Variabel Pilihan

Format tanggal
Rekam Medis
Register Nasional
Sex Laki-laki
Perempuan
Hamil/Tidak Tidak Hamil
Hamil
Status Perkawinan Menikah
Belum Menikah
Janda/Duda
Entry Point KIA
Rawat Jalan (TB, Anak, Penyakit Dalam, IMS,
lainnya….)
Rawat Inap
Praktek Swasta
Jangkauan (IDU, PSK, LSL, ……………….)
LSM
Datang Sendiri
Lainnya, Uraikan…..
Pendidikan Tidak sekolah
SD
SMP
SMU
Perguruan Tinggi
Status Pekerjaan Tidak Bekerja
Bekerja
Faktor Risiko Heteroseksual
Homoseksual
Biseksual
Perinatal
Transfusi Darah
NAPZA suntik
Lain2, uraikan ……..

Infeksi Opportunistik (IO) Kandidiasis

Diare cryptosporidia
Meningitis cryptocococal
Pneumonia Pneumocystis
Cytomegalovirus
Penicilliosis
 Herpes zoster
Herpes simpleks
Toxoplasmosis
Hepatitis
Menerima ART sebelumnya Ya
Tidak
Status Fungsional Kerja
Ambulatori
Baring
TB selama ART TB Paru
TB Ekstra Paru
Rejimen ART

Alasan Substitusi/Switch Toksisitas/efek samping

Hamil
Risiko hamil
TB baru
Ada obat baru
Stok obat habis
Alasan lain (uraikan)
Alasan hanya untuk SWITCH Gagal pengobatan secara klinis
Gagal imunologis
Gagal virologis
Alasan STOP Toksisitas/efek samping
Hamil
 Gagal pengobatan
Adherens buruk
Sakit/MRS
Stok obat habis
Kekurangan biaya
Keputusan pasien lainnya
Lain-lain
Adherence ART >95%) = < 3 dosis lupa diminum dlm 30 hari
(80-95%) = 3 - 12 dosis lupa diminum dlm 30 hari
< 80%) = >12 dosis lupa diminum dlm 30 hari
Keterangan Pasien Terapi/restart
Stop
Tidak Berkunjung /Alpa
Rujuk Keluar
Rujuk Masuk
Meninggal Dunia
 Kode Keterangan
Bulan/Hari/Tahun
sesuai masing-masing RS WAJIB DIISI
11 digit WAJIB DIISI
L
P
0
1
1
2
3
1

2
3
4
5
6
7
8
0
1
2
3
4
0
1
1
2
3
4
5
6
7

Jika IO lebih dari satu dipisahan

K dengan tanda koma (,) dan spasi
D Contoh:
Cr K, D, Cr
PCP
CMV
P
 Z
S
T
H
1
2
1
2
3
1
2
ZDV(300)+3TC(150)+NVP(200) Rejimen Lini 1
ZDV(300)+3TC(150)+EFV(600) Rejimen Lini 1
d4T(30)+3TC(150)+NVP(200) Rejimen Lini 1
d4T(30)+3TC(150)+EFV(600) Rejimen Lini 1
TDF(300)+3TC(150)+NVP(200) Rejimen Lini 1
TDF(300)+3TC(150)+EFV(600) Rejimen Lini 1
TDF(300)+FTC(200)+NVP(200) Rejimen Lini 1
TDF(300)+FTC(200)+EFV(600) Rejimen Lini 1
ZDV(100)+3TC(150)+NVP(200) Pediatrik
ZDV(100)+3TC(150)+EFV(200) Pediatrik
d4T(30)+3TC(150)+EFV(200) Pediatrik
d4T(12)+3TC(60)+NVP(100) Pediatrik (triple FDC Junior)
d4T(12)+3TC(60) Pediatrik (dual FDC+EFV(200)
ZDV+3TC+NVP(60/30/50) Pediatrik (FDC Pediatric)
ABC(300)+3TC(150)+NVP(200) Rejimen Alternatif/Lini 2
ABC(300)+3TC(150)+EFV(600) Rejimen Alternatif/Lini 2
TDF(300)+3TC(150)+LPV/r(200/50) Rejimen Alternatif/Lini 2
TDF(300)+FTC(200)+LPV/r(200/50) Rejimen Alternatif/Lini 2
d4T(30)+3TC(150)+LPV/r(200/50) Rejimen Alternatif/Lini 2
ZDV(300)+3TC(150)+LPV/r(200/50) Rejimen Alternatif/Lini 2
1
2
3
4
5
6
7
8
9
10
1
2
 3
4
5
6
7
8
9
1
2
3
T
S
A
RK
RM
M
 Dokumen Bantu REGISTER PRA ART

