FORM KEBERHASILAN PENGOBATAN TB SO

JANUARI-DESEMBER 2021

PUSKESMAS : PANGKALAN KASAI

Tanggal
Jenis
No. Nama Lengkap No. RM NIK Tanggal Lahir Selesai
Kelamin
Pengobatan

1 JUARI 1402060303430001 3/3/1943 L 6/22/2021

2 REPINO 1402062604720002 26 April 1972 L 6/27/2021
3 WILMA FIRMAWATI 1402064205880002 3/15/1986 P 7/5/2021
4 AGUS EFENDI 1402065412860001 12/14/1986 L
5 WAGIATI 1404196609900003 9/26/1990 P 2/4/2021
6 RISKI ANDRIAN 1402040112870004 12/1/1987 L 7/6/2021
7 SUDARMAN SIJABAT 1402063112580031 12/31/1958 L 7/6/2021
8 CANDRA SILA PUTRA 1402062809000005 10/28/1998 L 8/23/2021
9 IRWANSYAH 1402080101710004 1/1/1971 L
10 MASDAR 1402021308680001 13 Agustus 1968 p 4/1/2021
11 ROSSA MAINAR 1402066703850001 3/27/1985 P 7/18/2021
12 HASAN BASRI 1402012512840002 12/25/1984 L 7/21/2021
13 SUMITO 1401200201760002 1/2/1976 L 7/26/2021
14 SITI AMINAH 1402064404820008 4/4/1982 P
15 DASWATI 1402066412700001 12/24/1970 P
16 YAKUB 1402062506560001 6/25/1956 L
17 NURBAITI 1402066230170000 1/23/1970 P
18 AMRAN HARAHAP 1402060911640001 11/9/1964 L 8/4/2021
19 SYAHRUL MANIK 1402061112710001 12/11/1971 L
20 SRI HASTUTI 1402066610880001 10/26/1988 P
21 AMINAH 1402064410620001 12/31/1962 P
22 ARIF BUDIMAN 1402062211790001 11/22/1979 L
23 BUSTAMAR 1402061707700001 7/17/1970 L
24 FIRNANDO PRASETYA 1402060610500004 1/6/1978 L
25 ASMAWATI SAFRI Z 1402664087100001 P
26 ALUS 1402065607850005 P
27 ELMIATI 1402665208810000 P
28 SITI RAMLAH 1402094705900203 P
29 ENDAH PALUPI 1402065809760001 P
30 ISNAINI ULFA 1402000000000001 P
31 FITRI WANTI 1402000000000002 P
32 MINTARSIH 1402065008840004 P
33 NUNUNG 1402065503730001 P
34 SUSANTI 1402065009750003 P
35 SOSLADIANA 1402064066400001 P
36 YULI ASTUTI 1402067058200002 P
37 NELI YANI 1402066506810001 P
38 PUJI LESTARI 1402060000000005 P
39 SRI WAHYUNI 1402066306850005 P
40 SITI ROHANAH 1402064406830001 P
41 ANTEP NURIANI 1402064711700001 P
42 YATI DWITA SARI 1402064102840003 P
43 YUNI YANTI 1402064506920001 6/25/1992 P
44 JUMADI 1402060505660003 5/5/1966 L
45 ILA HAYATI 1402065504830001 4/5/1983 P
46 RAHIMI 1402063112720012 1/1/1972 L
47 SAHATA MARTUA SINAGA 1210081609010002 9/16/2001 L 10/3/2021
48 SUMILAH 1402064606690001 6/6/1989 P 10/3/2021
49 FIRDAUS 1402062706830002 6/27/1983 L
50 SUPARDI 1402061611590001 11/16/1959 L
51 PURNADI 1402060202820007 2/2/1982 L
52 MUHAMMAD NASIR 1402062507640001 7/25/1964 L
53 SRI WIYANTI 1402064805900003 5/8/1990 P 10/13/2021
54 PARSAROAN MANULANG 1402060101710008 1/1/1971 L 10/13/2021
55 ABDUL GHANI AKMAL 1302102104130001 4/21/2013 L
56 JONI CANIAGO 1402061707720001 7/17/1972 L
57 NURHAYATI 1402065212760005 12/12/1976 P
58 SUTARA 1402061301670001 1/13/1967 L
59 NARIMIN 1402060705320001 L
60 OHIR 1402063112450008 L
61 TATANG SUHARNA 1402063112530016 L
62 NAHROWI 1803102704830005 L
63 ESTEVANIA 1402065409010001 4-Sep-01 P
64 DARTO 1402063112650021 12/31/1965 L
65 ROSPIANA 1402056605680001 5/26/1968 P
66 LIKE YANRASTA BR GULTOM 1222024709990002 9/7/1999 P 12/8/2021
67 DUMAYANI CAHYA 1402065608780003 6/16/1978 P
68 SUCHI ANANDA PUTRI 1402066903970001 3/30/1999 P
69 ZUHRI RAMADHAN PAMUNGKAS 1402060512020004 12/5/2002 L
70 JIHAN ALFIZAH 1402065311100001 11/13/2010 P
71 SADIMAN 1402063112620024 12/31/1962 L
72 HERIA YETNI 1402066101070001 10/10/1970 P
73 DENI MUSTIKA SARI 1402065203950002 3/5/1995 P
74 PUTRA IRAWAN 1402060407010001 7/4/2001 L 12/14/2021
75 YULI ANGGRAINI 1205125805960001 6/18/1995 P 1/4/2022
76 JOSUA SAOR BARITA 1210081306980002 4/17/1998 L 1/4/2022
77 JUMIYATI 1402026707990001 7/26/1999 P 13 Februari 2
78 SUSILAWATI 1402074501740001 1/5/1974 P
79 ERMAWATI 1102074906880001 6/8/1988 P
80 MISDRAM 1402063112470013 12/31/1947 P
81 SUGIMAN 1402060904660001 L
82 TEMU 1402063112510008 12/31/1951 L
83 SUDIANA 1402065405750001 5/14/1975 L 01 Maret 202
84 CECEP TARSITA 1402060102830003 2/1/1983 L 01 Maret 202
 85 KARDION 1402060708680001 8/7/1968 L
86 AHADDIN MAULANA 1402060401100001 1/24/2010 L
