Untitled

FORMULIR 11
LAPORAN BULANAN KESAKITAN UMUM
Jml
Bula
Kode Maret Jml. PP 2 Poskesdes/bidan 5
n
desa
Tah
Puskesmas Santong 2022 Jml melapor Jml melapor
un
JUMLAH KASUS JUMLAH KASUS

JUMLAH KASUS (Umur dan Jenis Kelamin)
BARU LAMA
No. JENIS PENYAKIT ICD 10 0-7 hari 8-28 hari 1-11 bl 1-4 th 5-9 th 10-14 th 15-19 Th 20-44 th 45-59 th >59 th JML L P JML L P JML
L P L P L P L P L P L P L P L P L P L P
A KELOMPOK UMUM
1 Alergi makanan L27.2 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 2 0 2 2 0 0 0
2 Chikungunya A92.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Demam dengue dan

3 0 0 0
demam berdarah dengue
a. Demam berdarah dengue A91 0 0 0 0 0 0 0 0 1 2 1 1 0 0 0 0 0 0 0 0 5 2 2 4 0 1 1
b. Demam dengue A90 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 4 2 1 3 0 1 1

4 Filariasis B74 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0
5 Infeksi pada Umbilikus P38 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Kandidiasis Mulut B37.9 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2 2 0 0 0
7 Keracunan makanan T62.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Lepra A30 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Leptospirosis A27.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Malaria B54 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Morbili (Campak) B05.9 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 3 2 1 3 0 0 0
12 Reaksi Anafilaktik T78.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Syok R57.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
BARU LAMA
TB selain Paru (ekstra

14 A18 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Paru)
15 Tuberkulosis (TB) Paru A15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 1 1 0 0 0 4 3 0 3 1 0 1

16 Tuberkulosis dengan HIV B20.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
17 Varisela B01.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
DARAH, PEMBENTUKAN
B 0 0 0
DARAH DAN SISTEM IMUN
1 Anemia defisiensi besi D50.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HIV/ AIDS tanpa

2 Z21 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
komplikasi
3 Leukemia D55 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Limfadenitis B70 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Limfoma Maligna C85.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Lupus Eritematosus
6 M32 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sistemik
7 Thalasemia D56 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
C DIGESTIVE 0 0 0
1 Ankilostomiosis B76.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Apendisitis Akut K.35.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Askariasis B77.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Atresia (ani) dengan atau

4 Q42 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
tanpa fistula
Bibir dan langit-langit

5 Q37.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
sumbing
6 Bibir sumbing Q36.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

7 Demam tifoid A01.0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 3 1 2 3 0 0 0
Disentri basiler dan

8 A06.0 0 0 0 0 1 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 4 1 3 4 0 0 0
disentri amuba
BARU LAMA
9 Gastritis K29.7 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 1 2 1 6 4 0 4 0 2 2
Gastroenteritis (Kolera dan

10 A09 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Giardiasis)
11 Gastroschisis Q79.3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Hemoroid grade 1-2 I84 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Hepatitis A B15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
14 Hepatitis B B16 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
15 Hepatitis C B18.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
16 Intoleransi makanan K90.4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
17 Kolesistitis K81.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
18 Langit-langit sumbing Q35 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
19 Malabsorbsi makanan K90.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
20 Omphalocele Q79.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
21 Parotitis B26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
K92.2
22 Perdarahan gastrointestinal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
K62.5
23 Peritonitis K65.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
24 Refluks gastroesofageal K21.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
25 Skistosomiasis B65.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
26 Strongiloidiasis B78.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
27 Taeniasis B68.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
28 Ulkus mulut K12 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
D MATA 0 0 0
1 Astigmatisme H52.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Benda asing di konjungtiva T15.9 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0
3 Blefaritis H01.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Buta senja H53.6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
BARU LAMA
5 Episkleritis H15.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Glaukoma akut H40.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Glaukoma kronis H40.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Hifema H21.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Hipermetropia H52.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Hordeolum H00.0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0
11 Katarak kongenital Q12.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Katarak pada pasien

12 H26.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
dewasa
13 Konjungtivitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Konjungtivitis alergi H10.1 0 0 0 0 2 0 1 2 1 0 1 0 0 0 2 3 0 0 0 0 12 4 6 10 0 2 2
b. Konjungtivitis
H10.9 0 0 0 0 0 2 0 2 2 1 1 0 0 1 0 0 0 0 0 0 9 2 3 5 1 3 4
infeksi
14 Laserasi kelopak mata S01.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

15 Low vision H.54 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
16 Mata kering H04.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 2 1 1 2 0 0 0
17 Miopia ringan H52.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 3 1 1 2 1 0 1
18 Perdarahan subkonjungtiva H57.8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
19 Presbiopia H52.4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 2 1 1 2 0 0 0
20 Pterygium H11.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 2 1 1 2 0 0 0
21 Retinoblastoma C69.21 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
22 Retinopati diabetik H36.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
23 Trauma kimia mata T26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
24 Trikiasis H02 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
BARU LAMA
E TELINGA 0 0 0
1 Benda asing ditelinga T16 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2 2 0 0 0
2 Mastoiditis H70 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Otitis eksterna H60.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 3 3 0 8 2 2 4 2 2 4
4 Otitis media akut H65 0 0 0 0 0 1 2 0 0 1 1 0 0 0 0 0 0 0 0 0 5 2 1 3 1 1 2
Otitis media supuratif

5 H66 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
kronik
6 Presbiakusis H91.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Serumen prop H61.2 0 0 0 0 0 0 0 0 5 0 0 2 0 1 1 1 0 1 1 0 12 6 3 9 1 2 3
8 Tuli akibat bising H83 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Tuli kongenital H90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
F KARDIOVASKULER 0 0 0
1 Angina pektoris stabil I20.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Cardiorespiratory arrest R09.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gagal jantung akut dan

3 I50.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0
kronik
4 Hipertensi esensial I10 0 0 0 0 0 0 0 0 0 0 0 0 0 2 10 22 4 32 5 1 76 8 10 18 15 43 58

5 Infark miokard I21.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Takikardia I47 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
G MUSKULOSKELETAL 0 0 0
1 Artritis reumatoid M53.3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 3 2 2 1 9 0 1 1 5 3 8
2 Artritis, osteoartritis M19.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Fraktur terbuka S52.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Fraktur tertutup S52.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Lipoma D17.9 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0
6 Osteoporosis M81.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Osteosarkoma C41 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Polimialgia reumatik M53.3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
BARU LAMA
9 Reduction deformity Q73.8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

10 Talipes Q66 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Vulnus T14.1 0 0 0 0 0 0 0 10 0 0 0 0 5 0 0 0 0 0 0 0 15 10 5 15 0 0 0
H NEUROLOGI 0 0 0
1 Anencephaly Q00.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Bells’ Palsy G51.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Delirium F05.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Epilepsi G40.9 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 0 4 1 0 1 2 1 3
5 Kejang demam R56.0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 1 1 0 1 1
6 Meningo/encephalocele Q01.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Migren G43.9 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 2 0 2 2 0 0 0
8 Neuroblastoma C74.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Rabies A82.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Status epileptikus G41.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Stroke I63.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Tension headache G44.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Tetanus A35 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
14 Tetanus neonatorum A33 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Transient Ischemic Attack

15 G45.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
(TIA)/
16 Vertigo R42 0 0 0 0 0 0 0 0 0 0 0 0 3 2 0 0 1 1 0 0 7 1 1 2 3 2 5
I PSIKIATRI 0 0 0
1 Demensia F03 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Gangguan anxietas F40# 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gangguan campuran
3 F41.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
anxietas dan depresi
4 Gangguan depresi F33 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

BARU LAMA
Gangguan penggunaan
5 F10# 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
napza
Gangguan perkembangan
6 dan perilaku pada anak F80-90# 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
dan remaja
7 Gangguan psikotik F20# 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 3 0 7 0 0 0 6 1 7

8 Gangguan somatoform F45 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0
9 Insomnia F51.0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1
J RESPIRASI 0 0 0
1 Asma bronkial J45 0 0 0 0 3 3 0 0 0 0 0 0 10 2 0 0 0 0 0 0 18 2 2 4 11 3 14
2 Asfiksia R.09.0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2 2 0 0 0
3 Benda asing di hidung T17.1 0 0 0 0 3 3 0 0 0 0 0 0 10 1 0 0 0 0 0 0 17 2 1 3 11 3 14
Bronkitis akut (usia < 15

4 J20.9 0 0 0 0 0 0 2 1 1 2 0 2 0 0 0 0 0 0 0 0 8 2 3 5 1 2 3
tahun)
Bronkitis akut (usia > 15

5 J40 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
tahun)
6 Difteria A36.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Epistaksis R04.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Faringitis akut J02.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 2 0 0 4 1 0 1 3 0 3
9 Furunkel pada hidung J34.0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 2 2 0 2 0 0 0
10 Influenza J11 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Kanker nasofaring C11.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Kanker paru C34.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Laringitis akut J04.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Penyakit paru obstruktif

14 J44.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 0 0 0 3 0 0 0 2 1 3
kronis
15 Pertusis (batuk rejan) A37.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

16 Pneumonia aspirasi J69.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
BARU LAMA
Pneumonia,
17 0 0 0
Bronkopneumonia
a. Bronkopneumonia J18.0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 3 2 1 3 0 0 0
b. Pneumonia J18.9 0 0 0 0 0 3 5 0 1 0 0 0 0 0 0 0 0 0 1 0 10 4 4 8 1 1 2
18 Pneumotoraks J93.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
19 Rinitis akut J00 0 0 0 3 2 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 6 1 1 2 1 3 4
20 Rinitis alergi J30.4 0 0 0 0 0 0 0 0 0 0 0 2 2 2 1 0 2 1 2 0 12 4 6 10 1 1 2
21 Rinitis vasomotor J30.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
22 Sinusitis akut J01 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
23 Status asmatikus J46 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 8 2 6 0 0 18 0 4 4 4 10 14
24 Tonsilitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Tonsilitis akut J03.9 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0
b. Tonsilitis kronis J35.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
25 Penyakit ISPA tidak J06 0 0 0 0 14 10 36 26 13 9 4 9 3 6 6 6 5 18 1 1 167 45 46 91 43 33 76
spesifik
K KULIT 0 0 0
1 Akne Vulgaris Ringan L70.0 0 0 0 0 5 3 0 0 20 6 0 2 5 0 0 0 0 0 0 0 41 17 6 23 13 5 18
2 Cutaneus Larva Migrans B76.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Dermatitis atopik L20 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 0 0 0 0 4 0 0 0 2 2 4
4 Dermatitis kontak alergi L23 0 0 0 0 0 0 0 2 0 0 1 0 0 0 1 2 0 0 0 0 6 3 3 6 0 0 0
5 Dermatitis kontak iritan L24 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Dermatitis numularis L20.8 0 0 0 0 0 0 0 1 2 0 1 0 0 0 0 0 0 0 0 0 4 3 1 4 0 0 0
7 Dermatitis perioral L71.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Dermatitis popok L22 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Dermatitis seboroik L21 0 0 0 0 0 3 1 2 2 1 0 1 2 0 0 0 0 0 0 0 12 2 3 5 2 5 7
10 Dermatofitosis B35 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Tinea capitis dan

B35.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
tinea barbea
b. Tinea corporis B35.4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 2 1 0 1 0 1 1

BARU LAMA
c. Tinea cruris B35.6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

d. Tinea manuum B35.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
e. Tinea pedis B35.3 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 1 1 0 0 0
f. Tinea unguium B35.1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 2 0 2 2 0 0 0
11 Erisipelas A46 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Eritrasma L08.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Exanthematous drug
13 L27.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Eruption
14 Fixed Drug Eruption L27.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Frambusia RDT (+)

15 A66 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
konfirmasi/probable
16 Herpes simplek B00.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

17 Herpes zoster B02.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
18 Hidradenitis supuratif L73.2 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0
Liken simpleks kronik
19 (Neurodermatitis L28.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sirkumkripta)
20 Luka bakar derajat I dan II T30 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
21 Miliaria L74.3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
22 Moluskum kontagiosum B08.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
23 Pedikulosis kapitis B85.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
24 Pedikulosis pubis B85.3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
25 Pioderma 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Abses, furuncke
L02 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1 1 0 2 1 0 7 3 1 4 3 0 3
dan carbuncle
b. Impetigo L01 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
c. Pioderma L08.0 0 0 0 0 0 1 0 2 1 0 0 0 0 0 0 1 0 0 0 0 5 1 1 2 0 3 3
26 Pitiriasis Rosea L42 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
BARU LAMA
27 Pitiriasis versikolor B36.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

28 Reaksi Gigitan Serangga T63.4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
29 Sindrom Stevens Johnson L51.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
30 Skabies B86 0 0 0 0 1 2 1 1 2 4 1 2 3 2 2 1 1 0 0 1 24 8 6 14 4 6 10
31 Skrofuloderma A18.4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
32 Ulkus pada tungkai L98 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 1 1 0 0 0
33 Urtikaria L50 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 0 0 0 0 4 2 2 4 0 0 0
34 Veruka Vulgaris B07 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
METABOLIK ENDOKRIN
L 0 0 0
DAN NUTRISI
1 Diabetes Mellitus Tipe 1 E10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 6 4 14 0 0 28 1 2 3 6 19 25

2 Diabetes Mellitus Tipe 2 E11 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 3 0 0 5 0 0 0 2 3 5
Hiperglikemia
3 R73.9 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 3 0 0 0 3 0 3
Hiperosmolar Non Ketotik
Hiperurisemia – Gout
4 E79.0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 2 0 0 0 0 2 2
Arthritis
5 Hipoglikemia E16.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Hipotiroid kongenital E03.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Lipidemia E78.5 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1
8 Malnutrisi energi Protein E46 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Obesitas E66.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Tirotoksikosis E05.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Inkontinensia feses R15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Retensi urin R33 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
GINJAL DAN SALURAN