Tgl kunjungan
No. Tahun BLN LAPORAN No. Rekam Medik No.Reg.Nas
pertama

1 2010 11 4-Nov-10 0080344 3602011 0001

2 2011 1 29-Dec-10 0086792 3602011 0002

3 2011 1 20-Jan-11 0086400 3602011 0003

4 2011 2 4-Feb-11 0090456 3602011 0004

5 2011 2 27-Jan-11 0089859 3602011 0005

8 2011 7 4-Jul-11 0106344 3602011 0008

9 2011 7 12-Jul-11 360201102 3602011 0009

10 2011 8 3-Aug-11 112301 3602011 0010

13 2011 9 10-Sep-11 360201105 3602011 0013

14 2011 11 19-Nov-11 0121855 3602011 0014

15 2011 12 30-Nov-11 360201106 3602011 0015

17 2011 12 5-Dec-11 360201108 3602011 0017

18 2012 1 26-Dec-11 122132 3602011 0018

19 2012 1 28-Dec-11 360201109 3602011 0019

20 2012 2 28-Jan-12 360201110 3602011 0020

21 2012 2 2-Feb-12 360201111 3602011 0021

22 2012 2 15-Feb-12 360201112 3602011 0022

23 2012 2 15-Feb-12 360201113 3602011 0023

24 2012 2 18-Feb-12 360201114 3602011 0024

25 2012 2 21-Feb-12 360201115 3602011 0025

26 2012 3 3-Mar-12 360201116 3602011 0026

27 2012 3 6-Mar-12 360201117 3602011 0027

28 2012 3 9-Mar-12 134201 3602011 0028

29 2012 3 22-Mar-12 135219 3602011 0029

31 2012 4 16-Apr-12 128224 3602011 0031

32 2012 4 18-Apr-12 103607 3602011 0032

33 2012 5 27-Apr-12 140116 3602011 0033

34 2012 5 3-May-12 141073 3602011 0034

35 2012 5 22-May-12 142818 3602011 0035

37 2012 6 29-May-12 360201120/ 0143843 3602011 0037

38 2012 7 28-Jun-12 360201121 3602011 0038

39 2012 7 17-Jul-12 133991 3602011 0039

40 2012 7 15-Jul-12 3602011 0040

42 2012 7 24-Jul-12 3602011 0042

43 2012 8 1-Aug-12 151117 3602011 0043

44 2012 8 6-Aug-12 3602011 0044

45 2012 8 24-Aug-12 153236 3602011 0045

46 2012 9 30-Aug-12 154216 3602011 0046

47 2012 9 4-Sep-12 3602011 0047

49 2012 9 5-Sep-12 3602011 0049

50 2012 9 5-Sep-12 3602011 0050

51 2012 10 26-Sep-12 128870 3602011 0051

52 2012 10 18-Oct-12 3602011 0052

53 2012 10 22-Oct-12 3602011 0053

54 2012 12 29-Nov-12 3602011 0054

56 2012 12 6-Dec-12 016000 3602011 0056

59 2013 2 29-Jan-13 3602011 0059

60 2013 2 4-Feb-13 3602011 0060

61 2013 2 4-Feb-13 3602011 0061

62 2013 2 4-Feb-13 3602011 0062

63 2013 2 5-Feb-13 172505 3602011 0063

64 2013 2 18-Feb-13 3602011 0064

65 2013 2 20-Feb-13 172505 3602011 0065

66 2013 2 23-Feb-13 17489 3602011 0066

67 2013 3 28-Feb-13 3602011 0067

68 2013 3 1-Mar-13 3602011 0068

69 2013 4 2-Apr-13 156166 3602011 0069

70 2013 4 16-Apr-13 3602011 0070

71 2013 4 8-Apr-13 180103 3602011 0071

73 2013 5 6-May-13 182966 3602011 0073

75 2013 10 22-Oct-13 225127 3602011 0075

76 2013 11 29-Oct-13 3602011 0076

77 2013 11 22-Nov-13 3602011 0077

79 2014 1 9-Jan-14 3602011 0079

80 2014 2 29-Jan-14 3602011 0080

81 2014 2 9-Feb-14 212912 3602011 0081

83 2014 5 5-May-14 220953 3602011 0083

84 2014 6 3-Jun-14 224693 3602011 0084

85 2014 6 3-Jun-14 3602011 0085

86 2014 6 12-Jun-14 225554 3602011 0086

87 2014 7 1-Jul-14 227319 3602011 0087

88 2014 7 8-Jul-14 227825 3602011 0088

89 2014 9 5-Sep-14 232667 3602011 0089

92 2014 10 22-Oct-14 3602011 0092

93 2014 10 22-Oct-14 237355 3602011 0093

94 2014 10 24-Oct-14 224687 3602011 0094

95 2014 11 31-Oct-14 238763 3602011 0095

96 2014 11 6-Nov-14 238627 3602011 0096

97 2014 11 12-Nov-14 3602011 0097

98 2014 11 13-Nov-14 23092 3602011 0098

99 2014 11 12-Nov-14 3602011 0099

102 2014 12 19-Jan-15 3602011 0102

103 2015 1 13-Jan-15 3602011 0103

104 2015 2 3-Feb-15 247557 3602011 0104

105 2015 2 16-Feb-15 250092 3602011 0105

108 2015 3 25-Mar-15 252084 3602011 0108

109 2015 5 18-May-15 3602011 0109

111 2015 5 22-May-15 245931 3602011 0111

112 2015 5 12-May-15 252501 3602011 0112

113 2015 6 29-May-15 259635 3602011 0113

114 2015 6 11-Jun-15 260123 3602011 0114

117 2015 8 2-Aug-15 3602011 0117

118 2015 8 10-Aug-15 244567 3602011 0118

120 2015 9 30-Aug-15 60346 3602011 0120

121 2015 9 7-Sep-15 268808 3602011 0121

122 2015 9 8-Sep-15 270654 3602011 0122

124 2015 10 9-Oct-15 27069 3602011 0124

125 2015 10 13-Oct-15 272407 3602011 0125

126 2015 10 18-Oct-15 273750 3602011 0126

127 2015 10 19-Oct-15 274773 3602011 0127

129 2015 10 21-Oct-15 274996 3602011 0129

130 2015 10 22-Oct-15 264591 3602011 0130

131 2015 10 20-Oct-15 3602011 0131

132 2015 11 2-Nov-15 244025 3602011 0132

133 2015 11 4-Nov-15 248639 3602011 0133

134 2015 11 4-Nov-15 276317 3602011 0134

135 2015 12 2-Dec-15 279598 3602011 0135

136 2015 12 14-Dec-15 228430 3602011 0136

137 2015 12 16-Dec-15 271570 3602011 0137

138 2015 12 17-Dec-15 277620 3602011 0138

140 2016 1 16-Jan-16 289670 3602011 0140

141 2016 1 20-Jan-16 284520 3602011 0141

143 2016 1 23-Jan-16 285649 3602011 0143

145 2016 2 23-Feb-16 289270 3602011 0145

146 2016 3 8-Mar-16 1296236 3602011 0146

169 2011 8 25-Aug-11 360201104 3602011 0169

147 2016 3 15-Mar-16 291711 3602011147

148 2016 3 11-Mar-16 291515 3602011148
A ART

Umur Sex
NAMA ALAMAT No Telp TGL Lahir
(TAHUN) (L/P)

Irene Komplek Aspol II - 28 1-Jan-82 P

Rangkasbitung

M. Saprudin Kp. Sigeong RT.01/01 27 1-Jan-83 L

Solear Tangerang

Kp Pabuaran
Yayah 43 1-Jan-68 P
Warunggunung

Kp. Bojong Hilir,

Ny. Eros 24 1-Jan-87 P
Cibadak

Tn Cece Kp. Cirendeu, Solear 20 1-Jan-91 L

Kp. Sabagi,
NY. Wati Winarti 081218190580 23 6-May-88 P
Rankasbitung

Ny. Aam Amdiyah Kp. Sondol, Cimarga 087772949065 28 1-Jan-83 L

Ny. Satiah Leuwidamar 081910978054 29 1-Jan-82 P

Kp Lebak Saninten
Tn Sukra 43 1-Jan-68 L
Rangkasbitung

Ds. Datar Cae ,

Ny Suhanah 22 1-Jan-89 P
Cirinten

Tn Nana Kp. Lurah, Cipanas 51 1-Jan-61 L

an ines Kp.Babakan Datar Cae 1.5 1-Jul-05 p

Kp.Pasir Eurih Bj Cae

Tn Deden 87773964311 26 28-Jun-05 L
Cibadak

Kp.Somang Sajira
Ny Siti Juhariah 87886663825 38 3-Apr-73 P
Lebak

Kp.Pasir Pilar Curug

Ny Siti Supartini 85215587777 39 26-May-05 P
Bitung

Kp.Nangkak Ds.jaga
Tn Endang Romi 87884780280 24 10-Jun-05 L
Baya Warung gunung
Ny Iis Suryadi indramayu 87772796553 25 3-Jun-87 P