87 AMINARDI 1402062709680001 9/27/1968 L 27 Maret 202
88 RINALDI 1402061505730001 5/15/1973 L
89 HENDRO PRIONO GIRSANG 1404090810870003 10/8/1987 L
90 ANDINY TUSARY 1402066501030002 1/25/2003 P
91 SUWITO BIN JOYO TARMUN 1402061808720002 8/18/1972 L
92 AGUNG WAHYUDI 1402062001960003 1/20/1996 L 08 April 2022
93 DARMA KRISTINAWATI 1402065404750001 4/4/1975 P
94 SUEB 1402061203530001 3/12/1953 L 08 April 2022
95 AIRA ZHAWDA RIBINIA 1402066203120001 3/22/2012 P
96 RICKY ALDILA PRADEWA 1402061308890001 8/13/1989 L
97 KARNAIN 1402071005800002 5/10/1958 L
98 SUSILAWATI 1402074501740001 1/5/1974 P
99 SAMSUL BAHRI 1402062811700001 11/28/1970 L 13 April 2022
100 HENDRA 1402061006680001 6/7/1968 L
101 ZAMZANI 1402064105680001 5/1/1968 L
102 ERINDA MELATI 1207275107990001 7/11/1999 P
103 SUGIARTI 1402065805850001 5/18/1985 P
104 MUHAMMAD ARIPIN 1402060104100001 4/1/2010 L
105 JONI 1402061005480001 5/10/1948 L
106 SAHRIYAN 1402060311710005 11/3/1971 L 26 April 2022
107 ngatemi 1402065707680003 7/17/1964 P
108 LAMNA 1402076008580001 8/20/1958 P
109 SAPRI 1402060510650002 10/5/1965 L
110 NETI 1402075806920003 6/18/1992 P
111 Agus Sutikno 1402061008840005 8/10/1984 L 01 Mei 2022
112 CHOIROL ANAM 1402061411830001 11/14/1983 L
113 SUNAN SYARDANDI 1402062304990004 4/23/1999 L
114 YULI KANIDA 1402064807870002 7/8/1987 P
115 HERLINA 1402064503890002 3/5/1989 P
116 YUSILA 1402065212770004 12/12/1977 P
117 BAHARUDIN 1402060110700013 10/1/1970 L
118 MILA KARMILA 1402066009620001 9/20/1962 P
119 RIMA SUSANA 1402064808870002 8/9/1987 P
120 BONDAN 1402060607640002 7/6/1964 L
121 MARTUTIK 1402064710720003 10/14/1972 P
122 DIMAS WAHYUDI 1402062010030003 11/20/2003 L
123 HERI SUPRI 1402063112820017 12/31/1982 L
124 MARLIUN 1402061207680003 7/12/1968 L
125 DELI CHANDRA 1402060305880004 5/3/1988 L 16 Mei 2022
126 SYAHRONI 1402060107830005 7/1/1983 L 18 Mei 2022
127 RITA 1402064408930001 8/4/1993 P
128 BIMA 1402065601700001 1/16/1970 L
129 SLAMET 1404141603800001 3/16/1980 L
130 RIFQI FIDARA SANDI 1402062501890001 1/25/1989 L 25 Mei 2022
131 ALDI NURMIJA PUTRI 1402066905910001 5/29/1991 P
132 FATLA NANDA OKHOIRY 1402061910110001 10/19/2011 L
133 ALVEY NAILA ANNISA 1402065707160002 7/17/2016 P
134 SRI KAWIT 1402065507570001 7/15/1957 P
135 JOKO SUDARMANTO 1402060904750004 4/9/1975 L
136 KHUSAENI 1402061405730001 5/14/1973 L
137 SRI HARYATI 1402066708790001 8/27/1979 P
138 MOCH HISJAM 1402062512480001 12/25/1948 L
139 MUHAMAD IFIT 1402060402990002 04 Februari 1999 L 26 Mei 2022
140 AISYAH 1402064701610006 7/1/1961 P 02 Juni 2022
141 YOSO JEDUHU DUHA 1402061508790001 8/15/1979 L 31 Mei 2022
142 HAMAT 1402060702610001 2/7/1961 L
143 KARIMUN 1402060303480001 3/3/1948 L
144 ARYATI 1402064502710001 2/15/1971 P
145 YULI ANGGRAINI 1205125805960001 6/18/1995 P 03 Juni 2022
146 YATINI 1607047007870001 7/30/1987 P
147 AFNI NUR A 1402065903950002 3/9/1995 P
148 PONIEM 1402065504700001 4/15/1970 P
149 SUTOPO 1402060808650002 8/8/1965 L
150 NURKAHYADI 1402063006820004 6/30/1982 L
151 WALUYO 1402060306730004 6/3/1973 L
152 KUSMINAH 1402134907850001 7/19/1985 P
153 SUTILAH 1402065408670001 8/24/1967 P
154 SALIM 1402061007750004 7/10/1975 L
155 MUALIM 1402062602850002 2/26/1985 L
156 HARISYANI 1402065212730001 12/2/1973 P
157 RISANTI 1402065203820004 3/12/1982 P
158 SANJUM 1402063012370002 12/30/1937 L
159 MISNAH 1402067112560009 12/31/1956 P
160 ROFIUL HUDA 1402060605150001 5/6/2015 L
161 SOPYAN 1402062406730002 6/24/1973 L
162 ABU JOHAN 1402061902570001 2/19/1957 L
163 HEMLI 1402066607770002 7/26/1977 L
164 SUGIARSIH 1402065310970006 10/13/1997 P 22 Juni 2022
165 ZANDI LAILA 1402064607760005 7/6/1976 P 14 Juni 2022
166 BAWOK 1402062508500001 8/25/1950 L
 Pemeriksaan Dahak Yang Tepat dan Benar PEMBERIAN OBAT SESUAI REGIMEN &
DIAGNOSIS DOSIS YANG TEPAT (TB 01)
Pemeriksaan Permohonan PMO
Terduga TB Pemeriksaan TAHAP
Pemeriksaan TAHAP LANJUTAN
TCM/Xpert AWAL
Bakteriologis

