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DEPARTEMEN KESEHATAN

REPUBLIK INDONESIA
PKM-Lab
Sistem Registrasi Kanker di Indonesia (SRiKandI)
Nama Puskesmas : ................................................

No Registrasi

No. Rekam Medis

No. Epidemiologi

Nama Lengkap

Jenis Kelamin
Nama Depan

Nama Belakang

Nama Keluarga

No.Identitas / KTP
Tempat Lahir
tgl-bln-thn
Alamat Rumah

Kode Pos

Kel.

Kec.

Agama
0. Tidak tertulis
1. Islam
2. Katolik

Status perkawinan
0. Tidak Tertulis
1. Menikah

Keterangan
Suku/ dalam daftar
Pekerjaan/ dalam daftar
Tumor
Tanggal pertama kali didiagnosa kanker
tgl-bln-thn
Topography
: ........................
(Lokasi tumor/organ)
I

II

III

IV

Tidak tahu

Morfologi
(Jenis Keganasan)
1 Karsinoma
2 Sarkoma
3 Limfoma malignum
Dirujuk ke RS

4 Leukemia
5 Lain-lain, sebutkan.................

Ya

Nama RS Rujukan...................................

Tidak

Alasan .......................................

Dasar Diagnosis
1
2
3
4
5

Keterangan Klinik saja


Pemeriksaan radiologi
Autopsi tanpa pemeriksaan histologi
Pemeriksaan marker Lab Klinik
Sitologi

6
7
8
9

Histologi jaringan metastasis


Histologi jaringan primer
Autopsi dengan pemeriksaan histologi
Tidak diketahui dasar diagnosis

Keadaan klinis pasien saat didiagnosis kanker pertama kali


1 Lokal
2 Regional
3 Bermetastasis jauh
Tanggal kontak terakhir
tgl-bln-thn
Status pasien pada saat kontak terakhir
1 Hidup bebas kanker
2 Hidup dengan kanker

Registrar :

Paraf / Tanggal :

0. Tidak tertulis
1. Laki-laki
2. Perempuan

3. Protestan
4. Hindu
5. Budha
9. Lain-lain

Umur pada kunjungan pertama/ tahun

Kab. :
Prop. :

Stadium

Auto Number

3 Meninggal
4 Tidak ada follof up

Verifikator :

Paraf / Tanggal :

2. Janda / Duda
3. Lajang

SRiKandI

Sistem Registrasi Kan

Pasien
No. Rekam Medis
Nama Lengkap
Nama Depan

Nama Belakang

Nama Keluarga

No.Identitas / KTP
Tempat Lahir
dd-mm-yyyy

Alamat Rumah

Kode Pos

Kel.

Kec.

Kab.

Prop.

Keterangan

Tumor
Topography

Behaviour

(Lokasi tumor) ICD-O kode C

0. Benign
1. Uncertain
2. Carcinoma In Situ

Morphology
(Jenis tumor)

3. Malignant, primary site


6. Malignant, metastatic site
9. Malignant, uncertain

ICD-O kode M

Stage / TNM

Most valid basic of diagnosis of cancer

0. Stage 0
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
9. Unknown

1. Clinical only
2. Lab, X-ray, Endoscopy,
Isotopes Angiography, EEG
3. Surgent/ Autopsy without
histology
4. Spesific biochemical/
Immunology test

A
B
C
D

5. Cytology/ Haematology
6. Histology of metastasis
7. Histology of primary
8. Autopsy with histology
9. Unknown

Treatment at reporting institution

Site (s) of distant metastases

0. No Treatment

0. None

6. Radiotherapy &

5. Brain

1. Surgery
2. Radiotherapy
3. Surgery &
Radiotherapy
4. Chemotherapy
5. Surgery &
Chemotherapy

Chemotherapy
7. Surgery, Radio &
Chemotherapy
8. Other Therapy
9. Unknown

1. Distant lymph node


2. Bone
3. Liver
4. Lung and/ or pleura

6. Ovary
7. Skin
8. Other
9. Unknown

Tanggal pertama kali didiagnosa kanker


dd-mm-yy

Sources / Follow-up
Tgl. Periksa

Kode Rumah Sakit

Nama Rumah Sakit

Unit ID

Status at last contact


1. Alive, no evidence of cancer
2. Alive, localized tumour
3. Alive, direct extension or local involvement
4. Alive, distant metasates

Kesimpulan

5. Alive, subsequent primary discovery or first primary discover


6. Alive, nothing further specified
7. No follow-up
8. Dead
9. Unknown

strasi Kanker di Indonesia


No Registrasi
Epid. No.
Jenis Kelamin

Keluarga

d-mm-yyyy

gnant, primary site


gnant, metastatic site
gnant, uncertain

logy/ Haematology
ology of metastasis
ology of primary
psy with histology

Auto Number

0. Unknown
1. Laki-laki
2. Perempuan

Agama
0. Unknown

3. Protestan

1. Islam

4. Hindu

2. Katolik

5. Budha
9. Lain-lain

Umur pada kunjungan pertama/ tahun


Status perkawinan
0. Unknown

2. Janda / Duda

1. Menikah

3. Lajang

Suku/ dalam daftar


Grade
1. Well Differentiated
2. Moderately Differentiated
3. Poorly Differentiated
4. Undifferentiated
5. Positive T-cell

6. Positive B-cell
7. Null Cell
8. NK (Natural Killer) Cell
9. Not Applicable
10. Dedifferentiated

Clinical extent of disease


before treatment
1. Insitu
2. Localized
3. Direct Extension
4. Regional Lymph node
Involvement

5. Direct Extension with


regional lymph node
involvement
6. Distant metastases
8. Not applicable
9. Unknown

Laterality
1. Right

5. Multiple

2. Left
3. Central
4. Bilateral

Unit ID

6. Not Applicable
7. Unknown

Unit

or first primary discovered when previously unknown

9. Unknown

No. PA / Lab

SRiKandI Sistem Registrasi Kanker


Pasien
No. Rekam Medis
Nama Lengkap
Nama Depan

Nama Belakang

Nama Keluarga

No.Identitas / KTP
Tempat Lahir
dd-mm-yyyy

Alamat Rumah

Kode Pos

Kel.