Kp.Leumah Neundet
An Afeni 2 2-Jul-05 P
Cileles

Ny Yati 87772506542 45 8-Jun-67 P

Kp.Buyut ds Kujag Sari

NY Anah 30 4-Jun-05 P
Cileles

Kp. Cihangeur
Tn Nurohman 24 1-Jan-88 L
Wanasari Cibeber

Kp.Taman Adiyasa
Ny Ernawati 87771398651 40 25-May-05 P
tanggerang

Kp.Leuwiranji
Ny Dewi 30 4-Jun-05 P
Rangkasbitung

Kp.Pasir Gendok
Ny Dewi 81219894745 28 6-Jun-05 P
Cibadak

Kp Cibabang
Ny Eka Wahyuni 25 9-Jun-05 P
Leuwidamar

Ny Anita Kp Kaum Lebak 28 7-Jun-84 P

Rangkasbitung

An Nur Laphana Kp Kaung Caang Ds 85216630599 9 1-Jan-03 P

Cigoong Cikulur

Ny Herti Kp Cibuuk Cimarga 87775678395 35 30-May-05 P

Kp Salimah Ds Gintung
An A Sibli 81283938333 10 24-Jun-05 L
Bogor

Kp Perum Duta Graha

Tn Hery 43 1-Jan-69 L
igaraksa

Kp Salimah Ds
Tn cecep Sukamanah 2194958356 L
Tanggerang

Kp Luwuk Ds Padasuka
Ny Een P
Warungunung

Kp Cijulang Gn
Ny Yumairah 25 9-Jun-05 P
Kencana

Kp Kadubana Ds
Ny Saadah 82123250218 P
Pasindangan Cileles

Btn Depag Blok A3 No

Tn Angga L
3

Tn Sofyan Perum Korpri 8131414378140 34 6-Feb-78 L

Tn Rohani Cimarga 81311403909 31 31-Dec-85 L

Tn Fahrul Jl Sunan Kali Jaga 81910939666 29 5-Jun-05 L

Tn Suheli Kp Lebak Gedong 85888888093 L

An Aisyah Kp Cidahu Kopo Serang 9.9 3-Jul-05 P

Ny Saiyah Kp Cidahu Kopo Serang 25 9-Jun-05 P

Tn Muksin Kp Gaceng ds. Tambak 85231311903 38 1-Jan-74 L

Ny Junariah Kp Cijulang Bj Koneng 24 10-Jun-05 P

Gn Kencana

Tn Dede Kp.Gubug Ds 87808051619 37 28-May-05 L

Calungbungur Sajira

Ny Liah Kp Kaum Kembar Ds 29 1-Jan-83 P

Nayagati Cisimeut

Ny. Rohamah alias Lilis Karyajaya Cimarga 85775179363 24 1-Jan-88 P

Tn Nanda Kp Cikadu Malingping 87773145576 36 29-Jan-13 L

Tn Syarif Kp Rancamaraja 82114468777 31 3-Jun-05 L

By Ny Sti Nuraeni Kp Rancamaraja Cileles 1 hri 4-Feb-13 P

Ny Siti Nuraeni Kp.Rancamaraja Cileles 87808879106 25 9-Jun-05 P

Tn Hendra Kp Leuwikaung 30 4-Jun-05 L

Kp Sodang Tigaraksa
Tn Andre 2193631257 27 4-Jun-05 L
Tnggerng

Ny Nining Kp Pasir eurih Cibadak 35 1-Jan-78 P

Kp Cibaros Ds
Ny Tanti 81617352150 30 1-Jan-83 P
Cibungur Leuwidamar

Kp Cikabon Parung
Ny Tuti 27 1-Jan-86 P
Panjang

Kp Cikabon Parung
Tn Riki 8135233039 28 1-Jan-87 L
Panjang
Tn Sumitro Kp Pamarayan 81271587373 42 1-Jan-71 L

Kp Cihanyet Wanasari
By M Gilang 1 1-Jan-12 L
Cibeber

Pertelon Warung
Nn Gita Silvya 0813152828551 25 1-Jan-88 P
Gunung

Kp Kadulari Bojong
Tn Haerudin 85773683332 29 1-Jan-84 L
Manik

Kp Ranca Timah Cijoro

Ny E Sri Mulyani 85691803499 34 1-Jan-79 P
Lebak

Kp Cepak Baru
Ny Iroh 85888202474 20 1-Jan-93 P
Leuwidamar

kp Gunung Barat
Tn Madani 32 1-Jan-81 L
Gunung Kencana

Kp Pasir pedes Curug

Ny Junariah 23 1-Jan-91 P
Bitung

Kp Lebak Saninten
Tn Robi 43 1-Jan-71 L
Rangkasbitung

Tn Edi Junaedi Kp Babaka Seah 83873492376 21 1-Jan-93 L

Cipanas

Ny Suherti Kp sidawaras Ds 8988619555 35 1-Jan-79 P

pasarKeng Cibadak

Tn Tedi Hidayat Kp Sukasari Baru Tenjo 39 28-May-05 L

Bogor

Kp Sukasari Baru Tenjo

Ny Rini 87772366514 25 11-Jun-05 P
Bogor

KP Lembur Sawah
NN puput 27 9-Jun-05 P
Cijoro

Kp Bayawak Ds Taban
Tn Parulian 25 11-Jun-05 L
Tanggerang

KP Sawah Ds Bj Gede
Tn Rudi Fahrul 87772155160 31 5-Jun-05 L
Bogor

Tn Edi Basori Kp Sudamanik 87772664027 42 1-Jan-72 L

Ny Dede Kp Parung Cimarga 81381295660 31 1-Jan-83 P

Tn Yusron Kp Parung Cimarga 37 1-Jan-77 L

Pasir Harendong,
Ny Rohanah 33 1-Jan-81 P
Jawilan

Kp Tamaga Ds Narga
Ny Ika 22 1-Jan-92 P
Warna
Nn Nina Kp Cilaki Ds Marga Jaya 87772838639 26 1-Jan-88 P

Kp Ciapus Jasinga
Tn Rizal alfian 27 1-Jan-87 L
Bogor

Kp Ciapus Jasinga
Ny EEn 24 1-Jan-90 P
Bogor

Kp Cilaki Ds Marga
Tn Ondo 48 1-Jan-66 L
Jaya

Rancasema
An Nelli Fauziah 3 1-Jan-12 P
Rangkasbitung

Pegangsingan II Jakarta
Tn Daud 27 1-Jan-88 L
Utara

Kp Sindanglaya
Nn Oom 19 1-Jan-96 P
Cimayang Bj Manik

Komplek Depag
Tn Muhibudin 87871143433 36 1-Jan-79 L
Cipocok Jaya Serang

Kp Pasir Nangka
Ny Juenah 29 1-Jan-86 p
Curugbitung

Tn Sahroni Kp Ketug Masjid 35 1-Jan-80 L

Citeras

Tn Wawan Kp Babakan Ds. 81289758634 38 1-Jan-77 L

Kaduhauk

Tn Agus Heri Kp Janggan, Asem, 32 1-Jan-83 L

Cibadak

Kp Guludug Ds
Ny Badriah 22 1-Jan-92 P
Sukaharja Cikulur

Pasirbitung
Tn Suani 25 1-Jan-89 L
Bojongmanik

Babakan Nambo seeng

Ny Tini 34 1-Jan-81 P
Cijoro Lebak

Ny Eva Agustiani Pasar Keong, Cibadak 28 1-Aug-87 P

Tn Acep Kp Aweh 25 10-Jun-90 L

Tn Hari Lesmana Pasindangan, Cileles 33 16-Sep-82 L

Kp Karuga Ds Karang
Ny Mela 88808120217 27 10-Jun-05 P
Nunggal

Kp Pasir Bungur
Tn JUMANTA 36 1-Jan-79 L
Cimarga

Kp Bugel Ds Pasir
Ny Suhedah 85311844354 30 7-Jun-05 P
Buyut Jawilan
 Kp Batang
Ny oom Komalasari 23 6-Sep-94 P
Leuwidamar