M 0 0 0
KEMIH
1 Epispadia Q64.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
BARU LAMA
2 Fimosis N47 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Hipertropi prostat N40 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Hypospadia Q54 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Infeksi saluran kemih N39.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 3 0 0 0 5 2 0 2 3 0 3
6 Parafimosis N47.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Penyakit ginjal kronik N03 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pielonefritis tanpa
8 N10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
komplikasi
Batu Sistem Kemih (ginjal,
N20-
9 ureter, saluran kemih 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 1 0 1 0 5 3 0 3 2 0 2
N21
bawah)
N KESEHATAN WANITA 0 0 0
1 Abortus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Abortus inkomplit O06.4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 1 0 0 0
b. Abortus komplit O03.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 3 0 3 3 0 0 0
Anemia defisiensi besi pada

2 O99.0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 6 0 0 0 0 7 0 3 3 0 4 4
kehamilan
3 Cracked Nipple O9212 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 3 0 0 0 0 4 0 4 4 0 0 0

4 Eklampsi O15.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Hiperemesis gravidarum O21.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Inverted Nipple O92.02 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Kanker serviks C53.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Kehamilan normal O80.9 0 0 0 0 0 0 0 0 0 0 0 0 0 38 0 300 0 5 0 0 343 1 68 69 0 274 274
9 Ketuban pecah dini O42.9 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 6 0 0 0 0 7 0 7 7 0 0 0
10 Mastitis N61 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Perdarahan post partum 072.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 1 0 0 0
12 Persalinan lama O63.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Pre eklampsia O14.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
BARU LAMA
Ruptur perineum tingkat 1-

14 O70.0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 2 0 0 0 0 3 0 3 3 0 0 0
2
15 Tumor payudara C50.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

O PENYAKIT KELAMIN 0 0 0
1 Fluor albus N98.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Sifilis A53.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Gonore A54.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Vaginitis N76.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Vulvitis N76.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P PENYAKIT LAINNYA 0 0 0
1 Cedera pada kepala S00-S09 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Cedera pada leher S10-S19 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Cedera pada rongga dada

3 S20-S29 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
(toraks)
Cedera pada perut,
4 punggung, tulang S30-S39 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
belakang, dan pinggul
S40-
Cedera pada bahu, lengan
S49,
atas, siku, lengan bawah,
5 S50- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
pergelangan dan telapak
S59,
tangan
S60-S69
Cedera pada paha, lutut, S70-

kaki bagian bawah, telapak S79,S80
6 kaki -S89, 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
S90-S99
7 Persalinan tunggal spontan O80 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 15 0 0 0 0 19 0 11 11 0 8 8

8 Persalinan SC O82.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
PNC Routine Postpartum
9 Z39.2 0 0 0 0 0 0 0 0 0 0 0 0 0 6 0 65 0 3 0 0 74 0 49 49 0 25 25
Follow Up
BARU LAMA
10 Gemelli / Twin pregnancy O30.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 2 0 2 2 0 0 0

BARU LAMA
11 Pre-eklamsia sedang O14.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Kehamilan dengan
12 O25 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 26 0 0 0 0 30 0 3 3 0 27 27
malnutrisi
13 Gangguan
Neonatus yang 24 25 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 49 13 36 49 0 0 0
14 berhubungan
Blighted ovum dengan O02.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
pendeknya masa gestasi
P07
15 (kehamilan) dan berat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
badan lahir rendah BBLR,
16 Dispepsia
tidak terklasifikasikan di K30 0 0 0 0 0 0 0 0 3 0 2 0 0 0 3 14 2 5 0 0 29 7 4 11 5 13 18
Demam yang tidak R50
17 tempat lainnya 0 0 0 0 3 1 2 1 2 9 5 0 1 1 0 0 2 3 0 0 30 14 9 23 3 4 7
diketahui sebabnya
Gangguan telinga lain tidak
18 H93 0 0 0 0 0 0 0 9 4 0 10 2 0 0 5 0 0 0 0 0 30 6 9 15 13 2 15
spesifik
Rematisme, tidak spesifik, M79.0-
19 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 4 1 4 0 0 10 0 0 0 4 6 10
Myalgia M79.1
20 D48
Tumor tertentu atau tidak
diketahui perilaku lainnya, 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 5 0 0 0 0 6 0 0 0 0 6 6
tempat dan tidak spesifik
21 Nyeri kepala R51 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 3 1 2 3 0 0 0

22 Colic Abdomen r10 0 0 0 1 0 0 0 2 0 0 0 2 0 0 1 0 0 3 0 0 9 3 4 7 1 1 2
23 Low back pain M54.5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 1 0 0 3 0 3 3 0 0 0
24 Vomitus R11 0 0 0 0 0 0 0 0 2 0 0 3 0 0 0 2 0 1 0 0 8 2 6 8 0 0 0
25 Konstipasi K59 0 0 5 0 5 7 0 0 0 0 0 0 0 0 0 1 0 0 0 0 18 9 7 16 1 1 2
26 Selulitis L03 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 9 0 5 0 0 16 3 9 12 0 4 4
27 Chest Pain/Nyeri dada R07.9 0 0 0 1 0 0 0 0 0 0 2 2 1 0 0 0 0 0 0 0 6 5 1 6 0 0 0
28 Vertigo H81.4 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0
29 Snake Bite T63.0 0 0 1 0 0 2 0 0 0 0 0 0 0 0 0 0 0 1 0 0 4 2 2 4 0 0 0
30 Weakness R53.1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 3 2 1 3 0 0 0
31 ABDOMINAL PAIN B34.2 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 9 3 0 0 0 15 3 5 8 0 7 7
TOTAL 25 26 7 7 42 44 56 66 72 40 38 37 45 85 60 537 49 123 23 5 1387 243 409 652 183 552 735
1387 652 735
MENGETAHUI : Santong, Februari 2022
KEPALA UPT BLUD PUSKESMAS SANTONG Koordinator Sistem Informasi Puskesmas
Baiq Nirmalasari, S.Sos, MM Wahyu Candra, A.Md.Kep.

NIP. 19761112 200501 2 013 NIP.19940909 201902 1 007
FORMULIR 12
LAPORAN BULANAN KESAKITAN BERDASARKAN GEJALA, PENYEBAB PENYAKIT ATAU KONDISI PASIEN
Jml
Kode Bulan Maret Jml. PP 2 Poskesdes/b 5
idan desa
Jml Jml
Puskesmas Santong Tahun 2022
melapor melapor
GEJALA, PENYEBAB JUMLAH KASUS BARU (Umur dan Jenis Kelamin) JUMLAH KASUS LAMA
No. PENYAKIT ATAU KONDISI
PASIEN Kode 0-7 8-28 1-11 1-4 5-9 20-44
45-59 th >59 th L P JML L P JML
unik hari hari bl th th th
1 2 3 4 5 6 7 8 9 10 11 14 15 16 17 18 19
A INFEKSI PADA USUS
1 Diare tanpa dehidrasi 0
Diare dengan dehidrasi

2 0
ringan-sedang
Diare dengan dehidrasi
3 0
berat
INFEKSI PADA SALURAN
B
PERNAFASAN
1 Pneumonia berat 0
C INFEKSI UMUM BAKTERI
1 Demam tifoid probable 1 1
2 Demam tifoid konfirmasi
D INFEKSI UMUM VIRUS
1 Acute flaccid paralysis (AFP)
Hepatitis klinis
2 (ikterik/warna urine seperti
teh)
GANGGUAN MATA DAN
E
ADNEKSA
1 Buta
KECELAKAAN DAN
F
KERACUNAN
Cedera akibat kecelakaan

1 2 3 5
transport
2 Cedera akibat tenggelam
3 Cedera akibat jatuh

4 Cedera akibat terbakar
5 Cedera akibat digigit ular 2 2 1 5
Cedera atau gangguan
6 kesehatan akibat kekerasan
fisik
Gangguan kesehatan akibat
7
kekerasan mental
Gangguan kesehatan akibat

8
kekerasan seksual
Keracunan bahan kimia

9
(bukan makanan)
10 Keracunan makanan
GANGGUAN (CEDERA,
G
PENYAKIT) AKIBAT KERJA
1 Sakit akibat kerja
Cedera/kecelakaan akibat
2
kerja
H GANGGUAN MENTAL
Percobaan tindakan bunuh

1
diri
I PENYAKIT LAINNYA
1 Trauma lahir
KELAINAN BAWAAN
J
LAINNYA
1 Kembar siam
Total 0 0 0 0 0 3 2 2 4 0 0 11 0 0 0
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
Puskesmas Santong 2021
un melapor
No. JENIS PENYAKIT ICD 10

0-7 hari 8-28 hari 1-11 bl 1-4 th 5-9 th 10-14 th 15-19 Th 20-44 th 45-59 th >59 th JML
A KELOMPOK UMUM
1 Alergi makanan L27.2 0
2 Chikungunya A92.0 0
Demam dengue dan

3 0
a. Demam berdarah dengue A91 0
b. Demam dengue A90 0

4 Filariasis B74 0
5 Infeksi pada Umbilikus P38 0
6 Kandidiasis Mulut B37.9 0
7 Keracunan makanan T62.2 0
8 Lepra A30 0
9 Leptospirosis A27.9 0
10 Malaria B54 0
11 Morbili (Campak) B05.9 0
12 Reaksi Anafilaktik T78.2 0
13 Syok R57.9 0

14 A18 0
Paru)
15 Tuberkulosis (TB) Paru A15 2 1 1 0 4

16 Tuberkulosis dengan HIV B20.0 0
17 Varisela B01.9 0
DARAH, PEMBENTUKAN
B 0
1 Anemia defisiensi besi D50.9 0
HIV/ AIDS tanpa

2 Z21 0
komplikasi
3 Leukemia D55 0
4 Limfadenitis B70 0
5 Limfoma Maligna C85.9 0
Lupus Eritematosus
6 M32 0
Sistemik
7 Thalasemia D56 0
C DIGESTIVE 0
1 Ankilostomiosis B76.0 0
2 Apendisitis Akut K.35.9 0
3 Askariasis B77.9 0

4 Q42 0
tanpa fistula

5 Q37.9 0
sumbing
6 Bibir sumbing Q36.9 0

7 Demam tifoid A01.0 0

8 A06.0 0
disentri amuba
9 Gastritis K29.7 0

10 A09 0 0 0 0 0
Giardiasis)
11 Gastroschisis Q79.3 0
12 Hemoroid grade 1-2 I84 0
13 Hepatitis A B15 0
14 Hepatitis B B16 0
15 Hepatitis C B18.2 0

16 Intoleransi makanan K90.4 0

17 Kolesistitis K81.9 0

18 Langit-langit sumbing Q35 0

19 Malabsorbsi makanan K90.9 0
20 Omphalocele Q79.2 0
21 Parotitis B26 0
K92.2
22 Perdarahan gastrointestinal 0
K62.5
23 Peritonitis K65.9 0
24 Refluks gastroesofageal K21.9 0
25 Skistosomiasis B65.9 0
26 Strongiloidiasis B78.9 0
27 Taeniasis B68.9 0
28 Ulkus mulut K12 0
D MATA 0
1 Astigmatisme H52.2 0
2 Benda asing di konjungtiva T15.9 0 0 0 0
3 Blefaritis H01.0 0
4 Buta senja H53.6 0
5 Episkleritis H15.1 0
6 Glaukoma akut H40.2 0
7 Glaukoma kronis H40.2 0
8 Hifema H21.0 0
9 Hipermetropia H52.0 0 0 0
10 Hordeolum H00.0 0
11 Katarak kongenital Q12.0 0
Katarak pada pasien

12 H26.9 0 0 0 0 0
dewasa
13 Konjungtivitis 0
a. Konjungtivitis alergi H10.1 2 3 0 5
b. Konjungtivitis
H10.9 0
infeksi
14 Laserasi kelopak mata S01.1 0

15 Low vision H.54 0
16 Mata kering H04.1 1 1 2
17 Miopia ringan H52.1 1 1 1 3
18 Perdarahan subkonjungtiva H57.8 0
19 Presbiopia H52.4 1 1 0 2
20 Pterygium H11.0 1 1 2
21 Retinoblastoma C69.21 0
22 Retinopati diabetik H36.0 0
23 Trauma kimia mata T26 0
24 Trikiasis H02 0
E TELINGA 0
1 Benda asing ditelinga T16 0 0 0 0
2 Mastoiditis H70 0
3 Otitis eksterna H60.9 1 1 3 3 8
4 Otitis media akut H65 0 0 0 0 0 0

5 H66 0
kronik
6 Presbiakusis H91.1 0
7 Serumen prop H61.2 1 1 1 1 4
8 Tuli akibat bising H83 0
9 Tuli kongenital H90 0
F KARDIOVASKULER 0
1 Angina pektoris stabil I20.9 0
2 Cardiorespiratory arrest R09.2 0

3 I50.9 0
kronik
4 Hipertensi esensial I10 4 12 2 30 2 0 50

5 Infark miokard I21.9 0
6 Takikardia I47 0

G MUSKULOSKELETAL 0
1 Artritis reumatoid M53.3 0
2 Artritis, osteoartritis M19.9 0

3 Fraktur terbuka S52.9 0

4 Fraktur tertutup S52.9 0
5 Lipoma D17.9 0 0
6 Osteoporosis M81.9 0
7 Osteosarkoma C41 0
8 Polimialgia reumatik M53.3 0
9 Reduction deformity Q73.8 0
10 Talipes Q66 0
11 Vulnus T14.1 0
H NEUROLOGI 0
1 Anencephaly Q00.0 0
2 Bells’ Palsy G51.0 0
3 Delirium F05.9 0
4 Epilepsi G40.9 1 1 1 3
5 Kejang demam R56.0 0 0
6 Meningo/encephalocele Q01.9 0
7 Migren G43.9 0
8 Neuroblastoma C74.9 0
9 Rabies A82.9 0
10 Status epileptikus G41.9 0 0 0
11 Stroke I63.9 0 0
12 Tension headache G44.2 0
13 Tetanus A35 0
14 Tetanus neonatorum A33 0

