Register Poli Umum Januari 2023

POLI UMUM
Hari/ Tanggal : Senin, 02 Januari 2023

Petugas : Anton, Chaterine, Yani IGD :
Pembiayaan Wkt Playan PEMERIKSAAN Riwayat PTM
No Reg. No BPJS/NIK Nama Dokter Alamat JK Diagnosis Terapi & Tindakan Pekerjaan KIE Riwayat Riwayat Riwayat
s
ur
Riwayat PTM Riwayat Penyakit Riwayat
u
Um
at
Umum BPJS SKTM D P TB BB TD T HR LP Lab Penyakit Perdaraha Pemeriksaan
St
( ≥ 15 th ) Sebelumnya Alergi
Keluarga n IVA/Sadanis
CHF +CAD + ABSES Rujuk POLI BEDAH RS

1 17.731 6310091508620003 Tn. Csondang 60 th dr. Rahma jalan batu benawa L L ✓ CRURIS DHAAN 08.45 08.50 SWASTA ✓ 171 85 109/83 36,9 107
Metformin. Glibenclamid, GDP : 165,

4. 5449 0001922784524 Ny. Sukarni 51 th dr. Rahma JALAN HIDAYAH P L ✓ DM type II + NEUROPATY simvastatin, ibuprofen, vit 08.30 08.45 IRT ✓ 148 39 108/81 36,9 36,9 Chol 238, AU
b comp 3,7
furosemid, amlodipin,
5. 6189 0002520856506 Ny. Intang 57 th dr. Rahma Jalan anang kacil P L ✓ HT Urgency + insomnia ibuprofen, omeprazole, 09.00 09.10 IRT ✓ 147 53 210/117 37 68
alprazolam
Ibuprofen, omeprazole,
6 28.152 0001789410892 Tn. Ruspandi 59 th dr. Rahma Jalan Perum JB L L ✓ Frozen Shoulder eprison 09.10 09.15 WSWASTA ✓ 173 62 144/101 37,1 95
7 22332 0000756592356 An. M. Yusuf 13 th dr. Ferisa Jalan Borneo L L ✓ Post Heacting Dressing 09.00 09.05 Pelajar ✓ 158 45 36,9
8 27.242 6310096903050005 asrianti sari fortuna 17 dr. ferisa jalan perjuangan P L ✓ Dispepsia syndrom lansoprazole, antasida 09.06 09.11 IRT ✓ 147 39 110/94 37 83
Metformin, gliben,
amlodipin, captopril,
9 18.651 0001922783207 Ny. Rusma 50 th dr. Rahma Jalan Rahayu P P ✓ DM type II + HT cetirizine, MP, 09.15 09.30 IRT ✓ 154 50 164/105 36.9 90
Bretametason
Ambroxol, amoxilin, pct,

10 25.875 0001928841783 Ny. Misnawati 21 th dr. Rahma Jalan Perjuangan P L ✓ ISPA 09.30 09.40 IRT ✓ 144 53 117/86 37.2 108
vit c, MP
Ambroxol, ctm, vit c,

11 18.660 0003068420837 An. Ahza 10 th dr. Ferisa Jalan banyuwangi L L ✓ ISPA 09.12 09.18 Pelajar ✓ 126 25 36.8
cefadroxil
glibenclamid, metformin,
DM type II anemia,
12 2297 0002722676128 Ny. Rumayah 55 th dr. Ferisa Jalan Gawe sabumi P L ✓ natrium diclofenac, 09.19 09.25 IRT ✓ 151 48 127/91 36.9 109
hiperlipidemia
hemafort, simvastatin
domperidone, omeprazole,
13 22.814 0001672699432 Tn. Idul Fitri 38 th dr. Rahma Jalan Pasar ampera L L ✓ obs vomit+ispa pct, cotrimoxazole, 09.41 09.48 SWASTA ✓ 163 87 124/85 36.7 84
guafenesin, zink
Glibenclamid, metformin,
14 2.252 0002720672166 Ny. Linda wati 52 th dr. Ferisa jalan sepakat P L ✓ DM type II natrium diclofenac, vit b12 09.28 09.35 IRT ✓ 175 89 128/84 37 89
guafenesin, pct, ctm,

15 26901 0002722574158 Ny. Megawati 49 th dr. Rahma Jalan Lap 5 okt P L ✓ Common cold amoxiciln, vit c 09.50 10.00 IRT ✓ 153 55 110/76 36.9 70
amlodipin, natrium
HT Terkontrol, LBP Post
16 3593 0002767542445 Tn. Basuni 63 th dr. Ferisa Jalan raya sungai kecil L L ✓ diclofenac, 09.40 09.50 sWASTA ✓ 156 53 143/76 37.4 103
KLL
methylprednisolon, vit b12
17 28.153 0002376400476 Ny. Nurul Hidayah 50 th dr. Rahma jalan batu benawa P L ✓ Skoliosis + HT rujuk Sp. S, Amlodipin. 10.00 10.08 IRT ✓ 154 78 157/94 36.9 99
18 27.716 0002722825247 Tn. Rizki novdiandi 30 th dr. Ferisa Jalan nusa indah L B ✓ HT amlodipin, captopril 09.55 10.05 Wswasta ✓ 173 72 171/102 37,1 100
19 22.043 0002496357314 An. Aura Nabila 9 th dr. Rahma Jlan kupang P L ✓ Otitis eksterna ibuprofen, chlorampenicol, 10.10 10.18 IRT ✓ 129 18 36.8
Amlodiipin, cetirizine,
20 27.168 umum Tn. Yohanes 59 th dr. Rahma jalan raya serongga L L ✓ HT grade II + ISPA amoxilin, pehavral 10.05 10.12 PNS ✓ 158 74 161/93 37 79
flutrop, ambroxol, pct, vit

21 28.128 0002722681719 Tn. Edwin Noval 24 th dr. Rahma Jalan Banyuwangi L B ✓ Common cold 10.13 10.20 WSWASTA ✓ 172 69 130/74 36.9 79
c, surat sakit
An. M. Fakhry ambroxol, MP, PCT,

22 23.694 0002824169264 Ramadhan 10 th dr. Rahma Jalan sei dua L L ✓ Common cold Amoxiciln, vit C 10.20 10.29 Pelajar ✓ 129 20
PCT, Ambroxol, ctm, vit. C,

23 7200 0002722810713 An. Anggun Shafira 7 th dr. Ferisa jalan mufakat indah P L ✓ ISPA Cefadroxil 10.05 10.15 Pelajar ✓ 123 35 36,8
24 3213 0001548138857 Ny. Misawati 42 th dr. Rahma jln swarga P L ✓ Otitis eksterna chlorampenicol, pct, MP 10.30 10.40 IRT ✓ 168 50 92/74 37 82
rujuk poli penyakit dalam

25 11.486 0002722561738 Ny. Darmi 47 th dr. Rahma Jalan Pasar Sabtu P L ✓ HT Urgency + vertigo rs marina 10.40 10.50 IRT ✓ 155 48 208/110 37,1 90
26 7426 umum Ny. Saleha 61 th dr. Ferisa jalan borneo P L ✓ HT urgency Amlodipin, furosemid 10.15 10.25 IRT ✓ 149 50 208/124 36,8 92
jalan jembatan ambroxol, amoxiciln, pct,

27 20.924 000309272065 An. Aliv bryan suryadi 6 th dr. Rahma swadaya L L ✓ ISPA cetirizine, antasida 10.50 11.02 tidak bekerja ✓ 117 19 36,8
Ambroxol, flutrop,
28 27317 0003066231802 Tn. Ridwan 22 th dr. Ferisa jalan batu benawa L L ✓ ISPA 10.25 10.33 WSWASTA ✓ 162 53 118/90 37,4 98
amoxilin, pct, pehavral
asam mefenamat,
29 7684 0002722626707 Ny. Syamsiah 30 th dr. Ferisa tungkaran pangeran P L ✓ Konjunctivitas 10.35 10.40 IRT ✓ 153 71 123/84 36,4 82
gentamicin,
RUJUK Poli bedah IGD

30 18.205 6310096003670001 Ny. Hj. Rusidah Hartati 67 th dr. rahma jalan hidayah P L ✓ DM type II + DF RSUD 11.05 11.15 IRT ✓ Pasien tidak dibawa
31 27.356 0002720812105 Ny. Sumiati 23 th dr. Ferisa Tungkaran pangeran P L ✓ F.06.8 Rujuk poli jiwa 10.40 10.50 IRT ✓ 146 52 100/80 36,7 77
rujuk poli penyakit dalam

32 26.037 0002824173009 Tn. Rahman 24 th Dr. rahma jalan bina bakat L L ✓ PPOK (Long covid) 10.50 11.03 WSWASTA ✓ 170 56 145/108 36,8 139
rs marina
guafenesin, amoxiciln, pct,
33 28.156 7371030811020005 Tn. Incet 20 th dr. Rahma jalan kodeco L L ✓ commonn cold vit B 11.03 11.10 Tdk bekeja ✓ 165 63 124/84 36,9 80
34 17.856 0002722637913 Ny. Saderiyah 46 th dr. Rahma JALAN RAHAYU P L ✓ cholelitiasis +HT Rujuk poli penyakit dalam 11.10 11.18 IRT ✓ 159 78 191/107 36,9 78
POLI UMUM
Hari/ Tanggal : Selasa, 3 Januari 2023
Petugas : Imelda,chaterina,jumariah
Pembiayaan
Status
Status
ir
ah
No Register No BPJS NIK No Telpon Nama Dokter Alamat JK Penya Diagnosis Terapi & Tindakan
ur
Kunjungan
lL
Um
Umum BPJS SKTM
kit
Tg
post op fraktur digit III-IV
1 27.292 0002777404331 3305181211680003 0853.8945.3840 Tn.Usman 53 th 12-11-1968 dr.ferisa Jl.Kemakmuran RT.09 , KB L B L ✓ KIE
manus (S)
scabimet, cetirizine, metronidazole,

2 28159 0001928864226 6310094107790156 0822.6224.6169 Ny. Norrina 40 th 01-06-1979 dr.rahma Jl.pasar sabtu Rt.01 / TP P B B ✓ scabies gentamicine, PCT,
amlodipin, glibenclamide, metformin,

3 22249 0001554375104 6310094406550002 0853.4796.3622 Ny.mariam 66th 04-06-1955 dr.ferisa Jl.PLN RT.05 / KB P B L ✓ HT,DM,hiperlipidemia, anemia hemafort, simvastatin
4 28.160 tdk ada 3526105506820005 0852.4550.0728 Ny.Zehriyah 41 th 15-06-1982 dr.ferisa Jl.Aluh kacil RT.09 / TP P B B ✓ myalgia nadic, vit.b12
5 22.802 0001049520734 6573030909450004 tdk ada Tn.Soebandi 77 th 09-09-1945 dr.Rahma Jl.swarga RT.02 / TP L B B ✓ katarak _
6 133 0002745638572 6310061012730003 0823.5096.7386 Tn. Ahmad Effendi 49 th 10-12-1973 dr.ferisa Jl.kodeco Km.2,6 Rt.6 / GA L B B ✓ PPOK Rujuk. Poli paru RSMP
7 22.950 0001548134572 6310095912800002 0852.8071.4399 Ny. Ida wirda 42th 19-12-1980 dr. ferisa JL. perum JB / GA P B B ✓ HT gr.II +CC furocemite, amlodipin, PCT, flutrop,amroxol
0001869537148
8 22.951 6310065509140002 0852.8071.4400 An. Miftahul jannah 8 th 15-09-2014 dr.rahma JL. perum JB / GA L B B ✓ CC Pct, amox, amroxol, CTM, Vit.C
( PKM S4)
9 28.165 tdk ada 3506094405770003 0821.5175.8992 Ny.wiwiwk indriani 45th 04-05-1977 dr.rahma Jl.perum JB /GA P B B ✓ atraisia nadic, antasida, vit BC
10 10.893 0002720671558 6310060508200001 0821.5853.4189 An. Azka faizan 5th.5 bln 05-08-2020 dr.ferisa Jl.Malewa RT.03 / GA L B B ✓ Diare akut tampa dehidrasi dompridone, kotri, zinc, oralit
11 28.163 0002722609102 6310094810080001 0853.4807.3538 An. Yuvita 15 th 08-10-2007 dr.rahma Jl.mawar RT.04 /TP P B B ✓ OMA ibuprofen, amox, dexa, vit.c
cetirizine, hidrocortisone, amlodipin, gliben,

12 24.958 0002722619867 6310090101660013 0813.5141.2956 Tn.saman 62th 01-01-1966 dr.ferisa Jl.pasar ampera RT.18 L B B ✓ dermatitis alergi, DM tp.II HT metformin, nadic
13 24.794 0002722605535 6310090501590002 0821.5464.9991 Tn tafsir 63th 05-01-1959 dr.rahma Jl.Lap.5 okt /DB L B L ✓ HT gr.I amlodipin, nadic, vit.BC
14 28.164 0002849413342 6310094506630009 tdk ada Ny. Hartasiah 59th 05-06-1963 dr. rahma Jl.kodeco RT.01 / GA P B B ✓ HT + hiperurecemia amlodipin, alluprinol, ibuprofen, vit.BC, dexa
15 10.851 tdk ada 6310092012610001 0812.9583.6107 Tn.nurdin 62th 20-12-1961 dr.ferisa Jl.Hidayah RT.07 L B L ✓ HT + vertigo amlodipin, betahistin, antasida, vit BC
16 727 0002471389784 6310066002170001 0815.1746.5481 Ny. Siti khadijah 6th 20-09-2017 dr.rahma Jl.rahayu RT.06 P B B ✓ talasemia+ asma bronchial salbutamol, amroxol, dexa, pct
17 28.162 0002972790336 6302011212730001 0853.2235.5555 Tn.zainudin 49th 12-12-1973 dr.rahma Jl.Borneo RT.13 /Sejatera L B B ✓ Faringitis pct, dexa,amroxol,vit.c
18 15.203 0001922785536 6310091407930010 0823.5000.9343 Tn. Faizal 29th 14-07-1993 dr.ferisa Jl.lap.5 okt /DB L B B ✓ ispa, dispepsia syndrome amroxol, flutup, pct, amox, dexa vit. B
19 28.158 0002722701442 6310091803730002 0821.5015.8905 Tn.Endang supratna 57th 18-03-1973 dr.rahma Jl.usaha bersama RT.05 / GB L B B ✓ hypermetropia ruj. Poli mata RS DHAAN
furocemide, amlodipin, ibu, omeprazole,

20 27.499 0003270682552 6302114107740053 0853.4975.3994 Ny. Siti Patimah 48th 01-07-1974 dr. rahma Jl.Gabuk RT.17 / TP P B L ✓ HT gr.II + LBP kalk,vit.BC
21 17.731 0002722637428 6310091508620003 0821.5900.8890 Tn. C.sondang 60th 15-08-1962 dr.rahma JL.batu benawa RT.09 L B B ✓ CHF + CAD + Abses cruris Ruj.poli bedah RS.DHAAN
22 22.101 0002258233007 6310062305150002 0822.5166.5315 An.arkana 7th 23-05-2015 dr.rahma Jl.transmigrasi Km.03 L B B ✓ obs. Vomit dompridone, pct,kotri,oralit
23 27.040 0002312663141 6310061706690001 0813.4889.9800 Tn. H. Rusliadi 53th 17-06-1969 dr.ferisa TP Rt.04 L B L ✓ HT gr.II + hiperuresemia amlodipin, ibuprofen, alluprinol
Susp.STT dd.kista gaglion +

24 15.838 0002908917944 6310095212820009 0852.4827.8687 Ny.murni 40th 12-12-1982 dr.ferisa Jl.pel.speed Rt.05 P B B ✓ nadic, antasida
dispepsia syndrom
25 7295 0002659955938 6310094107510029 tdk ada Ny. Kamsiah 61th 7/1/1961 dr,rahma Jl.pelabuhan speed RT.05 P B B ✓ DM tp.II + OA metformin, amlodipin, ibu, amox, vit.BC
26 ✓
14,561 0002722678042 6310092011860002 0853.9087.3032 An.Nazwa 6th 7/13/2016 dr.rahma Jl.rahayu RT.06 /DB P B B CC amroxol, pct, vit.C , CTM
Wkt Playan ;l Riwayat PTM
Pekerjaan KIE Riwayat Riwayat Riwayat

Riwayat PTM Riwayat Penyakit Riwayat
D P TB BB TD T HR LP Lab Penyakit Perdaraha Pemeriksaan
( ≥ 15 th ) Sebelumnya Alergi
Keluarga n IVA/Sadanis
08.17 08.27 wiraswasta ✓ 173 78 130/90 36,9 85
08.24 08.34 IRT ✓ 138 51 142/93 37 109
HB: 10,4 GDP:

08.54 09.05 IRT ✓ 143 43 143/81 36,9 80 266 Chol: 251 HT,DM HT,DM HT,DM
08.35 08.45 IRT ✓ 147 71 154/87 36,1 80 HT HT
09.08 09.18 wiraswasta ✓ 151 48 147/81 36,1 79 HT
09.18 09.28 wiraswasta ✓ 158 78 154/92 36,1 81 HT
09.25 09.35 IRT ✓ 155 90 184/122 36,8 85 HT
09.38 09.48 _ ✓ 123 30 37,1
09.50 10.00 IRT ✓ 155 66 140/88 36,7 77 HT
10.01 10.11 _ ✓ 101 13,7 36,9
10.17 10.27 _ ✓ 153 36 108/93 36,7 113
HB: 12,1 GDS:

09.44 09.54 wiraswasta ✓ 157 43 137/81 36,7 68 141 Chols: HT, DM HT,DM HT,DM
185 AU : 4,9
GDS : 122 kols

09.33 09.34 wiraswasta ✓ 153 73 153/99 36.9 68 : 163 HT HT
GDS: 197
09.39 09.49 IRT ✓ 146 60 139/88 36,9 93 kols: 181 AU: HT
7,3
10.48 10.58 wiraswasta ✓ 169 61 150/89 37,1 78
10.43 10.53 _ ✓ 100 14 37
10.04 10.14 wiraswasta ✓ 154 60 107/61 36,7 81
11.02 11.12 wiraswasta ✓ 169 64 104/73 37,1 69
10.56 11.06 wiraswasta ✓ 163 59 134/84 36,7 51
11.11 11.21 IRT ✓ 154 62 182/112 36,7 111 HT HT
09.55 10.05 IRT ✓ 171 85 109/82 36,9 107 HT,Jantung HT,Jantung
12.02 12.12 ✓ 120 22 37
11.04 11.14 ✓ 159 76 172/103 36,7 78 HT HT
11.15. 11.18 IRT ✓ 156 51 115/88 36,7 74
11.19 11.23 IRT ✓ 163 58 157/88 36.7 74 DM,HT DM,HT
✓
11.20 11.25 148 38 37
POLI UMUM
Hari/ Tanggal : Rabu, 04 Januari 2023
Petugas : Imelda putri, melinda,widya,
Pembiayaan
Status
Status
ir
JK kunjunga penyakit
ah
No Register No BPJS NIK No Telpon Nama Dokter Alamat Diagnosis
ur
lL
m
n Umum BPJS SKTM
Tg
1 22.802 0001049520734 6573030909450004 Tidak ada Tn.Soebandi 77 th 9-9-1945 dr.Rahmah Jl.Swarga Rt.20 L B B ✓ Post op katarak
Tn.Andrei
2 28.168 Umum 6471032003760001 082248559600 Enrico,SE 46 th 20-3-1976 dr.Ferisa Perum JBV L B B ✓ HT + ISPA
3 22.861 Internet error 6310092303570001 Tidak ada Ny.Hasnah 65 th 23-1957 dr.Rahmah Pasar ampera RT.4 P B L Internet error HT gr I + Atralgia
Common cold + Chest

4. 3.781 Umum 6310095110630001 082255157536 Ny.Hj.Ainah 59 th 11-10-1963 dr.Rahmah Gg.Padi II P B B ✓
pain
5. 20.759 0002737322829 6310094611660001 082255813617 Ny.Fatmah 56 th 6-11-1966 dr.rahmah RT.7 TP P B L ✓ Susp TB + CHF
DM dg insulin + HT
6 4.440 0000894910814 6310094412700005 082252162001 Ny.Arbayah 52 th 1-12-1971 dr.Ferisa Jl.Kenanga RT.6 TP P B L Internet error urgency + Qabses pedis
Jl.Nusa Indah RT.1