Kp Malangbong s
Ny Yuyun 22 15-Jun-05 P
Argapura Cigudeg

Tn Ayudi Majasari, Sobang 37 12-May-78 L

Pasir Sukarayat
Tn Ahmad Isrof 46 19-Apr-69 L
Rangasbitung

Kp Malangbong s
Tn Eko Saputra 23 1-Jan-92 L
Argapura Cigudeg

Kp Sumur Buang Ds
Ny Roza Rafelina 82169888202 25 1-Jan-89 P
kadu Agung Tengah

Kp Sumur Buang Ds
Tn Dendi 31 9-Jan-84 L
kadu Agung Tengah

Kp Mekarjaya Pondk
Tn Sungga panjang, Cihara 31 9-Jan-84 L

BTN narimbang
Tn Reza 22 2-Apr-93 L
Rangkasbitung

Ny Yulia Yuningsih Kp Aweh Kalanganyar 36 1-Jul-79 P

Ny Rohmalina Cidahu, Serang 32 1-Jan-83 P

Gunung anten,
Tn Suherman 38 10-Nov-68 L
Cimarga

Muara Lebak, Muara

Tn Herman 33 1-Jan-82 L
dua, Cikulur

Kp Korehek
Tn Hanip 21 6-Dec-94 L
Warunggunung

Babakan Saputra,
Tn Pahrul 22 7-Jan-94 L
Warunggunung

Tn Agus Warunggunung 36 1-Jan-80 L

Tn Sadi Bojong Manik 8589045559 27 L

By Khaera Ramadhani /Anak IbuLeuwidamar 1 1-Aug-11 P

An Eji
Tn. Arsan
 Laki-laki Perempuan

Hamil/Ti
dak
<1 1-14 15-19 20-24 25-49 ≥ 50 <1 1-14 15-19 20-24 25-49 ≥ 50

28 0

27 0

43 0

24 0

20 0

23 0

28 0

29 0

43 0

22 0

51 0

1.5 0

26 0

38 0

39 0

24 0
 25 0

2 0

45 0

30 0

24 0

40 0

30 0

28 0

25 0

28 0

9 0

35 0

10 0

43 0

25 0

34 0
31 0

29 0

9.9 0

25 0

38 0

24 0

37 0

29 0

24 0

36 0

31 0

1 hri 0

25 0

30 0

27 0

35 0

30 0

27 0

28 0
 42 0

6hri 0

25 0

29 0

68 0

20 0

32 0

23 0

43 0

21 0

35 0

39 0

25 0

27 0

25 0

31 0

42 0

31 0

37 0

33 0

22 0
 26 0

27 0

24 0

48 0

3 0

27 0

19 0

36 0

29 0

35 0

28 0

32 0

22 0

25 0

34 0

28 0

25 0

33 0

28 0

36 0

30 0
 23 0

22 0

37 0

46 0

23 0

25 0

31 0

31 0

22 0

36 0

32 0

38 0

33 0

21 0

22 0

36 0

27 0

1 0
Keterangan tambahan Konfirmasi tes HIV+ IO yg terjadi
saat masuk

Faktor Risiko
Pendidikan
Entry
STATUS

Bekerja
point
PERKAWINA (No.
N kode)
BB TB Tgl Tempat Kode

TB Paru 2 4-Nov-11 Klinik 3 3 0 1 TB, PCP, Cr

Seroja

TB Paru 2 29-Dec-10 Klinik 3 3 0 1 TB, K, Cr

Seroja

Klinik
TB Paru 1 23-Jan-11 3 3 0 1 TB, K, D
Seroja

Klinik
TB Paru 1 4-Feb-11 3 2 0 1 TB
Seroja

Klinik
TB Paru 1 1-Feb-11 2 2 1 1 TB, K, D
Seroja

Klinik
38 TB Paru 1 5-Jul-11 3 2 0 1 TB, K
Seroja

Klinik
55 TB Paru 1 12-Jul-11 2 1 0 1 TB
Seroja

Klinik
56 1 3-Aug-11 8 1 0 1
Seroja

Klinik
TB Paru 2 10-Sep-11 3 2 1 2 D
Seroja

Klinik
29 TB Paru 1 1-May-10 8 2 0 1 D, K
Teratai

Klinik
TB Paru 3 30-Nov-11 3 1 1 1 tb
Seroja

Klinik
8.7 TB Paru 2 29-Nov-11 1 0 0 4
Seroja

Klinik
42 TB Paru 2 24-Dec-11 3 2 0 7 K
Seroja

Klinik
61 TB Paru 3 4-Nov-10 2 2 0 1
Seroja

Klinik
45 TB Paru 1 28-Jan-10 3 2 0 1
Seroja

Klinik
43 1-Feb-12 3 1 1 1 D
Seroja
 Klinik
45 TB Paru 3 15-Feb-12 2 0 1 TB
Seroja