15 G45.9 0
(TIA)/
16 Vertigo R42 1 1 2
I PSIKIATRI 0
1 Demensia F03 0
2 Gangguan anxietas F40# 0 0 0
Gangguan campuran
3 F41.2 0 0 0
4 Gangguan depresi F33 0 0
Gangguan penggunaan
5 F10# 0
napza
6 dan perilaku pada anak F80-90# 0
dan remaja
7 Gangguan psikotik F20# 0 1 1 0 1 1 3 0 7

8 Gangguan somatoform F45 0
9 Insomnia F51.0 0
J RESPIRASI 0
1 Asma bronkial J45 0
2 Asfiksia R.09.0 0
3 Benda asing di hidung T17.1 0

4 J20.9 0
tahun)

5 J40 0 0 0 0 0
tahun)
6 Difteria A36.9 0
7 Epistaksis R04.0 0
8 Faringitis akut J02.9 1 0 1 2 4
9 Furunkel pada hidung J34.0 0
10 Influenza J11 0
11 Kanker nasofaring C11.9 0
12 Kanker paru C34.9 0
13 Laringitis akut J04.0 0

14 J44.9 1 1 2
kronis
15 Pertusis (batuk rejan) A37.9 0

16 Pneumonia aspirasi J69.0 0
Pneumonia,
17 0
Bronkopneumonia

a. Bronkopneumonia J18.0 0
b. Pneumonia J18.9 0

18 Pneumotoraks J93.9 0
19 Rinitis akut J00 0 1 0 1
20 Rinitis alergi J30.4 0 0
21 Rinitis vasomotor J30.0 0
22 Sinusitis akut J01 0
23 Status asmatikus J46 2 8 2 6 18
24 Tonsilitis 0
a. Tonsilitis akut J03.9 0
b. Tonsilitis kronis J35.9 0
25 Penyakit ISPA tidak J06 1 4 2 6 0 0 13
spesifik
K KULIT 0
1 Akne Vulgaris Ringan L70.0 0
2 Cutaneus Larva Migrans B76.9 0
3 Dermatitis atopik L20 2 2 4
4 Dermatitis kontak alergi L23 1 1 2
5 Dermatitis kontak iritan L24 0
6 Dermatitis numularis L20.8 0
7 Dermatitis perioral L71.0 0
8 Dermatitis popok L22 0
9 Dermatitis seboroik L21 0
10 Dermatofitosis B35 0

B35.0 0
tinea barbea
b. Tinea corporis B35.4 1 1 2

c. Tinea cruris B35.6 0
d. Tinea manuum B35.2 0
e. Tinea pedis B35.3 0
f. Tinea unguium B35.1 0
11 Erisipelas A46 0
12 Eritrasma L08.1 0
Exanthematous drug
13 L27.0 0
Eruption
14 Fixed Drug Eruption L27.0 0
Frambusia RDT (+)

15 A66 0
konfirmasi/probable
16 Herpes simplek B00.9 0

17 Herpes zoster B02.9 0
18 Hidradenitis supuratif L73.2 0
19 (Neurodermatitis L28.0 0
Sirkumkripta)
20 Luka bakar derajat I dan II T30 0
21 Miliaria L74.3 0
22 Moluskum kontagiosum B08.1 0
23 Pedikulosis kapitis B85.0 0
24 Pedikulosis pubis B85.3 0
25 Pioderma 0
a. Abses, furuncke
L02 1 1 2 4
dan carbuncle
b. Impetigo L01 0
c. Pioderma L08.0 0 1 0 0 1
26 Pitiriasis Rosea L42 0
27 Pitiriasis versikolor B36.0 0
28 Reaksi Gigitan Serangga T63.4 0
29 Sindrom Stevens Johnson L51.1 0
30 Skabies B86 1 1 0 0 2
31 Skrofuloderma A18.4 0
32 Ulkus pada tungkai L98 0 0 0
33 Urtikaria L50 2 2 4
34 Veruka Vulgaris B07 0
METABOLIK ENDOKRIN
L 0
DAN NUTRISI

1 Diabetes Mellitus Tipe 1 E10 4 6 4 14 0 0 28

2 Diabetes Mellitus Tipe 2 E11 0 0 1 2 0 3
Hiperglikemia
3 R73.9 0
4 E79.0 0 0
Arthritis
5 Hipoglikemia E16.2 0
6 Hipotiroid kongenital E03.1 0
7 Lipidemia E78.5 0 0 0
8 Malnutrisi energi Protein E46 0
9 Obesitas E66.9 0
10 Tirotoksikosis E05.9 0
11 Inkontinensia feses R15 0
12 Retensi urin R33 0 0 0
GINJAL DAN SALURAN

M 0
KEMIH
1 Epispadia Q64.0 0
2 Fimosis N47 0
3 Hipertropi prostat N40 0
4 Hypospadia Q54 0
5 Infeksi saluran kemih N39.0 2 0 3 0 5
6 Parafimosis N47.2 0
7 Penyakit ginjal kronik N03 0
Pielonefritis tanpa
8 N10 0
komplikasi
N20-
9 ureter, saluran kemih 3 0 1 1 5
N21
bawah)
N KESEHATAN WANITA 0
1 Abortus 0
a. Abortus inkomplit O06.4 0
b. Abortus komplit O03.9 0

2 O99.0 0
kehamilan
3 Cracked Nipple O9212 0

4 Eklampsi O15.9 0
5 Hiperemesis gravidarum O21.0 0
6 Inverted Nipple O92.02 0
7 Kanker serviks C53.9 0
8 Kehamilan normal O80.9 0
9 Ketuban pecah dini O42.9 0
10 Mastitis N61 0
11 Perdarahan post partum 072.1 0
12 Persalinan lama O63.9 0
13 Pre eklampsia O14.9 0

14 O70.0 0
2
15 Tumor payudara C50.9 0 0 0

O PENYAKIT KELAMIN 0
1 Fluor albus N98.9 0
2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0
P PENYAKIT LAINNYA 0
1 Cedera pada kepala S00-S09 0
2 Cedera pada leher S10-S19 0

3 S20-S29 0
(toraks)
Cedera pada perut,
4 punggung, tulang S30-S39 0

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99

7 Persalinan tunggal spontan O80 0

8 Persalinan SC O82.9 0
9 Z39.2 0
Follow Up
10 Gemelli / Twin pregnancy O30.0 0

11 Pre-eklamsia sedang O14.0 0
Kehamilan dengan
12 O25 0
malnutrisi
13 Neonatus 0
14 Blighted ovum O02.0 0
P07
Gangguan yang
berhubungan dengan
15 (kehamilan) dan berat 0
tidak terklasifikasikan di
tempat lainnya
16 Dispepsia K30 2 10 2 4 18
Demam yang tidak R50 0 0 0 1
17 1
diketahui sebabnya
18 H93 0
spesifik
Rematisme, tidak spesifik, M79.0- 1 4 1 4
19 10
Myalgia M79.1
20 D48
diketahui perilaku lainnya, 0
21 Pemeriksaan Swab P3K B34.2

22 Gout Arthritis
23 Hipercolesterol
24
Rawat luka Post combosio
25 HT dan DM
26 Cepalgi
27 Susp TB
28
29
30
31
32
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0 1 36 61 29 81 11 0 219
219
MENGETAHUI : Santong,
KEPALA UPT BLUD PUSKESMAS SANTONG Kepala Ruangan Dewasa
H. SUBARI, S.Kep.,Ners Rubiati

NIP. 19871231 201101 1 019
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
L P JML L P JML
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
3 0 3 1 0 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
0 0
0 0
0 0 0 0 0 0
0 0
0 3 3 0 2 2
0 0
0 0
0 0
1 1 2 0
1 1 2 1 1
0 0
1 1 2 0 0
1 1 2 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0 0
0 0
2 2 4 2 2 4
0 0 0 0 0
0 0
0 0
2 2 4 0 0
0 0
0 0
0 0
0 0
0 0
0 0
4 4 8 8 34 42
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 2 1 3
0 0
0 0
0 0
0 0
0 0
0 0 0 0
0 0 0
0 0
0 0
0 0
0 0
0 1 1 2
0 0
0 0
0 0 0 0
0 0 0 0
0 0 0
0 0
0 0
0 0 6 1 7
0 0
0 0
0 0
0
0 0
0 0
0 0
0 0 0 0
0 0
0 0
1 0 1 3 0 3
0 0
0 0
0 0
0 0
0 0
0 1 1 2
0 0
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0 1 1
0 0 0
0 0
0 0
4 4 4 10 14
0 0
0 0
0 0
0 0 0 4 9 13
0 0
0 0
0 0
0 2 2 4
1 1 2 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 0 1 1 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 3 3
0 0
1 1 0 0 0
0 0
0 0
0 0
0 0
0 0 0 1 1 2
0 0
0 0 0 0
2 2 4 0
0 0
0 0
BARU LAMA
L P JML L P JML
1 2 3 6 19 25
0 0 0 1 2 3
0 0
0 0 0
0 0
0 0
0 0 0 0
0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0
0 0
0 0
2 0 2 3 0 3
0 0
0 0
0 0
3 3 2 2
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 2 3 4 11 15
0 0
0 1 1 0
0 0
0 0 0 4 6 10
0 0
28 28 56 59 104 163
219
Santong, 2021
Kepala Ruangan Dewasa
Rubiati
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

0-7 hari 8-28 hari 1-11 bl 1-4 th 5-9 th 10-14 th 15-19 Th 20-44 th 45-59 th >59 th JML L
A KELOMPOK UMUM
1 Alergi makanan L27.2
2 Chikungunya A92.0
Demam dengue dan

3
a. Demam berdarah dengue A91
b. Demam dengue A90

4 Filariasis B74
5 Infeksi pada Umbilikus P38
6 Kandidiasis Mulut B37.9
7 Keracunan makanan T62.2
8 Lepra A30
9 Leptospirosis A27.9
10 Malaria B54
11 Morbili (Campak) B05.9
12 Reaksi Anafilaktik T78.2
13 Syok R57.9

14 A18
Paru)
15 Tuberkulosis (TB) Paru A15

16 Tuberkulosis dengan HIV B20.0
17 Varisela B01.9
DARAH, PEMBENTUKAN
B
1 Anemia defisiensi besi D50.9
HIV/ AIDS tanpa

2 Z21
komplikasi
3 Leukemia D55
4 Limfadenitis B70
5 Limfoma Maligna C85.9
Lupus Eritematosus
6 M32
Sistemik
7 Thalasemia D56
C DIGESTIVE
1 Ankilostomiosis B76.0
2 Apendisitis Akut K.35.9
3 Askariasis B77.9

4 Q42
tanpa fistula

5 Q37.9
sumbing
6 Bibir sumbing Q36.9

7 Demam tifoid A01.0

8 A06.0
disentri amuba
9 Gastritis K29.7

10 A09
Giardiasis)
11 Gastroschisis Q79.3
12 Hemoroid grade 1-2 I84
13 Hepatitis A B15
14 Hepatitis B B16
15 Hepatitis C B18.2
JUMLAH KASUS
BARU

16 Intoleransi makanan K90.4

17 Kolesistitis K81.9
JUMLAH KASUS
BARU

18 Langit-langit sumbing Q35

19 Malabsorbsi makanan K90.9
20 Omphalocele Q79.2
21 Parotitis B26
K92.2
22 Perdarahan gastrointestinal
K62.5
23 Peritonitis K65.9
24 Refluks gastroesofageal K21.9
25 Skistosomiasis B65.9
26 Strongiloidiasis B78.9
27 Taeniasis B68.9
28 Ulkus mulut K12
D MATA
1 Astigmatisme H52.2
2 Benda asing di konjungtiva T15.9
3 Blefaritis H01.0
4 Buta senja H53.6
5 Episkleritis H15.1
6 Glaukoma akut H40.2
7 Glaukoma kronis H40.2
8 Hifema H21.0
9 Hipermetropia H52.0
10 Hordeolum H00.0
11 Katarak kongenital Q12.0
Katarak pada pasien

12 H26.9
dewasa
13 Konjungtivitis
a. Konjungtivitis alergi H10.1
b. Konjungtivitis
H10.9
infeksi
14 Laserasi kelopak mata S01.1

15 Low vision H.54
16 Mata kering H04.1
17 Miopia ringan H52.1
18 Perdarahan subkonjungtiva H57.8
19 Presbiopia H52.4
20 Pterygium H11.0
21 Retinoblastoma C69.21
22 Retinopati diabetik H36.0
23 Trauma kimia mata T26
24 Trikiasis H02
E TELINGA
1 Benda asing ditelinga T16
2 Mastoiditis H70
3 Otitis eksterna H60.9
4 Otitis media akut H65

5 H66
kronik
6 Presbiakusis H91.1
7 Serumen prop H61.2
8 Tuli akibat bising H83
9 Tuli kongenital H90
F KARDIOVASKULER
1 Angina pektoris stabil I20.9
2 Cardiorespiratory arrest R09.2

3 I50.9
kronik
4 Hipertensi esensial I10

5 Infark miokard I21.9
6 Takikardia I47
JUMLAH KASUS
BARU

G MUSKULOSKELETAL
1 Artritis reumatoid M53.3
2 Artritis, osteoartritis M19.9
JUMLAH KASUS
BARU

3 Fraktur terbuka S52.9

4 Fraktur tertutup S52.9
5 Lipoma D17.9
6 Osteoporosis M81.9
7 Osteosarkoma C41
8 Polimialgia reumatik M53.3
9 Reduction deformity Q73.8
10 Talipes Q66
11 Vulnus T14.1
H NEUROLOGI
1 Anencephaly Q00.0
2 Bells’ Palsy G51.0
3 Delirium F05.9
4 Epilepsi G40.9
5 Kejang demam R56.0
6 Meningo/encephalocele Q01.9
7 Migren G43.9
8 Neuroblastoma C74.9
9 Rabies A82.9
10 Status epileptikus G41.9
11 Stroke I63.9
12 Tension headache G44.2
13 Tetanus A35
14 Tetanus neonatorum A33

15 G45.9
(TIA)/
16 Vertigo R42
I PSIKIATRI
1 Demensia F03
2 Gangguan anxietas F40#
Gangguan campuran
3 F41.2
4 Gangguan depresi F33
Gangguan penggunaan
5 F10#
napza
6 dan perilaku pada anak F80-90#
dan remaja
7 Gangguan psikotik F20#

