PEMERINTAH KABUPATEN ACEH TAMIANG
DINAS KESEHATAN
PUSKESMAS SUNGAI IYU
Jln. Upah – Mesjid Sungai Iyu Kec. Bendahara – KodePos 24472
LAPORAN PERJALAN DINAS
YANG MELAKUKAN PERJALANAN
Nama :
TUJUAN
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MAKSUD PERJALANAN DINAS
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TANGGAL PERJALANAN DINAS
LAMA PERJALANAN DINAS
NOMOR SPT
HAL-HAL YANG DIBICARAKAN
TEMUAN
RENCANA TINDAK LANJUT
Mengetahui :
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E-mail : puskesmassungaiiyu@yahoo.co.id
Nip : Jabatan :
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Sungai Iyu, ...............................2017
Yang Melakukan Perjalanan Dinas
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 PEMERINTAH KABUPATEN ACEH TAMIANG
DINAS KESEHATAN
UPTD.PUSKESMAS SUNGAI IYU
Jln. Upah – Mesjid Sungai Iyu Kec. Bendahara – KodePos 24472
E-mail : puskesmassungaiiyu@yahoo.co.id

LAPORAN PERJALAN DINAS

YANG MELAKUKAN PERJALANAN

Nama : Nip : Jabatan :

TUJUAN
………………………………………………………………………...
MAKSUD PERJALANAN DINAS
…………………………………………………………………….......
TANGGAL PERJALANAN DINAS
LAMA PERJALANAN DINAS
NOMOR SPT
HAL-HAL YANG DIBICARAKAN
TEMUAN
RENCANA TINDAK LANJUT
:
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Mengetahui : Sungai Iyu, ................................ 2015

……………………………………… Yang Melakukan Perjalanan Dinas

1……………………………………..
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 CATATAN KESEHATAN JIWA

Nama Pasien : ……………………………………………………….....................………………...

Nama Puskesmas : UPTD Puskesmas Sungai Iyu
Tanggal : ……………………………………………………….....................………………...
Data S : ……………………………………………………….....................………………...
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O : ……………………………………………………….....................………………...
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Diagnosa : ……………………………………………………….....................………………...
Tindakan : ……………………………………………………….....................………………...
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Evaluasi S : ……………………………………………………….....................………………...
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O : ……………………………………………………….....................………………...
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A ::.……………………………………………………….....................………………..
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P : ……………………………………………………….....................………………...
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Kepala UPTD. Puskesmas Sungai Iyu

RADHIYAH, SKM
Penata Tk. I / Nip. 19710405 199101 2 001
 CATATAN KESEHATAN DIARE

Nama Pasien : ……………………………………………………….....................………………...

Nama Puskesmas : UPTD Puskesmas Sungai Iyu
Tanggal : ……………………………………………………….....................………………...
Data S : ……………………………………………………….....................………………...
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O : ……………………………………………………….....................………………...
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Diagnosa : ……………………………………………………….....................………………...
Tindakan : ……………………………………………………….....................………………...
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Evaluasi S : ……………………………………………………….....................………………...
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O : ……………………………………………………….....................………………...
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P : ……………………………………………………….....................………………...
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Kepala UPTD. Puskesmas Sungai Iyu

RADHIYAH, SKM
Penata Tk. I / Nip. 19710405 199101 2 001
 CATATAN KESEHATAN CAMPAK

Nama Pasien : ……………………………………………………….....................………………...

Nama Puskesmas : UPTD Puskesmas Sungai Iyu
Tanggal : ……………………………………………………….....................………………...
Data S : ……………………………………………………….....................………………...
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O : ……………………………………………………….....................………………...
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Diagnosa : ……………………………………………………….....................………………...
Tindakan : ……………………………………………………….....................………………...
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Evaluasi S : ……………………………………………………….....................………………...
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O : ……………………………………………………….....................………………...
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P : ……………………………………………………….....................………………...
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Kepala UPTD. Puskesmas Sungai Iyu

RADHIYAH, SKM
Penata Tk. I / Nip. 19710405 199101 2 001
 CATATAN KESEHATAN USILA

Nama Pasien : ……………………………………………………….....................………………...