Klinik
6 TB Paru 2 14-Feb-12 3 0 0 4 K
Seroja

Klinik
41 TB Paru 1 18-Feb-12 3 2 0 1
Seroja

Klinik
40 TB Paru 1 21-Feb-12 3 1 1 1
Seroja

Klinik
TB Paru 2 3-Mar-12 3 1 0 1 tb
Seroja

Klinik
35 TB paru 1 6-Mar-12 3 1 0 1
Seroja

Klinik
8-Mar-12 3 3
Seroja

Klinik
35 TB Paru 3 21-Feb-12 3 1 0 1
Seroja

Klinik
36 1 16-Apr-12 3 1 0 1
Seroja

40 TB Paru 1 18-Apr-12 Klinik 3 3 0 1

Seroja

11 2 27-Apr-12 Klinik 1 1 0 K
Seroja

42 1 3-May-12 Klinik 3 1 0 1
Seroja

Klinik
15 2 22-May-12 3 1 0
Seroja

Klinik
42 TB Paru 1 29-May-12 3 1 1 1 D
Seroja

Klinik
48 1 28-Jun-12 2 2 0 1
Seroja

Klinik
TB Paru 1 16-Jul-12 3 1 0 1
Seroja

Klinik
2 19-Jul-12 3 1 1 1
Seroja

Klinik
45 Tb Paru 3 24-Jul-12 2 1 0 1
Seroja

Klinik
2 1-Aug-12 4 0 6
Seroja

Klinik
70 1 2-Aug-12 2 4 1 1
Seroja
 Klinik
50 1 24-Aug-12 3 3 1 1
Seroja

55 TB Paru 2 29-Aug-12 Klinik 3 3 1 1

Seroja

Klinik
55 1 4-Sep-12 3 2 1 1
Seroja

Klinik
5.5 5-Sep-12 7 0 0 4 K
Seroja

Klinik
56 1 5-Sep-12 2 0 1
Seroja

Klinik
47 TB Paru 1 26-Sep-12 3 1 0 1 tb
Seroja

18-Oct-12 Klinik 3 1 0 1
Seroja

68 2 22-Oct-12 Klinik 2 2
Seroja

3 29-Nov-12 Klinik 3 0 0 1
Seroja

Klinik
TB Paru 1 6-Dec-12 3 1 0 1
Seroja

Klinik
56 2 29-Jan-13 2 1 0 1
Seroja

Klinik
59 1 4-Feb-13 2 3 1 1
Seroja

Klinik
2 4-Feb-13 0 0
Seroja

Klinik
49 1 4-Feb-13 3 2 0 1
Seroja

Klinik
TB Paru 1 5-Feb-13 3 2 1 1
Seroja

Klinik
44 TB Paru 1 18-Feb-13 2 1 1 1
Seroja

Klinik
40 TB Paru 3 20-Feb-13 3 1 1 1
Seroja

Klinik
35 TB Paru 1 17-Dec-12 3 0 0 1
Seroja

Klinik
TB Paru 1 28-Feb-13 3 1 0 1
Seroja

Klinik
TB Paru 1 1-Mar-13 2 1 1 1
Seroja
 Klinik
68 TB Paru 1 2-Apr-13 2 3 1 1
Seroja

Klinik
3.3 2 6-Apr-13 1 0 0
Seroja

Klinik
36 TB Paru 2 8-Apr-13 3 4 1 1
Seroja

Klinik
TB Paru 3 6-May-13 3 3 1 1
Seroja

Klinik
37 TB Paru 1 22-Oct-13 2 2 0 1
Seroja

Klinik
29-Oct-12 2 1 0 1
Seroja

Klinik
44 TB Paru 1 22-Nov-13 3 2 1 6
Seroja

Klinik
3 9-Jan-14 3 1 0 1
Seroja

Klinik
1 15-Nov-13 3 3 1 1 H
Seroja

45 TB Paru 2 9-Feb-14 Klinik 3 1 1 1

Seroja

43 TB Paru 1 5-May-14 Klinik 3 2 1 1

Seroja

TB Paru 1 3-Jun-14 Klinik 3 1 1 1

Seroja

Klinik
1 1 3-Jun-14 2 4 1 1
Seroja

Klinik
35 TB Paru 2 12-Jun-14 3 2 1 1
Seroja

Klinik
TB Paru 1 1-Jul-14 3 2 1 1
Seroja

Klinik
TB Paru 1 8-Jul-14 3 2 1 1
Seroja

Klinik
55 1 5-Sep-14 3 1 1 1
Seroja

Klinik
50 22-Oct-14 2 1 1 1
Seroja

Klinik
50 TB Paru 1 20-Oct-14 3 2 1 1
Seroja

Klinik
TB Paru 1 24-Oct-14 3 2 0 1 tb
Seroja

Klinik
29 TB Paru 1 30-Oct-14 3 1 1 1 tb
Seroja
 Klinik
29 TB Paru 1 4-Nov-14 3 2 1 1 tb
Seroja

Klinik
TB Paru 1 12-Nov-14 2 2 1 1 tb
Seroja

Klinik
35 TB Paru 1 13-Nov-14 3 2 0 1 tb, k
Seroja

Klinik
65 TB Paru 1 6-Nov-14 7 3 1 1 tb
Seroja

Klinik
7.2 2 5-Dec-14 1 0 0 4
Seroja

Klinik
TB Paru 2 13-Jan-15 2 3 1 1 tb
Seroja

Klinik
51 TB Paru 2 3-Feb-15 3 1 0 1
Seroja

Klinik
76 TB Paru 1 16-Feb-15 2 4 1 1 tb
Seroja

Klinik
TB Paru 1 18-Mar-15 3 1 0 1 TB
Seroja

TB Paru 1 5-May-15 Klinik 3 1 1 1 TB

Seroja

TB Paru 3 22-May-15 Klinik 3 2 1 1 d, tb

Seroja

TB Paru 1 12-May-15 Klinik 2 1 1 1 TB

Seroja

Klinik
TB Paru 1 29-May-15 3 2 0 1 TB
Seroja

Klinik
TB Paru 2 8-Jun-15 2 2 1 1 tb
Seroja

Klinik
TB Paru 3 2-Aug-15 3 1 0 1 K, D, TB
Seroja

Klinik
32 TB Paru 1 10-Aug-15 2 2 0 1 tb, k
Seroja

Klinik
TB Paru 30-Aug-15 3 1 0 1 tb
Seroja

Klinik
43 TB Paru 3 7-Sep-15 2 2 1 2 tb
Seroja

Klinik
0 TB Paru 1 8-Sep-15 3 1 1 1
Seroja

Klinik
52 TB Paru 2 9-Oct-15 3 3 1 1 TB
Seroja

Klinik
31 1 13-Oct-15 3 1 0 1
Seroja
 Klinik
40 TB Paru 3 18-Oct-15 3 3 0 1 D, TB
Seroja

Klinik
TB Paru 1 10-Oct-15 3 1 0 1 TB, K
Seroja

Klinik
58 TB Paru 1 21-Oct-15 3 1 1 1 TB
Seroja

Klinik
60 TB Paru 2 22-Oct-15 3 3 1 2 TB
Seroja

Klinik
TB Paru 1 20-Oct-15 7 2 1 1 TB
Seroja

Klinik
38 TB Paru 1 2-Nov-15 3 3 0 1 TB
Seroja

Klinik
TB Paru 1 4-Nov-15 3 3 0 1 TB
Seroja

Klinik
TB Paru 2 30-Oct-15 Seroja 3 2 1 1 k

Klinik
TB Paru 2 2-Dec-15 3 3 0 1 k
Seroja

43 TB Paru 3 9-Dec-15 Klinik 3 2 1 1 d, k

Seroja

Klinik
TB Paru 1 16-Dec-15 2 3 0 1 TB
Seroja

Klinik
TB Paru 1 17-Dec-15 2 1 1 1 K, TB
Seroja

Klinik
TB Paru 1 16-Jan-16 2 0 0 1 TB
Seroja

Klinik
TB Paru 2 20-Jan-16 2 3 0 2 k, tb
Seroja

Klinik
TB Paru 2 23-Jan-16 2 3 0 1 K, TB
Seroja

Klinik
TB Paru 1 23-Feb-16 3 2 1 1 TB
Seroja

Klinik
2 8-Mar-16 2 1 1 1 TB
Seroja

Klinik
3.2 TB Paru 2 8 0 0 4 K
Teratai
IO yg terjadi Skrining TB Alasan memenuhi syarat

Tgl memenuhi
Tgl pemberian
Terapi IO syarat medis utk
Cotrimoksazol ART
Tgl. Tanggal +/- Stad. WHO