8 Gangguan somatoform F45
9 Insomnia F51.0
J RESPIRASI
1 Asma bronkial J45
2 Asfiksia R.09.0
3 Benda asing di hidung T17.1

4 J20.9
tahun)

5 J40
tahun)
6 Difteria A36.9
7 Epistaksis R04.0
8 Faringitis akut J02.9
9 Furunkel pada hidung J34.0
10 Influenza J11
11 Kanker nasofaring C11.9
12 Kanker paru C34.9
13 Laringitis akut J04.0

14 J44.9
kronis
15 Pertusis (batuk rejan) A37.9

16 Pneumonia aspirasi J69.0
Pneumonia,
17
Bronkopneumonia
JUMLAH KASUS
BARU

a. Bronkopneumonia J18.0
b. Pneumonia J18.9
JUMLAH KASUS
BARU

18 Pneumotoraks J93.9
19 Rinitis akut J00
20 Rinitis alergi J30.4
21 Rinitis vasomotor J30.0
22 Sinusitis akut J01
23 Status asmatikus J46
24 Tonsilitis
a. Tonsilitis akut J03.9
b. Tonsilitis kronis J35.9
25 Penyakit ISPA tidak J06
spesifik
K KULIT
1 Akne Vulgaris Ringan L70.0
2 Cutaneus Larva Migrans B76.9
3 Dermatitis atopik L20
4 Dermatitis kontak alergi L23
5 Dermatitis kontak iritan L24
6 Dermatitis numularis L20.8
7 Dermatitis perioral L71.0
8 Dermatitis popok L22
9 Dermatitis seboroik L21
10 Dermatofitosis B35

B35.0
tinea barbea
b. Tinea corporis B35.4

c. Tinea cruris B35.6
d. Tinea manuum B35.2
e. Tinea pedis B35.3
f. Tinea unguium B35.1
11 Erisipelas A46
12 Eritrasma L08.1
Exanthematous drug
13 L27.0
Eruption
14 Fixed Drug Eruption L27.0
Frambusia RDT (+)

15 A66
konfirmasi/probable
16 Herpes simplek B00.9

17 Herpes zoster B02.9
18 Hidradenitis supuratif L73.2
19 (Neurodermatitis L28.0
Sirkumkripta)
20 Luka bakar derajat I dan II T30
21 Miliaria L74.3
22 Moluskum kontagiosum B08.1
23 Pedikulosis kapitis B85.0
24 Pedikulosis pubis B85.3
25 Pioderma
a. Abses, furuncke
L02
dan carbuncle
b. Impetigo L01
c. Pioderma L08.0
26 Pitiriasis Rosea L42
27 Pitiriasis versikolor B36.0
28 Reaksi Gigitan Serangga T63.4
29 Sindrom Stevens Johnson L51.1
30 Skabies B86
31 Skrofuloderma A18.4
32 Ulkus pada tungkai L98
33 Urtikaria L50
34 Veruka Vulgaris B07
METABOLIK ENDOKRIN
L
DAN NUTRISI
JUMLAH KASUS
BARU

1 Diabetes Mellitus Tipe 1 E10

Hiperglikemia
3 R73.9
4 E79.0
Arthritis
5 Hipoglikemia E16.2
6 Hipotiroid kongenital E03.1
7 Lipidemia E78.5
8 Malnutrisi energi Protein E46
9 Obesitas E66.9
10 Tirotoksikosis E05.9
11 Inkontinensia feses R15
12 Retensi urin R33
GINJAL DAN SALURAN

M
KEMIH
1 Epispadia Q64.0
2 Fimosis N47
3 Hipertropi prostat N40
4 Hypospadia Q54
5 Infeksi saluran kemih N39.0
6 Parafimosis N47.2
7 Penyakit ginjal kronik N03
Pielonefritis tanpa
8 N10
komplikasi
N20-
9 ureter, saluran kemih
N21
bawah)
N KESEHATAN WANITA
1 Abortus
a. Abortus inkomplit O06.4 1 1
b. Abortus komplit O03.9

2 O99.0
kehamilan
3 Cracked Nipple O9212 1 3 4

4 Eklampsi O15.9
5 Hiperemesis gravidarum O21.0
6 Inverted Nipple O92.02
7 Kanker serviks C53.9
8 Kehamilan normal O80.9 8 69 3 80
10 Mastitis N61 0

14 O70.0 0
2
15 Tumor payudara C50.9 0

2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0

3 S20-S29 0
(toraks)
Cedera pada perut,
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU


9 Z39.2 10 3 13
Follow Up
10 Gemelli / Twin pregnancy O30.0 1 1

Kehamilan dengan
12 O25 0
malnutrisi
13 Neonatus 0
P07
Gangguan yang
berhubungan dengan
tempat lainnya
16 Dispepsia K30 0
17 0
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
diketahui perilaku lainnya, 1 5 6
21 CONJUNGTIVITIS 1 1
22 STT 1 1
23 DERMATITIS 2 1 3
24 SCABIES 2 1 3
25 CONTACK WITH AND
EXPOSUREVTO VITAL 1 1
HEPATITIS
26 UP IMPLAN 9 4 13
27 MENORRHAGIA 1 1
28 KB 1 1 1
29 BBLR 1 2 3 1
30 NEONATAL JAUNDICE 1 1 1
31 KEK 3 9 12
32 PROTEIN URINE (+) 1 4 5
TOTAL 0 0 2 3 1 2 0 0 0 0 0 0 0 14 0 116 0 12 0 0 105 0
105
KEPALA UPT BLUD PUSKESMAS SANTONG Kepala Ruangan …......................
H. SUBARI, S.Kep.,Ners ( )
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
1 1
4 4 0 0
40 40 40 40
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
8 8 5 5
1 1 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 6 6
1 1 0
1 1 0
3 3 0
3 3 0
1 1 0
9 9 4 4
1 1 0
1 0
2 3 0
1 0
5 5 7 7
5 5 0
54 54 0 51 51
105
Santong, 2021
Kepala Ruangan …......................
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor

A KELOMPOK UMUM
Demam dengue dan

3 0
a. Demam berdarah dengue A91 1 1
b. Demam dengue A90 1 1

4 Filariasis B74 1 1
6 Kandidiasis Mulut B37.9 2 2
8 Lepra A30 0
10 Malaria B54 0
11 Morbili (Campak) B05.9 1 1 1 3
13 Syok R57.9 0

14 A18 0
Paru)
15 Tuberkulosis (TB) Paru A15 0

17 Varisela B01.9 0
DARAH, PEMBENTUKAN
B 0
HIV/ AIDS tanpa

2 Z21 0
komplikasi
3 Leukemia D55 0
Lupus Eritematosus
6 M32 0
Sistemik
7 Thalasemia D56 0
C DIGESTIVE 0

4 Q42 0
tanpa fistula

5 Q37.9 0
sumbing

7 Demam tifoid A01.0 1 1

8 A06.0 1 1
disentri amuba
9 Gastritis K29.7 0

10 A09 0
Giardiasis)




21 Parotitis B26 0
K92.2
K62.5
D MATA 0
2 Benda asing di konjungtiva T15.9 0
8 Hifema H21.0 0
9 Hipermetropia H52.0 0
10 Hordeolum H00.0 1 1
Katarak pada pasien

12 H26.9 0
dewasa
13 Konjungtivitis 0
a. Konjungtivitis alergi H10.1 0
b. Konjungtivitis
H10.9 2 2 2 1 1 1 9
infeksi

16 Mata kering H04.1 0
17 Miopia ringan H52.1 0
19 Presbiopia H52.4 0
20 Pterygium H11.0 0
24 Trikiasis H02 0
E TELINGA 0
1 Benda asing ditelinga T16 0
2 Mastoiditis H70 0
3 Otitis eksterna H60.9 0
4 Otitis media akut H65 1 2 1 1 5

5 H66 0
kronik
7 Serumen prop H61.2 5 2 1 8
F KARDIOVASKULER 0

3 I50.9 0
kronik
4 Hipertensi esensial I10 0

6 Takikardia I47 0

G MUSKULOSKELETAL 0


5 Lipoma D17.9 1 1
10 Talipes Q66 0
11 Vulnus T14.1 0
H NEUROLOGI 0
3 Delirium F05.9 0
4 Epilepsi G40.9 1 1
5 Kejang demam R56.0 0
7 Migren G43.9 2 2
9 Rabies A82.9 0
10 Status epileptikus G41.9 0
11 Stroke I63.9 0
13 Tetanus A35 0

15 G45.9 0
(TIA)/
16 Vertigo R42 0
I PSIKIATRI 0
1 Demensia F03 0
2 Gangguan anxietas F40# 0
Gangguan campuran
3 F41.2 0
4 Gangguan depresi F33 0
Gangguan penggunaan
5 F10# 0
napza
dan remaja
7 Gangguan psikotik F20# 0

9 Insomnia F51.0 0
J RESPIRASI 0
1 Asma bronkial J45 1 1
2 Asfiksia R.09.0 0

4 J20.9 2 1 1 2 2 8
tahun)

5 J40 0
tahun)
6 Difteria A36.9 0
8 Faringitis akut J02.9 0
10 Influenza J11 0

14 J44.9 0
kronis


Pneumonia,
17 0
Bronkopneumonia
a. Bronkopneumonia J18.0 1 1 2
b. Pneumonia J18.9 2 2 4

19 Rinitis akut J00 0
20 Rinitis alergi J30.4 0
23 Status asmatikus J46 0
24 Tonsilitis 0
a. Tonsilitis akut J03.9 1 1
25 Penyakit ISPA tidak J06 14 8 32 19 6 7 1 3 1 91
spesifik
K KULIT 0
3 Dermatitis atopik L20 0
4 Dermatitis kontak alergi L23 1 1
6 Dermatitis numularis L20.8 1 1 1 3
9 Dermatitis seboroik L21 3 1 2 2 1 1 2 12

B35.0 0
tinea barbea
b. Tinea corporis B35.4 0

e. Tinea pedis B35.3 1 1
f. Tinea unguium B35.1 1 1 2
11 Erisipelas A46 0
Exanthematous drug
13 L27.0 0
Eruption
Frambusia RDT (+)

15 A66 0
konfirmasi/probable

18 Hidradenitis supuratif L73.2 1 1
Sirkumkripta)
21 Miliaria L74.3 0
25 Pioderma 0
a. Abses, furuncke
L02 1 1 2
dan carbuncle
b. Impetigo L01 0
c. Pioderma L08.0 1 2 1 4
30 Skabies B86 1 2 1 1 2 4 1 2 3 1 18
32 Ulkus pada tungkai L98 1 1
33 Urtikaria L50 0

METABOLIK ENDOKRIN
L 0
DAN NUTRISI
1 Diabetes Mellitus Tipe 1 E10 0

Hiperglikemia
3 R73.9 0
4 E79.0 0
Arthritis
7 Lipidemia E78.5 0
9 Obesitas E66.9 0
12 Retensi urin R33 0
GINJAL DAN SALURAN

M 0
KEMIH
1 Epispadia Q64.0 0
2 Fimosis N47 0
4 Hypospadia Q54 0
5 Infeksi saluran kemih N39.0 0
Pielonefritis tanpa
8 N10 0
komplikasi
N20-
9 ureter, saluran kemih 0
N21
bawah)
1 Abortus 0

2 O99.0 0
kehamilan
3 Cracked Nipple 0
4 Eklampsi 0
5 Hiperemesis gravidarum 0
6 Inverted Nipple 0
10 Mastitis N61 0

14 O70.0 0
2

2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0

3 S20-S29 0
(toraks)
Cedera pada perut,

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99


9 Z39.2 0
Follow Up

Kehamilan dengan
12 O25 0
malnutrisi
13 Neonatus 0
P07
Gangguan yang
berhubungan dengan
tempat lainnya
16 Dispepsia K30 3 2 5
17 1 1 2 9 5 1 19
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 Vomiting R11.1 0
22 Diiare tanpa dehidrasi 0
23 Post OP 0
24 Trauma Basic cranial 0
25 Cacingan 0
26 ektima 0
27 ISK 0
28 Pubertas 0
29 Rawat Luka 0
30 Insect Bite 0
31 SuspekApendix 0
32 0
TOTAL 0 0 0 0 18 20 46 33 27 29 14 11 6 9 0 0 0 0 0 0 213
213
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
L P JML L P JML
0 0
0 0
0 0
0 1 1
1 1 0
1 1 0
0 0
2 2 0
0 0
0 0
0 0
0 0
2 1 3 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 0
1 1 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 0
0 0
0 0
0 0
0 0
2 3 5 1 3 4
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
2 1 3 1 1 2
0 0
0 0
4 1 5 1 2 3
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
1 1 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 0
0 0
0 0
2 2 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 0
0 0
0 0
2 3 5 1 2 3
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
1 1 2 0
2 2 4 0
BARU LAMA
L P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 0
0 0
20 22 42 33 16 49
0 0
0 0
0 0
0 0
1 1 0
0 0
2 1 3 0
0 0
0 0
2 3 5 2 5 7
0 0
0 0
0 0
0 0
0 0
1 1 0
2 2 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 2 0
0 0
1 1 3 3
0 0
0 0
0 0
0 0
5 5 10 3 5 8
0 0
1 1 0
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
BARU LAMA
L P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
5 5 0
9 5 14 2 3 5
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
67 61 128 44 41 85
213
Santong, 2021
Kepala Ruangan …......................
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
Demam dengue dan

3 0
a. Demam berdarah dengue A91 1 1 2 1

4 Filariasis B74 0
8 Lepra A30 0
10 Malaria B54 0
13 Syok R57.9 0

14 A18 0
Paru)

17 Varisela B01.9 0
DARAH, PEMBENTUKAN
B 0
HIV/ AIDS tanpa

2 Z21 0
komplikasi
3 Leukemia D55 0
Lupus Eritematosus
6 M32 0
Sistemik
7 Thalasemia D56 0
C DIGESTIVE 0

4 Q42 0
tanpa fistula

5 Q37.9 0
sumbing

7 Demam tifoid A01.0 2 2

8 A06.0 3 3
disentri amuba
9 Gastritis K29.7 2 2 2

10 A09 0
Giardiasis)
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26 0
K92.2
K62.5
D MATA 0
2 Benda asing di konjungtiva T15.9 1 1
8 Hifema H21.0 0
Katarak pada pasien