Nama Puskesmas : UPTD Puskesmas Sungai Iyu
Tanggal : ……………………………………………………….....................………………...
Data S : ……………………………………………………….....................………………...
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O : ……………………………………………………….....................………………...
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Diagnosa : ……………………………………………………….....................………………...
Tindakan : ……………………………………………………….....................………………...
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Evaluasi S : ……………………………………………………….....................………………...
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O : ……………………………………………………….....................………………...
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A ::.……………………………………………………….....................………………..
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P : ……………………………………………………….....................………………...
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Kepala UPTD. Puskesmas Sungai Iyu

RADHIYAH, SKM
Penata Tk. I / Nip. 19710405 199101 2 001
 LAPORAN PELAKSANAAN TUGAS

Dasar Penugasan : ……………………………………………………….....................………………...

Tujuan Kunjungan : ……………………………………………………….....................………………...
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Hasil Kunjungan :
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Kesimpulan / Saran Perbaikan :

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Sungai Iyu, ................................ 2018

Pejabat/Petugas Yang Ditemui Pelaksana Kegiatan

……………………………………… Nur Azizah, Am.Keb

Nip. 19760815 200701 2 002
Nip.
 LAPORAN PELAKSANAAN TUGAS

Dasar Penugasan : ……………………………………………………….....................………………...

Tujuan Kunjungan : ……………………………………………………….....................………………...
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Hasil Kunjungan :
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Kesimpulan / Saran Perbaikan :

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Sungai Iyu, ................................ 2018

Pejabat/Petugas Yang Ditemui Pelaksana Kegiatan

……………………………………… _________________________
Nip.
 LAPORAN PELAKSANAAN TUGAS

Dasar Penugasan : ……………………………………………………….....................………………...

Tujuan Kunjungan : ……………………………………………………….....................………………...
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Hasil Kunjungan :
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Kesimpulan / Saran Perbaikan :

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Sungai Iyu, ................................ 2017

Pejabat/Petugas Yang Ditemui Pelaksana Kegiatan

……………………………………… Asrul, AMKG

NIP. 19870422 201003 1 001
Nip.
 LAPORAN PELAKSANAAN TUGAS

Dasar Penugasan : ……………………………………………………….....................………………...

Tujuan Kunjungan : ……………………………………………………….....................………………...
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Hasil Kunjungan :
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Sungai Iyu, ................................ 2017

Pejabat/Petugas Yang Ditemui Pelaksana Kegiatan

……………………………………… ………………………………………
Nip. Nip.
 LAPORAN PELAKSANAAN TUGAS

YANG MELAKUKAN PERJALANAN

Dasar Penugasan : Surat Tugas Nomor : ________/ 800 / 2022
Tujuan : ……………………………………………………….....................………………...
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Hasil Kunjungan / Rapat :

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Kesimpulan / Saran Perbaikan :

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Sungai Iyu, ................................ 2022

Pelapor

1 .........................................
Nip.

2 ...........................................
 Nip.

LAPORAN PELAKSANAAN TUGAS

Dasar Penugasan : ……………………………………………………….....................………………...

Tujuan Kunjungan : ……………………………………………………….....................………………...
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Hasil Kunjungan :
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Kesimpulan / Saran Perbaikan :

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Sungai Iyu, ................................ 2017

Pejabat/Petugas Yang Ditemui Pelaksana Kegiatan

……………………………………… Nur Azizah, Am.Keb

Nip. 19760815 200701 2 002
Nip.
 LAPORAN PELAKSANAAN TUGAS

Dasar Penugasan : ……………………………………………………….....................………………...

Tujuan Kunjungan : ……………………………………………………….....................………………...
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Hasil Kunjungan :
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Sungai Iyu, ................................ 2018

Pejabat/Petugas Yang Ditemui Pelaksana Kegiatan

……………………………………… Satariah, AMK

Nip. NIP. 19820508 201410 2 001