4-Nov-10 RHZES, Levo, 4-Nov-11 4-Nov-11 + 4-Nov-11 3

Cotrim

29-Dec-10 Nistatin 29-Dec-10 29-Dec-10 + 29-Dec-10 4

Drop,RHZE

Nistatin, cotrim,
20-Jan-11
RHZE
23-Jan-11 23-Jan-11 + 23-Jan-11 3

4-Feb-11 RHZE 14-Mar-11 14-Mar-11 + 14-Mar-11 4

31-Jan-11 RHZE 1-Feb-11 1-Feb-11 + 1-Feb-11 3

4-Jul-11 nistatin , RHZE 4-Jul-11 4-Jul-11 + 4-Jul-11 3

12-Jul-11 RHZE 12-Jul-11 12-Jul-11 + 12-Jul-11

3-Aug-11 + 3-Aug-11

10-Sep-11 12-Sep-11 10-Sep-11 + 10-Sep-11 3

21-Nov-11 21-Nov-11 21-Nov-11 + 21-Nov-11 3

30-Nov-11 rhze 1-Dec-12 30-Nov-11 + 30-Nov-11 4

5-Dec-11 + 5-Dec-11 1

24-Dec-11 rhze 26-Dec-11 24-Dec-11 + 26-Dec-11 3

4-Nov-10 28-Dec-11 4-Nov-10 + 4-Nov-10 1

28-Jan-10 28-Jan-10 28-Jan-10 + 28-Jan-10 4

1-Feb-12 1-Feb-12 1-Feb-12 + 1-Feb-12 2

 15-Feb-12 15-Feb-12 15-Feb-12 + 22-Feb-12 2

14-Feb-12 Rhze 15-Feb-12 15-Feb-12 + 14-Feb-12 3

18-Feb-12 rhze 18-Feb-12 18-Feb-12 + 18-Feb-12 2

21-Feb-12 22-Feb-12 21-Feb-12 + 21-Feb-12 2

3-Mar-12 r 3-Mar-12 3-Mar-12 + 3-Mar-12 3

6-Mar-12 Rhze 6-Mar-12 6-Mar-12 + 6-Mar-12 2

8-Mar-12 8-Mar-12 + 8-Mar-12

21-Feb-12 Rhze 24-Mar-12 21-Feb-12 + 21-Feb-12 2

16-Apr-12 16-Apr-12 16-Apr-12 + 2

18-Apr-12 Rhze 18-Apr-12 18-Apr-12 + 2

27-Apr-12 27-Apr-12 27-Apr-12 + 28-May-12 2

3-May-12 5-May-12 3-May-12 + 3

22-May-12 22-May-12 22-May-12 + 2

29-May-12 29-May-12 + 29-May-12 2

28-Jun-12 28-Jun-12 28-Jun-12 + 28-Jun-12 2

16-Jul-12 Rhze 17-Jul-12 16-Jul-12 + 3

19-Jul-12 19-Jul-12 19-Jul-12 + 3

24-Jul-12 rhze 24-Jul-12 24-Jul-12 + 1

1-Aug-12 2-Aug-12 1-Aug-12 + 3

6-Aug-12 6-Aug-12 2-Aug-12 + 2

 24-Aug-12 25-Aug-12 24-Aug-12 +

29-Aug-12 30-Aug-12 29-Aug-12 + 2

4-Sep-12 4-Sep-12 4-Sep-12 + 1

5-Sep-12 5-Sep-12 5-Sep-12 +

5-Sep-12 5-Sep-12 5-Sep-12 +

26-Sep-12 cefo, rhze 26-Sep-12 26-Sep-12 + 26-Sep-12 3

18-Oct-12 18-Oct-12 +

22-Oct-12 22-Oct-12 +

29-Nov-12 29-Nov-12 29-Nov-12 +

6-Dec-12 6-Dec-12 + 6-Dec-12 2

29-Jan-13 29-Jan-13 29-Jan-13 +

4-Feb-13 5-Feb-13 4-Feb-13 + 1

4-Feb-13 4-Feb-13 4-Feb-13 + 1

4-Feb-13 5-Feb-13 4-Feb-13 + 1

5-Feb-13 7-Feb-13 5-Feb-13 + 2

18-Feb-13 18-Feb-13 18-Feb-13 + 1

20-Feb-13 20-Feb-13 20-Feb-13 + 1

17-Dec-12 23-Feb-13 17-Dec-12 + 1

28-Feb-13 28-Feb-13 28-Feb-13 +

1-Mar-13 1-Mar-13 1-Mar-13 +

 2-Apr-13 4-Apr-13 2-Apr-13 + 2

16-Apr-13 16-Apr-13 16-Apr-13 +

8-Apr-13 nystatin 8-Mar-13 8-Apr-13 + 26-Apr-13 2

6-May-13 8-May-13 6-May-13 +

22-Oct-13 ystati 31-Oct-13 22-Oct-13 + 2

29-Oct-12 29-Oct-12 29-Oct-12 + 2

22-Nov-13 23-Nov-13 22-Nov-13 +

9-Jan-14 9-Jan-14 9-Jan-14 +

29-Jan-14 29-Jan-14 15-Nov-13 +

9-Feb-14 14-Feb-14 9-Feb-14 + 2

5-May-14 Rhze 5-May-14 5-May-14 + 2

3-Jun-14 Rhze 9-Jun-14 3-Jun-14 + 2

3-Jun-14 3-Jun-14 3-Jun-14 + 2

12-Jun-14 Rhze 14-Jun-14 12-Jun-14 + 14-Jun-14 2

1-Jul-14 Rhze 1-Jul-14 1-Jul-14 + 1-Jul-14 2

8-Jul-14 Rhze 10-Jul-14 8-Jul-14 + 10-Jul-14 2

5-Sep-14 Nystatin Drop 5-Sep-14 5-Sep-14 + 5-Sep-14 2

22-Oct-14 22-Oct-14 +

20-Oct-14 Rhze 20-Oct-14 20-Oct-14 + 2

24-Oct-14 rhze 24-Oct-14 24-Oct-14 + 24-Oct-14 3

30-Oct-14 RHZE 31-Oct-14 30-Oct-14 + 2

 4-Nov-14 Rhze 6-Nov-14 4-Nov-14 + 2

12-Nov-14 rhze 12-Nov-14 12-Nov-14 + 12-Nov-14 2

13-Nov-14 Rhze 13-Nov-14 13-Nov-14 + 13-Nov-14 2

12-Nov-14 Rhze 12-Nov-14 12-Nov-14 + 9-Mar-15 1

19-Jan-15 19-Jan-15 19-Jan-15 + 19-Jan-15 2

13-Jan-15 Rhze 13-Jan-15 13-Jan-15 + 13-Jan-15 1

3-Feb-15 Rhze 5-Feb-15 3-Feb-15 + 2

16-Feb-15 rhze 16-Feb-15 16-Feb-15 + 16-Feb-15 2

18-Mar-15 Rhze 25-Mar-15 25-Mar-15 + 25-Mar-15 2

18-May-15 Rhze 18-May-15 18-May-15 + 18-May-15 2

22-May-15 rhze 22-May-15 22-May-15 + 22-May-15 1

12-May-15 Rhze 12-May-15 12-May-15 + 25-May-15 2

29-May-15 Rhze 29-May-15 29-May-15 + 29-May-15

8-Jun-15 Rhze 11-Jun-15 11-Jun-15 + 11-Jun-15 2

2-Aug-15 Rhze 2-Aug-15 2-Aug-15 + 2-Aug-15 3

10-Aug-15 Rhze 10-Aug-15 10-Aug-15 + 11-Nov-15 4

30-Aug-15 Rhze 30-Aug-15 30-Aug-15 + 30-Aug-15 2

7-Sep-15 Rhze 7-Sep-15 7-Sep-15 + 10-Sep-15 1

8-Sep-15 Rhze 15-Sep-15 8-Sep-15 +