7 14.755 Umum 6310095106680003 082358423237 Ny.Wardiah 54 th 11-6-1968 dr.Ferisa P B L ✓ HT gr II + LBP
Barokah
8 20.322 Internet error/ Umum 6310095108110002 081349432799 An.Ilfa Azkia 11 th 11-8-2011 dr.Rahmah RT.3 Kodeco P B B Internet error Epistaksis
9 25.785 Internet error 6310064804010003 082150482474 Ny.Nor Hasanah 21 th 8-4-2001 Jl.Nusa Indah RT.1 P B B ISPA
dr.Ferisa Internet error
Barokah
10 28.156 Umum 7371030811020005 089523905577 Tn.Incet Taruna 20 th 8-11-2002 dr.Rahmah Jl.Kodeco GA L B B ✓ susp.TB
11 22.344 Internet error 6310065403130002 081251055054 An.Nur Nadilla 6 th 14-3-2016 dr.Rahmah Jl.Insgub RT.11 KB P B B Internet error Susp.Def.Vit D + B
12 27.871 000272263361 6310095006800014 Tidak ada Ny.Normayanti 42 th 10-6-1980 dr.Ferisa RT.6 TP P B B ✓ ISPA
Nn.Alfina Obs febris + sindrom

13 22.599 Internet error 6310065307060006 Tidak ada Damayana 16 th 13-7-2006 dr.Ferisa RT.11 GA P B L Internet error dispepsia
14 28.172 Umum 6310021802990002 081248828183 Tn.M Zainal Fahmi 23 th 18-2-1999 Jl,Perjuangan RT.12 L B B ✓ ISPA
dr.Ferisa TP
Ny.Rabiatul
15 25.695 Umum 6310096906990002 085390621009 Adawiyah 23 th 29-6-1999 dr.Rahmah RT.11 Bersujud P B B ✓ Abses Periauricular
An.M Kasip 5th 4

13 12.950 Internet error 631006200817002 085332059183 20-8-2017 dr.Ferisa RT.1 TP L B B Internet error Common cold + Scabies
Maulana bln
14 12.950 Internet error 6310095008810005 085332059183 Ny.Hasnaba 41 th 10-8-1981 dr.Ferisa RT.1 TP P B B Internet error Scabies
15 28.095 Internet error 6310091609650003 082254618092 Tn.Abu Samah 57 th 16-9-1965 dr.Rahmah RT.8 KB L B B Internet error HT urgency
16 28.095 Internet error 6310092805070005 082254618092 An.M Yusuf 15 th 28-5-2007 dr.Rahmah RT.8 KB L B B Internet error Scabies
17 28.173 Internet error 6310091810000003 081391056922 Tn.M Ridho 22 th 18-10-2000 Jl.Perjuangan RT.15 L B B Internet error ISPA + Sindrom dispepsia
Alfiansyah dr.Ferisa TP
18 28.174 Internet error 6310090102700008 081254415954 Tn.Akhmad Gazali 52 th 1-2-1970 dr.Rahmah RT.14 Bersujud L B B Internet error Lifoma dd nervus
19 27.717 Internet error 63100955047000005 081216674488 Ny.Siti Aisyah 52 th 15-4-1970 dr.Rahmah RT.1 KB P B B Internet error HT gr II + dispepsia
20 19.776 Internet error 6310095702870003 082150479299 Ny.Rasmah 36 th 17-2-1987 dr.Ferisa Jl.Fitrianor P B B Internet error DM dg insulin
21 4.359 Internet error 6310060801160003 082351702290 An.M Rifki 6 th 8-1-2016 Swarga RT.20 TP L B B Internet error Common cold +
dr.Ferisa Susp.Dermatofitosis
19 28.175 Umum 6310091701110005 085654466255 An.Alfianor Fadil 12 th 17-1-2011 dr.Rahmah Rt.2 Sejahtera L B B ✓ Scabies
20 26.682 Internet error 6310093112990003 085337899599 Tn.M Ramadani 23 th 31-12-1999 dr.Ferisa Gg.Nurul Yakin L B B Internet error Common cold
21 23.320 Internet error 6310094910750007 085350450419 Ny.Bariah 48 th 9-10-1975 dr.Rahmah Rt.10 Barokah P B B Internet error HT gr II + Vertigo
22 27.126 0002722703139 6310096107000007 082153543381 Ny.Issabel Tiara 22 th 21-7-2000 dr.Ferisa Rt.5 Bersujud P B B ✓ Cephalgia
Wkt Playan Hasil Pemeriksaan Riwayat PTM
Riwayat
Riwayat
Terapi & Tindakan Pekerjaan KIE Riwayat Riwayat Riwayat Pemeriksa
Penyakit Riwayat
D P TB BB TD T HR LP Lab Penyakit PTM ( merokok Perdaraha an
Keluarga ≥ 15 th ) Sebelumn Alergi
n IVA/Sada
ya
nis
Rujuk poli mata
RSUD DHAAN 08.20 08.30 Wiraswasta ✓ 151 43 147/81 36,1 79 - - - - - - - - -
Amlodipine,
Furosemide, 08.27 08.37 Kary.Swasta ✓ 168 84 179/139 37 93 - - HT HT HT Tidak Tidak ada Tidak ada -
Ambroxol, PCT
Amlodipine,
Furosemide,
Ibuprofen, 08.33 08.40 IRT ✓ 143 46 140/84 36,9 81 - - - - - - - - -
Omeprasole,
Bcomp
Omeprasole, PCT,
Guaefenisin, 08.43 08.50 IRT ✓ 150 40 125/97 37 89 - - - - - - - - -
Bcomp
Rujuk poli paru RS

Marina, Ibuprofen, 08.52 09.00 IRT ✓ 144 48 113/93 37 92 - - - - - - - - -
Bcomp
Rujuk poli
penyakit dalam
RSMP, Dressing,
GDP:3
Amlodipine, 08.40 08.50 IRT ✓ 150 58 208/120 36,9 84 - 00 - - - - - - -
Furosemide,
Asmef,
Metronidasole
Amlodipine, Nadic,
Furosemide, 09.01 09.10 IRT ✓ 146 73 176/116 36,9 92 - - HT HT HT - Tidak ada Tidak ada -
Konsul gigi
PCT, VitC 09.08 09.15 Pelajar ✓ 140 31 - 36,8 - - - - - - - - - -
PCT, Flutrop,
Amox, Pehavral 09.04 09.10 IRT ✓ 155 47 113/82 37 110 - - - - - - - - -
Cek sputum 08.55 09.05 _ ✓ 165 62 108/75 36,9 88 - - - - Tidak ada - Tidak ada Tidak ada -
PCT, Bcomp 09.07 09.12 Pelajar ✓ 124 26 - 37 - - - - - - - - - -
Nadic, Ambroxol, Chol:1

Amox, Dexa, 09.11 09.20 IRT ✓ 144 31 128/85 37 90 - 50 ; - - - - - - -
Bcomp AU:4,9
PCT, Antasida,
Bcomp 09.13 09.20 Pelajar ✓ 164 69 105/79 36,9 79 - - - - - - - - -
PCT< Ambroxol,
Flutrop, Amox,
Domperidone, 09.31 09.40 Wiraswasta ✓ 172 85 125/86 37,6 109 - - HT Asma Asma Ya Tidak ada Tidak ada -
Lansoprasole
Ibuprofen,
Metronidasole, 09.15 09.25 IRT ✓ 156 75 135/109 36,7 116 - - - - - - - - -
Dexa, Antasida
Ambroxol, CTM,
09.43 09.50 Pelajar ✓ 108 15 - 36,7 - - - - - - - - - -
Scabimed salf
CTM, Scabimed IRT ✓ 153 70 130/91 37 74 - - - - - - - - -

salf 09.52 10.00
Furosemide,
Amlodipine, PCT, 09.30 09.40 Wiraswasta ✓ - 69 182/108 36,8 79 - - - HT - - Tidak ada Tidak ada -
Bcomp
Scabimet,
Cetrizine, PCT, 09.21 09.30 Pelajar ✓ 168 73 127/88 36 82 - - - - - - - - -
Amox
PCT, Ambroxol,
Amox, Antasida, 10.03 10.10 Wiraswasta ✓ 169 69 140/100 36,9 122 - - HT - Tidak ada - Tidak ada Tidak ada -
Domperidone
Rujuk poli bedah

RSUD DHAAN 09.40 09.50 Wiraswasta ✓ 159 69 150/100 36,9 75 - - HT HT,Asma HT Ya Tidak ada Tidak ada -
Captopril,
Amlodipine,
Ibuprofen, 09.50 09.57 IRT ✓ 146 47 170/103 37 80 - - - - - - - - -
Omeprasole,
Alprazolam
Rujuk poli
penyakit dalam 09.57 10.05 IRT ✓ 154 51 124/84 36,7 91 - - - - - - - - -
RSUD DHAAN
Ambroxol, CTM, Pelajar ✓ 121 28 - 36,8 - - - - - - - - - -

Ketokonasole 10.10 10.15
Salep 24, Amox,

PCT, Cetrizine 10.00 10.10 Pelajar ✓ 132 33 - 36,8 - - - - - - - - -
Ambroxol, PCT,
10.20 10.30 Swasta ✓ 162 59 126/88 37,1 100 - - - - - - - - -
Pehavral, Flutrop
Captopril,
Amlodipine,
Simvastatin, PCT, 10.49 10.59 IRT ✓ 141 38 161/89 36,9 - - - - - - - - - -
Betahistine,
Allopurinol
ibuprofen, Bcomp IRT ✓ 152 59 106/82 37 94 Hb:12,

10.35 10.45 1
POLI UMUM
Hari/ Tanggal : Kamis, 05 Januari 2022 pospindu : imelda
Petugas : Sumarning,etty,Abdilah,caterina Imunisasi:isti,Jumariah
Pembiayaan
ir
ah
us
No Register No BPJS NIK No Telpon Nama Dokter Alamat JK
ur
lL
at
m
Umum BPJS
St
U
Tg
1 27288 tdk ada 6308050809850002 082155059444 Tn.Hendar 37 th 08-081983 dr Rahmah jl kodeco pal 1 GA L L ✓
2 22332 tdk ada 6314220910090001 082132301854 An.M.yusuf 13 th 09-10-2009 dr.Ferisa jl.borneo rt 14 sejahtera L L ✓ ✓
3 8667 0002071335982 6310095908680001 082352259250 Ny.harliyah 52 th 1-8-1968 dr ferisa jl.cempka putih rt 7 TP P L ✓
Ny.nanik
4 26041 0002722844711 63502147112730001 081259590869 47 th 31-12-1973 dr Ferisa Jl komp.emil rt 8 TP L L ✓
setyowati
5 20239 0002897407225 6310090703500003 tdk ada Tn sarjono 72 th 7-03-1950 dr Rahmah jl anda ujung rt 9 DB L L ✓
6 26792 non aktif 6310090901590002 tdk ada Tn.Syamsudin 64 th 9-01-1959 dr Ferisa Jl.bb Rt 9 gg.blibis DB L L ✓
7 24797 0002586807775 6310064408160001 tdk ada Ny.Elfina nuri yani 52 th 4-8-2016 dr.Ferisa jl BB rt 8 DB P L ✓
8 28176 0001656185872 6302062309880004 08521840440 Tn.Heril Arifin 35 th 23-901988 dr.rahmah Jl perjuangan TP L B ✓
9 1458 0002754280708 6310094908000009 082154008033 Nn.Sinta rahim 22 th 9-08-2000 dr ferisa Jl pasar sabtu rt 1 TP P L ✓
10 23915 0002749459241 6310091902600002 085258091009 Ny.Asniah 62 th 19-02-1960 dr ferisa jl transmigrasi rt 1 0 DB P L ✓
11 10.138 0001677279587 63100931005950003 tdk ada Tn.Rusli hadri 26 th 31-05-1995 dr ferisa jl BB rt 3 DB L L ✓
12 4583 0000124113464 6310094204480002 082153752975 Ny.Tasmiah 74 th 2-4-1948 dr ferisa jl bb rt 8 DB P L ✓
13 573 0002743775458 6310095007700013 tdk ada Ny.khoyul 52 th 10-07-1970 dr Rahmah Jll.BB rt 09/provinsi DB P L ✓
Tn.Andi Abdul
14 11.492 0001103693782 6310095906990006 081251940221 Haris 63 th 19-09-1967 dr ferisa jl transmigrasi rt 9 DB L L ✓
15 18640 00019227842276 6310092760004 081349683887 Tn.Misransyah 46 th 27-2-1976 dr ferisa Jl.Raya btl rt 2 DB L L ✓
16 28163 0002722609102 6310094810080001 0853480737538 An.Yuvita 15 th 08-10-2007 dr Rahmah Jl mawar rt 4 TP P B ✓
17 20181 0002740177225 631009650860001 082159091205 Ny.Hj.sarmiati 62 th 25-08-1960 dr ferisa Jl.swarga rt 20 TP P B ✓
18 7684 0002722626718 631009230210002 085249859866 An.M.Ridho febian 12 th 23-2-2010 dr ferisa Rt 19 TP L L ✓
19 1003 0002720690019 6310095510700001 081250088000 Ny.Hapifah 52 th 15-10-1970 dr ferisa jl senada rt 1 GA P L ✓
20 24013 tdk ada 63100104707780002 082331244411 Ny.Sudarti 45 th 7-7-1978 dr ferisa jl raya Tp rt 13 TP P L ✓
21 983 0002221233309 6310090712920002 083152114323 Tn.Irwin setiawan 29 th 07-12-1992 dr.Ferisa Jl.senada rt 08 GA P L ✓
Nn.Nisa Azzahrah
22 24.165 0001564541245 7371072412030005 - Aziz 17 th 11-06-2004 dr ferisa Jl.perum jb rt 5 GA P L ✓
23 27923 000192799126 tdk ada 085159867655 Ny.Nor Aidah 65 tn 10-5-1961 dr.ferisa Ll.5 okt rt 4 DB P B ✓
embiayaan Wkt Playan ;l Riwayat PTM
Pekerjaa Riwayat Riwayat

Diagnosis Terapi & Tindakan KIE Riwayat
n PTM Penyakit Riwayat
SKTM D P TB BB TD T HR LP Lab Penyakit merokok
( ≥ 15 Sebelumn Alergi
Keluarga th ) ya
GEA tanpa dehidrasi pct,emeprazol,kaolin,gg,zink,sura 08.11 08.27

karyawa ✓ 165 61 120/81 36 HT tdk ada tdk ada
t sakit 2 hari n swasta
Post.hekting ccVL a/r

manus dextra dresing 08.24 08.34 peljar ✓ 158 45 36,8
Post cerebral Rujuk poli syaraf rsmp irt ✓ 151 50 215/121 37 tdk ada HT
infection (169.30) 08.18 08.23
Ht amplodipin,furosemid,vit.b12 08.35 08.45 irt ✓ 163 69 158/91 37 HT
Ambroxol,pct,dexa,vit.,surat wiraswas
cc 08.25 929 ✓ 157 50 158/80 36,9 HT
sakit 2 hari ta
Ambroxol,flutup,salbutamol,amo karyawa blm
Ispa 08.28 08.33 ✓ 155 53 118/78 blm scrining
xillin n sawsta 36.8 scrining
kol:256
hipercholestrolemia na.dik,dexa,simvastatin,vit.bcom 08.21 08.25 irt ✓ 154 55 120/87 36,9 tdk ada tdk ada
mg/dl
pct,ambroxol,atd,vit bcom,surat wiraswas
Obs febris sakit 2 hari 09.00 09.05 ta ✓ 170 77 162/105 36,7 tdk ada tdk ada
tdk
SLE (M32.9) Rujuk poli p.dalam rsmp 09.10 09.15 ✓ 153 52 109/86 36,9 tdk ada tdk ada
bekerja
tdk
169.3 rujuk poli saraf rsmp 09.03 09.08 ✓ 152 60 110/77 36,8 tdk ada tdk ada
bekerja
pct,ambroxol,flutrop,cefadroxil,p tdk
Ispa ehavral 09.24 09.29 bekerja ✓ 166 56 128/83 37
HT Terkontrol Amplodipin,Vit.B12 09.21 09.28 irt ✓ 156 61 152/66 36,9 HT HT
DM tipe II+ metformin,glibenklamid,pct,gg,ct irt ✓ 157 52 127/97 36,7 DM

Hiperkolestrolemia m,hemafort 09.06 09.11
wiraswas
Angina pectoris Rujuk sp.pD rsmp 09.26 09.31 ta ✓ 173 87 130/88 36,8 tdk ada tdk ada
GDP:
HT+DM tipe II + amplodipin,glibenklamid,metfor 172,kol:1
09.06 09.12 swasta ✓ 164 53 148/79 37 DM HT,DM tdk ada
Abses pedis sinistra min,gentamicin zalf 49,Au:5,
1
Post oma cloramphenicol tts 10.11 10.16 tdk ada ✓ 153 36
Amplodipin,furosemid,na.dik,gen
HT+Atralgia+piodera 09.51 09.56 IRT ✓ 155 71 177/101 36,7 tdk ada DM tdk ada
tamin zalf
ISpa ambroxol,pct,cefadroxil,vit,c 09.56 10.01 pelajar ✓ 146 30 36,9
GDS:
HT+GERD Amplodipin, 09.59 10.06 irt ✓ 142 52 157/94 36,8 95,AU: tdk ada
4,2 tdak ada
Amplodipin,Captropil 12,5
HT gr II 10.06 10.12 irt ✓ 163 80 150/106 36,
mg,vit.bcomp
Obs.hemoptoe+sind. wiradsw
Ambroxol,pct,atd,vit.comp 08.10 08.15 ✓ 62 128/95 36,9
dispepsia asta
Ambroxol,cetirizine,pct,amoxilin, tdk
ispa vit.c 10.18 10.23 bekerja ✓ 146 41 108/85 37
pct,ambroxol,cefadroxuil,vit.cbc
isp+LBP 10.24 10.30 irt ✓ 30 122/99 36,9
omp,rujuk poli syaraf rsmp
tdk ada tdk ada
Riwayat
Riwayat Pemeriksa
Perdaraha an
n IVA/Sada
nis
tdk ada
tdk ada
tdk ada
POLI
Hari/ Tanggal : Jumat, 06 Januari 2023
Petugas : Imelda Putri, Jumariah, etty, Isti, Chatrine
i r
ah
No Register No BPJS NIK No Telpon Nama Alamat JK
Tg r
u
lL
Um
Desa Kapung Baru
1 12700 000197494669 6310095510650007 081348407237 Ny. Maimunah 55 th 15-10-1965 P
Rt.13
Jl. Pasar Sabtu desa

2 278156 0002722624784 6310091707800008 081251267686 Tn. Hendri Wibowo 42 th 17-07-1980 Tungkaran pangeran L
RT.01
Jl. Pasar Sabtu desa

3 12950 0001548128384 6310090206700005 083141107130 Tn. Budiansyah 53 th 02-06-1970 Tungkaran pangeran L
RT.11
Ny. Rujainah Binti Jl. Pasar Ampera TP

4 25366 001928858343 6310095012700005 081251290688 52 th 10-12-1970 P
sukri RT.14
Batu Benawa Desa

5 5720 0002722641535 6310095104930002 081348922699 Ny. Khusnul Khotimah 29 th 11-04-1993 P
Bersujud RT. 2
Jl. Pasar Ampera TP

6 4082 0001928863438 6310091406740004 085252435959 Tn. Yusuf ridani 48 th 14-06-1974 L
RT.03
Jl. Banyuwangi RT.7

7 26235 0002720664753 6310094707830009 082351822100 Ny. Muslikah 39 th 07-07-1983 Gunung antasari P
8 25973 0002722705885 6310066203140002 081251940513 an. Annisa F 8 th 22-03-2014 Jl. PT SBT Rt.08 P
9 25973 0002722705852 6310096505760002 081251940513 Ny. Marlina 46 th 25-05-1976 Jl. PT SBT Rt.08 P
Jl. Cendana RT.08 Desa

10 693 0000012263376 6310096504520003 081265216697 Ny. Siti Khadijah 66 th 25-04-1952 P
Bersujud
11 28180 Tidak ada 6308105311700001 088804530897 Ny. Syamsiah 53 th 13-11-1970 Gg. Mawar TP Rt.05 P
12 18791 0002720689323 6310096103640003 081348191967 Ny. Siti Jamilah 58 th 21-03-1964 Jl. Kedondong Rt.7 P
13 28183 0003100260306 6306024102000001 083111641797 Ny. Lasmia Rafiah 22 th 01-02-2000 Batu Benawa RT.09 P
14 24023 0000889553542 6302065004650010 082271644774 Ny. Kartini 57 th 10-04-1965 Jl. Wonorejo RT.11 GA P
15 10138 000177279587 6310093105950003 08215700303 Tn. Rusli Hadri 27 th 31-05-1995 Jl. Batu Benawa Rt.09 L
16 3213 0002770416876 an. Gusti M. azril 6 th 16-11-2016 GG Sewarga RT.20 L

17 25714 0002722742065 6310076209170001 081345216415 an. Miftahul Jannah 5 th 22-09-2017 GB RT.09 P
18 17266 0000894880528 tidak ada 081254217474 Ny. Mariani 57 th 01-05-1965 Jl. Banyuwangi Rt.14 P
Jl. Bina Bersama Rt.1

19 26109 0002722701969 6310092212550001 081350887224 Tn. Sukarta 67 th 22-12-1955 GB L
20 13636 0001554372551 6310097004850008 081250021781 Ny. Dahliana 33 th 30-04-1985 Jl. Trans RT.13 P
Gg. Yudistira Desa

