FORMAT RAWAT JALAN

UPT PUSKESMAS MONCEK

UGD
BULAN : JANUARI 2015
NO KARTU/SPM/ UMUR THN
NO TANGGAL NO REG NAMA PASIEN ALAMAT
NIK L P
1 1/2/2015 1486 352907 270881 0001 Tn. Awam 33 Benaresep Barat
2 1/2/2015 1342 352907 300374 0001 Tn. Siri 41 Moncek Tengah
3 1/2/2015 1487 352907 561267 0003 Ny. Ainiyah 48 Bilapora Rebba
4 1/2/2015 1488 352907 270361 0002 Tn. Saikin 54 Benaresep Barat
5 1/3/2015 1489 352907 410165 0015 Ny. Saniya 50 Bilapora Rebba
6 1/3/2015 1450 352907 701256 0015 Ny. Bairah 59 Moncek timur
7 1/3/2015 1451 352907 100900 0007 Basit 25 Benaresep Barat
8 1/3/2015 1452 352907 510595 0006 Windayati 25 Moncek timur
9 1/3/2015 1453 352907 270493 0008 Badrul Munir 23 Bilapora Rebba
10 1/4/2015 1454 352907 221088 0002 Mansur 26 Lembung Barat
11 1/4/2015 1455 352907 270794 0004 Fajar Bahri 21 Moncek Timur
12 1/4/2015 145 352907 671187 0005 Mutmainnah 35 Benaresep Barat
13 1/4/2015 1456 352907 061072 1157 Saleh 40 Bilapora Rebba
14 1/6/2015 1457 352907 120187 0001 Nofal 27 Mocek Barat
15 1/8/2015 1458 352907 530695 0001 Lutfiyah 15 Benaresep Barat
16 1/9/2015 1459 352907 481163 0002 Sarifah 65 Moncek Barat
17 1/10/2015 1460 35907 171183 0003 Ashari 35 Bilapora Rebba
18 1/11/2015 1461 352907 210598 0005 Khalilurrahman 20 Moncek Tengah
19 1/12/2015 1551 352907 410297 0006 Yuliatin Ningsih 24 Bilapora Rebba
20 1/13/2015 1462 352907 671284 0002 Sri handayani 21 Moncek Timur
21 1/14/2015 1463 352907 641085 0001 Khalifah 35 Moncek Tengah
22 1/15/2015 1464 352907 650465 0001 Titiatul 55 Moncek Tengah
23 1/15/2015 1465 352907 200798 0008 Riswan 25 Moncek Tengah K
24 1/18/2015 1356 352907 410509 0001 Meisela 6 Banaresep Barat
25 1/18/2015 1466 352907 100278 0006 Sahid 60 Banaresep Barat
26 1/18/2015 1467 352907 461265 0003 Sahrum 80 Banaresep barat
27 1/20/2015 1468 352907 420207 0001 Jesika 17 Moncek Tengah
28 1/21/2015 1469 352907 291291 0003 NofaL 15 Banaresep Barat
29 1/21/2015 1470 352907 210545 0002 Saman 21 Bilapora Rebba
30 1/22/2015 1471 352907 500889 0001 Nafilah 25 Bilapora Rebba
31 1/24/2015 1472 352907 160691 0005 Taufik 18 Bilapora Rebba
32 1/24/2015 1473 352907 261096 0002 Khairul alim 17 Bilapora Rebba
33 1/24/2015 1474 352907 410904 0002 Masruroh 21 Bilapora Rebba
 NO KARTU/SPM/ UMUR THN
NO TANGGAL NO REG NAMA PASIEN ALAMAT
NIK L P
34 1/24/2015 1475 352907 580756 0001 Saniyah 59 Bilapora Rebba
35 1/24/2015 1476 352907 451268 0002 Jumaatun 57 Moncek Timur
 JALAN
MONCEK