12 H26.9 0
dewasa
13 Konjungtivitis 0
a. Konjungtivitis alergi H10.1 2 1 2 5 3
b. Konjungtivitis
H10.9 0
infeksi

24 Trikiasis H02 0
E TELINGA 0
1 Benda asing ditelinga T16 2 2
2 Mastoiditis H70 0
4 Otitis media akut H65 0

5 H66 0
kronik
7 Serumen prop H61.2 0
F KARDIOVASKULER 0

3 I50.9 0
kronik
4 Hipertensi esensial I10 2 1 3

6 Takikardia I47 0
JUMLAH KASUS
BARU

G MUSKULOSKELETAL 0
JUMLAH KASUS
BARU


5 Lipoma D17.9 0
10 Talipes Q66 0
11 Vulnus T14.1 10 5 15 10
H NEUROLOGI 0
3 Delirium F05.9 0
4 Epilepsi G40.9 0
5 Kejang demam R56.0 1 1 2
7 Migren G43.9 0
9 Rabies A82.9 0
11 Stroke I63.9 0
13 Tetanus A35 0

15 G45.9 0
(TIA)/
16 Vertigo R42 3 2 5 1
I PSIKIATRI 0
1 Demensia F03 0
Gangguan campuran
3 F41.2 0
Gangguan penggunaan
5 F10# 0
napza
dan remaja

8 Gangguan somatoform F45 1 1 1
9 Insomnia F51.0 1 1
J RESPIRASI 0
1 Asma bronkial J45 3 3 10 1 17 2
2 Asfiksia R.09.0 0

4 J20.9 0
tahun)

5 J40 0
tahun)
6 Difteria A36.9 0
7 Epistaksis R04.0 2 2 2
10 Influenza J11 0

14 J44.9 0
kronis

JUMLAH KASUS
BARU

Pneumonia,
17 0
Bronkopneumonia
b. Pneumonia J18.9 3 2 5 1
JUMLAH KASUS
BARU

24 Tonsilitis 0
a. Tonsilitis akut J03.9 2 2 2
25 Penyakit ISPA tidak J06 5 3 20 6 2 5 41 17
spesifik
K KULIT 0
4 Dermatitis kontak alergi L23 1 1 1

B35.0 0
tinea barbea

11 Erisipelas A46 0
Exanthematous drug
13 L27.0 0
Eruption
Frambusia RDT (+)

15 A66 0
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3 0
25 Pioderma 0
a. Abses, furuncke
L02 0
dan carbuncle
b. Impetigo L01 0
c. Pioderma L08.0 0
30 Skabies B86 0
32 Ulkus pada tungkai L98 0
33 Urtikaria L50 0
JUMLAH KASUS
BARU

METABOLIK ENDOKRIN
L 0
DAN NUTRISI
1 Diabetes Mellitus Tipe 1 E10 3 3

2 Diabetes Mellitus Tipe 2 E11 2 2
Hiperglikemia
3 R73.9 0
4 E79.0 0
Arthritis
5 Hipoglikemia E16.2 1 1
7 Lipidemia E78.5 0
9 Obesitas E66.9 0
GINJAL DAN SALURAN

M 0
KEMIH
1 Epispadia Q64.0 0
2 Fimosis N47 0
4 Hypospadia Q54 0
Pielonefritis tanpa
8 N10 0
komplikasi
N20-
N21
bawah)
1 Abortus 0

2 O99.0 0
kehamilan

4 Eklampsi O15.9 0
10 Mastitis N61 0

14 O70.0 0
2

2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0

3 S20-S29 0
(toraks)
Cedera pada perut,
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU


9 Z39.2 0
Follow Up

Kehamilan dengan
12 O25 0
malnutrisi
13 Neonatus 0
P07
Gangguan yang
berhubungan dengan
tempat lainnya
16 Dispepsia K30 9 4 10 2 5 30 6
17 0
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 Melena K92.1 0
22 Colic Abdomen r10 0
23 SCABIES B86 2 3 5 2
24 OBS FEBRIS R50 5 5 6 16 8
25 Vertigo H81.4 1 1 1
26 Snake Bite T63.0 2 2 1 5 5
27 Weakness R53.1 0
28 Combosio T58.2 1 1 1
29 CHF I50 2 2 1
30 Gingivitis k05.1 3 3 3
TOTAL 0 0 5 4 18 14 1 21 36 6 19 16 24 5 8 0 3 1 0 0 181 49
181
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
0
0 0
0 0
0 0
1 2 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
2 2 0
3 3 0
2 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
2 5 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
2 2 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 1 2 3
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
5 15 0
0 0
0 0
0 0
0 0
0 0
1 1 1 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 2 2 1 3
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 0
0 1 1
0 0
1 3 11 3 14
0 0
0 0
0 0
0 0
0 0
2 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
1 2 1 2 3
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
2 0
0 0
6 23 13 5 18
0 0
0 0
0 0
0 0
1 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 3 3
0 2 2
0 0
0 0
0 1 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
9 15 13 2 15
0 0
0 0
0 0
0 0
0 0
0 0
3 5 0
6 14 1 1 2
1 0
5 0
0 0
1 0
1 2 0
3 0
35 115 44 20 64
179
Santong, 2021
Kepala Ruangan …......................
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
Demam dengue dan

3 0

4 Filariasis B74 0
8 Lepra A30 0
10 Malaria B54 0
13 Syok R57.9 0

14 A18 0
Paru)

17 Varisela B01.9 0
DARAH, PEMBENTUKAN
B 0
HIV/ AIDS tanpa

2 Z21 0
komplikasi
3 Leukemia D55 0
Lupus Eritematosus
6 M32 0
Sistemik
7 Thalasemia D56 0
C DIGESTIVE 0

4 Q42 0
tanpa fistula

5 Q37.9 0
sumbing


8 A06.0 0
disentri amuba
9 Gastritis K29.7 0

10 A09 0
Giardiasis)
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26 0
K92.2
K62.5
D MATA 0
8 Hifema H21.0 0
Katarak pada pasien

12 H26.9 0
dewasa
13 Konjungtivitis 0
b. Konjungtivitis
H10.9 0
infeksi

24 Trikiasis H02 0
E TELINGA 0
2 Mastoiditis H70 0

5 H66 0
kronik
F KARDIOVASKULER 0

3 I50.9 0
kronik

6 Takikardia I47 0
JUMLAH KASUS
BARU

G MUSKULOSKELETAL 0
JUMLAH KASUS
BARU


5 Lipoma D17.9 0
10 Talipes Q66 0
11 Vulnus T14.1 0
H NEUROLOGI 0
3 Delirium F05.9 0
4 Epilepsi G40.9 0
7 Migren G43.9 0
9 Rabies A82.9 0
11 Stroke I63.9 0
13 Tetanus A35 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

15 G45.9 0
(TIA)/
16 Vertigo R42 0
I PSIKIATRI 0
1 Demensia F03 0
Gangguan campuran
3 F41.2 0
Gangguan penggunaan
5 F10# 0
napza
dan remaja

9 Insomnia F51.0 0
J RESPIRASI 0
2 Asfiksia R.09.0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2

4 J20.9 0
tahun)

5 J40 0
tahun)
6 Difteria A36.9 0
10 Influenza J11 0

14 J44.9 0
kronis

JUMLAH KASUS
BARU

Pneumonia,
17 0
Bronkopneumonia
JUMLAH KASUS
BARU

24 Tonsilitis 0
25 Penyakit ISPA tidak J06 0
spesifik
K KULIT 0
4 Dermatitis kontak alergi L23 0

B35.0 0
tinea barbea

11 Erisipelas A46 0
Exanthematous drug
13 L27.0 0
Eruption
Frambusia RDT (+)

15 A66 0
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3 0
25 Pioderma 0
a. Abses, furuncke
L02 0
dan carbuncle
b. Impetigo L01 0
c. Pioderma L08.0 0
30 Skabies B86 0
33 Urtikaria L50 0
JUMLAH KASUS
BARU

METABOLIK ENDOKRIN
L 0
DAN NUTRISI

Hiperglikemia
3 R73.9 0
4 E79.0 0
Arthritis
7 Lipidemia E78.5 0
9 Obesitas E66.9 0
GINJAL DAN SALURAN

M 0
KEMIH
1 Epispadia Q64.0 0
2 Fimosis N47 0
4 Hypospadia Q54 0
Pielonefritis tanpa
8 N10 0
komplikasi
N20-
N21
bawah)
1 Abortus 0
a. Abortus inkomplit O06.4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b. Abortus komplit O03.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 3

2 O99.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
kehamilan
3 Cracked Nipple O9212 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

4 Eklampsi O15.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Hiperemesis gravidarum O21.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Inverted Nipple O92.02 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Kanker serviks C53.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Kehamilan normal O80.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Ketuban pecah dini O42.9 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 6 0 0 0 0 7
10 Mastitis N61 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Perdarahan post partum 072.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1
12 Persalinan lama O63.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Pre eklampsia O14.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

14 O70.0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 2 0 0 0 0 3
2
15 Tumor payudara C50.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 Fluor albus N98.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Sifilis A53.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Gonore A54.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Vaginitis N76.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Vulvitis N76.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3 S20-S29 0
(toraks)
Cedera pada perut,
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU

7 Persalinan tunggal spontan O80 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 13 0 0 0 0 17

8 Persalinan SC O82.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Z39.2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Follow Up
10 Gemelli / Twin pregnancy O30.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1

11 Pre-eklamsia sedang O14.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kehamilan dengan
12 O25 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
malnutrisi
13 Neonatus 10 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18
14 Blighted ovum O02.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P07
Gangguan yang
berhubungan dengan
15 (kehamilan) dan berat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
tempat lainnya
16 Dispepsia K30 0
17 0
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 0
22 0
23 0
24 0
25 0
26 0
27 0
28 0
29 0
30 0
31 0
32 0
TOTAL 11 9 0 0 0 0 0 0 0 0 0 0 0 6 0 26 0 0 0 0 52 0
52
52
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
2 2 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
3 3 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
7 7 0 0
0 0 0
1 1 0 0
0 0 0 0
0 0 0 0
3 3 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
BARU LAMA
P JML L P JML
9 9 8 8 0
0 0 0
0 0 0
1 1 0 0
0 0 0
0 0 0
18 18 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
44 44 0 8 8 0
8
-8
Santong, 2021 14
Kepala Ruangan …...................... -22
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
Demam dengue dan

3 0
a. Demam berdarah dengue A91 1 1 2 1
b. Demam dengue A90 1 1 1 3 1

4 Filariasis B74 0
8 Lepra A30 0
10 Malaria B54 0
13 Syok R57.9 0

14 A18 0
Paru)

17 Varisela B01.9 0
DARAH, PEMBENTUKAN
B 0
HIV/ AIDS tanpa

2 Z21 0
komplikasi
3 Leukemia D55 0
Lupus Eritematosus
6 M32 0
Sistemik
7 Thalasemia D56 0
C DIGESTIVE 0

4 Q42 0
tanpa fistula

5 Q37.9 0
sumbing


8 A06.0 0
disentri amuba
9 Gastritis K29.7 0

10 A09 0
Giardiasis)
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26 0
K92.2
K62.5
D MATA 0
8 Hifema H21.0 0
Katarak pada pasien

12 H26.9 0
dewasa
13 Konjungtivitis 0
b. Konjungtivitis
H10.9 0
infeksi

24 Trikiasis H02 0
E TELINGA 0
2 Mastoiditis H70 0

5 H66 0
kronik
F KARDIOVASKULER 0

3 I50.9 1 1 1
kronik
4 Hipertensi esensial I10 1 1

6 Takikardia I47 0
JUMLAH KASUS
BARU

G MUSKULOSKELETAL 0
JUMLAH KASUS
BARU


5 Lipoma D17.9 0
10 Talipes Q66 0
11 Vulnus T14.1 0
H NEUROLOGI 0
3 Delirium F05.9 0
4 Epilepsi G40.9 0
7 Migren G43.9 0
9 Rabies A82.9 0
11 Stroke I63.9 0
13 Tetanus A35 0

15 G45.9 0
(TIA)/
16 Vertigo R42 0
I PSIKIATRI 0
1 Demensia F03 0
Gangguan campuran
3 F41.2 0
Gangguan penggunaan
5 F10# 0
napza
dan remaja

9 Insomnia F51.0 0
J RESPIRASI 0
2 Asfiksia R.09.0 0

4 J20.9 0
tahun)

5 J40 0
tahun)
6 Difteria A36.9 0
10 Influenza J11 0

14 J44.9 1 1
kronis

Pneumonia,
17 0
Bronkopneumonia
JUMLAH KASUS
BARU

a. Bronkopneumonia J18.0 1 1 1
b. Pneumonia J18.9 1 3 1 1 6 2
JUMLAH KASUS
BARU

24 Tonsilitis 0
spesifik
K KULIT 0

B35.0 0
tinea barbea

11 Erisipelas A46 0
Exanthematous drug
13 L27.0 0
Eruption
Frambusia RDT (+)

15 A66 0
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3 0
25 Pioderma 0
a. Abses, furuncke
L02 1 1 1
dan carbuncle
b. Impetigo L01 0
c. Pioderma L08.0 0
30 Skabies B86 0
33 Urtikaria L50 0
METABOLIK ENDOKRIN
L 0
DAN NUTRISI
JUMLAH KASUS
BARU


2 Diabetes Mellitus Tipe 2 E11 1 1 2
Hiperglikemia
3 R73.9 0
4 E79.0 0
Arthritis
7 Lipidemia E78.5 0
9 Obesitas E66.9 0
GINJAL DAN SALURAN

