FORMULIR PENGAJUAN KLAIM BPJS

PONKESDES : PANDEMAN
BULAN : SEPTEMBER 2022

PEMERIKSAAN FISIK TEKANAN DARAH

NO TANNGAL NO.BPJS NIK NAMA UMUR ALAMAT DIAGNOSA RR NADI SUHU ALERGI
TB BB LP SISTOL DIASTOL
1 9/1/2022 0000782276218 3529240107741230 MATANGWAR 47 th Pandeman Diarea (A09) 164 45 96 100 60 24 80 36.1 Tdk ada
2 0000782276319 3529246004760000 RADIYA 45 th Pandeman ISPA (J06) 150 60 65 120 70 20 80 37.9 Tdk ada
3 9/2/2022 0001049354234 3529240107530080 DUSSALEH 68 th Pandeman Alergi (L23) 163 52 56 100 60 24 84 36.2 Tdk ada
4 0001049354245 3529245508550000 NINTIYA 66 th Pandeman Influenza (J11) 149 58 89 110 70 24 80 36.1 Tdk ada
5 9/3/2022 0000782278097 3529244507940000 SULISTIA NINGSIH 27 th Pandeman Faringitis (J02) 148 50 90 120 60 20 80 36.3 Tdk ada
6 0001049354357 3529242702980000 LUKMAN 23 th Pandeman Capek Pegal (R53) 161 45 92 120 60 20 84 36.3 Tdk ada
7 9/5/2022 0000782283442 3529244107820897 ADANIAH 43 th Pandeman Asma (J45) 153 54 88 90 60 20 80 36.4 Tdk ada
8 0000782283633 3529246005990003 IIS ANDRIANA 22 th Pandeman Sinusitis (J01) 149 54 95 110 80 24 84 36.4 Tdk ada
9 9/6/2022 0000782283824 3529242805060002 ARIF 15 th Pandeman Tonsilitis (J03) 162 45 85 110 70 24 84 36.4 Tdk ada
10 0000782280303 3529246408900000 SALMA 43 th Pandeman Nyeri Haid (N91) 154 57 91 110 70 24 84 37.9 Tdk ada
11 9/7/2022 0000782281192 3529241403070000 SYARIF HIDAYATULLAH 14 th Pandeman Demam (R50) 156 38 89 100 60 24 80 36.1 Tdk ada
12 0000782281394 3529240107791220 SAINI 42 th Pandeman Gout (M10) 163 58 90 100 60 24 80 36.4 Tdk ada
13 9/8/2022 0000782281618 3529246003880000 SAINATUN 33 th Pandeman Konstipasi (K59) 149 59 91 90 60 20 80 36.3 Tdk ada
14 0000782282079 3529244107330240 ADIM 88 th Pandeman Hipertensi (I10) 164 52 86 160 90 24 84 36.3 Tdk ada
15 9/9/2022 0001049354302 3529240204850000 ARIF ZULKARNAIN 36 th Pandeman Diarea (A09) 165 50 87 100 70 24 80 36.5 Tdk ada
16 0000782278479 3529244107710700 BUNGASIA 50 th Pandeman Sinusitis (J01) 150 53 80 120 70 20 80 36.1 Tdk ada
17 9/10/2022 0000782278593 3529241707830000 MATSAINI 38 th Pandeman Glakoma (H40) 162 58 82 100 60 20 84 36.6 Tdk ada
18 0000782284072 3529243112740026 MISRAWAN 47 th Pandeman Diarea (A09) 169 60 85 90 80 20 80 36.1 Tdk ada
19 9/12/2022 0000782284511 3529243112740026 SITI AMRIYA 47 th Pandeman Vomiting (R11) 151 53 76 90 70 24 84 38.2 Tdk ada
20 0000782286131 3529244107470260 KHAIRIYAH 74 th Pandeman GEA (A09) 153 50 86 90 70 24 80 36.2 Tdk ada
21 9/13/2022 0000782287244 3529240107871160 SAINUR RAHMAT 34 th Pandeman Neuralgia (G50) 168 59 87 100 70 20 80 36.1 Tdk ada
22 0000782288954 3529244803980000 BUDIARMAN 23 th Pandeman Demam (R50) 166 58 96 100 60 24 80 36.1 Tdk ada
23 9/14/2022 0000782289911 3529247112010000 WINAQ 20 th Pandeman Influenza (J11) 150 54 88 90 60 20 80 36.4 Tdk ada
24 0001049354313 3529247112890010 IKET BYANTI 32 th Pandeman Migren (G43) 152 56 47 100 60 20 84 36.6 Tdk ada
