1.

Petugas Entri
Data
REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

1 2 V 4 5 6
3 3 0 4 0 1 0 Bulan : 2022
NAMA FASKES/ PUSKESMAS KALIBENING 7 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

PESERTA KB JENIS TINDAKAN Kasus PENGGUNAAN SUMBER ALOKON

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
STATUS PESERTA KB

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN
ISTRI

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN
PENCABUTAN

PENCABUTAN

KEGAGALAN
PEMBERIAN/

KOMPLIKASI
NAMA SUAMI

OPERATIF/

LAINNYA
TANGGAL

MANDIRI
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

BERAT
LAHIR

(Kode)

TIDAK

APBN

APBD
DAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1 01-March-2022 AHMAD SURATNO 3 3 0 4 1 8 0 9 0 7 8 4 0 0 0 2 SURATMI 08-July-1984 KASINOMAN RT03 RW04 2 0 0 0 3 0 1 0 1 0 0 0

04-February-
2 01-March-2022 BAGYO 3 3 0 4 1 8 4 5 0 2 8 0 0 0 0 1 SUMINI SIDAKANGEN 2 1 0 0 3 0 1 0 1 0 0 0
1980

3 01-March-2022 DARMANTO 3 3 0 4 1 8 6 1 0 4 9 1 0 0 0 6 AMINAH 21-April-1991 KALIBOMBONG 3 0 0 0 3 0 1 0 1 0 0 0

4 01-March-2022 JAIDIN HIDAYAT 3 3 0 4 1 8 6 1 1 0 3 7 3 0 0 0 TRIMA 20-March-1973 PLORENGAN 2 1 0 0 3 0 1 0 1 0 0 0

26-August-1989
5 01-March-2022 KANDONO 3 3 0 4 1 8 6 7 0 8 8 9 0 0 0 3 KARTINI BEDANA 2 1 0 0 3 0 1 0 1 0 0 0

08-September-
6 01-March-2022 MISNO 3 3 0 4 1 8 4 8 0 9 8 4 0 0 0 1 HARTATI SIRUKEM 2 1 0 0 3 0 1 0 1 0 0 0
1984
07-November-
7 01-March-2022 MUHAMMAD SUBUR 3 3 0 4 1 8 4 9 0 9 8 7 0 0 0 1 TATI NUROHMAH PLORENGAN 2 1 0 0 3 0 1 0 1 0 0 0
1987

8 01-March-2022 NARTO 3 3 0 4 1 8 4 1 0 7 8 0 0 0 5 5 JAYATIN 01-July-1980 KALIBENING 3 1 0 0 3 0 0 1 1 0 0 0

10-December-
9 01-March-2022 PONDOH 3 3 0 4 1 8 5 0 1 2 9 6 0 0 0 2 EKA SUTRIYANTI KALISATKIDUL RT 002 RW 007 2 0 0 0 3 0 1 0 1 0 0 0
1996
11-December-
10 01-March-2022 RIONO 3 3 0 4 1 8 6 1 1 2 0 0 0 0 0 2 YAYU RIZKIANA PLORENGAN 3 0 0 0 3 0 0 1 1 0 0 0
2000
19-February-
11 01-March-2022 SATUN 3 3 0 4 1 8 6 0 0 2 8 2 0 0 0 5 RATI KALISAT KIDUL 2 1 0 0 3 0 1 0 1 0 0 0
1982

12 01-March-2022 TARTO 3 3 0 4 1 8 6 7 0 7 9 6 0 0 0 1 SULASTRI LIS SUGIART 26-July-1996 KALIBOMBONG 2 1 0 0 3 0 1 0 1 0 0 0

WAHMAD
13 01-March-2022 3 3 0 4 1 8 5 6 0 4 7 2 0 0 0 1 SAMINAH 17-April-1972 SIRUKEM RT 01 RW 02 3 0 0 0 3 0 1 0 1 0 0 0
SAMDIONO

14 08-March-2022 KISMO 3 3 0 4 1 8 4 1 0 7 7 5 0 0 3 6 KARINAH 01-July-1975 KERTOSARI 2 1 0 0 3 0 0 1 1 0 0 0

14-October-1998
15 11-March-2022 SLAMET RIYADI 3 3 0 4 1 8 5 4 1 0 9 8 0 0 0 2 TUTI KARANGANYAR 1 1 1 0 3 0 1 0 1 0 0 0

01-October-1987
16 14-March-2022 ISWANTO 3 3 0 4 1 8 4 1 1 0 8 7 0 0 0 1 MUSLINAH SIDAKANGEN 2 1 0 0 3 0 0 1 1 0 0 0

21-October-1999
17 14-March-2022 MISNO 3 3 0 4 1 8 6 1 1 0 9 9 0 0 0 1 MISNI MELANI KERTOSARI 3 1 0 0 3 0 0 1 1 0 0 0

22-August-1991
18 14-March-2022 NUR ARIFIN 3 3 0 4 1 8 6 2 0 8 9 1 0 0 0 1 EKA KUSTIANINGSIH GUNUNG LANGIT 2 1 0 0 3 0 0 1 1 0 0 0

01-January-1988
19 14-March-2022 TRIYONO 3 3 0 4 1 8 4 1 0 1 8 8 0 0 0 1 PUJI RAHAYU MAJATENGAH 3 1 0 0 3 0 1 0 1 0 0 0

20 14-March-2022 WARNOTO 3 3 0 4 1 8 4 7 0 3 7 5 0 0 0 2 TURWATI 07-March-1975 BEDANA 3 1 0 0 3 0 0 1 1 0 0 0

21 15-March-2022 DARSO 3 3 0 4 1 8 5 5 0 5 8 9 0 0 0 4 YANTI 15-May-1989 KALIBOMBONG 3 1 0 0 3 0 0 1 1 0 0 0