M 0
KEMIH
1 Epispadia Q64.0 0
2 Fimosis N47 0
4 Hypospadia Q54 0
Pielonefritis tanpa
8 N10 0
komplikasi
N20-
N21
bawah)
1 Abortus 0

2 O99.0 0
kehamilan

4 Eklampsi O15.9 0
10 Mastitis N61 0

14 O70.0 0
2

2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0

3 S20-S29 0
(toraks)
Cedera pada perut,
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU


9 Z39.2 0
Follow Up

Kehamilan dengan
12 O25 0
malnutrisi
13 Neonatus 0
P07
Gangguan yang
berhubungan dengan
tempat lainnya
16 Dispepsia K30 2 1 3
17 0
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 ABDOMINAL PAIN 1 1 2 1
22 DIARE 2 2 3 7 2
23 TIFOID FEVER 0
24 HEG 0
25 VOMITING 1 1 1
26 SNAKE BITE 1 1 2 2
27 0
28 0
29 0
30 0
31 0
32 0
TOTAL 0 0 0 0 0 1 4 3 3 2 0 2 0 0 0 3 5 5 2 0 30 10
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
1 2 0 0
1 2 1 1 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
1 0 0
0 1 1 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 1 1 0
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
1 0 0
2 4 1 1 2 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
1 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 1 1 2 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
BARU LAMA
P JML L P JML
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 1 2 3 0
0 0 0
0 0 0
0 0 0
0 0 0
1 2 0 0
3 5 1 1 2 0
0 0 0
0 0 0
1 0 0
2 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
8 18 5 7 12 0
12
-12
Santong, 2021 14
Kepala Ruangan …...................... -26
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
2 Chikungunya A92.0
Demam dengue dan

3
b. Demam dengue A90

4 Filariasis B74
8 Lepra A30
10 Malaria B54
13 Syok R57.9

14 A18
Paru)

17 Varisela B01.9
DARAH, PEMBENTUKAN
B
HIV/ AIDS tanpa

2 Z21
komplikasi
3 Leukemia D55
4 Limfadenitis B70
Lupus Eritematosus
6 M32
Sistemik
7 Thalasemia D56
C DIGESTIVE
3 Askariasis B77.9

4 Q42
tanpa fistula

5 Q37.9
sumbing


8 A06.0
disentri amuba
9 Gastritis K29.7

10 A09
Giardiasis)
13 Hepatitis A B15
14 Hepatitis B B16
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26
K92.2
K62.5
27 Taeniasis B68.9
28 Ulkus mulut K12
D MATA
3 Blefaritis H01.0
4 Buta senja H53.6
8 Hifema H21.0
10 Hordeolum H00.0
Katarak pada pasien

12 H26.9
dewasa
13 Konjungtivitis
b. Konjungtivitis
H10.9
infeksi

15 Low vision H.54
19 Presbiopia H52.4
20 Pterygium H11.0
24 Trikiasis H02
E TELINGA
2 Mastoiditis H70

5 H66
kronik
F KARDIOVASKULER

3 I50.9
kronik

6 Takikardia I47
JUMLAH KASUS
BARU

G MUSKULOSKELETAL
JUMLAH KASUS
BARU


5 Lipoma D17.9
7 Osteosarkoma C41
10 Talipes Q66
11 Vulnus T14.1
H NEUROLOGI
1 Anencephaly Q00.0
3 Delirium F05.9
4 Epilepsi G40.9
7 Migren G43.9
9 Rabies A82.9
11 Stroke I63.9
13 Tetanus A35

15 G45.9
(TIA)/
16 Vertigo R42
I PSIKIATRI
1 Demensia F03
Gangguan campuran
3 F41.2
Gangguan penggunaan
5 F10#
napza
dan remaja

9 Insomnia F51.0
J RESPIRASI
1 Asma bronkial J45
2 Asfiksia R.09.0

4 J20.9
tahun)

5 J40
tahun)
6 Difteria A36.9
7 Epistaksis R04.0
10 Influenza J11

14 J44.9
kronis

Pneumonia,
17
Bronkopneumonia
JUMLAH KASUS
BARU

b. Pneumonia J18.9
JUMLAH KASUS
BARU

19 Rinitis akut J00
24 Tonsilitis
spesifik
K KULIT

B35.0
tinea barbea

11 Erisipelas A46
12 Eritrasma L08.1
Exanthematous drug
13 L27.0
Eruption
Frambusia RDT (+)

15 A66
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3
25 Pioderma
a. Abses, furuncke
L02
dan carbuncle
b. Impetigo L01
c. Pioderma L08.0
30 Skabies B86
33 Urtikaria L50
METABOLIK ENDOKRIN
L
DAN NUTRISI
JUMLAH KASUS
BARU


Hiperglikemia
3 R73.9
4 E79.0
Arthritis
7 Lipidemia E78.5
9 Obesitas E66.9
12 Retensi urin R33
GINJAL DAN SALURAN

M
KEMIH
1 Epispadia Q64.0
2 Fimosis N47
4 Hypospadia Q54
6 Parafimosis N47.2
Pielonefritis tanpa
8 N10
komplikasi
N20-
N21
bawah)
N KESEHATAN WANITA
1 Abortus
a. Abortus inkomplit O06.4

2 O99.0
kehamilan
3 Cracked Nipple O9212

4 Eklampsi O15.9
8 Kehamilan normal O80.9
9 Ketuban pecah dini O42.9
10 Mastitis N61
11 Perdarahan post partum 072.1
12 Persalinan lama O63.9
13 Pre eklampsia O14.9

14 O70.0
2
15 Tumor payudara C50.9

O PENYAKIT KELAMIN
1 Fluor albus N98.9
2 Sifilis A53.9
3 Gonore A54.9
4 Vaginitis N76.0
5 Vulvitis N76.2
P PENYAKIT LAINNYA
1 Cedera pada kepala S00-S09
2 Cedera pada leher S10-S19

3 S20-S29
(toraks)
Cedera pada perut,
4 punggung, tulang S30-S39
JUMLAH KASUS
BARU

S40-
S49,
5 S50-
S59,
tangan
S60-S69

6 kaki -S89,
S90-S99
JUMLAH KASUS
BARU

7 Persalinan tunggal spontan O80

8 Persalinan SC O82.9
9 Z39.2
Follow Up
10 Gemelli / Twin pregnancy O30.0

11 Pre-eklamsia sedang O14.0
Kehamilan dengan
12 O25
malnutrisi
13 Neonatus
14 Blighted ovum O02.0
P07
Gangguan yang
berhubungan dengan
15 (kehamilan) dan berat
tempat lainnya
16 Dispepsia K30
17
diketahui sebabnya
18 H93
spesifik
19
Myalgia M79.1
20 D48
diketahui perilaku lainnya,
21
22
23
24
25
26
27
28
29
30
31
32
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
0 0 0 0 0
Santong, 2021
Kepala Ruangan …......................
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
Demam dengue dan

3 0

4 Filariasis B74 0
8 Lepra A30 0
10 Malaria B54 0
13 Syok R57.9 0

14 A18 0
Paru)

17 Varisela B01.9 0
DARAH, PEMBENTUKAN
B 0
HIV/ AIDS tanpa

2 Z21 0
komplikasi
3 Leukemia D55 0
Lupus Eritematosus
6 M32 0
Sistemik
7 Thalasemia D56 0
C DIGESTIVE 0

4 Q42 0
tanpa fistula

5 Q37.9 0
sumbing


8 A06.0 0
disentri amuba
9 Gastritis K29.7 0

10 A09 0
Giardiasis)
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26 0
K92.2
K62.5
D MATA 0
8 Hifema H21.0 0
Katarak pada pasien

12 H26.9 0
dewasa
13 Konjungtivitis 0
a. Konjungtivitis alergi H10.1 1 1 2 1
b. Konjungtivitis
H10.9 0
infeksi

24 Trikiasis H02 0
E TELINGA 0
2 Mastoiditis H70 0

5 H66 0
kronik
F KARDIOVASKULER 0

3 I50.9 0
kronik
4 Hipertensi esensial I10 5 9 14 4

6 Takikardia I47 0
JUMLAH KASUS
BARU

G MUSKULOSKELETAL 0
1 Artritis reumatoid M53.3 1 1 1 3
JUMLAH KASUS
BARU


5 Lipoma D17.9 0
10 Talipes Q66 0
11 Vulnus T14.1 0
H NEUROLOGI 0
3 Delirium F05.9 0
4 Epilepsi G40.9 0
7 Migren G43.9 0
9 Rabies A82.9 0
11 Stroke I63.9 0
13 Tetanus A35 0

15 G45.9 0
(TIA)/
16 Vertigo R42 0
I PSIKIATRI 0
1 Demensia F03 0
Gangguan campuran
3 F41.2 0
Gangguan penggunaan
5 F10# 0
napza
dan remaja

9 Insomnia F51.0 0
J RESPIRASI 0
2 Asfiksia R.09.0 0

4 J20.9 0
tahun)

5 J40 0
tahun)
6 Difteria A36.9 0
10 Influenza J11 0

14 J44.9 0
kronis

Pneumonia,
17 0
Bronkopneumonia
JUMLAH KASUS
BARU

JUMLAH KASUS
BARU

20 Rinitis alergi J30.4 0 0
24 Tonsilitis 0
25 Penyakit ISPA tidak J06 3 4 4 1 4 2 1 10 29 7
spesifik
K KULIT 0
4 Dermatitis kontak alergi L23 1 1 1 3 2

B35.0 0
tinea barbea

11 Erisipelas A46 0
Exanthematous drug
13 L27.0 0
Eruption
Frambusia RDT (+)

15 A66 0
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3 0
25 Pioderma 0
a. Abses, furuncke
L02 0
dan carbuncle
b. Impetigo L01 0
c. Pioderma L08.0 0
30 Skabies B86 0 0
33 Urtikaria L50 0
METABOLIK ENDOKRIN
L 0
DAN NUTRISI
JUMLAH KASUS
BARU


Hiperglikemia
3 R73.9 0
4 E79.0 0
Arthritis
7 Lipidemia E78.5 0
9 Obesitas E66.9 0
GINJAL DAN SALURAN

M 0
KEMIH
1 Epispadia Q64.0 0
2 Fimosis N47 0
4 Hypospadia Q54 0
Pielonefritis tanpa
8 N10 0
komplikasi
N20-
N21
bawah)
1 Abortus 0

2 O99.0 0
kehamilan

4 Eklampsi O15.9 0
10 Mastitis N61 0

14 O70.0 0
2

2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0

3 S20-S29 0
(toraks)
Cedera pada perut,
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU


9 Z39.2 0
Follow Up

Kehamilan dengan
12 O25 0
malnutrisi
13 Neonatus 0
P07
Gangguan yang
berhubungan dengan
tempat lainnya
16 Dispepsia K30 1 2 3 1
Demam yang tidak R50 1 1 1 1 2 2 5
17 2 10
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 Diare 0
Gangguan Gigi dan

22 1 1 1
jaringan penunjang lainnya
Low Back Pain (Nyeri

23 0
Punggung Bawah)
24
Kecelakaan angkutan darat 0
25 0
26 0
27 0
28 0
29 0
30 0
31 0
32 Malaise 1 1 1 3 1
TOTAL 0 0 0 0 2 1 4 6 1 0 2 4 1 5 11 12 4 14 0 1 68 22
68
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 2 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
5 9 2 3 5
0 0
0 0
BARU LAMA
P JML L P JML
0 0
1 1 1 1 2
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
8 15 6 8 14
0 0
0 0
0 0
0 0
1 3 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
2 3 0
3 1 1
8 2
0 0
0 0
0 0
0 0
1 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
2 3 0
23 45 10 13 23
68
Santong, 2021
Kepala Ruangan …......................
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
1 Alergi makanan L27.2 1 1 2
Demam dengue dan

3 0

4 Filariasis B74 0
8 Lepra A30 0
10 Malaria B54 0
13 Syok R57.9 0

14 A18 0
Paru)

17 Varisela B01.9 0
DARAH, PEMBENTUKAN
B 0
HIV/ AIDS tanpa

2 Z21 0
komplikasi
3 Leukemia D55 0
Lupus Eritematosus
6 M32 0
Sistemik
7 Thalasemia D56 0
C DIGESTIVE 0

4 Q42 0
tanpa fistula

5 Q37.9 0
sumbing


8 A06.0 0
disentri amuba
9 Gastritis K29.7 1 2 1 4 2

10 A09 0
Giardiasis)
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26 0
K92.2
K62.5
D MATA 0
8 Hifema H21.0 0
Katarak pada pasien

12 H26.9 0
dewasa
13 Konjungtivitis 0
b. Konjungtivitis
H10.9 0
infeksi

24 Trikiasis H02 0
E TELINGA 0
2 Mastoiditis H70 0

5 H66 0
kronik
F KARDIOVASKULER 0

3 I50.9 0
kronik
4 Hipertensi esensial I10 1 1 2 3 1 8

6 Takikardia I47 0
JUMLAH KASUS
BARU

G MUSKULOSKELETAL 0
1 Artritis reumatoid M53.3 2 1 2 1 6
JUMLAH KASUS
BARU


5 Lipoma D17.9 0
10 Talipes Q66 0
11 Vulnus T14.1 0
H NEUROLOGI 0
3 Delirium F05.9 0
4 Epilepsi G40.9 0
7 Migren G43.9 0
9 Rabies A82.9 0
11 Stroke I63.9 0
13 Tetanus A35 0

15 G45.9 0
(TIA)/
16 Vertigo R42 0
I PSIKIATRI 0
1 Demensia F03 0
Gangguan campuran
3 F41.2 0
Gangguan penggunaan
5 F10# 0
napza
dan remaja

9 Insomnia F51.0 0
J RESPIRASI 0
2 Asfiksia R.09.0 0

4 J20.9 0
tahun)

5 J40 0
tahun)
6 Difteria A36.9 0
10 Influenza J11 0

14 J44.9 0
kronis

Pneumonia,
17 0
Bronkopneumonia
JUMLAH KASUS
BARU

JUMLAH KASUS
BARU

20 Rinitis alergi J30.4 2 2 2 1 2 1 2 12 4
24 Tonsilitis 0
Penyakit ISPA tidak
25 spesifik J06 2 1 3 5 2 3 2 2 1 3 2 2 2 1 1 32 16
K KULIT 0