21 13636 0002494505654 6310066206150002 081250021781 an. Noor Halimah 7 th 22-06-2015 P
Kampung Baru
Jl. Raya Serongga Rt.4

22 21373 0003057627172 6310024602700001 081349669078 Ny. Fitria 52 th 06-02-1970 GB P
Jl. Raya Serongga Rt.4

23 21373 0003057627249 6310024212970002 081349669078 an. Gita Nurhikmah 25 th 02-12-1997 P
GB
24 6851 0002659958212 6310064509160002 085389253456 an. Nabila Zaskia Putri 6 th 05-09-2016 Jl. Perjuangan RT.17 P
Jl. Perum bumi

25 28015 0000630361416 3329024104980005 085701974733 Ny. Silvi dewi apriani 24 th 01-04-1998 P
Bersujud Desa Barokah
Jl. Kodeco KM 2 Desa

26 28185 0002220980002 6310096707100004 Tidak ada an. Nareshya S 12 th 27-07-2010 P
Gunung Antasari
Jl. Batu Benawa RT.8

27 4583 000124113464 6310094204480002 082153752975 Ny. Tasmiah 71 th 02-04-1948 P
Desa Bersujud
POLI UMUM
Pembiayaan Wkt Playan
Status
Pendididk
Pekerjaan Dokter kunjunga Status Diagnosis Terapi & Tindakan KIE
an penyakit Umum BPJS SKTM D P
n
HT terkontrol + DM amlodipin, glibenclamid,

IRT dr. Ferisa B B ✓ ✓
Tipe II metformin, ibuprofen, vit B 12 08.15 08.25
Hyosin, Nadic, Kotrimoxazol,

Swasta dr. Ferisa B B ✓ GEA + Ischialgia Zink, Oralit 08.25 08.35 ✓
ambroxol, flutrop, amox,

Wiraswasta dr. Ferisa B B ✓ Ispa + Scabies 08.20 08.30 ✓
pehavral
IRT dr. Ferisa B B ✓ CAD + GERD Rujuk poli penyakit dalam 08.05 08.10 ✓
SMP IRT dr. Rahmah B B ✓ Commond Cold amlodipin, GG, cetirizine, pct 08.30 08.40 ✓
amlodipin, ambroxol, amox,

SMA Wiraswasta dr. Ferisa B B ✓ HT terkontrol + Ispa 09.10 09.20 ✓
vit B com
SD IRT dr. Ferisa B B ✓ Anemia ibuprofen, hemafort 09.05 09.15 ✓
Furunkel a/r nasal + Ibuprofen, cefadroxile,

SD Pelajar dr. Ferisa B B ✓ 08.45 09.55 ✓
stomatitis nistatin drop
HT gr II + Sindrom amlodipin, furosemid,

SD IRT dr. Ferisa B B ✓ Dispepsia allopurinol, Nadic, antasida 08.50 08.55 ✓
amlodipin, ibuprofen,
IRT dr. Ferisa B B ✓ HT gr I + GERD ✓
lansoprazol, antasida, vit B 12 08.35 08.45
metformin, glibenclamide,
furosemide, amlodipin,
MI IRT dr. Rahmah B B ✓ DM Tipe II + HT ✓
ibuprofen, omeprazole, vit B 08.50 09.00
com
Furosemid, amlodipin, nadic,

SD IRT dr. Rahmah B B ✓ HT urgency + LBP ✓
omeprazole, vit B com, kalk 09.10 09.20
Kaolin pectin, domperidon,

SMP IRT dr. Ferisa B B ✓ GEA tanpa dehidrasi 09.23 09.33 ✓
kotrimoxazole, zinc, oralit
Captopril, amlodipine, Vit B,

SD IRT dr. Rahmah B B ✓ Krisis HT antasida 08.54 09.05 ✓
SMA Tidak ada dr. Ferisa B B ✓ Ispa Surat Sakit, Obat masih ada 09.05 09.15 ✓
Belum sek Tidak ada dr. Ferisa B B ✓ Scabies CTM, Scabimite 09.35 09.45 ✓
Belum
sekolah Tidak ada dr. Rahmah B B ✓ Commond Cold pct, ambroxol, ctm, vit C 09.45 09.55 ✓
amlodipin, pct, omeprazole,

SD IRT dr. Rahmah B B ✓ HT gr II + Dispepsia 09.30 09.40 ✓
vit B, simvastatin
SD Wiraswasta dr. Ferisa B B ✓ Post SNH Rujuk Poli Saraf RSMPH 09.30 09.40 ✓
ambroxol, flutrop, antasida,

SMA IRT dr. Ferisa B B ✓ CC + Synd Dispepsia 09.40 09.50 ✓
Vit B com
Belum
Tidak ada dr. Ferisa B B ✓ GEA pct, kotrimoxazole, zinc, oralit 09.40 09.50 ✓
sekolah
SMP IRT dr. Rahmah B B ✓ LBP + OA Genue Rujuk Poli saraf RSMP 09.25 09.35 ✓
SD Tidak ada dr. Rahmah B B ✓ LBP + OA Genue Rujuk poli saraf RSMP 09.25 09.35 ✓
Belum
sekolah Tidak ada dr. Ferisa B B ✓ Epilepsy Rujuk poli anak RSMP 10.00 10.10 ✓
Susp Demam pct, kotrimoxazole, antasida,

SMP IRT dr. Ferisa B B ✓ 09.40 09.50 ✓
Typoid vit B com
ibuprofen, antasida, Hyosine,

SD Tidak ada dr. Rahmah B B ✓ Atralgia 09.40 09.50 ✓
vit B comp
SD IRT dr. Ferisa B B ✓ HT terkontrol Amlodipin, Vit B 12 09.21 09.31 ✓

;l Riwayat PTM
Riwayat
Riwayat Riwayat
Riwayat Riwayat Pemeriksa
PTM Penyakit
TB BB TD T HR LP Lab Penyakit merokok Riwayat Alergi Perdaraha an
( ≥ 15 Sebelumn
Keluarga th ) n IVA/Sada
ya
nis
158 58 125/77 36.9 90 GDP : 286 DM + HT DM + HT
157 52 135/91 36,9 77
165 60 124/76 37 78
141 58 153/102 36,8 74 DM + HT DM + HT
Sea food +
157 65 141/99 36,4 96 HT HT
ayam ras
162 64 154/95 37 101
155 51 123/83 37 94 HB : 9,3 HT, Asma
135 25 36,8
157 62 157/111 36,8 78
155 51 130/81 36,7 69
GDS : 357,
58 162/92 36,8 Chol : 215,
AU : ^,8
158 71 212/124 37 103
151 55 111/92 36,9
79 203/110 37 79
106 59 134/78 37,1 87
118 16 37
102 17 36,9
150 57 150/92 37 93
122/84 37 73
147 56 128/79 37 78
119 20 37
157 63 123/81 36,9 78
157 63 123/81 36,9 78
101 14 37
155 48 110/87 37 124
149 36 36,7
156 61 152/66 36,9 75

POLI
Hari/ Tanggal : Sabtu, 07 Januari 2023
Petugas : Jumariah, Chatrine, Abdilah, Suradi
ir
ah
No Register No BPJS NIK No Telpon Nama Alamat JK
Tg r
u
lL
m
U
Jl. Padaidi Rt.9
1 14,785 tidak ada 6310064205160004 085387660689 An. Maria 6 th 12/05/2016 P
Sejahtera
Jl. Karya Stil Rt.01

2 24,778 0002942659078 6310094305980004 083143865547 Ny. Norma 26 th 03/05/1996 Kampung Baru P
Jl. Raya Kampung baru

3 15,887 0002274667064 6310064712140001 082358935029 A. Vania 8 th 07/12/2014 P
Rt.4 Sejahtera
Jl. Banyuwangi Rt.01

4 28,187 Non faskes 6307045404990001 085849758724 An. Siti Zainab 23 14/04/1999 P
GA
Jl. Pasar Ampera Rt.4

5 6,310 0002722617371 6310094107650106 085349391013 Ny. Salasiah 57 th 01/07/1965 P
TP
Jl. Komp. SMP Kodeco

6 26,983 Non Aktif 6310092408950003 082225008385 Tn. Harliadi 27 th 24/08/1995 L
Rt.11 TP
Jl. Komp. BHP Blok L

7 23,377 0000124102991 6310091007680011 081351074333 Tn. M. Wahyu Yulianto 54 th 10/07/1968 Rt.3 GB L
Jl. Pel. Samudera Rt.2

8 28,175 0003068387976 6310091004680008 085654466523 Tn. Dilah 54 th 10/04/1968 L
Sejahtera
Jl. Pel. Samudera Rt.2

9 28,175 0002119360353 6310095010740010 085654466523 Ny. Halipah Tusadiah 48 th 10/10/1974 Sejahtera P
10 13,974 0002484308485 6310090305690005 085347062501 Tn. Satimin 60 th 31/03/1963 Jl. Banyuwangi Rt.14 TP L
Jl. Cempaka Putih Rt.14

11 14,704 0001928844922 6310092908920005 082350166809 Tn. M. Heryadi 30 th 29/08/1992 L
TP
12 5,192 0000895205799 tidak ada di status 085349541936 Ny. Khairunnisa 63 th 14/06/1959 Jl. Kenanga Rt.6 TP P
An. Destio Bayu Jl. Perum Bumi Raya

13 18,406 0002722603702 3307032112050002 081344650451 17 th 21/12/2005 L
Wicaksono Rt.4 GB
Jl. Kodeco KM 2,5 Rt.12

14 28,189 0002722632715 6310092703400001 082246493755 Tn. Winarto 83 th 27/03/1940 GA L
Jl. Rahmat Ujung Rt.3

15 28,192 tidak ada 6302164705780002 085754858831 Ny. Rasidah 44 th 07/05/1978 P
Kampung Baru
Jl. Banyuwangi/Senada
16 17,587 0001429904158 6310097112580007 081348647943 Ny. Srikonah 64 th 31/12/1958 Rt.7 GA P
0001098738617 Jl. Perum Bumi
17 28,193 (Faskes S4) 6310094401040 08198403073 Nn. Tia Nur Safitri 18 th 04/01/2004 Bersujud Baroqah P
0003089815525
Jl. Batu Benawa
18 28,194 (faskes PKM 63210267001170001 082254220049 An. Rehana Samrotul F 6 th 30/01/2017 P
Maulasam) Bersujud
19 25,784 0002722700496 6310095612010006 087806967919 Ny. Siti Aisyah 21 th 16/12/2001 Jl. Mega Indah rt.6 GB P
20
21
22
23
24
25
26
27
POLI UMUM
Pembiayaan Wkt Playan
Status
Pendididk
Pekerjaan Dokter kunjunga Status Diagnosis Terapi & Tindakan KIE
an penyakit Umum BPJS SKTM D P
n
Masih PCT, Amoxilin, Domperidon,

Pelajar dr. Ferisa B B ✓ Tonsilitis 08.15 08.20 ✓
Sekolah Vit. Bcomp
Ambroxol, Cetirizine,
SMK IRT dr. Ferisa B B ✓ ISPA Amoxilin, Vit.C 08.25 08.35 ✓
Masih
Pelajar dr. Rahmah B B ✓ Commond Cold PCT, Ambroxol, CTM 08.25 08.35 ✓
Sekolah
Amoxilin, Flutrop, Guafenesin,

S1 Staf Pajak dr. Rahmah B B ✓ Commond Cold 08.30 08.40 ✓
PCT
Amlodipin, Metformin,
DM tp.II + HT +
SD IRT dr. Rahmah B B ✓ Simvastatin, Rujuk Poli Mata 08.20 08.30 ✓
Susp. Miopi RSUD DHAAN
Metronidazole, Ibuprofen,
SMK Wiraswasta dr. Rahmah B B ✓ Abses Mandibulla 08.20 08.25 ✓
Dexamethasone, Antasida
S2 PNS dr. Ferisa B B ✓ HT gr.II Amlodipin, Vit. Bcomp 08.30 08.40 ✓
Cetirizine, Scabimid,
SD Wiraswasta dr. Ferisa B B ✓ Scabies + HT 09.00 09.10 ✓
Amlodipin
Scabies + HT Cetirizine, Scabimid,

SD IRT dr. Ferisa B B ✓ Urgency Amlodipin, Furoisemide 09.00 09.10 ✓
HT Urgency + Captopril, Amlodipin, PCT,

STM Wiraswasta dr. Rahmah B B ✓ 08.30 08.40 ✓
Insomnia Vit.Bcomp, Alprazolam
Captopril, PCT, Vit. Bcomp,

SD Swasta dr. Rahmah B B ✓ LBP + Skoliosis + HT 08.51 09.00 ✓
Rujuk Poli Saraf RSMP
tidak ada DM on Terapi Rujuk Poli penyakit Dalam

IRT dr. Ferisa B B ✓ 08.40 08.50 ✓
di status Insulin + HT RSMP
Asam Mefenamat, Cefadroxil,

SMA Pelajar dr. Ferisa B B ✓ Otitis Eksterna 09.56 10.05 ✓
Chloramfenicol ear drop
Rujuk Poli Penyakit Dalam

SD tidak Bekerja dr. Rahmah B B ✓ CHF ec. CAD + CKD RSMP 08.54 09.05 ✓
OMA std Perforasi + Asam Mefenamat,

SD IRT dr. Ferisa B B ✓ ✓
HT gr.I Ciprofloxacin, Vit.C, Amlodipin 10.00 10.10
HT gr.I + PCT, Omeprazole, Captopril

SD IRT dr. Rahmah B B ✓ 12,5, Amlodipine, Allopurinol, 10.10 10.20 ✓
Hiperurisemia
Vit. Bcomp
SMK tidak Bekerja dr. Ferisa B B ✓ Syndrom Dyspepsia Lansoprazole, Antasida 09.45 09.55 ✓
Masih
Pelajar dr. Ferisa B B ✓ Tonsilitis PCT, Amoxilin, Vit.Bcomp 10.35 10.45 ✓
Sekolah
SMK IRT dr. Ferisa B B ✓ Faringitis + Anemia PCT, Amoxilin, Vit.C, Hemafort 10.30 10.40 ✓
✓ 09.40 09.50 ✓
✓ 09.40 09.50 ✓
✓ 09.25 09.35 ✓
✓ 09.25 09.35 ✓
✓ 10.00 10.10 ✓
✓ 09.40 09.50 ✓
✓ 09.40 09.50 ✓
✓ 09.21 09.31 ✓
;l Riwayat PTM
Riwayat
Riwayat Riwayat
PTM Penyakit
TB BB TD T HR LP Lab Penyakit merokok Riwayat Alergi Perdaraha an
( ≥ 15 Sebelumn
ya
nis
114 19 38,4
145,
5 55 120/95 37 94
120 20
154 50 102/80 37 92 Asma
157 58 131/77 36,8 79
165 53 147/96 37 72 HT
HT, HT,
166 77 169/113 36,9 86 Stroke Stroke
157 68 157/87 36,7 76
155 72 190/118 36 72
157 72 197/107 37 60 HT HT
147 57 140/117 36,9 114
156 55 168/86 37 103 GDP: 2019
162 53 130/96 36,7 86
126/75 36,8
155 52 147/99 36,7 89
GDS:152
150 65 154/87 36,7 71 AU:7,9 HT
160 50 128/82 36,9 88
122 20 37,4
160 45 109/67 37,6 109

Petugas : Chatrine, Abdilah, Bertha, Sumarning, Imelda
r
i
ah
No Register No BPJS NIK No Telpon Nama Alamat
Tg r
u
lL
m
U
00027228 63100670 An. Azzahra 30/05/20 Jl. Raya TP
1 26,663 03118 05140003 081253908430 Arinata 8 Th 14 RT.07 / TP
Jl. Lapangan
00022836 63100911 Tn. 11/04/19
2 28,195 43427 04730005 081280045476 Budiyardi 48 Th 73 5 Oktober
RT.05/ DB
63100960 Ny. Umi 20/08/19

3 17,250 - Tidak Ada 49 Th Jl. TP RT.19
08730003 Kalsum 73
Jl.
Pelabuhan
4 7,295 00026599 63100941 Tidak Ada Ny. Kamsiah 61 Th 01/07/19 Speed
55938 07510029 61
RT.05 (Desa
Sejahtera)
Jl.
00019227 63100957 Ny. Devi Ika 17/11/19 Sampurna /
5 26,566 085346045626 28 Th
36442 11930002 Noviana 93 Desa
Barokah
6 22,784 00025186 63100254 082158211554 Ny. Mami 37 Th 14/04/19 Jl. Rahayu

51102 04650001 85 RT.07/ DB
An. Adibah Jl.

00027225 63100643 03/08/20
7 27,372 085391114751 Alifa 7 Th Pelabuhan
50815 08150005 15
Hibatillah Speed
Tn. Jl.
00027220 63100910 10/11/19
8 27,642 088242108363 Muhammad 50 Th Perjuangan
78991 11720005 Nur 72 RT.17/TP
00019297 63050843 Ny. 20/08/19 Jl. Perum JB

9 28,196 085338500151 24 Th
64338 05990002 Norhikmah 98 RT.05
63020616 Tn. Anwar 16/10/19 Jl. Mega

10 26,890 - 082352122435 61 Th Indah rt.6
10600001 Syadat 60 GB
Jl. Borneo
00007565 63242209 An. M. 09/10/20
11 22,332 082132301854 13 Th RT.14 / Ds.
92356 10090001 Yusuf 09
Sejahtera
Jl. Lapangan
00008959 63100912 01/12/19
12 15,252
07720005 Tidak Ada
Tn. Asruni 51 Th 71 5 Oktober
84209
RT.06/ DB
Jl.
63060413 Tn. Ahmad 13/05/19
13 27,950 - 081253484784 24 Th Mulawarma
05980001 Baihaqi 98
n RT.15 /TP
Jl. Raya
14 27,717 - 63100955 081216174488 Ny. Siti 52 Th 15/04/19 Batulicin
04700005 Aisyah 70
RT.01 /KB
Jl. Pel.
63100989 Tn. M. 09/06/19 Speed
15 7,885 tidak ada 085390828406 45 Th
06740006 Taher 74 RT.05 / Ds.
Sejahtera
Jl. Pelita
00001224 63020645 Ny. Noer 05/01/19 Permai
16 23,566 80357 01750004 085251454388 Hasanah 44 Th 75 Insgub , Ds.
KB
Jl. Mangga
00030719 63100965 25/11/19
17 15,893 081349602988 Ny. Irliani 51 Th II RT.14 /
21275 11710003 71
DB
An. Alzena
00018946 63100657 17/06/20 Jl.
18 24,185 10204
05130001 082150766667
Ayesha 7 Th 13 Mulawarma
Hawari n RT.16 /TP
Jl. Raya
19 20,546 00027227 63100952 082158924552 Ny. Puji 48 Th 12/10/19 SERONGGA
23536 10740006 Tuaningsih 74 KM.05
RT.04/ GB
Jl. Raya
00027227 63100621 An. Septian 21/09/20 SERONGGA
20 20,546 082158924552 6 Th
23569 09160001 Risky 16 KM.05
RT.04/ GB
Jl. Raya
00027227 63100958 Ny. 18/04/19 Serongga
21 26,314 085332060895 67 Th
23931 04550002 Wartinah 55 KM.07
RT.05/ GB
00017949 64090170 Tn. Abdul 10/01/19 Jl. Senada

22 26,221 51865
11580002 081250960422 Murad
72 Th 50
RT.03 /GA
00079288 63100966 Ny. Siti 26/03/19 Jl. Pasar

23 5,034
63550001 081395005596 Hadijah
59 Th 63 Sabtu RT.02
61853
/TP
00008898 63020149 09/07/19 Jl. Pel.

24 28,200 - Ny. Derita 37 Th
54456 07850001 85 Speed
Jl. Lapangan
25 18,063 00026564 63100644 082256068312 An. Sa'adah 8 Th 04/05/20 5 Oktober
06878 05150004 Rahmawati 15
RT.05 / DB
00008942 63100941 Ny. 01/07/19 Jl. BB

26 16,044 - 35 Th
57796 07870206 Heldawati 87 RT.09/ DB
00010797 63100941 01/07/19 Jl. Kodeco

27 1,718 081348590395 Ny. UMI 56 Th KM. I
43331 07660078 66 RT.02 /GA
Gg. Bunga
63100905 An. M. 05/10/20 RT.07 /
28 28,202 - 18030007 089689119689 Firmansyah 19 Th 03 Kupang
Berkah
Jl. Raya
Ny. Mariya Transmigras
63100947 07/05/19
29 28,204 - 089560605956 Mukti 25 Th i Dusun II
05980004 Hasma 98 RT.12 /
Mantewe
Jl. Perum
00016726 63021906 06/11/19
30 15,346 081251255727 Tn. Suyanto 27 Th PT. SMART/
99307 11950001 95
TP
Jl. Pasar
00027226 63100910 10-05-
31 25,731 085348860943 Tn. Cangga 74 Th Ampera
38655 05580005 1958
RT.18
00033059 63020611 Tn. M. 11/09/20 Jl. Kodeco
32 4,302 45968 09030001 082256034518 Alfian 19 Th 03 RT.04 /GA
63100954 Nn. Alda 14/04/20 Jl. Kodeco

33 21,292 -
04030004 081349351085 Arti . S
19 Th 03
KM.2,5 /GA
34 17,707 00019712 63100667 Ny. Anawati 43 Th 27/02/19 Jl. GB RT.07

96763 02790001 79
POLI UMUM
Pembiayaan
Status
Pendidik Status
JK Pekerjaan Dokter kunjun Diagnosis
an penyakit Umum BPJS SKTM
gan
Diare Akut dd.