DANANG RUDI 07-January-1984

22 16-March-2022 3 3 0 4 1 8 4 7 0 1 8 4 0 0 0 2 SARSIH MAJATENGAH 3 1 0 0 3 0 0 1 1 0 0 0
HARTONO
DESA ASINAN, DUSUN
23 01-March-2022 AMIN SANTOSA 3 3 0 4 1 8 5 1 0 3 9 5 0 0 0 2 WASTINI 09-March-1997 1 0 0 0 5 0 1 0 1 0 0 0
KRUNGKRUNGAN RT 01/RW 04

24 01-March-2022 DIYANTO 3 3 0 4 1 8 6 2 0 6 8 5 0 0 0 1 ISTIQOMAH 02-June-1985 SIKUMPUL 2 0 0 0 5 0 0 1 1 0 0 0

25 01-March-2022 ISKANDAR 3 3 0 4 1 8 4 1 0 8 8 2 0 0 0 3 RUKAYAH 31-July-1982 RT.03/RW.02 DUSUN PARAKAN 3 0 0 0 5 0 1 0 1 0 0 0

26 01-March-2022 SHOLEH 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 DWIATI 06-July-1997 BEDDANA 3 0 0 0 5 0 1 0 1 0 0 0

27 08-March-2022 MULYONO 3 3 0 4 1 8 4 5 0 3 7 8 0 0 0 1 JUMIRAH 05-March-1978 KALIBENING 2 0 0 0 5 0 0 1 1 0 0 0

 26-December-
28 01-March-2022 SOBIRIN 3 3 0 4 1 8 6 7 1 2 8 6 0 0 0 1 WASIH KASINOMAN RT03 RW01 2 1 0 0 8 0 1 0 1 0 0 0
1986
14-October-2000
29 01-March-2022 TOHIDIN 3 3 0 4 1 8 5 4 1 0 0 0 0 0 0 1 WINARSIH PLORENGAN 2 1 0 0 8 0 0 1 1 0 0 0

09-August-1992
30 01-March-2022 AGUS SETIO 3 3 0 4 1 8 4 9 0 6 9 2 0 0 0 2 KHUSNUL KHOTIMAH MAJATENGAH 1 1 0 0 9 0 1 0 1 0 0 0

11-September-
31 01-March-2022 DUROHMAN 3 3 0 4 1 8 5 4 0 9 8 6 0 0 0 3 SULINAH KALIBENING 4 0 0 0 9 0 0 0 0 0 0 0
1986

1) Keterangan Kode

STATUS PESERTA KB KODE JENIS ALOKON (Diisi Pada Jenis Tindakan dan Kasus)
1 : Peserta KB Baru 3 : Peserta KB Ulangan 1 : Suntikan 1 Bulanan 3 : Suntikan 3 Bulanan 5 : Pil Progestin 7 : Implan 1 Batang 9 : IUD 11 : Tubektomi
2 : Peserta KB Ganti 4 : Komplikasi 2 : Suntikan 3 Bulanan 4 : Pil Kombinasi 6 : Kondom 8 : Implan 2 Batang 10 : Vasektomi

2) SELAIN STATUS PESERTA KB, JENIS TINDAKAN DAN KASUS DIISI TANDA CENTANG (V)
1. Petugas Entri Lamp.R/I/KB/20
Data LAMPIRAN R/I/KB/20 Lembar 3

1 2 V 4 5 6
3 3 0 4 0 1 0 Bulan : 2022
NAMA FASKES/ PUSKESMAS KALIBENING 7 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

RINGKASAN HASIL PELAYANAN KB

PESERTA KB BARU (PB) PESERTA KB ULANGAN PELAYANAN KASUS

PEMBERIAN
PEMBERIAN INFORMED PB DAN KESERTAAN JKN INFORMED CONSENT
METODE
NO. CONSENT (Untuk Peserta KB
KONTRASEPSI
(Untuk PB) PB PASCA PB PASCA Ulangan) PELAYANAN ULANG KOMPLIKASI BERAT
GANTI CARA PENCABUTAN KEGAGALAN
PERSALINAN KEGUGURAN
PB JKN PB NON JKN TOTAL PB

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1 SUNTIKAN 0 0 0 0 0 0 0 1 0 0 0 0
2 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
3 SUNTIKAN 0 0 0 0 0 0 1 1 0 0 0 0
4 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
5 PIL 0 0 0 0 0 0 0 0 1 0 0 0
6 SUNTIKAN 0 0 0 0 0 0 1 1 0 0 0 0
7 SUNTIKAN 0 0 0 0 0 0 1 1 0 0 0 0
8 PIL 0 0 0 0 0 0 0 1 0 0 0 0
9 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
10 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
11 SUNTIKAN 0 0 0 0 0 0 1 1 0 0 0 0
12 IUD 1 0 1 1 0 0 0 0 0 0 0 0
13 SUNTIKAN 0 0 0 0 0 0 1 1 0 0 0 0
14 SUNTIKAN 0 0 0 0 0 0 0 1 0 0 0 0
15 PIL 0 0 1 1 0 0 0 0 0 0 0 0
16 IUD 0 0 0 0 0 0 0 0 0 1 0 0
17 IMPLAN 0 0 0 0 0 0 1 1 0 0 0 0
18 SUNTIKAN 1 0 1 1 1 0 0 0 0 0 0 0
19 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
20 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0
21 SUNTIKAN 0 0 0 0 0 0 1 1 0 0 0 0
22 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0

JUMLAH 2 0 3 3 1 0 18 16 11 1 0 0

,
Pimpinan Faskes KB/Jaringan/Jejaring*

( .................................................................................................)

NIP/NRP
* Coret yang tidak perlu