B35.0 0
tinea barbea

11 Erisipelas A46 0
Exanthematous drug
13 L27.0 0
Eruption
Frambusia RDT (+)

15 A66 0
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3 0
25 Pioderma 0
a. Abses, furuncke
L02 0
dan carbuncle
b. Impetigo L01 0
c. Pioderma L08.0 0
30 Skabies B86 1 1 1 1 4 3
33 Urtikaria L50 0
JUMLAH KASUS
BARU

METABOLIK ENDOKRIN
L 0
DAN NUTRISI

Hiperglikemia
3 R73.9 0
4 E79.0 0
Arthritis
7 Lipidemia E78.5 0
9 Obesitas E66.9 0
GINJAL DAN SALURAN

M 0
KEMIH
1 Epispadia Q64.0 0
2 Fimosis N47 0
4 Hypospadia Q54 0
Pielonefritis tanpa
8 N10 0
komplikasi
N20-
N21
bawah)
1 Abortus 0

2 O99.0 0
kehamilan

4 Eklampsi O15.9 0
10 Mastitis N61 0

14 O70.0 0
2

2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0

3 S20-S29 0
(toraks)
Cedera pada perut,
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU


9 Z39.2 0
Follow Up

Kehamilan dengan
12 O25 0
malnutrisi
13 Neonatus 0
P07
Gangguan yang
berhubungan dengan
tempat lainnya
16 Dispepsia K30 0
17 0
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 0
22 0
23 0
24 0
25 0
26 0
27 0
28 0
29 0
30 0
31 0
32 0
TOTAL 0 0 0 0 0 2 1 3 5 3 3 4 4 4 5 3 8 8 10 5 68 25
68
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
2 2 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
2 2 2
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 4 3 7
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 4 2 6
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
6 10 1 1 2
0 0
0 0
0 0
0 0
0 0
0 0
16 32 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 4 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
26 51 9 8 17
Santong, 2021
Kepala Ruangan …......................
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
2 Chikungunya A92.0
Demam dengue dan

3
b. Demam dengue A90

4 Filariasis B74
8 Lepra A30
10 Malaria B54
13 Syok R57.9

14 A18
Paru)

17 Varisela B01.9
DARAH, PEMBENTUKAN
B
HIV/ AIDS tanpa

2 Z21
komplikasi
3 Leukemia D55
4 Limfadenitis B70
Lupus Eritematosus
6 M32
Sistemik
7 Thalasemia D56
C DIGESTIVE
3 Askariasis B77.9

4 Q42
tanpa fistula

5 Q37.9
sumbing


8 A06.0
disentri amuba
9 Gastritis K29.7

10 A09
Giardiasis)
13 Hepatitis A B15
14 Hepatitis B B16
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26
K92.2
K62.5
27 Taeniasis B68.9
28 Ulkus mulut K12
D MATA
3 Blefaritis H01.0
4 Buta senja H53.6
8 Hifema H21.0
10 Hordeolum H00.0
Katarak pada pasien

12 H26.9
dewasa
13 Konjungtivitis
b. Konjungtivitis
H10.9
infeksi

15 Low vision H.54
19 Presbiopia H52.4
20 Pterygium H11.0
24 Trikiasis H02
E TELINGA
2 Mastoiditis H70

5 H66
kronik
F KARDIOVASKULER

3 I50.9
kronik

6 Takikardia I47
JUMLAH KASUS
BARU

G MUSKULOSKELETAL
JUMLAH KASUS
BARU


5 Lipoma D17.9
7 Osteosarkoma C41
10 Talipes Q66
11 Vulnus T14.1
H NEUROLOGI
1 Anencephaly Q00.0
3 Delirium F05.9
4 Epilepsi G40.9
7 Migren G43.9
9 Rabies A82.9
11 Stroke I63.9
13 Tetanus A35

15 G45.9
(TIA)/
16 Vertigo R42
I PSIKIATRI
1 Demensia F03
Gangguan campuran
3 F41.2
Gangguan penggunaan
5 F10#
napza
dan remaja

9 Insomnia F51.0
J RESPIRASI
1 Asma bronkial J45
2 Asfiksia R.09.0

4 J20.9
tahun)

5 J40
tahun)
6 Difteria A36.9
7 Epistaksis R04.0
10 Influenza J11

14 J44.9
kronis

Pneumonia,
17
Bronkopneumonia
JUMLAH KASUS
BARU

b. Pneumonia J18.9
JUMLAH KASUS
BARU

19 Rinitis akut J00
24 Tonsilitis
spesifik
K KULIT

B35.0
tinea barbea

11 Erisipelas A46
12 Eritrasma L08.1
Exanthematous drug
13 L27.0
Eruption
Frambusia RDT (+)

15 A66
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3
25 Pioderma
a. Abses, furuncke
L02
dan carbuncle
b. Impetigo L01
c. Pioderma L08.0
30 Skabies B86
33 Urtikaria L50
METABOLIK ENDOKRIN
L
DAN NUTRISI
JUMLAH KASUS
BARU


Hiperglikemia
3 R73.9
4 E79.0
Arthritis
7 Lipidemia E78.5
9 Obesitas E66.9
12 Retensi urin R33
GINJAL DAN SALURAN

M
KEMIH
1 Epispadia Q64.0
2 Fimosis N47
4 Hypospadia Q54
6 Parafimosis N47.2
Pielonefritis tanpa
8 N10
komplikasi
N20-
N21
bawah)
N KESEHATAN WANITA
1 Abortus

2 O99.0 1 4 5
kehamilan

4 Eklampsi O15.9
9 Ketuban pecah dini O42.9
10 Mastitis N61
11 Perdarahan post partum 072.1
12 Persalinan lama O63.9
13 Pre eklampsia O14.9

14 O70.0
2
15 Tumor payudara C50.9

O PENYAKIT KELAMIN
1 Fluor albus N98.9
2 Sifilis A53.9
3 Gonore A54.9
4 Vaginitis N76.0
5 Vulvitis N76.2
P PENYAKIT LAINNYA
1 Cedera pada kepala S00-S09
2 Cedera pada leher S10-S19

3 S20-S29
(toraks)
Cedera pada perut,
4 punggung, tulang S30-S39
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU


9 Z39.2 2 18 0 20
Follow Up

Kehamilan dengan
12 O25 2 6 8
malnutrisi
13 Neonatus 11 9 20 11
P07
Gangguan yang
berhubungan dengan
tempat lainnya
16 Dispepsia K30 0
17 0
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 0
22 0
23 0
24 0
25 0
26 0
27 0
28 0
29 0
30 0
31 0
32 0
TOTAL 11 9 0 0 0 0 0 0 0 0 0 0 0 12 0 98 0 2 0 0 132 11
132
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
2 2 3 3
8 8 71 71
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
20 20
1 1 7 7
9 20
40 51 0 81 81
Santong, 2021
Kepala Ruangan …......................
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
2 Chikungunya A92.0
Demam dengue dan

3
b. Demam dengue A90

4 Filariasis B74
8 Lepra A30
10 Malaria B54
13 Syok R57.9

14 A18
Paru)

17 Varisela B01.9
DARAH, PEMBENTUKAN
B
HIV/ AIDS tanpa

2 Z21
komplikasi
3 Leukemia D55
4 Limfadenitis B70
Lupus Eritematosus
6 M32
Sistemik
7 Thalasemia D56
C DIGESTIVE
3 Askariasis B77.9

4 Q42
tanpa fistula

5 Q37.9
sumbing


8 A06.0
disentri amuba
9 Gastritis K29.7

10 A09
Giardiasis)
13 Hepatitis A B15
14 Hepatitis B B16
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26
K92.2
K62.5
27 Taeniasis B68.9
28 Ulkus mulut K12
D MATA
3 Blefaritis H01.0
4 Buta senja H53.6
8 Hifema H21.0
10 Hordeolum H00.0
Katarak pada pasien

12 H26.9
dewasa
13 Konjungtivitis
b. Konjungtivitis
H10.9
infeksi

15 Low vision H.54
19 Presbiopia H52.4
20 Pterygium H11.0
24 Trikiasis H02
E TELINGA
2 Mastoiditis H70

5 H66
kronik
F KARDIOVASKULER

3 I50.9
kronik

6 Takikardia I47
JUMLAH KASUS
BARU

G MUSKULOSKELETAL
JUMLAH KASUS
BARU


5 Lipoma D17.9
7 Osteosarkoma C41
10 Talipes Q66
11 Vulnus T14.1
H NEUROLOGI
1 Anencephaly Q00.0
3 Delirium F05.9
4 Epilepsi G40.9
7 Migren G43.9
9 Rabies A82.9
11 Stroke I63.9
13 Tetanus A35

15 G45.9
(TIA)/
16 Vertigo R42
I PSIKIATRI
1 Demensia F03
Gangguan campuran
3 F41.2
Gangguan penggunaan
5 F10#
napza
dan remaja

9 Insomnia F51.0
J RESPIRASI
1 Asma bronkial J45
2 Asfiksia R.09.0

4 J20.9
tahun)

5 J40
tahun)
6 Difteria A36.9
7 Epistaksis R04.0
10 Influenza J11

14 J44.9
kronis

Pneumonia,
17
Bronkopneumonia
JUMLAH KASUS
BARU

b. Pneumonia J18.9
JUMLAH KASUS
BARU

19 Rinitis akut J00
24 Tonsilitis
spesifik
K KULIT

B35.0
tinea barbea

11 Erisipelas A46
12 Eritrasma L08.1
Exanthematous drug
13 L27.0
Eruption
Frambusia RDT (+)

15 A66
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3
25 Pioderma
a. Abses, furuncke
L02
dan carbuncle
b. Impetigo L01
c. Pioderma L08.0
30 Skabies B86
33 Urtikaria L50
METABOLIK ENDOKRIN
L
DAN NUTRISI
JUMLAH KASUS
BARU


Hiperglikemia
3 R73.9
4 E79.0
Arthritis
7 Lipidemia E78.5
9 Obesitas E66.9
12 Retensi urin R33
GINJAL DAN SALURAN

M
KEMIH
1 Epispadia Q64.0
2 Fimosis N47
4 Hypospadia Q54
6 Parafimosis N47.2
Pielonefritis tanpa
8 N10
komplikasi
N20-
N21
bawah)
N KESEHATAN WANITA
1 Abortus

2 O99.0
kehamilan

4 Eklampsi O15.9
8 Kehamilan normal O80.9 12 68 80
10 Mastitis N61 0

14 O70.0 0
2

2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0

3 S20-S29 0
(toraks)
Cedera pada perut,
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU

7 Persalinan tunggal spontan O80 1 1

9 Z39.2 2 7 9
Follow Up

Kehamilan dengan
12 O25 2 10 12
malnutrisi
13 Neonatus 1 8 9 1
P07
Gangguan yang
berhubungan dengan
15 (kehamilan) dan berat
tempat lainnya
16 Dispepsia K30 0
17 0
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 0
22 0
23 0
24 0
25 0
26 0
27 0
28 0
29 0
30 0
31 0
32 0
TOTAL 1 8 0 0 0 0 0 0 0 0 0 0 0 16 0 86 0 0 0 0 111 1
111
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
0
0 0
0 0
7 7 73 73
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
BARU LAMA
P JML L P JML
0 0
0 0
BARU LAMA
P JML L P JML
1 1
9 9
2 2 10 10
8 9
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
27 28 0 83 83
Santong, 2021
Kepala Ruangan …......................
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
2 Chikungunya A92.0
Demam dengue dan

3
b. Demam dengue A90

4 Filariasis B74
8 Lepra A30
10 Malaria B54
13 Syok R57.9

14 A18
Paru)

17 Varisela B01.9
DARAH, PEMBENTUKAN
B
HIV/ AIDS tanpa

2 Z21
komplikasi
3 Leukemia D55
4 Limfadenitis B70
Lupus Eritematosus
6 M32
Sistemik
7 Thalasemia D56
C DIGESTIVE
3 Askariasis B77.9

4 Q42
tanpa fistula

5 Q37.9
sumbing


8 A06.0
disentri amuba
9 Gastritis K29.7

10 A09
Giardiasis)
13 Hepatitis A B15
14 Hepatitis B B16
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26
K92.2
K62.5
27 Taeniasis B68.9
28 Ulkus mulut K12
D MATA
3 Blefaritis H01.0
4 Buta senja H53.6
8 Hifema H21.0
10 Hordeolum H00.0
Katarak pada pasien

12 H26.9
dewasa
13 Konjungtivitis
b. Konjungtivitis
H10.9
infeksi

15 Low vision H.54
19 Presbiopia H52.4
20 Pterygium H11.0
24 Trikiasis H02
E TELINGA
2 Mastoiditis H70

5 H66
kronik
F KARDIOVASKULER

3 I50.9
kronik

6 Takikardia I47
JUMLAH KASUS
BARU

G MUSKULOSKELETAL
JUMLAH KASUS
BARU


5 Lipoma D17.9
7 Osteosarkoma C41
10 Talipes Q66
11 Vulnus T14.1
H NEUROLOGI
1 Anencephaly Q00.0
3 Delirium F05.9
4 Epilepsi G40.9
7 Migren G43.9
9 Rabies A82.9
11 Stroke I63.9
13 Tetanus A35

15 G45.9
(TIA)/
16 Vertigo R42
I PSIKIATRI
1 Demensia F03
Gangguan campuran
3 F41.2
Gangguan penggunaan
5 F10#
napza
dan remaja

9 Insomnia F51.0
J RESPIRASI
1 Asma bronkial J45
2 Asfiksia R.09.0

4 J20.9
tahun)

5 J40
tahun)
6 Difteria A36.9
7 Epistaksis R04.0
10 Influenza J11

14 J44.9
kronis

Pneumonia,
17
Bronkopneumonia
JUMLAH KASUS
BARU

b. Pneumonia J18.9
JUMLAH KASUS
BARU

19 Rinitis akut J00
24 Tonsilitis
spesifik
K KULIT

B35.0
tinea barbea

11 Erisipelas A46
12 Eritrasma L08.1
Exanthematous drug
13 L27.0
Eruption
Frambusia RDT (+)

15 A66
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3
25 Pioderma
a. Abses, furuncke
L02
dan carbuncle
b. Impetigo L01
c. Pioderma L08.0
30 Skabies B86
33 Urtikaria L50
JUMLAH KASUS
BARU