9-Oct-15 rhze 9-Oct-15 9-Oct-15 + 9-Oct-15 2

13-Oct-05 cotrim 13-Oct-15 13-Oct-15 + 13-Oct-15 2

18-Oct-15 rhze 18-Oct-15 18-Oct-15 + 18-Oct-15 3

10-Oct-15 Rhze 19-Oct-15 19-Oct-15 + 19-Oct-15 3

21-Oct-15 Rhze 21-Oct-15 21-Oct-15 + 21-Oct-15 2

22-Oct-15 rhze 22-Oct-15 22-Oct-15 + 22-Oct-15 2

20-Oct-15 rhze 20-Oct-15 20-Oct-15 + 20-Oct-15 2

2-Nov-15 Rhze 4-Nov-15 2-Nov-15 + 2-Nov-15 2

4-Nov-15 rhze 11-Nov-15 4-Nov-15 + 4-Nov-15 2

4-Nov-15 rhze 4-Nov-15 4-Nov-15 + 4-Nov-15 2

2-Dec-15 rhze 2-Dec-15 2-Dec-15 + 2-Dec-15

14-Dec-15 Rhze 14-Dec-15 14-Dec-15 + 14-Dec-15 2

16-Dec-15 rhze 16-Dec-15 16-Dec-15 + 16-Dec-15 2

17-Dec-15 rhze 17-Dec-15 17-Dec-15 + 17-Dec-15 2

16-Jan-16 rhze 16-Jan-16 16-Jan-16 + 16-Jan-16 2

20-Jan-16 Rhze 20-Jan-16 20-Jan-16 + 20-Jan-16 2

23-Jan-16 23-Jan-16 23-Jan-16 + 23-Jan-16 2

23-Feb-16 Rhze 23-Feb-16 23-Feb-16 + 23-Feb-16 2

3-Jul-16 Rhze 7-Mar-16 +

25-Aug-11 nistatin 25-Aug-11 + 25-Aug-11 1

Alasan memenuhi syarat Akhir follow-up sebelum mulai ART

Tgl mulai ART

Tgl. kunjungan
Penyebab
CD4: TLC/VL: Tgl. meninggal Kematian terakhir gagal Tgl. Rujuk Keluar
follow-up

teratai

29-Dec-10 teratai

26-Jan-11 teratai

19-Mar-11 teratai

5-Feb-11 teratai

4-Aug-11

12-Aug-11

12-Aug-11

25-Nov-11

1-May-10 8-Mar-12 rm teratai

4-Apr-12 25-May-12

8-Mar-12

17-Feb-12 20-Jan-12

25-Jan-11

30-Jan-12
22-Feb-12 30-Mar-12 29-Mar-12

15-May-12 3-May-12

28-Feb-12

25-Dec-12 13-Jun-12

6-Jun-12 30-Jun-14

9-Mar-12

3-Jul-12 25-Jun-12

30-Apr-12

20-Apr-12

28-May-12 9-Dec-12

15-May-12

29-May-12

5-Jul-12 12-Jul-12

30-Jul-12
 13-Nov-12

5-Nov-12 1-Oct-12

1-Jan-13

10-Dec-12

11-Feb-13

4-Mar-13

4-Mar-13
 26-Jun-13

11-Jul-13

26-Apr-15 18-Jul-15

15-May-13

2-Jul-14 14-Jun-14

6-Jul-14 22-Jun-14

14-Feb-14

17-Oct-14 23-Dec-14

9-Sep-14

27-Nov-14
 13-Dec-14

13-Dec-14

9-Mar-15

19-Jan-15 16-Mar-15 26-Jan-15

24-Feb-15

22-Oct-15

25-May-15

4-Jun-15

3-Mar-16

11-Nov-15 22-Jan-16

10-Sep-15

14-Jan-16

23-Nov-15 19-Jan-16 18-Jan-16

 5-Apr-16

19-Jan-16

9 2-Dec-15

18-Nov-15

18-Nov-15

22 5-Dec-15

59 11-Apr-16

128 15-Mar-16

6-Aug-11 3-Sep-12
Dokumen Bantu REGISTER ART Referensi warna: Rujuk Keluar Stop Gagal follow up
Mati Rujuk Masuk

Laki-laki Perempuan
Remarks

Bulan Nomor

Umur
BLN TGL mulai No Rekam Sex Hamil
No. Th Rujuk Register Nama TGL Lahir Alamat pasien
LAPORAN ART Medik / KODE (L/P) /Tidak
Masuk Nasional <1 1-14 15-19 20-24 25-49 ≥ 50 <1 1-14 15-19 20-24 25-49 ≥ 50

1 2011 8 12-Aug-11 112301 3602011 0010 Ny. Satiah 29 1-Jan-82 P 29 0 Leuwidamar

2 2011 11 19-Nov-11 1-May-10 121855 3602011 0014 Ny Suhanah 22 1-Jan-89 P 22 0 Datar Cae, Cirinten

3 2011 12 4-Apr-12 360201106 3602011 0015 Tn Nana 51 1-Jan-61 L 51 0 Kp. Lurah, Cipanas

4 12 1-Dec-11 18-Apr-12 360201107 3602011 0016 Ny. Amaniah 48 1-Jan-63 p 48 0 Kp. Lurah, Cipanas

5 2012 2 22-Feb-12 360201112 3602011 0022 Iis Suryadi 25 3-Jun-87 P 25 0 Indramayu

Kp. Cihangeur Wanasari

6 2012 3 6-Jun-12 360201116 3602011 0026 Tn Nurohman 24 1-Jan-88 Cibeber

7 2012 5 28-May-12 140116 3602011 0033 An Nur Laphana

1-Jun-14 3602011 0030 Ny. Risma

3602011 0071 Nn Gita Silvya

3602011 0074 Tn Raka

3602011 0078 Ny Yayu

3602011 0082 Ny Siti Munawaroh

3602011 0083 Ny Suherti

3602011 0083 Ny Suherti

3602011 0094 Ny Rohanah

3602011 0099 Tn Ondo

3602011 0102 An Nelli Fauziah

3602011 0107 Tn Irwanto

3602011 0105 Tn Muhibudin

3602011 0109 Tn Sahroni

3602011 0112 Tn Agus Heri

3602011 0116 Ny Sumiyati

3602011 0121 Tn Hari Lesmana

3602011 0118 Ny Eva Agustiani

3602011 0124 Tn JUMANTA

3602011 0125 Ny Suhedah

3602011 0126 Ny oom Komalasari

3602011 0129 Tn Ayudi

3602011 0130 Tn Ahmad Isrof

3602011 0136 Ny Yulia Yuningsih

3602011 0141 Tn Hanip

3602011 0142 Ny Aniyah

3602011 0169 By Khaera Ramadhani /Anak Ibu Satiah

 CATATAN:
perhatikan konsistensi pengisian antara adherence dan keterangan pasien
dengan status fungsional, BB, dan CD4