Terkonfirmasi
Dilakukan Tidak Negatif Positif Negatif Ada Tidak Ada 1 2 1 2 3
TB

√ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √
√ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √
√ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √ √ √ √ √
√ √ √
√ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √ √ √ √ √
√ √
√ √ √
√ √ √ √ √ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √
√ √ √ √ √ √ √
√ √ √
√ √
√ √ √
√ √ √
√ √ √
√ √ √ √ √ √ √
√ √ √ √ √ √ √
√ √ √
√ √ √
√ √ √ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √
√ √ √ √ √ √
√ √ √
√ √ √ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √ √
√ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √
√ √ √ √
√ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √
√ √ √ √
√ √ √ √
√ √ √
SUAI REGIMEN & PEMANTAUAN PENGOBATAN DAN EFEK SAMPING
PAT (TB 01) PEMERIKSAAN ULANG DAHAK
PEMANTAUA PENCATATAN HASIL AKHIR
N EFEK REKAM MEDIS PENGOBATAN
AP LANJUTAN Akhir Bulan ke 2 Akhir Bulan ke 5 Akhir Bulan ke 6 SAMPING

Tidak Tidak
4 Positif Negatif Positif Negatif Positif Negatif Ada Lengkap Lengkap Sembuh
Ada
dan benar dan Benar
√ √ √ √ √ √
√ √ √ √ √ √
√ √ √

√ √
√ √ √
√ √ √
√ √ √

√ √
√ √ √
√ √ √ √ √ √ √
√ √ √ √ √

√ √ √

√
√ √ √ √ √ √
√ √ √ √ √ √

√ √ √ √ √ √
√ √ √

√ √ √

√ √ √

√ √ √
√ √ √
√ √ √ √ √ √
√

√
√
√

√
√

√
√
√
√
√

√
HASIL AKHIR
PENGOBATAN

Lengkap

PUTUS
√
√
√

MENINGGAL
√

MENOLAK BEROBAT
√

√
MENOLAK BEROBAT

√
√

MENINGGAL SEBELUM BEROBAT

MENINGGAL

BELUM BEROBAT