METABOLIK ENDOKRIN
L
DAN NUTRISI

Hiperglikemia
3 R73.9
4 E79.0
Arthritis
7 Lipidemia E78.5
9 Obesitas E66.9
12 Retensi urin R33
GINJAL DAN SALURAN

M
KEMIH
1 Epispadia Q64.0
2 Fimosis N47
4 Hypospadia Q54
6 Parafimosis N47.2
Pielonefritis tanpa
8 N10
komplikasi
N20-
N21
bawah)
N KESEHATAN WANITA
1 Abortus

2 O99.0 1 1
kehamilan

4 Eklampsi O15.9 0
10 Mastitis N61 0

14 O70.0 0
2

2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0

3 S20-S29 0
(toraks)
Cedera pada perut,
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU

7 Persalinan tunggal spontan O80 1 1

9 Z39.2 1 15 16
Follow Up

Kehamilan dengan
12 O25 5 5
malnutrisi
13 Neonatus 2 2 1
P07
Gangguan yang
berhubungan dengan
tempat lainnya
16 Dispepsia K30 0
17 0
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 0
22 0
23 0
24 0
25 0
26 0
27 0
28 0
29 0
30 0
31
32
TOTAL 2 0 0 0 0 0 0 0 0 0 0 0 0 4 0 51 0 0 0 0 57 2
57
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
1 1 0
0
0
0
0
0
4 5 27 27 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
BARU LAMA
P JML L P JML
0
BARU LAMA
P JML L P JML
1 1 0
0
6 10 16 0
0
0
0 5 5 0
1 2 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
13 9 0 42 48 0
42
-42
Santong, 2021 14
Kepala Ruangan …...................... -56
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
Demam dengue dan

3 0

4 Filariasis B74 0
8 Lepra A30 0
10 Malaria B54 0
13 Syok R57.9 0

14 A18 0
Paru)

17 Varisela B01.9 0
DARAH, PEMBENTUKAN
B 0
HIV/ AIDS tanpa

2 Z21 0
komplikasi
3 Leukemia D55 0
Lupus Eritematosus
6 M32 0
Sistemik
7 Thalasemia D56 0
C DIGESTIVE 0

4 Q42 0
tanpa fistula

5 Q37.9 0
sumbing


8 A06.0 0
disentri amuba
9 Gastritis K29.7 0

10 A09 0
Giardiasis)
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26 0
K92.2
K62.5
D MATA 0
8 Hifema H21.0 0
Katarak pada pasien

12 H26.9 0
dewasa
13 Konjungtivitis 0
b. Konjungtivitis
H10.9 0
infeksi

24 Trikiasis H02 0
E TELINGA 0
2 Mastoiditis H70 0

5 H66 0
kronik
F KARDIOVASKULER 0

3 I50.9 0
kronik

6 Takikardia I47 0
JUMLAH KASUS
BARU

G MUSKULOSKELETAL 0
JUMLAH KASUS
BARU


5 Lipoma D17.9 0
10 Talipes Q66 0
11 Vulnus T14.1 0
H NEUROLOGI 0
3 Delirium F05.9 0
4 Epilepsi G40.9 0
7 Migren G43.9 0
9 Rabies A82.9 0
11 Stroke I63.9 0
13 Tetanus A35 0

15 G45.9 0
(TIA)/
16 Vertigo R42 0
I PSIKIATRI 0
1 Demensia F03 0
Gangguan campuran
3 F41.2 0
Gangguan penggunaan
5 F10# 0
napza
dan remaja

9 Insomnia F51.0 0
J RESPIRASI 0
2 Asfiksia R.09.0 0

4 J20.9 0
tahun)

5 J40 0
tahun)
6 Difteria A36.9 0
10 Influenza J11 0

14 J44.9 0
kronis

Pneumonia,
17 0
Bronkopneumonia
JUMLAH KASUS
BARU

JUMLAH KASUS
BARU

24 Tonsilitis 0
spesifik
K KULIT 0

B35.0 0
tinea barbea

11 Erisipelas A46 0
Exanthematous drug
13 L27.0 0
Eruption
Frambusia RDT (+)

15 A66 0
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3 0
25 Pioderma 0
a. Abses, furuncke
L02 0
dan carbuncle
b. Impetigo L01 0
c. Pioderma L08.0 0
30 Skabies B86 0
33 Urtikaria L50 0
METABOLIK ENDOKRIN
L 0
DAN NUTRISI
JUMLAH KASUS
BARU


Hiperglikemia
3 R73.9 0
4 E79.0 0
Arthritis
7 Lipidemia E78.5 0
9 Obesitas E66.9 0
GINJAL DAN SALURAN

M 0
KEMIH
1 Epispadia Q64.0 0
2 Fimosis N47 0
4 Hypospadia Q54 0
Pielonefritis tanpa
8 N10 0
komplikasi
N20-
N21
bawah)
1 Abortus 0

2 O99.0 1 1
kehamilan

4 Eklampsi O15.9 0
10 Mastitis N61 0

14 O70.0 0
2

2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0

3 S20-S29 0
(toraks)
Cedera pada perut,
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU


9 Z39.2 1 15 16
Follow Up

Kehamilan dengan
12 O25 5 5
malnutrisi
13 Neonatus 0
P07
Gangguan yang
berhubungan dengan
tempat lainnya
16 Dispepsia K30 0
17 0
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 0
22 0
23 0
24 0
25 0
26 0
27 0
28 0
29 0
30 0
31 0
32 0
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 50 0 0 0 0 54 0
54
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
1 1
5 5 27 27
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
6 6 10 10
0 5 5
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
11 11 0 43 43
Santong, 2021
Kepala Ruangan …......................
( )
NIP….....................................
FORMULIR 11
Bula
Kode Jml. PP
n
Tah Jml
un melapor
JUMLAH KASUS
BARU

A KELOMPOK UMUM
Demam dengue dan

3 0

4 Filariasis B74 0
8 Lepra A30 0
10 Malaria B54 0
13 Syok R57.9 0

14 A18 0
Paru)

17 Varisela B01.9 0
DARAH, PEMBENTUKAN
B 0
HIV/ AIDS tanpa

2 Z21 0
komplikasi
3 Leukemia D55 0
Lupus Eritematosus
6 M32 0
Sistemik
7 Thalasemia D56 0
C DIGESTIVE 0

4 Q42 0
tanpa fistula

5 Q37.9 0
sumbing


8 A06.0 0
disentri amuba
9 Gastritis K29.7 0

10 A09 0
Giardiasis)
JUMLAH KASUS
BARU


JUMLAH KASUS
BARU


21 Parotitis B26 0
K92.2
K62.5
D MATA 0
8 Hifema H21.0 0
Katarak pada pasien

12 H26.9 0
dewasa
13 Konjungtivitis 0
b. Konjungtivitis
H10.9 0
infeksi

24 Trikiasis H02 0
E TELINGA 0
2 Mastoiditis H70 0

5 H66 0
kronik
F KARDIOVASKULER 0

3 I50.9 0
kronik

6 Takikardia I47 0
JUMLAH KASUS
BARU

G MUSKULOSKELETAL 0
JUMLAH KASUS
BARU


5 Lipoma D17.9 0
10 Talipes Q66 0
11 Vulnus T14.1 0
H NEUROLOGI 0
3 Delirium F05.9 0
4 Epilepsi G40.9 0
7 Migren G43.9 0
9 Rabies A82.9 0
11 Stroke I63.9 0
13 Tetanus A35 0

15 G45.9 0
(TIA)/
16 Vertigo R42 0
I PSIKIATRI 0
1 Demensia F03 0
Gangguan campuran
3 F41.2 0
Gangguan penggunaan
5 F10# 0
napza
dan remaja

9 Insomnia F51.0 0
J RESPIRASI 0
2 Asfiksia R.09.0 0

4 J20.9 0
tahun)

5 J40 0
tahun)
6 Difteria A36.9 0
10 Influenza J11 0

14 J44.9 0
kronis

Pneumonia,
17 0
Bronkopneumonia
JUMLAH KASUS
BARU

JUMLAH KASUS
BARU

24 Tonsilitis 0
spesifik
K KULIT 0

B35.0 0
tinea barbea

11 Erisipelas A46 0
Exanthematous drug
13 L27.0 0
Eruption
Frambusia RDT (+)

15 A66 0
konfirmasi/probable

Sirkumkripta)
21 Miliaria L74.3 0
25 Pioderma 0
a. Abses, furuncke
L02 0
dan carbuncle
b. Impetigo L01 0
c. Pioderma L08.0 0
30 Skabies B86 0
33 Urtikaria L50 0
METABOLIK ENDOKRIN
L 0
DAN NUTRISI
JUMLAH KASUS
BARU


Hiperglikemia
3 R73.9 0
4 E79.0 0
Arthritis
7 Lipidemia E78.5 0
9 Obesitas E66.9 0
GINJAL DAN SALURAN

M 0
KEMIH
1 Epispadia Q64.0 0
2 Fimosis N47 0
4 Hypospadia Q54 0
Pielonefritis tanpa
8 N10 0
komplikasi
N20-
N21
bawah)
1 Abortus 0

2 O99.0 0
kehamilan

4 Eklampsi O15.9 0
10 Mastitis N61 0

14 O70.0 0
2

2 Sifilis A53.9 0
3 Gonore A54.9 0
4 Vaginitis N76.0 0
5 Vulvitis N76.2 0

3 S20-S29 0
(toraks)
Cedera pada perut,
JUMLAH KASUS
BARU

S40-
S49,
5 S50- 0
S59,
tangan
S60-S69

6 kaki -S89, 0
S90-S99
JUMLAH KASUS
BARU


9 Z39.2 0
Follow Up

Kehamilan dengan
12 O25 0
malnutrisi
13 Neonatus 0
P07
Gangguan yang
berhubungan dengan
tempat lainnya
16 Dispepsia K30 0
17 0
diketahui sebabnya
18 H93 0
spesifik
19 0
Myalgia M79.1
20 D48
21 0
22 0
23 0
24 0
25 0
26 0
27 0
28 0
29 0
30 0
31 0
32 0
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 35 0 0 0 0 40 0
40
NIP. 19871231 201101 1 019 NIP….....................................
Jml
Poskesdes/bidan
desa
Jml melapor

BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
4 4 36 36
BARU LAMA
P JML L P JML
BARU LAMA
P JML L P JML
4 4 0 36 36
Santong, 2021
Kepala Ruangan …......................
( )
NIP….....................................

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FORMULIR 11

LAPORAN BULANAN KESAKITAN UMUM

JUMLAH KASUS JUMLAH KASUS

Demam dengue dan

a. Demam berdarah dengue A91 0 0 0 0 0 0 0 0 1 2 1 1 0 0 0 0 0 0 0 0 5 2 2 4 0 1 1

b. Demam dengue A90 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 4 2 1 3 0 1 1

TB selain Paru (ekstra

15 Tuberkulosis (TB) Paru A15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 1 1 0 0 0 4 3 0 3 1 0 1

1 Anemia defisiensi besi D50.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

HIV/ AIDS tanpa

Atresia (ani) dengan atau

Bibir dan langit-langit

6 Bibir sumbing Q36.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Disentri basiler dan

Gastroenteritis (Kolera dan

2 Benda asing di konjungtiva T15.9 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0

Katarak pada pasien

a. Konjungtivitis alergi H10.1 0 0 0 0 2 0 1 2 1 0 1 0 0 0 2 3 0 0 0 0 12 4 6 10 0 2 2

14 Laserasi kelopak mata S01.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

18 Perdarahan subkonjungtiva H57.8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Otitis media supuratif

Gagal jantung akut dan

4 Hipertensi esensial I10 0 0 0 0 0 0 0 0 0 0 0 0 0 2 10 22 4 32 5 1 76 8 10 18 15 43 58

9 Reduction deformity Q73.8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Transient Ischemic Attack

4 Gangguan depresi F33 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

7 Gangguan psikotik F20# 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 3 0 7 0 0 0 6 1 7

Bronkitis akut (usia < 15

Bronkitis akut (usia > 15

Penyakit paru obstruktif

15 Pertusis (batuk rejan) A37.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

a. Tinea capitis dan

b. Tinea corporis B35.4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 2 1 0 1 0 1 1

c. Tinea cruris B35.6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

14 Fixed Drug Eruption L27.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Frambusia RDT (+)

16 Herpes simplek B00.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

20 Luka bakar derajat I dan II T30 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

27 Pitiriasis versikolor B36.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

29 Sindrom Stevens Johnson L51.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 Diabetes Mellitus Tipe 1 E10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 6 4 14 0 0 28 1 2 3 6 19 25

GINJAL DAN SALURAN

Anemia defisiensi besi pada

3 Cracked Nipple O9212 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 3 0 0 0 0 4 0 4 4 0 0 0

Ruptur perineum tingkat 1-

15 Tumor payudara C50.9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2 Cedera pada leher S10-S19 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cedera pada rongga dada

Cedera pada paha, lutut, S70-

7 Persalinan tunggal spontan O80 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 15 0 0 0 0 19 0 11 11 0 8 8

10 Gemelli / Twin pregnancy O30.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 2 0 2 2 0 0 0

11 Pre-eklamsia sedang O14.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

21 Nyeri kepala R51 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 3 1 2 3 0 0 0

Baiq Nirmalasari, S.Sos, MM Wahyu Candra, A.Md.Kep.

1 Diare tanpa dehidrasi 0

Diare dengan dehidrasi

C INFEKSI UMUM BAKTERI

1 Demam tifoid probable 1 1

2 Demam tifoid konfirmasi

D INFEKSI UMUM VIRUS

1 Acute flaccid paralysis (AFP)

Cedera akibat kecelakaan

2 Cedera akibat tenggelam