Masih
P Sekolah Pelajar dr. Ferisa B B ✓ Susp. Demam
Tyfoid
Wiraswas dr. Ttb On

L S1 ta B B ✓ Treatment
Rahmah
P SD IRT dr. B B ✓ Athralgia

Rahmah
P SD IRT dr. L L ✓ DM Type II +

Rahmah OA Genue
DIII
DM Type II dg
P Kebidan Bidan dr. Ferisa B L ✓
Insulin, LBP
an
P SD IRT dr. B L ✓ Skizofrenia

Rahmah
ISPA +
p SD Pelajar dr. Ferisa B B ✓ Dispepsia
Syndrom
Wiraswas
L TK dr. Ferisa B L ✓ Enduftalmitis
ta
P SMK IRT dr. Ferisa B B ✓ Obs Cephalgia
Wiraswas
L SMP dr. Ferisa B L ✓ HT GR II
ta
Post Hecting ec
L SD Pelajar dr. Ferisa L L ✓
VL a/r Manus
Wiraswas HT Gr. I
L SD dr. Ferisa B L ✓
ta Terkontrol
Wiraswas
L SMP dr. Ferisa B B ✓ ISPA
ta
HT, Dispepsia
P SMA IRT dr. Ferisa L L ✓ Syndrome,
Faringitis
L SLTP Swasta dr. Ferisa B B ✓ KIR
HT Gr. II +
P - Guru dr. Ferisa B B ✓ Insomnia
P SMP IRT dr. Ferisa B L ✓ HT Urgency
Tonsilitis + Obs.
P SD Pelajar dr. Ferisa B B ✓ Vomitus +
Susp. GEA
P SMK IRT dr. Ferisa B B ✓ Athralgia
Syndrome
L SD Pelajar dr. Ferisa B B ✓ Dispepsia +
Miliaria
HT terkontrol +
P SD IRT dr. Ferisa B L ✓ Obs
AbdominalPain
Susp. Ulkus
Wiraswas
L SD dr. Ferisa B B ✓ Peptik + Susp.
ta
BPH + HT
DM dengan
Terapi Insulin +
P SD IRT dr. Ferisa B B ✓
HT +
Haemorroid
P SD IRT dr. Ferisa B B ✓ OMA
ISPA + Suspek
P SD Pelajar dr. Ferisa B B ✓ Demam
Typhoid
P - IRT dr. Ferisa B B ✓ Obs. Cephalgia
DM Type II ON
P SMP IRT dr. Ferisa B L ✓
Insulin
Belum Hidradenitis
L SMA Bekerja dr. Ferisa B B ✓ Supurativa
P S1 Guru dr. Ferisa B B ✓ Susp. ISK
Konjungtivitis
L SMK Swasta dr. Ferisa B B ✓
OD
Wiraswas
L SMU dr. Ferisa B B ✓ Vertigo
ta
L SMP - dr. Ferisa B B ✓ Post Hecting
Mahasisw Susp. STT

P SMA dr. Ferisa B B ✓
a (021.9)
P SMA IRT dr. B B ✓ Dispepsia

Rahmah
Wkt Playan ;l
Terapi & Riwayat

KIE
Tindakan D P TB BB TD T HR LP Lab Penyakit
Keluarga
PCT,
Typhoid
Domperidone, 08.23 08.28 ✓ 120 26 - 37,1 88 Tongue (+)
Kotri, Zinc
GDS: 151
HIV: NR
OAT Kat I (1x3 TCM: High
Tab) Pagi 08.25 08.35 ✓ 165 47 112/95 36,8 106 Detected
(27/12/202
2)
Nadic,
Dexamethasone,
✓ 155 73 133/85 36,9 78
Omeprazole, Vit 08.35 08.40
Bcomplek
Methformin,
Amlodipin, Nadic,
Omeprazole, 08.40 08.45 ✓ 163 57 153/99 36,8 75 Asma
Simvastatin, Vit
BC
Rujuk Poli
penyakit Dalam 08.30 08.35 ✓ 151 78 120/84 36,8 89
RSMP
Rujuk Poli Jiwa

08.50 08.55 ✓ 156 46 131/92 36,9 82 HT
RSUD DHAAN
PCT, Ambroxol,
CTM, Amoxilin, 08.43 08.48 ✓ 123 20 - 36,9 88
Antasida
Rujuk Poli Mata
09.05 09.10 ✓ 167 71 154/96 36,9 57
RSUD DHAAN
Ibuprofen,
09.20 09.25 ✓ 152 49 129/97 37 116
Antasida, Vit B1
Amlodipin,
Furosemid, 09.15 09.20 ✓ 162 72 160/96 37 77
Ibuprofen
Dressing,
08.50 08.57 ✓ 158 44 - 37 92
Gentamicin Zalf
Amlodipin 09.30 09.35 ✓ 160 57 127/80 37.1 60 GDP: 2019
Ambroxol, CTM,
PCT, Amoxilin, 09.40 09.45 ✓ 165 50 134/83 36,9 64
Vit.C
Captropil,
Faring
Ibuprofen, ✓ 146 48 137/88 37 76 Hiperemesi
Amoxilin, Lanso, 09.45 09.50
s
Antacid, VitBC
Visus: (-)
Surat Keterangan 200 BW:( -)
Sehat, Tidak BW, 09.55 10.00 ✓ 154 77 128/87 37 88
Golongan
Sehat
Darah : O
Amlodipin,
Furosemid, Lanso,
Antasida, 10.06 10.11 ✓ 148 56 162/119 37 96
Ibuprofen,
Alprazolam
Amlodipin,
GDS: 131
Furosemid, 09.45 09.50 ✓ 152 48 183/104 37 116
AU: 4,4
Ibuprofen, VitBC
PCT, Domperidon,
Amoxilin, Antasid, 10.05 10.10 ✓ 126 23 37,4 88
Zinc
Nadic, Vit B1 ✓ 153 70 154/99 36,9 75 GDP: 97
10.15 10.20 AU: 4,1
Antasida, PCT,
CTM, 10.25 10.30 ✓ 111 18 37 92
Hidrocortison
Amlodipin, CTM,
Hyoscine,
10.10 10.15 ✓ 144 51 115/72 36,8 109
Antasida,
Scabimite, PCT
Rujuk Poli
penyakit Dalam 09.45 09.50 ✓ 165 73 152/85 36,9 66
RSMP
Rujuk Poli
Penyakit Dalam
RSMP, Amlodipin, 09.30 09.35 ✓ 150 69 155/82 36,9 79
Furosemid,
Antihaemorroid
Asam
Mefenamat,
10.30 10.35 ✓ 150 64 145/111 37,2 115
Cefadroxil,
Chloramphenicol
PCT, Ambroxol,
CTM, ✓ 135 17 37,4 92
Domperidon, 10.35 09.50
Kotrimoxazol
AU: 4,9 Hb:

Ibuprofen , Vit B1 10.10 10.15 ✓ 156 70 120/81 37 77
12,3
Rujuk Sp. PD
10.30 10.35 ✓ 162 65 138/88 36,9 102
RSMP
Asam
Mefenamat,
Cefadroxil, 10.40 10.45 ✓ 169 124 162/133 36,7 127
Gentamicin Zalf
Asam
Mefenamat, 11.00 11.06 ✓ 154 45 95/66 37 86
Ciprofloxacin
Chloramfenicol
11.07 11.12 ✓ 166 71 145/98 37 92
Eye Drop
Betahistin,
10.55 11.00 ✓ 157 58 110/71 36,9 75
Antasida, Vit B1
Dressing, Up.
Hecting 11.55 12.00 ✓ 168 55 147/76 36,9 83
Rujuk Poli Bedah

11.40 11.45 ✓ 151 58 96/72 36,9 78
RSMP
Betahistin, PCT.
Omeprazole, 11.50 11.55 ✓ 67 122/78 36,6 76
Pehavral
Riwayat PTM
Riwayat
Riwayat Riwayat
Riwayat Pemeriksa
PTM Penyakit Riwayat
merokok Perdaraha an
th ) n IVA/Sada
ya
nis
HT, HT,
Stroke Stroke
HT HT
HT
Hari/ Tanggal : Selasa, 10 Januari 2023
Petugas : Sumarning, Bertha,Caterina
ir
ah
No Register No BPJS NIK No Telpon Nama
ur
lL
m
U
Tg
631009420271
1 18,651 0001922783207 08521634125 Ny.Rusmah 50 th 2-2-1971
0001
631009020358 02-03-
2 2,602 0001548130375 0002 081258412512 Tn.Samson 60 th 1958
3 25,428 0001922697011 631009260757 081280734770 Tn.Tamrin 63 th 26-7-1957

0001
631009150856 085393835433 Tn.Suriansyah

4 21,127 0001891170505 65 th 5-8-1956
0003
630206640462 24-04-
5 27,843 0001929135014 08225013626 NY.Rarbayah 60 th
0001 1962
00019222277788 631009120368
6 25,117 6 085362932378 Tn.Jainadi 51 th 12-3-1968
0006
110213260205
7 12,776 0000214014767 082153040620 An.Alfred 17 th 26-2-2005
00003
630206560983 085247076198 Ny.Jumiati

8 26,370 0003062833929 37 th 16-9-1983
0006
9 17,731 0002722637428 631009150862 082159008890 Tn.C.sondang 56 Th 15-8-1962
0003
631009220799 Tn.Dwi 22-07-

10 28,206 0002722641142 081283446748 23 th
005 Abdurrahman 1999
631009550901 Ny. Siska Maya 04-04-

11 27,714 - 088704080426 22 Th
0001 Sari 2000
0001548077635 631009630797 Ny. Fitria 23-07-

12 28,031 (BTL I) 0011 085349454005 Maulida 25 Th 1997
000928863833 631009071094 081350011866 Tn. Heri 07-10-

13 27,982 28 Th
(Klinik Simpang) 0002 Setiawan 1994
631009110473 11/04/19
14 28,195 0002283643427 081280045476 Tn. Budiyardi 48 Th
0005 73
15 22,330 0001928856857 631009450764 085248278655 Ny. Lili Yuliana 57 Th 05-07-

0010 1964
631009040281 04-02-
16 23,873 0000124102776 085350475000 Tn. Triyono 41 Th
0003 1981
01-12-
17 10,489 0000894710981 - - Ny. Makiyah 40 Th 1973
631009410707 Nn. Siti 18/08/20

18 6,310 0002722571875 085349391013 17 Th 05
0098 Fatimah
19 27,560 0002722631207 631009500769 - Ny. Rusdiah 53 Th 10-07-

0007 1969
631009020272 081348737376 Tn. Edi

20 28,208 0002658284537 50 Th 02-02-
0005 Sugianto 1972
631009480873 08/08/19
21 26,901 0002722574158 0824094223.. Ny. Megawati 49 Th
0008 73
631009521284 12-12-
22 26,820 0002722843967 082153238871 Ny. Suarni 38 Th
0010 1984
POLI UMUM
Pembiayaan
Status Status
Pendidi
r
hi
Alamat JK Pekerjaan Dokter kunjun penya Diagnosis

ur
La
kan
m
gan kit Umum BPJS SKTM

U
l
Tg
DM tipe
Jl rahayu rt 7
P SD irt dr.Ferisa B L ✓ II,HT,Derma
DB
titis
Jl.transmigrasi
DM tipe
rt 11 L SD swasta dr rahmah B L ✓ II+dispepsia
sarigadung
Transmigrasi rt L SMA wiraswast B B ✓ CAD+HT

1 bersujud a dr rahmah
Lap.5 okt.rt 5b
SLTA wiraswast dr DM tipe II dg
L B B ✓
DB a Rahmah insulin +CKD
Jl.mutiara
P SD irt dr rahmah B B ✓ OA genu
indah rt 2 Gb
Gg sejahtrera rt
L SMA wirswasta dr rahmah B B ✓ cc
13 sejahtera
jl kaca piring gg tdk

L SMP B B ✓ cc
pinang rt 7 GA bekerja dr rahmah
Jlmmawar rt 8 I20
P SLTA irt dr rahmah B B ✓
GA skizofrenia
Jl.batu benawa L SLTP wiraswast dr B B ✓ CHF
rt 9 Bersujud a Rahmah ec.CAD+HT
Jl gunung dispepsia
L D3 tdk ada dr rahmah B B ✓
antasari rt 2 GA sind.
Jl. Banyuwangi
P SMK IRT dr rahmah B L ✓ Susp. ISK
RT.01 /GA
Jl. Perum Ar-

Raudah 3 / Commond
Desa P SMA IRT dr rahmah B B ✓ Cold
Sarigadung
Jl. Batu Benawa

L SMA Swasta dr rahmah B B ✓ Konsultasi
RT.12/ DB
Jl. Lapangan 5
Wiraswas
Oktober L S1 dr rahmah L L ✓ Konsultasi
RT.05 / DB ta
Jl. Kedondong Katarak

P SD IRT dr rahmah B B ✓
RT.07/ TP Imature + HT
Gg.
Wira
Hidayatullah L D3 dr rahmah L L ✓ Pterigium
RT.10 / DB swata
Jl. Hidayah DM Type II +

RT.13 /TP P SD IRT dr rahmah B B ✓ HT Gr. II
Jl. Pasar Susp.

Wira
Ampera RT.04/ P SD B B ✓ Costochendr
Swasta dr rahmah
TP itis
Jl. TP RT.09 P SLTA IRT dr rahmah B B ✓ Cephalgia
Jl. Cendrawasih CHF NYHA III

L SD SMA dr rahmah B B ✓
RT.11 / GA + CAD
Jl. Lapangan 5
Oktober . RT.05 P SD IRT dr rahmah L B ✓ Katarak
/DB
Jl. TP RT.19 P SD IRT dr rahmah B B ✓ Cephalgia

Wkt Playan ;l
Terapi &
KIE
Tindakan D P TB BB TD T HR LP Lab
metfotmin,glib
enklamid,ampl
✓ 154 52 143/87 36,9 80
odipin,cetirizin, 09.15 09.20
betametazonen
metformin,glib
enklamid,pct,o
meprazole,vit.b 09.16 09.20 ✓ 167 70 134/83 36,8 73
com
Rujuk poli
penyakit dalam 09.21 09.25 ✓ 165 67 157/85 37,2 85
rsmp
Rujuk poli sp.D

09.25 929 ✓ 160 70 190/94 36,9 86
rsmp
tdk di
Na.dik,omepraz
ukur px
ole,amplodipin, 09.30 09.35 ✓ 48 150/102 36,9 100
sakit
kalk
lutut
pct,amoxillin,a
mbroxol,ctm,vi 09.45 09.50 ✓ 164 54 151/94 36,9 67
t.c
pct,amoxilil,gg,
09.00 09.04 ✓ 168 62 127/92 36,9 90
flutrop,vit.c
Rujuk poli jiwa

08.20 08.24 ✓ 141 65 126/90 36,8 78
rsud DHAAN
Rujuk polisp.PD
rsmp 09.02 09.06 ✓ 171 84 120/79 36,9 85
iso.o+111.9
pct,omeprazole
,vit.bcom,surat 08.40 08.45 ✓ 166 82 136/82 36,9 69
sakit
Ciprofloxacin,
Asam
10.20 10.25 ✓ 158 44 - 37 92
Mefenamat,
Antasida
PCT,
Dexametason,
Vit.C,
Omeprazole, 09.45 09.50 ✓ 149 80 112/96 36,8 97
Surat Sakit 1
Hari
KIE 08.15 08.25 ✓ 168 60 146/88 37 83
- 09.30 09.35 ✓ 165 47 116/90 37,1 113
Rujuk Poli Mata

09.15 09.20 ✓ 153 69 158/91 37 63
RS DHAAN
Rujuk Poli Mata

11.15 11.20 ✓ 158 47 145/92 37 65
RS DHAAN
Methformin,
Furosemid,
Amlodipin, 11.20 11.25 ✓ 165 90 166/99 37 89
Aspilet, PCT,
Omeprazole
Nadic, MPH,
11.05 11.10 ✓ - 48 121/89 37,1 92
Vit. BC
Ibuprofen,
Omeprazole, 09.40 09.45 ✓ 146 69 114/80 36,8 80
Vit.BC
Rujuk Poli
Penyakit Dalam 10.05 10.10 ✓ 165 101 163/120 36,5 87
RSMP
Rujuk Poli Mata
11.45 11.50 ✓ 153 51 135/71 36,9 79
RS DHAAN
PCT,
Omeprazole, 11.55 12.00 ✓ 145 62 116/82 36,7 77
Pehavral
Riwayat PTM
Riwayat
Riwayat Riwayat
Penyakit merokok Perdaraha an
ya
nis
stroke HT,DM
DM(adek) DM
HT HT
tdk ada DM
blm
blm scrining
scrining
tdk ada tdk ada
DM,stroke tdk ada

tdk ada DM,Strok
e
tdk ada tdk ada
HT
Petugas : Sumarning, Bertha,Caterina
No
ir
ah
No Register No BPJS NIK Nama Alamat JK
ur
Telpon
lL
m
U
Tg
Jl. Simpang
00027226 63100945 05-06-
1 16,790 - Ny. Yatmi 58 Th Sari RT.02 / P
22973 06650005 1965
TP
Jl.
63100924 08539079 Tn. Deny 24-01- Mulawarm
2 25,592 - 01990003 1180 Cahyono 23 Th 1999 an RT.16/ L
TP
Tn.
3 28,211 00018346 63100903 08134541 Muhammad 29 Th 03-03- Jl. BB L
41786 03930008 4243 Agus 1993 rt.09 /DB
Jl. Poros
63100944 08539383 Lapangan 5
4 10,947 - Ny. Faridah 35 Th - P
02870006 5433 Oktober
RT.05 /DB
Jl. Perum
00019227 63100927 08538874 Nn. Nur Fitri 27-12- Plajau
5 27,548 20 Th P
82217 12010004 2060 Natalia Sidik 2001 Indah RT.07
/DB
00027226 63100641 08134868 An. Luthfia 01-12- Jl. Pelita

6 19,996 8 Th L
08707 1240001 3228 Nazhifa 2014 RT.10 / KB
Jl.
Lapangan 5
00012408 63100945 08213592 05-06-
7 7,124 Ny. Saniati 70 Th 1952 Oktober P
4912 06520002 9361
Gg.
Delima / DB
An. Mozes Jl. Serongga
00027512 63020624 08238953 24-01- Komlek
8 24,899 Vallentino 12 Th L
96354 01080002 00.. 2008 Griya Raya
Putra
Permai/ GB
9 19,808 00030684 63100649 08215900 Rismei Arianti 11 Th 09-05- Jl. Rahayu P

01689 05110001 8890 Nasa'i 2011 RT.09 / DB
00026569 63100901 08575458 01-01- Jl.

10 4,908 Tn. Tamino 67 Th Banyuwang L
74745 01550004 3860 1955 i RT.14 / TP
Jl.
00012454 31009680 08134973 28-08-
11 3,363 Ny. Nurhayati 60 Th 1962 Kedondong P
02745 8620001 9089
RT.07/ TP
Jl. Pasar
00028869 63100968 08534853 28-12-
12 6,307 Ny. Mariani 55 Th 1977 Ampera P
91841 12770003 2371
RT.04/ TP
Jl. Raya
63100610 08386272 Tn. Wahyuni 10-09-
13 26,960 - 09850004 6923 Abidin 36 Th 1985 Serongga L
RT. 02/ GB
Jl.
00016772 63010714 08225170 Ny. Hasma
14 26,658 34 Th 14-11- Banyuwang P
78788 11880002 0705 1988
i RT.14 / GA
00078201 63100958 08134716 Ny.