25 9/15/2022 0001049354212 3529245202880000 RISKIYAH 33 th Pandeman ISPA (J06) 155 59 87 100 70 20 80 36.1 Tdk ada
26 0001049354155 3529244107820880 TIWARNI 82 th Pandeman Jamur (B36) 152 58 65 90 60 24 80 36.3 Tdk ada
27 9/16/2022 0001049354166 3529242811050000 MIFTAHUL ULUM 16 th Pandeman Stomatitis (K12) 168 50 67 110 70 24 80 36.2 Tdk ada
28 0000782272146 3529244107480360 MADRIYA 73 th Pandeman Anemia (D64) 150 59 88 120 70 24 80 36.2 Tdk ada
29 9/17/2022 0000782272179 3529240107640470 NIKMAT 57 th Pandeman Chepalgia(G44) 169 53 80 120 70 20 80 36.1 Tdk ada
30 0000782266533 3529244107880560 SUHANA 33 th Pandeman Chepalgia(G44) 156 60 86 90 70 20 80 36.3 Tdk ada
31 0001049354087 3529241010850000 ABD SAMAD 36 th Pandeman Influenza (J11) 168 56 85 90 80 20 80 36.2 Tdk ada
32 0000782267916 3529242504470000 M SALEH 47 th Pandeman Faringitis (J02) 165 60 76 90 70 24 84 38.2 Tdk ada
33 9/20/2022 0000782268524 3529244101070000 RIKA ALFIANI 13 th Pandeman Gastritis (K29) 144 35 88 90 70 24 80 36.4 Tdk ada
34 9/21/2022 0000782268647 3529240907780000 HANNAN 43 th Pandeman GEA (A09) 164 55 90 120 60 20 80 36.4 Tdk ada
35 9/22/2022 0000782268726 3529244207810000 40 th Pandeman Vomiting (R11) 150 54 92 120 60 20 84 36.3 Tdk ada
36 0000782272539 3529244107650730 MARWIYA 56 th Pandeman Gout (M10) 155 50 87 100 70 20 80 36.4 Tdk ada
37 9/23/2022 0000782273654 3529246711730000 MAENNA 48 th Pandeman Glakoma (H40) 156 52 65 90 60 24 80 36.3 Tdk ada
38 0001049354177 3529247112620000 UMMI 59 th Pandeman Migren (G43) 149 53 85 110 60 20 80 36.2 Tdk ada
39 9/24/2022 0001049354188 3529244111920000 TRIAINI 29 th Pandeman Konstipasi (K59) 152 52 86 110 70 24 80 36.5 Tdk ada
40 0001049354199 3529244107410150 SATNA 80 th Pandeman Hipertensi (I10) 148 54 95 150 80 24 84 36.4 Tdk ada
41 9/26/2022 0000782274148 3529240107750540 AMINUDDIN 46 th Pandeman Demam (R50) 169 59 65 120 70 20 80 37.9 Tdk ada
42 0000782274611 3529244808900000 SUATI 31th Pandeman Anemia (D64) 150 60 50 90 60 24 80 36.2 Tdk ada
43 9/27/2022 0001049354111 3529240107650500 MARSUKI 56 th Pandeman Conjungtivitis (H10) 150 51 56 100 60 24 84 36.2 Tdk ada
44 0001049354122 3529246407790000 MAIMUNA 42 th Pandeman Nyeri Haid (N91) 151 59 88 90 70 24 80 36.1 Tdk ada
45 9/28/2022 0000782270897 3529244504040000 TILKA AIFATUL AIDA 17 th Pandeman Asma (J45) 153 42 87 100 70 20 80 36.4 Tdk ada
46 0000782278615 3529247012910000 RISKIYAH 30 th Pandeman Demam (R50) 155 56 89 100 60 20 84 36.7 Tdk ada
47 9/29/2022 0001049354291 3529245203530000 MUNAMI 68 th Pandeman Capek Pegal (R53) 146 43 90 90 70 24 84 36.1 Tdk ada
48 0000782280077 3529244505780000 MAIMUNA 30 th Pandeman ISPA (J06) 150 56 86 100 70 20 80 36.1 Tdk ada
49 9/30/2022 0001049354201 3529241709740000 MATSALE 45 th Pandeman Hipertensi (I10) 160 58 87 150 90 24 80 36.2 Tdk ada
50 0001049354212 3529245202880000 RISKIYAH 33 th Pandeman ISPA (J06) 155 59 87 100 70 20 80 36.1 Tdk ada

Pandeman, 30 september 2022

Penanggung Jawab

Masrurah,A.Md.Kep