KARCIS BIAYA TOTAL

DIAGNOSE KOIDE(ICDX) TINDAKAN
MASUK TINDAKAN BIAYA
K29/Gastritis Inj.B12 7,500 1,000 8,500
M25/Gangguan sendi Inj.B12 7,500 1,000 8,500
R51/Nyeri kepala Inj.antalgin 7,500 1,000 8,500
I10/Hipertensi 7,500 - 7,500
R50/Demam Inj.antalgin 7,500 1,000 8,500
M25/gangguan sendi Inj.B12 7,500 1,000 8,500
R50/Demam Inj.antalgin 7,500 1,000 8,500
R50/Demam Inj.antalgin 7,500 1,000 8,500
R50/Demam Inj.antalgin 7,500 1,000 8,500
K29/Gastritis Inj.B12 7,500 1,000 8,500
A09/GEA Inj.B12 7,500 1,000 8,500
A09/GEA Inj.B12 7,500 1,000 8,500
R50/Demam Inj.antalgin 7,500 1,000 8,500
R05/Batuk Inj.dhipen 7,500 1,000 8,500
R50/Demam 7,500 - 7,500
A09/GEA Inj.B12 7,500 1,000 8,500
R51/nyeri kepala Inj.antalgin 7,500 1,000 8,500
R50/Demam Inj.antalgin 7,500 1,000 8,500
R50/Demam Inj.antalgin 7,500 1,000 8,500
R51/nyeri kepala Inj.antalgin 7,500 1,000 8,500
A09/GEA Inj.B12 7,500 1,000 8,500
R51/nyeri kepala Inj.antalgin 7,500 1,000 8,500
K29/Gastritis Inj.antalgin 7,500 1,000 8,500
R50/Demam 7,500 - 8,500
R51/nyeri kepala Inj.antalgin 7,500 1,000 8,500
R51/nyeri kepala Inj.antalgin 7,500 1,000 8,500
R05/Batuk 7,500 - 8,500
R50/Demam 7,500 - 7,500
A09/GEA Inj. B12 7,500 1,000 8,500
R50/Demam Inj. antalgin 7,500 1,000 8,500
A09/GEA Inj.B12 7,500 1,000 8,500
R50/Demam Inj. antalgin 7,500 1,000 8,500
R51/nyeri kepala Inj.antalgin 7,500 1,000 8,500
 KARCIS BIAYA TOTAL
DIAGNOSE KOIDE(ICDX) TINDAKAN
MASUK TINDAKAN BIAYA
R11/Vomiting Inj.Dhipen 7,500 1,000 8,500
M25/Gangguan sendi Inj.B12 7,500 1,000 8,500
262,500 30,000 294,500

Moncek,..2015
KEPALA UPT PUSKESMAS MONCEK

Dr HANIFAH. M.Si
NIP. 19681104 200604 2 005
 FORMAT RAWAT JALAN
UPT PUSKESMAS MONCEK
UGD
BULAN : JANUARI 2015
NO KARTU/SPM/ UMUR THN
NO TANGGAL NO REG NAMA PASIEN ALAMAT
NIK L P
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
 NO KARTU/SPM/ UMUR THN
NO TANGGAL NO REG NAMA PASIEN ALAMAT
NIK L P
34
35
 JALAN
MONCEK

KARCIS BIAYA TOTAL

DIAGNOSE KOIDE(ICDX) TINDAKAN
MASUK TINDAKAN BIAYA
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 - 7,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 - 7,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 - 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 - 8,500
7,500 - 7,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
7,500 1,000 8,500
 KARCIS BIAYA TOTAL
DIAGNOSE KOIDE(ICDX) TINDAKAN
MASUK TINDAKAN BIAYA
7,500 1,000 8,500
7,500 1,000 8,500
262,500 30,000 294,500

Moncek,..2015
KEPALA UPT PUSKESMAS MONCEK

Dr HANIFAH. M.Si
NIP. 19681104 200604 2 005