39 Th 18-11-
Jl. DB
15 11,244 P
90881 11820006 7525 Nofitripena 1983 RT.12/ DB
00027226 63100921 08125180 Tn. M. Arif
53 Th 21-04-
Jl. TP
16 16,989 L
31218 04630006 953 1963 RT.19/ TP
17 4,648 00027436 63100942 - Ny. Arbayah 68 Th 02-03- Jl. Senada P

68303 03540001 1954 RT.08 / GA
Jl. Raya
00029111 63100601 08575400 01-05- Serongga
18 28,065 An. M. Rizky 7 Th L
73524 05160005 5634 2016 KM.3,5
RT.01 / GB
Jl. Mangga
00030719 63100965 08134960 26-11-
19 15,893 Ny. Irliani 51 Th II RT.14 / P
21275 11710003 2988 1971 DB
Jl. Pasar
00028967 63100909 08215311 09-03-
20 20,392 Tn. Mahmud 60 Th Ampera L
75482 03820003 5069 1962
RT.02 / TP
Tn.
00022209 63100925 08135144 25-05- Jl. Swarga I
21 18,001 Muhammad 49 Th L
822468 05730007 1644 1973 RT.01/ TP
Toyib
00020921 18020647 08238783 Ny. Eli 07-05- Perum JB

22 25,569 38 Th P
57177 05830001 4078 Ratnawati 1983 RT.04/ GA
Jl.
00027225 63100657 08539283 An. Aisyaa 17-07-
23 11,614 6748 07150002 2525 Salsabila T 7 Th 2015 Perjuangan P
RT.14/TP
Tn. Jhon Jl.

00029273 63020603 08520000 05-09- Sempurna /
24 28,027 Freedy 25 Th 1997 L
23664 09970003 0131 Ds.
Panata. S
Sejahtera
Jl.
08520000 Ny. Hadiana 07-03- Sempurna /
25 28,027 - - 23 Th P
0131 Aulia 1999 Ds.
Sejahtera
00027725 63100950 08934926 Nn. Novi 10-02- Jl. Kodeco

26 27,471 20 Th P
77348 02020012 9668 Yanti 2002 RT.06 / GA
Jl.
Transmigra
00019227 63100909 08235250 Tn. M. Hasbi 09-12-
27 28,212 46 Th si RT.02 / L
62823 12760001 1094 Hairullah 1976
Desa
Barokah
Jl. Nusa
00019227 63100950 08524848 Nt. Siti 10-02- indah
28 6,365 50 Th RT.01/ P
48254 02720008 5095 Fatimah 1972
Desa
Barokah
Jl.
00010657 63101029 08782770 29-09- Transmigra
29 28,213 Tn. M. Lestari 21 Th L
61043 09010002 2548 2001 si RT.11 /
Dukuh Rejo
Jl. Pasar
Minggu
00022281 16-03-
30 13,537 - - Ny. Sanainah 57 Th RT.02/ P
18041 1965 Desa
Sejahtera
31 23,031 00027226 63100954 08218891 Ny. 63 Th 14-07- Jl. Cempaka P

09214 0790008 0907 Nirmawati 1959 Putih RT.07
Jl.
00027228 63100959 08134946 Ny. Muna 19-03- Hidayatulla
32 26,206 49 Th 1973 P
44531 03730001 0455 Wati Murni h RT.10 /
DB
POLI UMUM
Pembiayaan
Status Status
Pendidika Pekerjaa Terapi &
Dokter kunjunga penyak Diagnosis
n n n it Umum BPJS SKTM Tindakan
Methformin,
DM Type II + Amlodipin, PCT,
SD IRT dr rahmah B B ✓ HT +
Vit B, Gentamicin
Konjungtivitis
Eye Drop
Tidak dr. Paratusin,

SMK Ada B B ✓ ISPA Amoxilin, Vit BC
Ferisha
Ibuprofen,
Amoxilin,
S1 Karyawa B B ✓ Tonsilitis Akut Dexamethasone,
n Swasta dr rahmah Antasida, Surat
Sakit 1 Hr
PCT, Hyoscine,
dr Kolic
- IRT B B ✓ Omeprazole,
Rahmah Abdomen VitBC
OAT TB Fase
Tidak TB Paru + Lanjutan 1 x 3
SMA dr. B L ✓ Tab. Masker TB,
Ada Ferisha Insomnia
Vit BC,
Alprazolam
dr. Ambroxol, CTM,

SD Pelajar B L ✓ ISPA
Ferisha Amoxilin, PCT
Amlodipin,
dr. Sindrom
D2 IRT B B ✓ Ranitidin,
Ferisha Dispepsia
Antacida, VITBC
PCT, Ambroxol,
dr. ISPA + Flutrop, Amoxilin,
SD Pelajar B B ✓
Ferisha Konjungtivitis Gentamicin Eye
Drop
PCT, Ambroxol,
SD Pelajar dr. B B ✓ ISPA + Scabies Flutrop, Amoxilin,
Ferisha Scabimed
Amlodipin,
Wira dr. HT + DM Type Methformin,
- B L ✓
Swasta Ferisha II + ISPA Ambroxol,
Flutrop, Cetirizine
DM Type II
denganInsulin Rujuk Poli
Aliah IRT dr. B L ✓ + Neuropaty Penyakit Dalam
Ferisha DM + HT On RSMP
Treatment
Rujuk POLI
DM Type II Penyakit Dalam
SD IRT dr. B L ✓ dengan
Ferisha RSMP, Amlodipin
Insulin
1 x 10mg
SD Swasta dr. B B ✓ Athralgia Nadic, Kalk, Vit BC

Ferisha
Amlodipin,
HT Gr. II + Ambroxol,
SD IRT dr. B L ✓ ISPA + Flutrop, PCT,
Ferisha Dispepsia Amoxilin,
Ranitidin
dr. Serumen
S1 IRT B B ✓ Phenol Glyserol
Ferisha Prop AD
Wira dr. Pterigium Rujuk Poli Mata
SD B L ✓
swata Ferisha Post OP RS DHAAN
SD IRT dr. B L ✓ HT Amlodipin,

Ferisha Flutrop, Vit BC
dr. PCT, Amoxilin,

SD Pelajar B B ✓ Faringitis
Ferisha Antacida, Vit BC
dr. Hiperlipidemi
SMP IRT L B ✓ Simvastatin
Ferisha a
HT Amlodipin,
Perangk dr. +Dermatofito Captropil, CTM,
SMA B B ✓
at Desa Ferisha sis + Ketocomazole,
Dispepsia Ranitidine
Infus RL 1 Kolf,
Sindrom Inj. Esomeprazole
dr. Dispepsia + 1 Vial. Inj.
SMP Swasta B B ✓
Ferisha TB On Metoclopramid.
TREATMENT Obat Oral : PCT,
Ranitidin, Antasid
dr. Susp. Demam PCT,

SMU IRT B B ✓ Kotrimoxazole,
Ferisha Tyfoid
Antasida, Vit BC
PCT,
SD Pelajar dr. B B ✓ Diare Akut Kotrimoxazole,
Ferisha Zinc, Oralit
Wira dr. Commond PCT, Ambroxol,

D3 B B ✓
Swasta Ferisha Cold Flutrop, Vit BC
dr. Dermatofitosi CTM,

SMA IRT B B ✓
Ferisha s Ketocomazole
Asam
Tidak dr. Mefenamat,
SMK B B ✓ Kalazion
Bekerja Ferisha Gentamicin Zalf
Mata
PCT. Ambroxol,
Karyawa dr.
SMA B B ✓ ISPA Flutrop, Amoxilin,
n PUPR Ferisha
Vit BC
Glibenclamid,
DM Type II + Methformin,
SD IRT dr. B L ✓ Hiperurisemia Allupurinol,
Ferisha + Dispepsia Ranitidin,
Antasida
SMA - dr. B B ✓ Obs. Febris PCT, Vit BC
Ferisha
Amlodipin,
Lansoprazole,
dr. ISPA + HT + Ibuprofen,
SD IRT B L ✓
Ferisha Vertigo + LBP Betahistin, Kalk,
Vit BC, Ambroxol,
Cetirizine
Rujuk Poli
SD IRT dr. B B ✓ Susp. CHF Penyakit Dalam
Ferisha RSMP
dr. Rujuk Poli Saraf

SMA IRT B L ✓ HT + LBP
Ferisha RSMP
Wkt Playan ;l Riwa
Riwayat
KIE Riwayat
PTM
D P TB BB TD T HR LP Lab Penyakit
( ≥ 15
Keluarga th )
08.15 08.19 ✓ 155 48 159/87 36,9 87
Faring
08.19 08.24 ✓ 164 49 124/88 36,9 64 Hiperemesi
s
Tonsil :
09.21 09.25 ✓ 166 55 157/85 37.1 114 T3/T3
Hiperemis
08.30 08.35 ✓ 155 70 137/96 36,9 133 tdk ada DM
blm blm
08.35 08.40 ✓ 152 39,7 86/55 37,2 77
scrining scrining
08.40 08.43 ✓ 113 15 - 38 86 tdk ada tdk ada
08.45 08.50 ✓ 159 68 130/88 36,7 85

Faring
08.55 08.59 ✓ 169 52 99/68 36,8 103
Hiperemis
✓ 136 28 - 36,9 92 Faring

09.05 09.10 Hiperemis
09.15 09.20 ✓ 169 62 142/81 36,8 62 tdk ada tdk ada
09.20 09.23 ✓ 146 46 160/81 36,8 76 GDS: 288
08.59 09.04 ✓ 147 66 173/109 37 107
09.05 09.10 ✓ 168 55 113/66 37 98
Faring
09.10 09.15 ✓ 149 55 169/105 36,9 122
Hiperemis
09.20 09.25 ✓ 146 54 143/96 36,9 97
09.15 09.20 ✓ 174 52 154/88 36,8 91
09.40 09.45 ✓ 142 47 141/86 36,8 73
09.50 09.55 ✓ 125 20 - 37,7 92

09.25 09.30 ✓ 152 48 137/95 36,8 100 Chol: 255
10.19 10.24 ✓ 159 65 158/96 37 92
10.25
09.05 (up ✓ 162 54 110/70 36,8 69
Infus)
10.00 10.06 ✓ 151 61 115/83 37,7 115
10.06 10.10 ✓ 121 18 - 38 92
10.19 10.24 ✓ 160 52 119/78 37,3 105
10.50 10.55 ✓ 155 50 134/103 37 117
10.05 10.10 ✓ 154 59 110/76 37 88
10.20 10.25 ✓ 154 68 142/90 36,8 90
10.15 10.20 ✓ 155 51 93/81 36,8 98

10.20 10.25 ✓ 167,5 57 122/92 36 107
10.25 10.30 ✓ 157 73 135/78 36,9 80
10.31 10.35 ✓ 154 58 180/106 36,9 90
11.10 11.15 ✓ 149 75 141/88 36,9 56

Riwayat PTM
Riwayat
Riwayat
Riwayat Pemeriksa
Penyakit Riwayat
Sebelumn Alergi
n IVA/Sada
ya
nis
HT
Hari/ Tanggal : Kamis, 12 Januari 2023
Petugas : Caterina, Melynda, Widya
No
ir
ah
ur
Telpon
lL
m
U
Tg
Jl.Padaidi
63100950 08538766 10-11-
1 14,785 Umum 09890003 0689 Ny.Ria Andini 33 th Rt.9 P
1989
Sejahtera
63020203 08592489
2 27,044 Umum 08950002 4534 Tn.Junaedi 27 th 3-8-1995 Lap 5 Okt L
00028241 63100952 Tidak ada Ny.Rusnawati 58 th 12-2-1962 Jl.Kedondo

3 24,714 P
78051 02620002 ng RT.7 TP
4 28,216 Umum 63100910 08225477 Tn.Robiyanto 43 th 10-2-1978 Rt.14 L

02780004 8638 Sejahtera
5 9,296 Umum 63009560 Tidak ada Ny.Agustina 73 th 16-5-1949 Rt.16 TP P

5490001
00019288 63100941
6 4,168 Tidak ada Ny.Samsidar 55 th 1-2-1950 Rt.2 TP P
44189 03600001
00024577 63100912 08524862 Tn.ali Gg.Bersam

7 261 46638 03560004 0116 Mursidin 56 th 12-3-1966 a RT.3 GA L
00022889 63100947 08235333 An.Nur RT.10

8 1,224 16 th 8-7-2006 P
21387 07060010 5022 Hidayah Bersujud
00027226 63100960 08784671 Ny.Suwi 20-12-
9 28,218 70 th RT.3 TP P
7473 12520002 739 Astuti 1952
63021209 08515523 Ny.Yusman

10 28,219 Umum 22 th 9-9-2000 RT.6 GB L
09000001 2381 Sartana
00024778 63100263 08251212 An.Nesya Rt.9

10 577 6 th 23-9-2016 P
43741 09160001 799 Alya Alesha Bersujud
63100114 08533261 Tn.Zainal Rt.4 Kersik

12 28,223 Umum 43 th 14-9-1979 L
0979002 2857 Abidin Putih
63100654 08125116 Ny.Putri Salsa Rt.9

13 26,846 Umum 07140003 5553 Maulida 8 th 14-7-2014 Bersujud P
63100655 08125433 5th

14 28,220 Umum 05170003 5283 An.Lovelyn
8bln 15-5-2017 Rt.2 GB
P
00008952 63100960 08314864 20-12- Rt.6

15 727 Ny.Syariani 40 th 1982 P
70116 12820010 6209 Bersujud
16 1,769 00008942 63100905 08214890 An.M Rendi 12 th 1-12-2010 Rt.5 L

34914 11100004 4877 Bersujud
00018685 63100925 08524585 25-12-

17 10,749 50197 1210002 7659 An.M Rafa 10 th 2012 Rt.10 KB L
18 18,640 00019227 63100927 08134968 Tn.Misransya 46 th 27-2-1976 Rt.2 L

84276 02760004 3887 h Bersujud
00027722 63021764 08525152 24-11-

19 25,021 Nn.Halimah 24 th RT.20 TP P
867277 11000001 4711 1998
Tidak ada 08315564

20 27,184 Umum An.Putri 8 th 3-6-2013 RT.1 GA P
KK 149
00089489 63100956 08534660 16-12-

21 17,791 7955 12780002 4899 Ny.Inita 44 th 1978 Rt.5 TP P
00019277 63100930 08225972 Rt.1

22 27,927 Tn.M Sevy 26 th 30-3-1996 Sarigadung L
1542 03960003 4332
00027228 63100952 08215323
23 26,820 Nn.Anita 18 th 12-9-2004 RT.19 TP P
43989 09040007 8871
63100945 08215505 Ny.Siti Rt.4

24 28,105 Umum 55 th 5-6-1968 P
06680006 3833 Muhani Barokah
00030524 63100944 08126719 RT.11

25 25,501 Ny.Nisa 19 th 4-9-2001 P
41754 09010008 4186 Barokah
63100955 RT.9
26 28,225 Umum 09920005 Tdk ada Ny.Ika Novita 30 th 15-9-1992 Sejahtera P
63100929
00019228 08539325 Jl.Karang
27 25,902 07620000 5119 Tn.Sayinudin 60 th 29-7-1962 jawa L
04537
1
00019228 63100964 08539325 Ny.Tiah RT.10

28 25,902 46 th 24-8-1973 P
04548 08730001 5119 Jumini Bersujud
00024945 63100957 08534650 Rt.5

29 6,323 Ny.Nadiyah 62 th 17-3- P
54862 03700003 5920 Bersujud
30
POLI UMUM
Pembiayaan
Status Status
dr.Rahma Obs febris + PCT, Amox,

D3 IRT B B ✓
h Faringitis Omeprasole, VitC
Sindrom Lansoprasole,
SMA Satpam dr.Ferisa B B ✓
dispepsia Antasida, PCT
Amlodipin,
Captopril,
HT+DM+Ane Glibenclamide,
SMP IRT dr.Ferisa B B ✓
mia
Metformin,
Heafort, Bcomp
Obs.edema+a
sites, KIE kontrol ke RS,
SMA Wiraswa B B ✓ Susp.ganggua Furosemide,
sta dr.Ferisa n liver, Ambroxol, CTM,
Insomnia, Amox
ISPA
Amlodipine,
SD IRT dr.Ferisa B B ✓ HT gr Nadic, Ranitidine,
Kalk
Nadic,
dr.Rahma HT gr II + OA Amlodipine,
SD IRT B L ✓ Allopurinol,
h Genu
Omeprasole,
Bcomp
HT terkontrol Amlodipine,
Wiraswa dr.Rahma + Ambroxol,
SMA sta B L ✓ Hiperurisemia Allopurinol, PCT,
h
+ ISPA Bcomp
PCT, Dexa,
Ponpes Pelajar dr.Rahma B B ✓ Faringitis Omeprasole,
h Bcomp
Ibuprofen,
Amlodipine,
Bcomp,
dr.Rahma OA Genu + HT
SMP - B B ✓ Simvastatin,
h gr II
Rujuk poli
penyakit dalam
RS Marina
dr.Rahma Open fracture Ibuprofen,

D3 - B B ✓
h digiti V Ciprofloxaacyn
TK Pelajar dr.Rahma B B ✓ Dispepsia Antasida, VitC

h
Wiraswa dr.Rahma Keratitis dd PCT, Gentamicin

SMA B B ✓
sta h corpus cornea eye drop
TK Pelajar dr.Rahma B B ✓ Skin loss PCT, Amox, VitC

h
dr.Rahma PCT, Ambroxol,

- - B B ✓ Common cold
h CTM, Amox
dr.Rahma PCT, Omeprasole,

SD IRT B B ✓ Cephalgia
h Pehavral
Scabies +
SD Pelajar dr.Rahma B B ✓ infeksi PCT, Cetrizine,
h Amox, Salep 24
sekunder
- Pelajar dr.Rahma B B ✓ Obs febris Ibuprofen, VitC

h
Amlodipine,
SD Swasta dr.Rahma L L ✓ DM tipe II + Glibenclamide,
h HT gr II Metformine,
Bcomp
dr.Rahma F20 Rujuk poli jiwa

SMP - B L ✓
h skizofrenia RSUD DHAAN
PCt, Amox,
TK Pelajar dr.Rahma B B ✓ Ectima Cetrizine,
h Gentamicin zalf
Rujuk poli
SD IRT dr.Rahma B L ✓ CHF + UAP penyakit dalam
h RS MArina
Ibuprofen,
Wiraswa dr.Rahma Muscle
SMA B L ✓ Antasida, Bcomp,
sta h spasme
Eperison HCl
dr.Rahma PCT, Amox,
SMP - B B ✓ Obs febrsi H4
h Antasida, Bcomp
Amlodipine,
dr.Rahma Common cold Furosemide, PCT,
SD IRT B B ✓
h + HT gr II Guaefenisine,
CTM
Ergofamin
maleat,
SMK IRT dr.Rahma B B ✓ Migrain Ibuprofen,
h Omeprasole,
Bcomp
G3P2A0 Uk
dr.Rahma 26- Acyclovir, PCT,
SMK IRT B B ✓ 27mgg+Varic VitC
h
ella
PCT, Amlodipine,
Wiraswa dr.Rahma Ht gr II +
SD B B ✓ Omeprasole,
sta h Gastritis
Pehavral
Furosemide,
dr.Rahma HT gr II + Amlodipine,
SD IRT B B ✓
h Dislipidemia Simvastatin, PCT,
Bcomp
Ciprofloxacyn,
dr.Rahma Susp.ISK + PCT, Ambroxol,
- IRT B B ✓
h Common cold Omeprasole,
Amlodipine
dr.Rahma ✓
h
Wkt Playan ;l Riwa
Riwayat
KIE Riwayat
PTM
( ≥ 15
Keluarga th )
08.20 08.25 ✓ 147 58 119/86 37,9 116 - - - -
08.25 08.30 ✓ 165 86 143/94 37 84 - - - -
Hb:9,9
08.15 08.23 ✓ 152 36 163/98 36,9 117 - - -
GDP:223
08.35 08.43 ✓ 162 68 136/105 36,8 104 - - - -
08.45 08.52 ✓ 144 42 146/71 37 102 - - - -
GDS:171 ;
08.50 08.56 ✓ 143 45 152/83 36,7 90 - - -
AU:8,6
GDS:200 ;
08.40 08.46 ✓ 166 66 138/81 36,9 109 - AU:8,6 - -
09.00 09.06 ✓ 150 43 129/90 37 127 - - - -

08.55 09.05 ✓ 146 63 157/92 36,9 89 - - DM DM,HT
09.15 09.18 ✓ 178 64 152/97 36,7 82 - - - -
09.30 09.37 ✓ 110 15 - 37 - - - - -
09.40 09.45 ✓ 164 51 143/100 37 69 - - - -
09.20 09.25 ✓ 133 25 - 36,9 - - - - -
09.25 09.30 ✓ 113 22 - 36,9 - - - - -
09.46 09.52 ✓ 147 70 115/74 36,9 71 - - - -
09.53 09.58 ✓ 132 25 - 37,1 - - - - -
09.59 10.04 ✓ 127 27 - 37,2 - - - - -
10.05 10.10 ✓ 164 54 153/81 37,1 99 - - - -
10.11 10.16 ✓ 158 70 118/97 36,3 112 - - - -
10.17 10.22 ✓ 121 21 - 36,9 - - - - -
10.03 10.10 ✓ 158 70 171/118 36,8 13 - - - -
10.10 10.15 ✓ 169 68 136/91 36,9 82 - - - -

10.30 10.35 ✓ 159 40 126/93 36,9 96 - - - -
10.36 10.42 ✓ 149 62 173/111 36,9 68 - - - -
10.45 10.50 ✓ 150 55 118/89 36,8 74 - - - -
10.52 10.57 ✓ 151 58 126/78 37,2 112 - - - -
10.58 11.03 ✓ 173 53 152/92 37 59 - - - -
Chol:228 ;
11.04 11.09 ✓ 148 57 167/98 37 86 - GDS:168 ; - -
AU:56
11.10 11.15 ✓ 146 52 145/80 37 69 - - - -
✓ - - - -
Riwayat PTM
Riwayat
Riwayat
Riwayat Pemeriksa
Penyakit Riwayat
Sebelumn Alergi
n IVA/Sada
ya
nis
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
Hari/ Tanggal : Jum'at, 13 Januari 2023
Petugas : Caterina, Erni, Widya,Jumariah
No
ir
ah
ur
Telpon
lL
m
U
Tg
Jl. Kodeco
63100944
1 17,033 Umum 12750005 - Ny. Yuliana 48 th 4-12-1975 Km. 2,5 P
RT.11
Jl. Kodeco
63100958 An. Wafa 18-09-
2 17,033 Umum 09090005 - Aisyah 13 th 2009 Km. 2,5 P
RT.11
3 20,234 00028974 63100907 08134840 Tn. Sarjono 72 Th 7-3-1950 Jl. Anda L

07225 03500003 3482 Ujung RT.9
00027225 63100903 08582144 Tn. Wiranto

4 707 29 th 3-3-1994 Jl. BB rt. 19 L
60175 03940004 3764
63100919 08235756 An. M. Arifin 19-10- Jl. Jambrut

5 13,548 Umum 14 th L
1008002 8632 Ilham 2008 RT. 12
Jl.
00008895 63929650
6 24,023
04650010 Tidak ada Ny. Kartini
57 th 10-4-1965 Wonorejo P
53542
RT 11
00008952 63100903
7 14,030 66843 03540003 Tidak ada Tn. Bahrudin 65 th 3-3-1954 JL. Antasan L
00019226 63100921 98215846 Tn. Surya 21-11-

8 26,254 27 th Jl. BB rt. 9 L
97887 11840003 20003 Prayudha 1994
63020642 08524974 Ny. Risa Jl. Lap 5
9 28,229 - 28 th 2-6-1995 P
06950029 7616 Kadrianor Okt RT.14
00011311 63100918 08134857 Jl. Lap 5

10 3,212 Tn. Aspri 52 th 18-5-1970 L
77249 05700006 7500 Okt RT 5
Jl. Raya
00027227 63100621 08215892 An. Septian
11 20,546 6 th 21-9-2016 Serongga L
23569 09160001 4552 Riski RT 4
73020121 08529905 Tn.

