FORMAT 1

LAPORAN KUNJUNGAN & RUJUKAN

FASILITAS KESEHATAN TINGKAT PERTAMA
BULAN PELAYANAN JUNI 2014
DOKTER/KLINIK :

BULAN PELAYANAN JUNI 2014

JUMLAH KUNJUNGAN JUMLAH RUJUKAN RATIO

NO NAMA FASKES RATIO RUJUKAN
PESERTA KUNJUNGAN
PESERTA PESERTA
TERDAFTAR PESERTA PESERTA TAK PESERTA PESERTA
TAK TERDAFTAR
TERDAFTAR TERDAFTAR TERDAFTAR TERDAFTAR
TERDAFTAR
2 5 6 7 8 9 10 = (6/5) 11 =(8/6)
1 dr a 1,111 571 0 60 0 51.40 10.51

2
3
4
5
6
7

8
9
10
11
12
13
14
15
16
17
Nb : rincian diagnosa rujukan tetap dilampirkan seperti biasa
Lubuk Alung, 30 Juni 2014
Dokter/Klinik

.............................
 RINCIAN RUJUKAN

DIAGNOSA RUMAH SAKIT RUJUKAN JUMLAH

12 13 14
Myopia RSUD PDG PRM 16
RSUD PRM 2
DHF RSUD PDG PRM 1
Other acne RSUD PRD PRM 1
Other spec injuries of RSUD PDG PRM 1
Redundant prepuce,phRSUD PDG PRM 1
HHD with (congestive)RSUD PDG PRM 1
Dyspepsia RSUD PDG PRM 1
RSUP M Jamil 1
Supervision of other h RSUD PDG PRM 1
Bronchiale asthma in RSUD PDG PRM 1
RSUD PRM 2
Anaemia unspec RSUD PDG PRM 1
Cataract unspec RSUD PDG PRM 1
Allergic contact dermatRSUD PDG PRM 1
unspec appendicities RSUD PDG PRM 1
Pterygium RSUD PDG PRM 1
NIDDM with unspec c RSUD PDG PRM 1
Other spec chronic ob RSUD PDG PRM 1
Interstitialand deep kerRSUD PDG PRM 1
Hypertension stage II RSUD PDG PRM 1
RSUD PRM 1
Herpes viral vesicular RSUD PDG PRM 1
Stress fracture not els RSUD PDG PRM 1
Keratoconjunctivitis RSUD PDG PRM 1
Chronic obstruc pulmoRSUDd PDG PRM 1
Senile insipient catara RSUD PDG PRM 1
Other iodine deff relateRSUP M Jamil 1
Old myocardial infarctiRSUP M Jamil 3
RSUD PRM 1
Predominantly allergi BP 4 1
Tinnitus RSUD PRM 1
Other glaucoma RSUD PRM 1
Acute myocardial infarRSUD PRM 1
Other intra cerebral RSUD PRM 1
Sequelae of strokenot RSUD PRM 1
Follow-up after combinRSUD PRM 1
Non toxic goitre unspeRSUD PRM 1
Cataract right (patiensRSUD PRM 1