Status fungsional 1 (Kerja), 2 (Ambulatori), 3 (Baring) Berat badan (kg) Nilai CD4 (% utk anak dan ibu hamil) TB selama ART
sebelumnya (1/2)
Menerima ARV

Stad klinis
Nama tgl
WHO pd
no Telp PMO & No. Screening /
saat mulai Pd saat Pd 6 Pd 12 Pd 24 Pd 36 Pd 48 Pd 60 Pd 72 Pd 84 Pd 96 Pd saat Pd 6 Pd 12 Pd 24 Pd 36 Pd 48 Pd 60 Pd 72 Pd 84 Pd 96 Pd saat Pd 6 Pd 12 Pd 24 Pd 36 Pd 48 Pd 60 Pd 72 Pd 84 Pd 96
Telp Tapis TB P/EP
ART mulai Rx bulan bulan bulan bulan bulan bulan bulan bulan bulan mulai Rx bulan bulan bulan bulan bulan bulan bulan bulan bulan mulai Rx bulan bulan bulan bulan bulan bulan bulan bulan bulan

2 1 1 1 1 1 1 1 1 56 56 56 54 55 54 58 3-Aug-11 1

1 3 3 3 2 30 30 34 19-Nov-11 1

2 4 3 40 30-Nov-11 1

2 1 1 1 1 1 1 50 50 48 45 43 165 1-Dec-11

2 2 3 45 15-Feb-12 1
selama ART IO yang terjadi IMS Substitusi dgn ARV lini ke-1 VL Switch dengan ARV lini ke-2 Akhir follow-up

Tgl mulai
pemberian
Nama rejimen ART orisinal
tgl mulai profilaksis Terapi Tgl Tgl Tgl stop yg
Kode IO Tgl IO Terapi IO Kotrimoksazol Tgl. subst. Alasan Rejimen baru Tanggal VL Alasan Rejimen baru
terapi IMS switch Meninggal pasti

ZDV(300)+3TC(150)+NVP(200)

5-Nov-11 K, D 21-Nov-11 Cotrim, RH 21-Nov-11 ZDV(300)+3TC(150)+NVP(200)

5-Dec-12 TB 30-Nov-11 rhze 30-Nov-11 ZDV(300)+3TC(150)+NVP(200) 25-May-12

K 1-Dec-11 Nistatin Dr 12-Dec-11 ZDV(300)+3TC(150)+NVP(200)

15-Feb-12 tb 15-Feb-12 rhze 15-Feb-12 ZDV(300)+3TC(150)+NVP(200) 30-Mar-12

ZDV(300)+3TC(150)+NVP(200) 30-Jun-14

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)
ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)

ZDV(300)+3TC(150)+NVP(200)
 terakhir)
(kunjungan
Tgl lolos FU

8-Mar-12
hir follow-up dengan ART

ART
Tgl Rujuk
Keluar dgn
Lokasi

1
2
2
ADHERENCE

1t
1t

T
T
bln 1

1
ADHERENCE

1 t
1 t

T
bln 2

1
ADHERENCE

1 t
1 t

T
bln 3
1
ADHERENCE

1t
1t

bln 4
ADHERENCE

1 t
1 t

bln 5
ADHERENCE
1t
1t

bln 6
ADHERENCE
1 t
1 t

bln 7
ADHERENCE
1 t
1 t

bln 8
ADHERENCE
1 t
1 t

bln 9
ADHERENCE
1 t
1 t

bln 10
ADHERENCE
1 t
1 t

bln 11
ADHERENCE
1t
1t

bln 12
ADHERENCE
1 t
1 t

bln 13
ADHERENCE
1 t
1 t

bln 14
ADHERENCE
1 t
1 t

bln 15
ADHERENCE
1 t
1 t

bln 16

ADHERENCE
1t
1t

bln 17
ADHERENCE
1t
1t

bln 18
ADHERENCE
1t
1t

bln 19
ADHERENCE
1 t
1 t

bln 20
ADHERENCE
1 t
1 t

bln 21
ADHERENCE
1 t
1 t

bln 22

ADHERENCE
1t
1t

bln 23
ADHERENCE
1t
1t

bln 24
ADHERENCE
1t
1t

bln 25
ADHERENCE
1t
1t

bln 26
ADHERENCE
1t
1t

bln 27
ADHERENCE
1
1
t
t
bln 28
ADHERENCE

1 t
1 t
bln 29
ADHERENCE

1t
1t
bln 30
ADHERENCE

1t
1t
bln 31
ADHERENCE

1t
1t
bln 32
ADHERENCE

1 t
1 t
bln 33
ADHERENCE

1 t
1 t
bln 34
ADHERENCE

1t
1t
bln 35
ADHERENCE

1t
1t

bln 36
ADHERENCE

1t
1t

bln 37
ADHERENCE

1t
1t

bln 38
ADHERENCE
1t
1t

bln 39
ADHERENCE
1t
1t

bln 40
ADHERENCE
1 t
1 t

bln 41
ADHERENCE
1 t
1 t

bln 42
ADHERENCE
1t
1t

bln 43
ADHERENCE
1 t
1 t

bln 44
ADHERENCE
1t
1t

bln 45
ADHERENCE
1t
1t

bln 46
ADHERENCE
1t
1t

bln 47
ADHERENCE
1t
1t

bln 48
ADHERENCE
bln 49
ADHERENCE
bln 50
ADHERENCE
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ADHERENCE
bln 52
ADHERENCE
bln 53
ADHERENCE
bln 54

ADHERENCE

bln 55
ADHERENCE
bln 56

ADHERENCE
bln 57
ADHERENCE
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ADHERENCE
bln 59
ADHERENCE
bln 60

ADHERENCE
 bln 61
ADHERENCE
bln 62
ADHERENCE
bln 63
ADHERENCE
bln 64
ADHERENCE
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ADHERENCE
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ADHERENCE
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ADHERENCE
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ADHERENCE
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ADHERENCE
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ADHERENCE
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ADHERENCE
bln 73
ADHERENCE
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ADHERENCE
bln 75
ADHERENCE
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ADHERENCE
bln 77
ADHERENCE
bln 78
ADHERENCE
bln 79
ADHERENCE
bln 80
ADHERENCE
bln 81
ADHERENCE
bln 82
ADHERENCE
bln 83
ADHERENCE
bln 84