp. 5000
KLINIK
HAMIL
UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
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UMUM / Rp. 5000
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KLINIK Rp. 5000
KLINIK
HAMIL / Rp. 5000
UMUM
KLINIK
BP
UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
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UMUM Rp. 5000
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KLINIK Rp. 5000
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UMUM / Rp. 5000
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UMUM
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HAMIL
UMUM Rp. 5000
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BP
UMUM / Rp. 5000
BP Rp. 5000
KLINIK
KLINIK
UMUM KIA Rp. 5000
KLINIK /
BP
UMUM / Rp. 5000
BP
KLINIK Rp. 5000
KLINIK
GIGI
UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
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UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
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KLINIK
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UMUM Rp. 5000
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UMUM / Rp. 5000
BP Rp. 5000
KLINIK
KLINIK
UMUM KIA Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
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UMUM / Rp. 5000
BP Rp. 5000
KLINIK
KLINIK
UMUM KIA Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM / Rp. 5000
BP
KLINIK Rp. 5000
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HAMIL
UMUM / Rp. 5000
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UMUM / Rp. 5000
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UMUM
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KLINIK Rp. 5000
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HAMIL
UMUM / Rp. 5000
BP Rp. 5000
KLINIK KIA Rp. 5000
KLINIK
KLINIK
UMUM KIA Rp. 5000
KLINIK /
BP
UMUM / Rp. 5000
KLINIK
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM / Rp. 5000
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KLINIK Rp. 5000
KLINIK
HAMIL
UMUM Rp. 5000
KLINIK /
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UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM Rp. 5000
KLINIK /
BP
UMUM / Rp. 5000
BP Rp. 5000

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DAFTAR TAGIHAN KLAIM RAWAT JALAN JAMKESDA / KBS DI PELAYANAN D

PROPINSI : JAWA TENGAH BULAN : Januari

Total : 116 Pasien

No Nama Alamat No Asuransi Umur Jenis Kel Tgl Transaksi

1 IKLIL KAFIAH PARUNGKAMAL, 3/7 '1011102001140257 2 P 2/1/2016

12 TUMINAH RANDEGAN 2/11 '1021051608690260 46 P 5/1/2016

41 MUHAMMAD SEPTIAN ALIF WANGON 4/4 '1021010909150235 L 13-01-2016

93 ROPINGAH KLAPAGADING 1/10 '1021021506770278 38 P 26-01-2016

Kepala Puskesmas I Wangon

dr. Tulus Budi Purwanto

Diagnosa Tujuan Berobat Karcis + Tindakan

Diare dan gastroenteritis KLINIK UMUM / BP Rp 5,000

Kehamilan (ANC) KLINIK HAMIL Rp 5,000

KLINIK KIA Rp 5,000

Dispepsia RUJUKAN Rp 5,000

No Nama Alamat No Asuransi Umur Jenis Kel Tgl Transaksi

1 SAMSUDIN BANTERAN 4/1 '1021010607560218 59 L 2/1/2016

7 AMINAH KLAPAGADING KULON 3/4 '1021033112610212 48 P 2/3/2016

42 TURAHMI KLAPAGADING KULON 02/16 '1021032203730165 41 P 2/15/2016

56 MUH IZHAR SAPUTRA KLAPAGADING 2/8 '102122202130164 3 L 2/17/2016

57 SUGENG SUJARWO JURANGBAHAS 6/1 '1022030504540027 59 L 2/17/2016

77 MUH IMDADUR R KLAPAGADING 2/5 '1021021504130289 3 L 2/24/2016

87 JURIYAH BANTERAN 4/1 '1021011407660182 48 P 2/26/2016

90 OKTA DWI YULIAWAN JAMBU 03/12 '1022020307880057 0 L 2/26/2016

91 NAKIYAH RANCABANTENG 3/1 '1021020312570197 59 P 2/27/2016

93 SUMIAH BANTERAN 3/4 '1021011408760206 40 P 2/29/2016

Kepala Puskesmas I Wangon

dr. Tulus Budi Purwanto

Diagnosa Tujuan Berobat Karcis + Tindakan

Gagal jantung KLINIK UMUM / BP Rp 5,000

Gagal Ginjal Kronis RUJUKAN Rp 5,000

Arthritis lain RUJUKAN Rp 5,000

Hipertensi primer KLINIK UMUM / BP Rp 5,000

Infeksi saluran kemih bagian bawah KLINIK UMUM / BP Rp 5,000

Diabetes Mellitus (NIDDM) KLINIK UMUM / BP Rp 5,000

Infeksi Akut lain pada saluran Pernafasan KLINIK UMUM / BP Rp 5,000

Diabetes Mellitus (NIDDM) KLINIK UMUM / BP Rp 5,000

Keluarga Berencana (KB) KLINIK KB Rp 5,000

Total : 117 Pasien

No Nama Alamat No Asuransi Umur Jenis Kel Tgl Transaksi

1 SUKESIH BANTERAN 3/4 '1021013112630029 52 P 3/1/2016

8 SOIMAH KLAPAGADING 1/12 '1021021106690087 46 P 3/2/2016

20 SISWANTO WANGON 3/2 '1021070806810032 34 L 3/3/2016

24 JONI WARDADI RAWAHENG 5/2 '1021061606780026 38 L 3/5/2016

27 SANROKYAT ANGKAT WANGON 1/7 '1021073112550033 60 L 3/5/2016

33 SUWARNI PENGADEGAN RT 1/2 '1021042311680260 47 P 3/7/2016

35 SITI KHOMARIYAH WANGON 3/2 '1021070502610226 54 P 3/7/2016

37 ALVIANSYAH MAULANA S TUNJUNG 2/1 '1031110804140169 1 L 3/7/2016

38 MARMI BANTERAN 3/1 '1021013112530244 63 P 3/8/2016

39 ERNA ASMARANI KLAPAGADING 1/7 '1021021806900137 25 P 3/8/2016

55 YASAERI ASWIN RANDEGAN 2/11 '1021051911470270 60 L 3/12/2016

67 SUTIYEM WANGON 2/7 '1021073112350104 78 P 3/15/2016

80 TIRWAN YASMIREJA KLAPAGADING KULON 2/13 '1021030603840126 69 L 3/18/2016

92 WARTEM PENGADEGAN 2/1 '1021040209590162 60 P 3/22/2016

106 ROMINI KLAPAGADING 2/10 '1021020705800292 35 P 3/28/2016

109 DIKI DERMAWAN BANTERAN 1/3 '1021011904970228 19 L 3/29/2016

Kepala Puskesmas I Wangon

dr. Tulus Budi Purwanto

Diagnosa Tujuan Berobat Karcis + Tindakan

Diabetes Mellitus (NIDDM) RUJUKAN Rp 5,000

Demam tifoid dan paratifoid RUJUKAN Rp 5,000

Dermatitis kontak alergi KLINIK UMUM / BP Rp 5,000

PERIODONTITIS KRONIS KLINIK GIGI Rp 5,000