12 20,624 Umum 09880006 5680 Darmawan 27 th 22-8-1994 Jl. KB RT.1 L
00019288 63100951 08215045 11-10- Jl. Kodeco

13 21,195 Ny. Sarminah 49 th P
66206 10730009 5067 1973 RT.3
00022717 63020153 08534850 Ny. Dewi 16-07- Jl. Plajau

14 22,202 30 th 1991 P
48768 06910001 5337 Reskiah RT. 8
27225675 63100966 08235274 26-05- Jl. Kodeco

15 28,232 Ny. Jumiati 61 th P
11 05620001 4406 1962 RT.2
16 25,861 00024786 63100967 08125539 Ny. Hj. 65 th 27-09- Jl. Pel. P

17234 09560001 2082 Nahrah 1956 Speed rt.4
Jl.
17 10,145 00022201 63100919 Sudah Tn. Sanib 66 th 19-03- Bhayangkar L
78937 03560002 ada 1956
a RT.10
00027226 63100942 Jl. Senada

18 25,718 Tidak ada Ny. Nuriani 54 th 2-8-1965 P
33312 08650003 RT.8
00019288 63100965 Sudah Ny. Maya Jl. Pasar

19 4,082 63449 07770003 ada Triana 45 th 25-7-1977 Ampera P
20 13,102 00020480 63100950 Tidak ada Ny. Samsiah 64 th 10-8-1945 Jl. Plajau P
38637 08450001 RT. 8
Jl. Raya
21 27,729 Umum 63100951 08134670 Ny. Masitah 47 th 11-05- Batulicin, L
05750006 0990 1975
RT.03
POLI UMUM
IGD: Suradi, Abdillah
Pembiayaan
Status Status
PCT, Amox,
dr.Rahma HT gr I, Cetirizine,
S1 IRT B L ✓
h Scabies Amlodipin, Salep
24, Furocemide
Amoxilin,
Cetirizine, PCT,
SD Pelajar dr. Rahma B L ✓ Ectima, CC Guafenesin,
Flutrop
Amoxilin,
Cetirizine,
SMA Wiraswa B L ✓ HT, Susp. Ambroxol, PCT,
sta dr. Rahma Bronkitis Omeprazole,
Amlodipine
Tidak Rujuk Sp.J RSUD

SD dr.Ferisa B L ✓ F06.8
Ada DHAAN
Scabies
dengan CTM, Scabimide
SMP Pelajar dr.Ferisa B B ✓
Infeksi Zalf, Gentamicin
Skunder
SD IRT dr. Ferisa B L ✓ HT terkontrol Amlodipin, Vit B1
Amlodipijn,
Metfprmin,
HT gr II, DM
SMA Swasta dr.Rahma B L ✓ Tipe II Glibenclamide,
h PCT, Omeprazole,
Vit BC
Wiraswa Flutrop,
SMA dr. Ferisa B B ✓ CC
sta Ibuprofen, Vit C
HT, Kolik
Amlodipin,
SMP IRT dr. Ferisa B B ✓ Abdomen,
Susp. BSK Hyoscin,Antacida
Obstruksi
Wiraswa Kolik
SMP dr. Ferisa B B ✓ Hyoscin, PCT
sta Abdomen,
Susp. BSK
Susp. Antasida, Cotri,

TK Pelajar dr.Rahma K L ✓
h Dispepsia PCT, Vit C
Amoxilin, Asam
Wiraswa dr.Rahma Hemoroid Gr Tranexamat,
S1 sta B B ✓ II Ibuprofen, Anti
h
Hemoroid
Amlodipin,
dr.Rahma HT gr II, DM Furocemide,
SD IRT B L ✓
h Tipe II Metformin,
Gliben, PCT
SMA IRT dr. Ferisa B B ✓ OA Nadic, Kalk
Furocemide,
Amlodipine,
dr.Rahma HT Gr II, OA Nadic,
SD IRT B B ✓
h Genu Omeprazole, Vit.
BC, Gentamicin,
zalf
SD IRT dr.Rahma B L ✓ Post Cerebral Rujuk Sp.S

h Infarction RSMPH
Amlodipin,
SMP Tidak B L ✓ HT Gr II, OA Captopril,
Berkerja dr. Ferisa Genu Natrium, Kalk, Vit
B1
HT
Nadic, Kalk, Vit
SD IRT dr. Ferisa B L ✓ Terkontrol,
Atralgia B1, Amlodipin
Amlodipin,
Hemafort,
SMK IRT dr. Ferisa B L ✓ HT, Anemia Ibuprofen,
Antasida
HT gr II, Furocemide,
SD IRT dr.Rahma B L ✓ Amlodipin, PCT,
Hiperuresemi Omeprazole,
h
a Allopurinol,Vit BC
Guanifensin, PCT,
SMP IRT dr.Rahma B L ✓ CC Omeprazole, Vit
h BC
Wkt Playan ;l Riwa
Riwayat
KIE Riwayat
PTM
( ≥ 15
Keluarga th )
07.55 08.10 ✓ 160 70 147/100 36,8 91 - - - -
08.00 08.10 ✓ 163 54 113/86 37,1 94 - - - -
08.13 08. 20 ✓ 157 51 175/80 36,8 78 - - - -
08.10 08.20 ✓ 162 55 107/74 36,9 79 - - - -
08.30 08.40 ✓ 157 71 - 36,9 - - - - -
08.40 08.50 ✓ 159 77 141/93 36,8 79 - - - -
GDS: 165 ;
08.40 08.46 ✓ 160 69 160/103 36,9 76 - AU : 5,4 - -
09.00 09.06 ✓ 167 65 105/65 36,8 78 - - - -

08.55 09.05 ✓ 148 67 149/109 36 82 - - HT HT
09.15 09.18 ✓ 165 60 115/81 36,8 71 - - - -
08.50 09.00 ✓ 111 18 - 37 - - - - -
09.05 09.15 ✓ 157 50 99/56 36,9 57 - - - -
08.59 09.10 ✓ 157 60 189/95 36,8 96 - GDS: 338 - -
09.00 09.10 ✓ 152 60 114/96 36,8 108 - AU : 3,7 - -
09.19 09.29 ✓ 148 55 177/100 36,9 75 - - - -
08.50 09.10 ✓ - 64 200/121 36,8 95 - - - -
09.15 09.25 ✓ 155 65 157/100 37 100 - - - -
GDS : 109 ;
09.46 09.55 ✓ 146 44 151/86 36,8 92 - - -
AU : 6,0
10.11 10.16 ✓ 158 52 146/109 37 87 - HB : 10,1 - -

✓ 151 60 182/103 37 75 - GDS : 113 ; - -
10.17 10.22 AU : 7,4
10.03 10.10 ✓ 155 73 130/81 37 89 - - - -

Riwayat PTM
Riwayat
Riwayat
Riwayat Pemeriksa
Penyakit Riwayat
Sebelumn Alergi
n IVA/Sada
ya
nis
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
HT - - - -
- - - - -
- - - - -
- - - - -
HT,DM - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- HT - - -
- HT - - -
- - - - -
Hari/ Tanggal : Sabtu, 14 Januari 2023
Petugas : Caterina, Erni, Widya
No
ir
ah
ur
Telpon
lL
m
U
Tg
Jl.Suka
63100954 08535030
1 8,006 Umum 02640002 8695 Ny.Haryani 58 th 14-2-1964 Damai RT.7 P
KB
Nn.Noor
63100923 08134992 23-12-
2 5,424 Umum Ramadhan 24 th RT.6 GA P
12980005 1757 1998
Rizkiah
Jl.Pembatu
00027227 63100941 08139393
3 28,234 Ny.Ririn 52 th 1-7-1970 an Atas P
10519 07700203 4272
Rt.5 GB
00027226 63100951 08315045 Ny.Sulis 11-11- RT.5

4 17,518 49 th P
35865 11730001 2494 Amarpoh 1973 Bersujud
00024629 63100609 08211143 JL.PNPM

5 20,575 An.Al Bady 9 th 9-9-2013 L
21166 09130001 6873 RT.18 TP
00027774 33051812 08538945 Tn.Usman 12-11- Jl.Kemakm

6 28,235 54 th
1968 uran RT.9
L
04331 11680003 3840 Urs Sagala
KB
Jl.Sampurn
00019227 63100912 08524842
7 27,455 69369 05850003 3244 Tn.Mustafa 37 th 12-5-1985 a RT.8 L
Barokah
Jl.Sampurn
00019227 63100959 08524842 Ny.Yani
8 27,455 34 th 19-9-1988 a RT.8 P
69371 09880005 3244
Barokah
00001241 63100910 08135107 Tn.M Wahyu Komp.BHP
9 23,377 54 th 10-7-1968 L
02991 07680011 4333 Yulianto RT.3 GB
63100928 08135107 Tn.Jaka Yuda Komp.BHP

10 23,377 BPJS 25 th 28-9-1997 L
09970004 4333 Ainun S RT.3 GB
11 25,618 00010728 73240412 08313345 Tn.Rahman G 21 th 12-12- Blok A Rt.2 L

63909 12010002 6568 2001 Manunggal
00027227 63100901 08539729 Tn.H M

12 16,276 54 th 1-12-1968 Rt.4 GB L
01868 12680007 9167 Nurdin
Jl.Nusa
63100901 Tn.Husain
13 28,238 Umum 03610005 - 61 th 1-3-1961 Indah RT.1 L
Effendi
Barokah
00024301 63100620 08525148 An.M Ibrahim Jl.Rahayu

14 25,012 7 th 20-5-2015 Rt.6 L
14039 05150002 0868 Yusuf
Bersujud
00089379 63070648 08534953 Rt.10

15 22,647 0191 03930002 2330 Ny.Faridah 29 th 8-3-1993 Sejahtera P
16 28,219 Umum 63021209 08515523 Tn.Yusman 22 th 9-9-2000 Rt.6 GB L

09000001 2381 Sartana
Samping
17 27,073 00027226 63100965 08524655 Ny.Sabrina 34 th 25-6-1988 SMP P
10182 06880001 6022 Kodeco
Rt.11 TP
An.Balqis Az
00023156 63100643 08133065 5th
18 15,011 Zahra 3-6-2017 Rt.8 TP P
60951 06170001 6028 7bln
Ramadani
00026599 63100968 08123696 Ny.Sahri 28-12- Rt.11

19 16,661 55 th P
55771 12670004 2377 Bulan 1967 Barokah
63100930 08128286 Jl.Senada
20 26,361 Umum Tn.M Arie 22 th 30-7-2000 L
07000004 4627 Rt.7 GA
00019227 63100909 08235250 Tn.M Hasbi Rt.2

21 28,212 46 th 9-12-1976 L
62823 12760001 1094 Hairullah Barokah
63100662 08134964 An.Savinatun Rt.13

21 10,736 Umum 6 th 22-7-2016 P
07160001 8899 Nazwa Bersujud
00008955 63100926
22 17,261 35842 05990004 Tidak ada Tn.Diddi 22 th 1-5-2000 Rt.7 GA L
00019228 63100954 Ny.Noor Jl.Hidayah

23 2,900
06780004 Tidak ada
44 th 14-6-1978 Bersujud P
06359 Asiah
POLI UMUM
IGD:
Pembiayaan
Status Status
Captopril,
dr.Rahma Amlodipine, PCT,
SD IRT B L ✓ Ht gr II
h Omeprasole,
Bcomp
Wiraswa dr.Rahma Faringitis PCT, Amox, Dexa,

Paket C B B ✓
sta h acute VitC
Ambroxol, PCT,
SD IRT dr.Rahma B B ✓ Susp.TB VitC, Omeprasole,
h Cek sputum
Metformine,
DM tipe II +
Krisis Glimipiride,
SMP IRT dr.Rahma B L ✓ Ibuprofen,
h hiperglikemia
VitB12,
+ Neuropati Omeprasole
Domperidone,
- Pelajar dr.Rahma B B ✓ Obs.vomit Antasida, PCT,
h Zinc
Post op
Wiraswa dr.Rahma Fraktur Digiti Nadic, VitB12,
SMA B L ✓
sta h III-IV + Antasida
Neuropati
Ibuprofen,
Wiraswa dr.Rahma Dispepsia
SD sta B B ✓ sindrome Omeprasole,
h Bcomp
dr.Rahma Furosemide,
SD IRT B L ✓ HT
h Amlodipine
Sequele of
dr.Rahma Rujuk poli saraf
A.II PNS B B ✓ cerebral
h infarctum RS Marina
Furosemide,
SMA - dr.Rahma B B ✓ HT gr II Amlodipine, PCT,
h Bcomp
Ambroxol,
SMA Guru dr.Rahma B B ✓ Common cold Ibuprofen,
Kontrak h Antasdia, Bcomp
Wiraswa dr.Rahma Nadic,

SD B B ✓ OA Omeprasole,
sta h Bcomp, Kalk
Captopril,
Wiraswa dr.Rahma Amlodipine, PCT,
SMP B B ✓ HT urgency
sta h Omeprasole,
Bcomp
Ibuprofen, Amox,
Ambroxol, KIE ke
- Pelajar dr.Rahma B B ✓ Obs febris H2 IGD jika tidak ada
h
perubahan 2 hari
Ibuprofen, Asam
dr.Rahma Hemoroid gr
- IRT B B ✓ II traneksamat,
h Antihaemoroid
D3 - dr.Rahma L L ✓ Open fracture Wound dressing

h digiti V
SMP IRT dr.Rahma B B ✓ Pterigium Gentamicin eye

h drop, Asmef
Common cold PCT, Ambroxol,

- Pelajar dr.Rahma B B ✓ + GEA tanpa Amox, Antasida,
h dehidrasi Zink
PCT, Omeprasole,
dr.Rahma Dispepsia +
SMA IRT B B ✓ Amlodipine,
h HT
Bcomp
Susp.Typoid Kaolin pectin,
Wiraswa dr.Rahma Omeprasole, PCT,
SMA B B ✓ + GEA tanpa
sta h Kotrimoxasole,
dehidrasi Guaefenisine
PCT, Dexa,
Kary.PU dr.Rahma
SMA L B ✓ Common cold Ambroxol, Vit.C,
PR h Surat ket berobat
- Pelajar dr.Rahma B B ✓ V.Laceratum PCT, Amox

h
PCT, Flutrop,
Kary.sw dr.Rahma
SMA asta B B ✓ Common cold Guafenisin, VitC,
h Surat sakit 1 hari
Frozen
shoulder + Nadic,
SMP IRT dr.Rahma B B ✓ Omeprasole,
h Dispepsia
Bcomp
sindrom
Wkt Playan ;l Riwa
Riwayat
KIE Riwayat
PTM
( ≥ 15
Keluarga th )
08.20 08.25 ✓ 157 58 166/88 37 114 - - - -
08.28 08.33 ✓ 161 58 101/80 36,8 100 - - - -
08.34 08.39 ✓ 153 36 131/84 37 99 - - Tidak ada Tidak ada
08.41 08.46 ✓ 150 52 138/86 36,7 73 - GDS:493 - -
08.46 08.52 ✓ 122 23 - 37 - - - - -
08.53 08.58 ✓ 173 76 126/88 37 98 - - - -
09.00 09.05 ✓ 152 46 136/71 37 76 - - Tidak ada Tidak ada
09.06 09.12 ✓ 148 62 172/111 36,9 93 - - - -

09.13 09.18 ✓ 166 77 141/105 - 85 - - - -
GDS:102 ;
09.19 09.24 ✓ 162 87 169/128 37,1 105 - - -
AU:5,7
09.25 09.30 ✓ 168 59 142/97 36,9 124 - - - -
GDS:106 ;
09.30 09.35 ✓ 155 58 121/84 36,9 75 - - -
AU:5,7
09.35 09.40 ✓ 168 71 207/104 36,9 80 - - Tidak ada HT
09.41 09.46 ✓ 129 32 - 37,6 - - - - -
09.48 09.53 ✓ 151 68 121/97 36,9 69 - - - -
09.54 10.00 ✓ 178 65 130/90 37 97 - - - -
10.01 10.06 ✓ 143 73 124/81 36,9 73 - - - -
10.07 10.12 ✓ 116 25 - 36,8 - - - - -
10.13 10.18 ✓ 148 41 162/92 36,9 84 - - - -

10.20 10.25 ✓ 165 57 128/69 36,7 99 - - - -
10.26 10.32 ✓ 154 68 148/93 36,7 91 - - - -
10.34 10.39 ✓ 109 16 - 37 - - - - -
10.45 10.50 ✓ 167 69 130/82 36,3 73 - - - -
10.55 11.00 ✓ 149 52 130/87 36,7 70 - - - -

Riwayat PTM
Riwayat
Riwayat
Riwayat Pemeriksa
Penyakit Riwayat
Sebelumn Alergi
n IVA/Sada
ya
nis
- - - - -
- - - - -
Tidak ada - Tidak ada Tidak ada -
- - - - -
- - - - -
- - - - -
Tidak ada - Tidak ada Tidak ada -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - Tidak ada Tidak ada -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
Petugas : Caterina, Melynda, Widya
No
ir
ah
ur
Telpon
lL
m
U
Tg
Sungai
63100905 08539327
1 24,781 Umum 06650007 2333 Tn.Hairuddin 57 th 5-6-1965 Hanau RT.7 L
GB
2 22,950 Umum 63100591 08228071 Ny.Ida 42 th 19-12- Rt.9 KB P

2800002 4394 Wirdawati 1980
Jl.Kemakm
00027774 33051812 08538943 Tn.Usman 12-11-
3 28,235 54 th uran Rt.9 L
04331 11680003 3840 Urs Sagala 1968
KB
4 20,965 00019298 63100956 Tidak ada Ny.Sudartik 57 th 16-8-1965 Jl.Banyuwa P

69392 09650003 ngi RT.7 GA
63502147 Komp emil

00027228 08125959 Ny.Nanik 31-12-
5 26,041 11273000 49 th timber Rt.8 P
44711 1 0869 Setyowati 1973 TP
Jl.Borneo
63242209 08213230
6 22,332 Umum 10090001 1854 An.M Yusuf 13 th 9-10-2009 RT.14 L
Sejahtera
00027391 63100961 08325575 21-11-

7 287 Ny.Hadijah 46 th Rt.17 TP P
38265 11780002 9926 1976
00027228 63100952 08215323 12-12-