Kec.

Kab.

Prop.

Keterangan

Tumor
Topography

Behaviour

(Lokasi tumor) ICD-O kode C

0. Benign
1. Uncertain
2. Carcinoma In Situ

Morphology
(Jenis tumor)

3. Malignant, primary site


6. Malignant, metastatic site
9. Malignant, uncertain

ICD-O kode M

Stage / TNM
0. Stage 0
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
9. Unknown

Most valid basic of diagnosis of cancer


1. Clinical only
2. Lab, X-ray, Endoscopy,
Isotopes Angiography, EEG
3. Surgent/ Autopsy without
histology
4. Spesific biochemical/
Immunology tests

A
B
C
D

5. Cytology/ Haematology
6. Histology of metastasis
7. Histology of primary
8. Autopsy with histology
9. Unknown

Treatment at reporting institution

Site (s) of distant metastases

0. No Treatment

0. None

6. Radiotherapy &

5. Brain

1. Surgery
2. Radiotherapy
3. Surgery &
Radiotherapy
4. Chemotherapy
5. Surgery &
Chemotherapy

Chemotherapy
7. Surg, Radiotherapy &
Chemotherapy
8. Other Therapy
9. Unknown

1. Distant lymph node


2. Bone
3. Liver
4. Lung and/ or pleura

6. Ovary
7. Skin
8. Other
9. Unknown

Tanggal pertama kali didiagnosa kanker


dd-mm-yy

Sources / Follow-up
Tgl. Periksa

Kode Rumah Sakit

Nama Rumah Sakit

Unit ID

Status at last contact


1. Alive, no evidence of cancer
2. Alive, localized tumour
3. Alive, direct extension or local involvement
4. Alive, distant metastases

Kesimpulan

5. Alive, subsequent primary discovery or first primary discover


6. Alive, nothing further specified
7. No follow-up
8. Dead
9. Unknown

si Kanker di Indonesia
No Registrasi
Epid. No.
Jenis Kelamin

Keluarga

d-mm-yyyy

gnant, primary site


gnant, metastatic site
gnant, uncertain

logy/ Haematology
ology of metastasis
ology of primary
psy with histology

Auto Number

0. Unknown
1. Laki-laki
2. Perempuan

Agama
0. Unknown

3. Protestan

1. Islam

4. Hindu

2. Katolik

5. Budha
9. Lain-lain

Umur pada kunjungan pertama/ tahun


Status perkawinan
0. Unknown

2. Janda / Duda

1. Menikah

3. Lajang

Suku/ dalam daftar


Pekerjaan/ dalam daftar
Grade
1. Well Differentiated
2. Moderately Differentiated
3. Poorly Differentiated
4. Undifferentiated
5. Positive T-cell

6. Positive B-cell
7. Null Cell
8. NK (Natural Killer) Cell
9. Not Applicable
10. Dedifferentiated

Clinical extent of disease


before treatment
1. Insitu
2. Localized
3. Direct Extension
4. Regional Lymph node
Involvement

5. Direct Extension with


regional lymph node
involvement
6. Distant metastases
8. Not applicable
9. Unknown

Laterality
1. Right

5. Multiple

2. Left
3. Central
4. Bilateral

Unit ID

6. Not Applicable
9. Unknown

Unit

Date of last contact

or first primary discovered when previously unknown

9. Unknown

No. PA / Lab

dd-mm-yy

PETUNJUK PENGISIAN

No. Registrasi

: Otomatis akan terisi

Biodata Pasien
1 No. Rekam Medis
2 Nama Lengkap
- Nama Depan
- Nama Belakang
- Nama Keluarga
3 Nomor Identitas / KTP
4 Tempat Lahir
- Tanggal Lahir
5 Alamat rumah
6 Kode Pos
- Kelurahan
- Kecamatan
- Kabupaten
- Propinsi
7 Keterangan
8 Epid No.
9 Jenis Kelamin
10 Agama
11 Umur pada kunjungan pertama/ tahun
12 Status perkawinan
13 Suku/ dalam daftar
14 Pekerjaan/ dalam daftar

Tumor
15
16
17
18
19
20
21
22
23
24
25

Topography
: Lokasi tumor, diisi dengan kode C menggunakan ICD-O
Morphology
: Jenis tumor, diisi dengan kode M menggunakan ICD-O
Behaviour
:
Grade
:
Stage / TNM
:
Most valid basic of diagnosis of cancer
Clinical extent of disease before treatment
Treatment at reporting institution
Site (s) of distant metastases
Laterality
Tanggal pertama kali didiagnosa kanker

Sources / Follow-up
26 Status at last contact
27 Date of last contact
28 Kesimpulan
29
30
31
32