8 26,820 Ny.Suarni 38 th Rt.19 TP P
43967 12840010 8871 1984
00019298 63100970 08314151 Ny.Muldiana Rt.19Bersuj
9 12,422 47 th 30-4-1975 P
55464 04750002 4100 h ud
Pelita
00001224 63020645 08525145 Ny.Noer Permai
10 23,566 47 th 5-1-1975 P
80357 01750004 4388 Hasanah,S.Pd InsGub
Rt.11 KB
00027512 63100904 08135138

11 11,330 Tn.M Yunus 60 th 4-1-1963 Rt.2 GA L
90741 01630006 0632
00027226 63100912 08125376 Jl.Perjuang

12 1,482
11609 00360000 7079 Tn.Syahmadi
62 th 12-3-1960 an RT.17 TP L
3
63020665 08215271 Ny.Mas Jl.Senada

13 28,245 Umum 07930007 3560 Rosita 29 th 25-7-1993 P
Rt.3 GA
Tidak ada 08225013 Jl.Mutiara

14 27,843 Umum KK
6206 An.Kevin
7 th 3-8-2005 Indah Rt.2 L
GB
Jl.Mutiara
63020664 08225013
15 27,843 Umum Ny.Arbayah 60 th 24-4-1962 Indah Rt.2 P
04620001 6206
GB
16 904 Umum 63100953 08125553 Ny.Siti 56 th 13-8-1966 Jl.Bhayangk P

08660003 4053 Mariyam ara Rt.9 TP
00022642 Jl.Singosari
17 19,612 - Tidak ada Ny.Aslamiah 46 th 15-1-1976 P
23249 RT.15 TP
Jl.Borneo
18 1,394 Umum 63021765 08124712 An.Rizki Rini 9 th 25-3-2013 Rt.12 P
03130001 1267 Anjani
Sejahtera
19 27,456 00027225 63100601 08125334 Tn.M Alwi 60 th 1-1-1963 RT.3 GA L
79918 01630003 4155
63021647 08575485
20 28,192 Umum Ny.Rasidah 44 th 7-5-1978 Rt.3 KB P
05780002 8831
00027225 63100641 08135261

21 25,889 Ny.Tasmiyati 30 th 25-8-1992 Rt.5 GB P
77398 08180002 7920
21 28,044 Umum 63020203 08592489 Tn.Junaedi 27 th 3-8-1995 Lap 5 okt L

08950002 4534 Bersujud
63100651 08771619 An.Nurul Jl.Perjuang

22 22,500 Umum 7 th 11-4-2015 P
04150003 8812 Hidayah an RT.15 TP
63100541 08771619 Jl.Perjuang

23 22,500 Umum 07830134 8812 Ny.Risnawati 39 th 1-7-1983 an RT.15 TP P
00027675 63100925 08575344

24 3,593
42445 05590003 2509 Tn.Basuni
63 th 25-5-1959 Rt.4 GB L
25 1,080 00001639 63100950 08125102 Ny.Junaidah 43 th 10-6-1979 Jl.Kedondo P

14221 06790005 25457 ng
00027226 63100959 08125116 Rt.9

26 25,389 Ny.Yuning 52 th 19-4-1971 P
36067 04710002 5553 Bersujud
63100904 08225073 Tn.Adi Nopi RT.14

27 28,244 Umum 27 th 4-11-1995 L
11950005 3323 Irawan Sarigadung
00022713 35781604 08225518 An.Sugih Jl.Kebanjira

28 11,579 10 th 4-3-2012 L
46244 03120002 638 Tyanara n Rt.2 TP
29 28,095 Umum 63100916 08123387 Tn.Abu 57 th 16-9-1965 Rt.8 KB L
09650003 3731 Samah
00016298 63100959 08314420

30 19,030 Ny.Meliyanti 38 th 5-1-1985 Rt.19 TP P
55701 04870003 5910
00011311 63100918 08134857 Rt.5

31 3,212 Tn.aspari 52 th 18-5-1970 L
77249 05700006 7500 Bersujud
00027227 63100950 08534976 Ny.Hariyawa

32 20,336 41 th 10-3-1981 Rt.7 GB P
09349 03810010 2009 ti
63100641
33 15,327 Umum Tidak ada Ny.Arbayah 36 th 1-1-1987 Rt.6 GA P
01870001
00029157 63060213 08582293 Tn.M Rujani Jl.Bakau

34 26,344 34 th 13-8-1988 L
59542 08880002 8067 S.Pd RT.3 TP
POLI UMUM
IGD: Anton, Totok
Pembiayaan
Status Status
Ibuprofen, VitB1,
Wiraswa
SMP sta dr.Ferisa B B ✓ Cephalgia Saran cek
kolesterol diluar
Amlodipine,
D2 IRT dr.Ferisa B L ✓ Krisis HT Furosemide,
Nadic, VitB1
Psot op Rujuk poli

Wiraswa dr.Rahma
SMA L L ✓ fraktur digiti ortopedi RS
sta h III-IV DHAAN
Pterigium + Rujuk poli mata

SMP IRT B B ✓ HT + DM tipe RS DHAAN,
dr.Ferisa Amlodipine,
II
Metformin
Furosemide,
dr.Rahma HT gr II + Amlodipine,
SMP IRT L L ✓
h Insomnia Alprazolam,
VitBcomp
Post hecting Aff hecting,

SD Pelajar dr.Rahma L L ✓ ec VL a/r Gentamicin zalf
h manus dextra kulit, VitBcomp
Metformin,
dr.Rahma DM tipe II + Amlodipine, PCT,
- IRT B L ✓
h HT + OA Omeprasole, KIE
kontrol Ke RSMP
Myalgia + Nadic, VitB1,

SD IRT dr.Ferisa L B ✓
Hiperurisemia Allopurinol
Asmef,
Pedagan
- dr.Ferisa B B ✓ Susp.ISK Ciprofloxacin,
g VitB1
HT + Amlodipine,
Hiperurisemia Simvastatin,
- Guru dr.Ferisa B B ✓ + Allopurinol,
Hiperlipidemi Alprazolam,
a + Insomina Josnul poli gigi
Amlodipine,
Wiraswa HT gr II +
SMA dr.Ferisa B B ✓ Captopril,
sta Hiperurisemia
Allopurinol, Nadic
Amlodipine,
Ht gr II + DM Captopril,
SMP - dr.Ferisa B L ✓ tipe II +
Metformin,
Anemia
Hemafort, Bcomp
SMA IRT dr.Ferisa B B ✓ Cephalgia Ibuprofen, Bcomp
dr.Rahma Ibuprofen, Amox,

SD Pelajar B B ✓ Obs febris H1 VitC
h
MNAdic,
dr.Rahma Amlodipine, Kalk,
SD IRT L L ✓ OA Genu + HT
h Alprazolam,
Omeprasole
Furosemide,
Amlodipine, PCT,
dr.Rahma Ht gr II +
SD IRT B B ✓ Omeprasole,
h Common cold
Guaefenisin,
Flutrop
dr.Rahma Captopril,
- IRT B B ✓ HT gr II
h Amlodipine
PCT, Ambroxol,
ISPA +
Tk Pelajar dr.Ferisa B B ✓ VitBcomp, Amox,
Stomatitis
Nystatin drop
Furosemide,
Ht gr II +
Amlodipine, PCT,
SD - dr.Rahma B L ✓ Katarak Omeprasole,
h imatur +
Rujuk poli mata
Suele stroke
RSUD DHAAN
Amlodipine,
Ibuprofen,
OMA std Ciprofloxacin,
SD IRT dr.Ferisa L L ✓ perforasi dd Chloramphenicol
OMSK + HT tetes telinga,
Saran:konsul ke
poli THT
Asmef,
OMA std
SMP IRT dr.Ferisa B B ✓ Ciprofloxacin,
perforasi
Chloramphenicol
SMA Satpam L B ✓ Obs.kolik Hyocine, PCT,

dr.Ferisa abdomen Lansoprasole
dr.Rahma Amox, PCT, CTM,

- Pelajar B B ✓ Common cold
h Ambroxol, VitC
Captopril,
dr.Rahma HT gr II + Ibuprofen,
SD IRT B L ✓
h Dispepsia Omeprasole,
VitBcomp
Wiraswa dr.Rahma Amlodipine,

SD B L ✓ HT gr II + LBP Nadic, Dexa,
sta h VitBcomp, Kalk
- IRT dr.Rahma B B ✓ Otitis media Asmef, Amox,

h supuratif akut Dexa, VitC
Captopril,
SD IRT dr.Rahma B B ✓ HT urgency Amlodipine,
h VitBcomp
Omeprasole, PCT,
Wiraswa dr.Rahma Dispepsia Domperidone,
SMK B B ✓
sta h sindrom Hyocine, Surat
sakit 1 hari
dr.Rahma Ambroxol, PCT,

- Pelajar B B ✓ Common cold
h CTM, Amox, VitC
Amlodipine,
SMA Wiraswa B B ✓ Ht urgency + Captopril,
sta dr.Ferisa Common cold Ibuprofen,
Flutrop, VitC
Ibuprofen,
dr.Rahma Konjungtivitis Gentamicin zalf
SD IRT B B ✓ mata,
h + HT
Amlodipine,
Bcomp
Wiraswa Retensi urine Rujuk poli bedah

SMP dr.Ferisa L B ✓
sta cc BPH RSMP
Betahistine,
Dispepsia Lansoprasole,
SD IRT dr.Ferisa B L ✓ Antasida,
sindrom
Domperidoene,
VitBcomp
Amlodipine,
SD IRT dr.Ferisa B B ✓ HT gr II Captopril,
Ibuprofen
Alloputirinol,
Kary.hon dr.Rahma
S1 B B ✓ Common cold Ibuprofen,
orer h Antasida, VitC
Wkt Playan ;l Riwa
Riwayat
KIE Riwayat
PTM
( ≥ 15
Keluarga th )
08.22 08.27 ✓ 174 62 136/83 36,9 64 - - - -
08.29 08.34 ✓ 155 100 189/135 36,9 89 - - - -
08.20 08.25 ✓ 173 77 160/99 37,7 85 - - - -
08.35 08.40 ✓ 147 53 154/109 - 88 - - HT DM
08.27 08.32 ✓ 163 69 190/114 37,7 110 - - - -
08.34 08.39 ✓ 158 43 - 36,8 - - - - -
08.40 08.45 ✓ 154 61 158/109 36,9 82 - - - -
08.40 08.45 ✓ 145 63 111/86 36,7 - - AU:7,6 - -

08.46 08.51 ✓ 141 46 146/97 37 77 - GDP:100 - -
Chol:275 ;
09.15 09.20 ✓ 150 55 137/100 37 104 - GDS:120 ; - -
AU:11,5
GDP:99 ;
08.52 08.57 ✓ 166 71 175/112 37 68 - - -
AU:8
Hb:10,1 ;
08.57 09.02 ✓ 162 56 176/93 37 71 - - -
GDS:188
09.26 09.32 ✓ 149 67 131/99 36,9 76 - Hb:12,6 - -
08.47 08.52 ✓ 124 29 - 36,8 - - - - -
08.54 08.59 ✓ - 49 113/80 37 107 - - - -
09.00 09.05 ✓ 149 66 190/102 36,8 83 - - - -
09.06 09.12 ✓ 149 62 198/112 - - - - - -
09.05 09.10 ✓ 135 25 - 37 - - - - -

✓ 165 58 203/108 37 95 - GDS:158 ; - -
09.14 09.15 AU:4,9
09.40 09.45 ✓ 155 64 152/98 36,7 71 - - - -
09.48 09.53 ✓ 164 71 125/83 36,4 74 - - - -
09.53 09.58 ✓ 165 88 146/83 36,9 62 - - - -
09.31 09.36 ✓ 118 18 - 36,9 - - - - -
09.37 09.42 ✓ 160 101 141/109 36,9 92 - - - -
09.42 09.47 ✓ 159 53 157/73 37 94 - - - -
09.50 09.55 ✓ 152 47 148/99 36,9 95 - - - -
10.01 10.06 ✓ 153 77 202/113 - - - - - -
10.06 10.13 ✓ 166 88 149/95 36,6 87 - - Tidak ada Tidak ada
10.15 10.20 ✓ 124 73 - 36,7 - - - - -

10.23 10.28 ✓ 159 68 186/95 36,7 78 - - Tidak ada HT
10.29 10.34 ✓ 159 69 166/118 36 107 - - Tidak ada HT
10.00 10.05 ✓ 165 60 120/78 36,3 70 - - - -
10.44 10.49 ✓ 147 40 104/88 36,4 74 - - - -
11.06 11.12 ✓ 147 78 164/125 36,6 121 - - - -
11.03 11.08 ✓ 159 72 136/84 36,7 87 - AU:9,5 - -

Riwayat PTM
Riwayat
Riwayat
Riwayat Pemeriksa
Penyakit Riwayat
Sebelumn Alergi
n IVA/Sada
ya
nis
- - - - -
- - - - -
- - - - -
DM - Tidak ada Tidak ada Tidak

pernah
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
Tidak ada Tidak ada Antibiotik Tidak ada -
- - - - -
HT Tidak ada Tidak ada Tidak ada -
HT Tidak ada Tidak ada Tidak ada -
- - - - -
- - - - -
- - - - -
- - - - -
Petugas : Caterina, Etty, Sumarning, Isti, Bertha, Melynda
r
hi
ur
La
m
U
l
Tg
Tn. Addein Waliyyu
1 12,585 tdk ada 6310090306980004 082223425644 24 th
Mahri
2 27,759 tdk ada Tidak ada 082152023363 an. Ahmad Aldi 6 th
Tn. Maulana Rizki

3 27,855 1922736431 6310091106010008 085249502109 Ikhwani 21 th
4 11,696 0002720672155 6310091111680003 081251740347 Tn. Tomi 54 th
5 25,728 0002737419208 6310062812150005 085389669339 an. M. Maulid Akbar 7 th
6 18,605 0002049595312 6310091908440001 085249642044 Tn. H. Yusran HD 78 th
7 19,978 0000894899125 Tidak ada 085248589301 an. Piona 17 th
8 10,738 0002722561345 6371055104760002 081255523202 Ny. Linda wati 46 th
9 661 2749828599 6310094607670001 085754114976 Ny. Fatmawati 55 th
10 28,250 tdk ada 6310090505650009 081348801978 Tn. Sahril 57 th
an. Akyas Abiyyu

11 18,660 0003068420951 6310061006140002 082351822100 Umam 8 th
12 18,660 0003068420681 6310091304850003 082351822100 Tn. Heriyanto 38 th
13 26,481 0000893500817 6308046307570001 085348319149 Ny. Martinah 65 th
14 28,251 0002722554808 6310063105670001 082250243366 Tn. Raboini 55 th
15 25,715 0002722637957 6310091207460002 085718790304 Tn. Mannang 76 th
16 19,212 0002824168645 6310095207880007 085348338330 Ny. Dewi Yuliana 29 th
17 24,797 0002849409088 6310095403700004 082158771547 Ny. Elfina Nuri Yani 52 th
18 28,249 0000893709977 6310091209930004 082265951155 an. Ronald Syaputra 30 th
Tidak bawa
19 16,612 identitas Tidak bawa identitas 085804227809 an. Galang 15 th
20 16,612 0000894947275 Tidak ada 085804227809 Ny. Sri Mulyani 54 th
21 28,254 0001548138677 63314166303780002 082136896596 Ny. Yasmi 44 th
21 26,360 0002722849751 6310095508680008 Tidak ada Ny. Siti Makiah 51 th
22 11,402 0002752912563 6310090404530003 088704657033 Tn. H.R. Satimin 64 th
23 718 0001922780046 6310094509520002 082352211772 Ny. Faridah 70 th
24 23,317 0002746532283 6310025305810002 082151357465 Ny. Mariyani 39 th
25 5,035 0000124101271 6310093003650002 085345466269 Tn. Totot Indrawan 57 th
Tidak bawa an. Berlian Permata

26 28,256 Tidak ada 087704233345 Sari 18 th
identitas
27 27,052 0002722633075 6310095809810004 082148811082 Ny. Siti Hamdah 41 th
28 28216 0002722840143 6310061204140001 082254778638 an. Riduan al 8 th

Waraffa
29 28,255 000089488268 6310061207960002 082158419630 Tn. Juli Irwandi 26 th
30 14,145 0002722612882 6310090110710001 082149637300 Tn. Achmad Sariadi 51 th
31 28,028 2741867583 6310096206710001 085348014624 Ny. Nunik Hidayah 51 th
an. Ahmad Kavito

32 25,752 000222987349 6310010403170002 082154404599 abqary 5,5 th
33
34
POLI UMUM
IGD: Anton, Totok
Pembiayaan
Status Status
Pendidi
ir
Dokter kunjung penyaki

ah
Alamat JK Pekerjaan
ur
kan
lL
m
an t Umum BPJS
U
Tg
03-06-1998 Jl. Perintis Rt.10 L SMA Wiraswasta dr. Risky B B ✓
Tidak
Tidak ada Jl. Pasar Ampera L Tidak ada dr. Risky B B ✓
ada
Desa Barokah KM.4

11-06-2001 RT.9 L SMK Wiraswasta dr. Ferisa B B ✓
11 Nov
Jl. Senada RT.8 L SD Wiraswasta dr. Ferisa B B ✓
1968
Belum
28-12-2015 TP RT.18 L Tidak ada dr. Risky B B ✓
sekolah
19-08-1944 Jl. Provinsi RT.6 L SR Tidak Bekerja dr. Risky B B ✓
01-04-2005 Jl. Mawar RT.19 P SMP Pelajar dr. Risky B B ✓
11-04-1976 Jl. Kodeco Pal 2 P SMA IRT dr. Ferisa B B ✓
06-07-1967 Jl. Banyuwangi RT.14 P SMP IRT dr. Ferisa B B ✓
05-05-1965 Gg. Kemakmuran L SD Wiraswasta dr. Ferisa B B ✓
10-06-2014 Jl. Banyuwangi RT.07 P SD Tidak ada dr. Risky B B ✓

13-04-1984 Jl. Banyuwangi RT.07 L SMA Wiraswasta dr. Risky B B ✓
23-07-1957 Jl. Kodeco KM 2 P Tidak IRT B B ✓

ada dr. Ferisa
31-05-1967 Jl. Rahayu Gg. L Tidak Wiraswasta B B ✓

Menanti RT.6 sekolah dr. Ferisa
12-07-1946 Jl. Hidayah RT.7 L SD Tidak bekerja dr. Risky B B ✓
12-07-1988 Jl. Mangga II RT.14 P SMA Wiraswasta dr. Ferisa B B ✓
Jl. Batu Benawa

14-03-1970 P SMA IRT dr. Risky B B ✓
Rt.08
12-09-1993 Jl. Bina Bersama L SMK Tidak ada dr. Ferisa B B ✓
Jl. Mekar Sari RT.15

12-01-2008 TP L SD Tidak ada dr. Ferisa B B ✓
Jl. Mekar Sari RT.15

01-12-1968 P SD IRT dr. Risky B B ✓
TP
23-03-1978 Jl. Perum JB RT.6 P SD IRT dr. Risky B B ✓
15-08-1968 Jl. Transmigrasi Rt.11 P SMA IRT dr. Risky B B ✓
04-04-1958 Jl. Kodeco KM 1,5 L SMP Wiraswasta dr. Risky B B ✓
Tidak
05-09-1952 Gg. Mangga II RT.14 P
ada IRT dr. Risky B B ✓
Jl. Pasar Ampera

13-05-1983 P SD Wiraswasta dr. Ferisa B B ✓
Rt.10
Tidak
30-03-1965 Jl. Pesantren L
ada Guru dr. Risky B B ✓
- Jl. Lap 5 Okt RT.14 P SMK Pelajar dr. B B ✓

Rahmah
18-09-1081 Jl. Senada Rt.1 P SD IRT dr. Risky B B ✓
12-04-2014 Kampung Baru RT.14 L SD Pelajar dr. Risky B B ✓
Desa Bayan Sari

12-07-1996 L SMA Wiraswasta dr. Ferisa B B ✓
angsana
Jl. Mulawarman
01-10-1971 L SMA Wiraswasta dr. Ferisa B B ✓
RT.16
22-06-1971 Jl. Kodeco RT.06 P SMP IRT dr. Ferisa B B ✓
perumahan gunung Belum

04-03-2017 tinggi permai L sekolah Tidak ada dr. Risky B B ✓
✓
✓
Pembiayaan Wkt Playan ;l
Diagnosis Terapi & Tindakan KIE

SKTM D P TB BB TD T
Ispa amox, ambroxol, pct 08.40 08.44 ✓ 173 96 127/93 36,8
amox, ambroxol,
Ispa 08.50 09.00 ✓ 102 14 37,1
salbutamol, cetirizine
ambroxol, flutrop,
Ispa amox, pct, vit C 08.30 08.40 ✓ 168 85 127/79 37
ambroxol, amox,
Ispa+ HT gr II + amlodipin,
08.26 08.31 ✓ 166 62 164/105 37
DM Tipe II glibenclamid,
metformin
Ispa ambroxol, cetirizin 08.32 08.37 ✓ 120 21 37
HT gr II + amlodipin,
Hipercolestero simvastatin, ✓ 154 48 150/70 37,3
l+ allopurinol, 08.18 08.23
Hiperurisemia abuprofen
Gastritis + Ispa lanso, ambroxol, 08.20 08.30 ✓ 152 41 98/80 36,9

abuprofen
ambroxol, flutrop,
Ispa + HT 09.04 09.08 ✓ 142 73 168/107 37
cefadroxil, vit C
HT terkontrol amlodipin, vit B com 09.10 09.20 ✓ 154 50 121/102 36,9
HT + Dispepsia amlodipin,
lansoprazole, 09.07 09.12 ✓ 162 55 150/103 37,1
Synd
antasida, vit B com
amox, ambroxol,
Ispa 09.20 09.30 ✓ 116 22 37,8
cetirizine, pct
amox, pct, ambroxol,
Ispa 09.20 09.25 ✓ - 56 131/83 37,9
vit Bcom
amlodipin,
DM tipe II + glibenclamid, ✓ 150 55 143/94 36,9
HT metformin, antasida, 09.15 09.20
Vit B com
amlodipin, captopril,
HT urgency + glibenclamid, ✓ 172 87 192/125 37
DM Tipe II 09.20 09.25
metformin
Rujuk RSMP bagian

CHF ec. CAD 09.30 09.35 ✓ 174 63 164/97 36,9
penyakit dalam
Rujuk poli penyakit
CHF + CAD Dalam RSMP 09.36 09.40 ✓ - 65 131/92 36,9
RA + Tinitus
asmef, dexa, kalk,
Auricula 08.56 09.06 ✓ 154 56 116/80 36,9
rujuk poli THT RSUD
Deztra
TB ileocaecal + Rujuk poli paru RS ✓ 172 58 110/86 37

B.20 DHAAN 08.47 08.51
Scabies Scabimite, cetirizin 09.46 09.50 ✓ 167 47 130/94 37,1
amlodipin, ambroxol,
Ispa + HT 09.49 09.54 ✓ 145 70 149/96 36,8
amox
HT gr II+ amlodipin, pct, amox ✓ 155 77 153/115 36,8
Faringitis 09.41 09.45
Krisis HT + DM amlodipin, captopril,

merformin, 08.55 08.59 ✓ 145 54 198/111 36,8
tipe II + OA
glibenclamid, Nadic
metformin,
DM Tipe II +
Hiperurisemia allopurinol, asmef, 09.10 09.20 ✓ 159 78 126/67 37
antasida
Anemia + hemafort,
09.30 09.40 ✓ 155 37 112/72 36,9
Gastritis lansoprazole, pct
Ambroxol, flutrop,
Ispa 10.03 10.08 ✓ 152 57 111/83 36,7
amox, vit C, pct
lansoprazole,
Gastritis 10.24 10.29 ✓ 165 73 136/87 36,7
antasida, pct
Kolik pct, hyocine,
10.15 10.25 ✓ 127/80 36,5
Abdomen omeprazole
ambroxol, amlodipin,
HT gr I + Ispa 10.46 10.56 ✓ 158 64 146/102 36,8
ibuprofen, amox
Faringitis + amox, pct, ambroxol ✓ 25 37

Ispa 10.07 10.12
Corpal mata +
Trauma dd Rujuk poli mata RSUD
09.52 09.57 ✓ 164 52 129/81 37
orbital OD. DHAAN
(SOS)
DM dgn
Rujuk poli penyakit
Terapi insulin 09.51 09.55 ✓ 159 55 163/87 37,2
dalam RSMP
+ HT gr II
amlodipin, ibuprofen,
HT terkontrol Vit B1 10.20 10.25 ✓ 150 52 136/81 36,9
amox, ambroxol,
Ispa cetirizine, pct 10.58 11.03 ✓ 108 18 36.7
;l Riwayat PTM
Riwayat
Riwayat Riwayat
Riwayat Riwayat Pemeriks
HR LP Lab Penyakit merokok Perdarah aan
( ≥ 15 Sebelum Alergi
Keluarga th ) an IVA/Sad
nya
anis
86 - - - - - - - - -
- - - - - - - - -
75 - - DM - - - - - -
GDP :
76 - - DM + HT
217
- - - - - - - - -
89 - - - HT - - - - -
113 - - - - - - - - -
90 - - - - - - - -
96 - - - - - - - -
82 - - - - - - - -
- - - - - - - -
87 - - - - - - - -
GDS :
103 - 364 , - DM + HT - - - - -
Hb : 13,1
78 - GDS : - - - - - - -
337
87 - - - - - - - - -
99 - - - - - - - - -
75 - AU : 4,4 - - - - - - -
128 - - - - - - - - -
101 - - - - - - - -
78 - - - - - - - - -
84 - - - - - - - - -
GDS :
113 - - - - - - - -
312
AU : 7,9 ,
78 - GDP : - - - - - - -
174
GDS :
78 - 138, Hb : - - - - - - -
8,6
86 - - - - - - - - -
86 - - - - - - - - -
68 - - - - - - - - -
97 - - HT HT -
- - -
72 - - -
GDS :
101 - -
429
90 - - - - - - - - -
- - - - - - - - -
- - - - - - - - -
- - - - - - - -
Petugas : Caterina, Abdilah
ur
L
m
U
l
Tg
Tn. Rakhmad Lufi
1 12,936 0001148169677 6310092506810001 081348667253 41 th
Fauzi
An. M. Alfian
2 28,257 0003068743252 6310020311130003 085888817099 9 th
Ansyori
3 20,353 0001389731163 6310096512880016 085247050034 Ny. Siti Maysarah 34 th
4 18,651 0001922783207 6310094202710001 085251634125 Ny. Rusmah 51 th
5 27,133 0003068400497 6310095909760001 082148923547 Ny. Munawari 46 th
6 27,267 0002722613433 6310093112580005 tidak ada di Tn. Ramli 61 th

status
tidak ada di
7 26,999 0002849409426 3573055802760006 Ny. Sulistiyaningsih 46 th
status
8 11,283 0001922748434 6310094102740004 085821703440 Ny. Herniyati 48 th
0002722852293 An. N. Ikhsan

9 26,245 6310090705060003 085348581562 16 th
(Non Aktif) Fadillah
10 24,088 0001922780632 6310094406860004 082154893989 Ny. Risnawati 36 th
11 28,100 0002722843359 6310093009010003 085753241639 Tn. Askar 21 th
12 28,190 0002751285216 6310091709780005 081253743035 Tn. Munanto 44 th

(Non Aktif)
13 1,739 0001825085957 6310062406110002 082350946342 An. Akhmad Habibi 11 th
14 22,209 0002902581347 6310094702790008 081349602678 Ny. Mutmainah 43 th
15 22,209 0002902581505 6310097011110003 081349602678 An. Novy Nabila 11 th
16 20,453 0001554188624 6310104712110001 085395060664 An. Jesslyn 11 th
17 28,188 tidak ada 7309017112400050 085350280098 Ny. Hj. Maneng 82 th
18 17,874 0003068548481 6371054202800015 085393375284 Ny. Iriani 42 th
tidak ada di
19 11,316 0002722617437 6310096905760002 Ny. Konik Atur R 47 th
status
20 13,827 000276118839 6310096501040006 082150467531 Nn. Kissy Rella 19 th
tidak ada di
21 7,295 0002659955938 6310094107510029 Ny. Kamsiah 61 th
status
tidak ada di
22 20,967 0000593001022 3320116607790001 Ny. Lestari Ningsih 43 th
status
Ny. Hj. Ariani

23 26,951 0002722616256 6310096311730001 085346307686 Susanti 49 th
24 6,323 0002494554862 6310095703700003 085346505920 Ny. Nadiyah 62 th

An. Hernanda
25 15,212 0001922738736 6310092612080003 082358456062 14 th
Prayata R
26 25,234 0002501157464 6310091010710012 082148559620 Tn. Syukur Palawa 51 th
27
28
29
30
31
32
33
34
35
POLI UMUM
IGD: Anton
Pembiayaan
Status Status
Pendidi
ir
Dokter kunjung penyaki

ah
Alamat JK Pekerjaan
ur
kan
lL
m
an t Umum
U
Tg
25/06/1981 Jl. Banyuwangi Rt.7 L SMA Wiraswasta dr. Risky B B
Jl. Rahayu Rt.2 Masih

03/11/2013 L Pelajar dr. Risky B B
Bersujud Sekolah
Jl. Kemakmuran II dr.

25/12/1988 P SMA IRT B B
Rt.2 Kampung baru Rahmah
Jl. Rahayu Rt.7

02/02/1971 P SD IRT dr. Risky L L
Bersujud
19/09/1976 Jl. Rahayu Rt.6 P SD IRT B B

Bersujud dr. Risky
tidak
31/12/1961 Jl. Pasar Sabtu Rt.10 L ada di Wiraswasta dr. Risky B B
TP
status
Jl. Transmigrasi Rt.11
18/02/1976 P SMA IRT dr. Risky B B
Bersujud
tidak
Jl. Karya Budaya dr.
01/02/1974 P ada di IRT B B
Rt.11 Baroqah Rahmah
status
07/05/2006 Jl. Cendana Rt.8 L SMP Pelajar dr. B B ✓

Rahmah
Jl. Kampung Baru

04/06/1986 P S1 Guru dr. Risky B B
Rt.12 Kampung Baru
Jl. Perum Bumi raya

30/08/2001 L SMA Polri dr. Risky B B
Rt.4 GB
17/09/1978 Jl. Mega Indah Rt.6 L SD Wiraswasta B B ✓

GB dr. Risky
Jl. Mangga 2 Rt.14 Masih dr.
24/06/2011 L pelajar B B
Bersujud Sekolah Rahmah
tidak
Jl. Raya Serongga KM
07/02/1979 P ada di IRT dr. Risky B B
5 Rt.2 GB
status
Jl. Raya Serongga KM Masih

30/11/2011 P Pelajar dr. Risky B B
5 Rt.2 GB Sekolah
Jl. Batu Benawa Rt.9 Masih

07/12/2011 P Pelajar dr. Risky B B
Bersujud Sekolah
31/12/1940 Gunung Besar Rt.4 P SMP Wiraswasta dr. B B ✓

Rahmah
02/02/1980 Jl. Kodeco rt.3 GA P SMA IRT dr. B B

Rahmah
Jl. Mekar sari Rt.15

29/05/1976 P SMP IRT dr. Risky B B
GA
25/01/2004 Jl. Senada Rt.7 GB P SMA Pelajar dr. B B

Rahmah
Jl. Pel. Speed Rt.5 dr.

01/07/1961 P SD IRT B B
Sejahtera Rahmah
26/07/1979 Jl. Sei Kecil GB P SD IRT dr. Risky B B
Jl. Tungkaran
23/11/1973 Pangeran rt.8 P SMP IRT dr. Risky B B
tidak
Jl. Lap 5 Okt Rt.5
17/03/1960 P ada di IRT dr. Risky L L
Bersujud
status
Jl. Bangun Banua dr.
26/12/2008 L SMP Pelajar B B
Rt.11 Baroqah Rahmah
Jl. Ins-Gub Rt.11 dr.

10/10/1971 L B B B B
Kampung Baru Rahmah
✓
M
Pembiayaan Wkt Playan ;l
Diagnosis Terapi & Tindakan KIE

BPJS SKTM D P TB BB
Rujuk Poli Kulit

✓ Vitiligo 08.15 18.25 ✓ 154 58
Kelamin RS Husada
Rujuk Poli Bedah

✓ Hernia 08.17 08.27 ✓ 131 37
RSMP
Rujuk Poli Jiwa RSUD

✓ Skizofrenia 08.20 08.30 ✓ 148 62
DHAAN
Metformin,
DM + HT + Glibenclamid,
✓ 08.20 08.30 ✓ 154 51
Dermatitis Amlodipin, Cetirizin,
Betametason Zalf
✓ F41.0 Rujuk Poli Jiwa RSUD ✓ 153 52

DHAAN 08.35 08.45
✓ DM dg Insulin Rujuk Poli penyakit 08.45 08.55 ✓ 47

Dalam RSUD DHAAN
✓ DM tp.II Metformin, Ibuprofen 08.55 09.05 ✓ 68
Omeprazole, PCT,
Dyspepsia +
✓ Hyoscine, Zink, Vit. 08.40 08.50 ✓ 155 72
GEA
Bcomp
Epistaksis Asmef, Vit.C, PCT 09.00 09.10 ✓ 165 72
Rujuk Poli THT RSUD

✓ Tinitis 08.50 09.00 ✓ 145 69
DHAAN
Vulnus
✓ Up. Jahitan 09.00 09.10 ✓ 167 65
Laceratum
Lansoprazole,
Diare + Domperidone, ✓ 160 46
Dyspepsia 09.20 09.30
Neodiaform, PCT
Commond Amoxilin, PCT,
✓ 09.10 09.20 ✓ 143 38
Cold Ambroxol, Vit.C
✓ Tennis Elbow nadic, Kalk 09.30 09.40 ✓ 161 52
Diare + Neodiaform,
✓ 09.33 09.43 ✓ 147 32
Dyspepsia Lansoprazole
Dermatitis
✓ Seboroik + Amoxilin, Ibuprofen, 09.36 09.46 ✓ 148 39
furunkel
Ibuprofen,
Myalgia + Omeprazole,
Susp. TB Ambroxole, Vit. 09.22 09.32 ✓ 155 35
Bcomp,
DM tp.II Metformin,
+Hiperglikemi Glibenclamid,
✓ 09.55 10.05 ✓ 146 54
a + Candidiasis Omeprazole, PCT,
Vagina Vit.B12 Cetirizine
Dyspepsia + Amlodipin, Ibuprofen,

✓ 10.00 10.10 ✓ 139 48
HT Lansoprazole
Susp. Kuadran
✓ Saluran Cerna Omeprazole, PCT, 10.10 10.20 ✓ 153 39
atas Asmef, Hemafort
Metformin,
DM tp.II + OA Amlodipine,
✓ Ibuprofen, 10.15 10.25 ✓ 163 55
Genu
Omeprazole, Vit
Bcomp, Kalk
Ambroxole, Amoxilin,
✓ ISPA 10.20 10.30 ✓ 159 89
Cetirizine, PCT
Konjungtivitis
Bakterial OD + Gentamicin eye Zalf,
✓ Hordeolum Amoxiline, Nadic, 10.30 10.40 ✓ 147 56
Eksterne OS + PCT, Dexa
Abses
Cifroploxacin,
✓ Susp. ISK + HT Amlodipin, Nadic, 11.08 11.18 ✓ 146 55
PCT, Lanso,
Omeprazole, PCT,
Abdominal
✓ Hyoscine, 10.03 10.08 ✓ 43
Pain
Cotrimoxazole, Zink
Furosemide,
HT gr.II + GEA
Amlodipin, PCT,
✓ Tanpa 11.17 11.27 ✓ 163 94
Omeprazole, Zink, Vit
Dehidrasi
Bcomp
10.15 10.25 ✓
✓ 10.46 10.56 ✓
10.07 10.12 ✓
✓ 09.52 09.57 ✓
✓ 09.51 09.55 ✓
✓ 10.20 10.25 ✓
✓ 10.58 11.03 ✓
✓
;l Riwayat PTM
Riwayat Riwayat
Riwayat Riwayat
TD T HR LP Lab Penyakit merokok Perdarah
( ≥ 15 Sebelum Alergi
Keluarga th ) an
nya
141/90 37 65 - -
36,9 - -
129/79 37 115 - -
142/86 36,8 86 GDP: 99 Stroke Stroke
130/97 36,8 79 - -
130/75 36,5 88 - -
136/75 36,8 97 - -
114/66 36,8 93 - -
143/104 36,9 89 DM, HT - -
147/105 36,9 91 - -
125/90 36,9 81 - -
123/72 36,9 93 - -
36,9 - -
133/66 37 70 - -
37,1 - -
36,8 - -
123/79 36,8 81 - -
DM,
131/98 37 98 DM, HT Kolester DM - -
ol
149/95 36,9 103 HT Gastritis - -
90/63 36,7 Hb:10,2 - -
148/89 36,8 89 - -
HT,
143/105 36,9 110 Asma - -
Asma
120/86 37,2 111 GDS: 110 - -
149/82 37 77 - -
36,7 - -
175/117 36,6 84 DM, HT HT HT - -
- -
- -
- -
- - - - - - - -
- - - - - - -
Riwayat
Pemeriks
aan
IVA/Sad
anis
-
-
-
-
-
-
-
-
-
-
-
-
-

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POLI UMUM

Hari/ Tanggal : Senin, 02 Januari 2023

Pembiayaan Wkt Playan PEMERIKSAAN Riwayat PTM

CHF +CAD + ABSES Rujuk POLI BEDAH RS

Metformin. Glibenclamid, GDP : 165,

Ambroxol, amoxilin, pct,

Ambroxol, ctm, vit c,

guafenesin, pct, ctm,

flutrop, ambroxol, pct, vit

An. M. Fakhry ambroxol, MP, PCT,

PCT, Ambroxol, ctm, vit. C,

rujuk poli penyakit dalam

jalan jembatan ambroxol, amoxiciln, pct,

RUJUK Poli bedah IGD

rujuk poli penyakit dalam

scabimet, cetirizine, metronidazole,

amlodipin, glibenclamide, metformin,

cetirizine, hidrocortisone, amlodipin, gliben,

furocemide, amlodipin, ibu, omeprazole,

Susp.STT dd.kista gaglion +

Pekerjaan KIE Riwayat Riwayat Riwayat

08.17 08.27 wiraswasta ✓ 173 78 130/90 36,9 85

08.24 08.34 IRT ✓ 138 51 142/93 37 109

HB: 10,4 GDP:

08.35 08.45 IRT ✓ 147 71 154/87 36,1 80 HT HT

09.08 09.18 wiraswasta ✓ 151 48 147/81 36,1 79 HT

09.18 09.28 wiraswasta ✓ 158 78 154/92 36,1 81 HT

09.25 09.35 IRT ✓ 155 90 184/122 36,8 85 HT

09.38 09.48 _ ✓ 123 30 37,1

09.50 10.00 IRT ✓ 155 66 140/88 36,7 77 HT

10.01 10.11 _ ✓ 101 13,7 36,9

10.17 10.27 _ ✓ 153 36 108/93 36,7 113

HB: 12,1 GDS:

GDS : 122 kols

10.48 10.58 wiraswasta ✓ 169 61 150/89 37,1 78

10.43 10.53 _ ✓ 100 14 37

10.04 10.14 wiraswasta ✓ 154 60 107/61 36,7 81

11.02 11.12 wiraswasta ✓ 169 64 104/73 37,1 69

10.56 11.06 wiraswasta ✓ 163 59 134/84 36,7 51

11.11 11.21 IRT ✓ 154 62 182/112 36,7 111 HT HT

09.55 10.05 IRT ✓ 171 85 109/82 36,9 107 HT,Jantung HT,Jantung

12.02 12.12 ✓ 120 22 37

11.04 11.14 ✓ 159 76 172/103 36,7 78 HT HT

11.15. 11.18 IRT ✓ 156 51 115/88 36,7 74

11.19 11.23 IRT ✓ 163 58 157/88 36.7 74 DM,HT DM,HT

Common cold + Chest

Jl.Nusa Indah RT.1

Nn.Alfina Obs febris + sindrom

An.M Kasip 5th 4

Rujuk poli paru RS

PCT, VitC 09.08 09.15 Pelajar ✓ 140 31 - 36,8 - - - - - - - - - -

Nadic, Ambroxol, Chol:1

CTM, Scabimed IRT ✓ 153 70 130/91 37 74 - - - - - - - - -

Rujuk poli bedah

Ambroxol, CTM, Pelajar ✓ 121 28 - 36,8 - - - - - - - - - -

Salep 24, Amox,

ibuprofen, Bcomp IRT ✓ 152 59 106/82 37 94 Hb:12,

3 8667 0002071335982 6310095908680001 082352259250 Ny.harliyah 52 th 1-8-1968 dr ferisa jl.cempka putih rt 7 TP P L ✓

8 28176 0001656185872 6302062309880004 08521840440 Tn.Heril Arifin 35 th 23-901988 dr.rahmah Jl perjuangan TP L B ✓

10 23915 0002749459241 6310091902600002 085258091009 Ny.Asniah 62 th 19-02-1960 dr ferisa jl transmigrasi rt 1 0 DB P L ✓

11 10.138 0001677279587 63100931005950003 tdk ada Tn.Rusli hadri 26 th 31-05-1995 dr ferisa jl BB rt 3 DB L L ✓

12 4583 0000124113464 6310094204480002 082153752975 Ny.Tasmiah 74 th 2-4-1948 dr ferisa jl bb rt 8 DB P L ✓

15 18640 00019227842276 6310092760004 081349683887 Tn.Misransyah 46 th 27-2-1976 dr ferisa Jl.Raya btl rt 2 DB L L ✓