Lampiran 1 : Surat Tugas

Nomor : 824/15730-Dinkes
Tanggal : 24 Agustus 2018

JADWAL KEGIATAN
PENDAMPINGAN DAN PEMBINAAN AKREDITASI PUSKESMAS TAHUN 2018

WAKTU NAMA UPT

NO JABATAN PENDAMPING NIP PEMBINA PENANGGUNG JAWAB
PELAKSANAAN PUSKESMAS
1 Rabu M. Ramdan Pendamping ADMEN Mulyani Amd Kep 198105072007012007 Nining Supiah S.Sos dr Siska Gerfianty MH.Kes Sp. DLP
29 Agustus 2018 Pendamping UKM Lilis Trimulayati M, Sp. M.Kes 196407211992032003
Pendamping UKP Kartini 196903281993032005

2 Rabu Cempaka Arum Pendamping ADMEN dr Budhi BM Sonjaya 197311052005011006 Popy Satriadewi S.Kep
29 Agustus 2018 Pendamping UKM Siti Suwarti,SP 19750826 1994022001
Pendamping UKP dr Nitta Kurnia Sp DLP 197204282006042000

3 Rabu Cigondewah Pendamping ADMEN RR Theresia Widuri 197702082006042000 dr Fetty Sugiharti

29 Agustus 2018 Pendamping UKM Asep Wahyu, SKM 197501112005011003
Pendamping UKP dr Erti Rostianty, MH Kes SP DLP 19730921 2002122003

4 Rabu Rusunawa Pendamping ADMEN Eulis Yulia Amkg 19710721 1992032007 Sri Murtini S.Kep.Ners
29 Agustus 2018 Pendamping UKM Tati Hartati Permata 19661226 1995032 001
Pendamping UKP dr Fatimah 197310012005012011

5 Rabu Antapani Pendamping ADMEN dr Vita Purnamasari 198205082010012011 Nining Supiah S.Sos
29 Agustus 2018 Pendamping UKM Ellya Rosa SKM MAP MH Kes 19740226 2006042000
Pendamping UKP Teti H Agustin 19730711 2005012004

6 Rabu Jajaway Pendamping ADMEN Ir Dodi Rohaendi 196504092008011001 Etna Fatmini, SKM. M.Kes
29 Agustus 2018 Pendamping UKM Erlisawati, Amd Keb 19750519 1990032004
Pendamping UKP dr Deborah Johana Ratu MH.Kes, MKM197303152006042016
7 Senin Gumuruh Pendamping ADMEN Etna Fatmini SKM M.Kes 19640505 198603 2 023
3-Sep-18 Pendamping UKM Lilis Trimulayati M, Sp. M.Kes 198105072007012007 dr. ira Dewijani, MT
Pendamping UKP Kartini 196903281993032005

8 Senin Sukawarna Pendamping ADMEN dr Budhi BM Sonjaya 197311052005011006 Popy Satriadewi S.Kep
3-Sep-18 Pendamping UKM Siti Suwarti,SP 19750826 1994022001
Pendamping UKP dr Nitta Kurnia Sp DLP 197204282006042000

9 Senin Ledeng Pendamping ADMEN RR Theresia Widuri 197702082006042000 Sri Murtini S.Kep.Ners dr Herliani Sudardja MS
3-Sep-18 Pendamping UKM Asep Wahyu, SKM 197501112005011003
Pendamping UKP dr Erti Rostianty MH Kes SP DLP 19730921 2002122003

10 Senin Sarijadi Pendamping ADMEN Eulis Yulia Amkg 19710721 1992032007 dr Fetty Sugiharti
3-Sep-18 Pendamping UKM Herawati 19870728 2009022002
Pendamping UKP dr Fatimah 197310012005012011

11 Senin Babatan Pendamping ADMEN dr Vita Purnamasari 198205082010012011 Lilis Trimulyati M,P M.Kes
3-Sep-18 Pendamping UKM Ellya Rosa SKM. MAP MH Kes 19740226 2006042000
Pendamping UKP Teti H Agustin 19730711 2005012004

12 Senin Cikutra lama Pendamping ADMEN Ir Dodi Rohaendi 196504092008011001 dr. Ira Dewijani, MT
3-Sep-18 Pendamping UKM Erlisawati,Amd Keb 19750519 1990032004
Pendamping UKP dr Deborah Johana Ratu MH Kes,MKM197303152006042016

13 Selasa Cijerah Pendamping ADMEN Etna Fatmini SKM M.Kes 19640505 198603 2 023Nia Kaniawati M.Kes
4 September 2018 Pendamping UKM Mulyani Amd Kep 198105072007012007
Pendamping UKP Kartini 196903281993032005

14 Selasa Astana Anyar Pendamping ADMEN dr Budhi BM Sonjaya 197311052005011006 Nilla Avianti S.Sos MKM
4 September 2018 Pendamping UKM Siti Suwarti,SP 19750826 1994022001
 Pendamping UKP dr Nitta Kurnia Sp DLP 197204282006042000

15 Selasa Pel Hewan Pendamping ADMEN RR Theresia Widuri 197702082006042000

4 September 2018 Pendamping UKM Asep Wahyu, SKM 197501112005011003 dr Fetty Sugiharti
Pendamping UKP dr Erti Rostianty MH Kes SP DLP 19730921 2002122003

16 Selasa Pasawahan Pendamping ADMEN Eulis Yulia Amkg 19710721 1992032007 Sri Murtini S.Kep.Ners
4 September 2018 Pendamping UKM Herawati 19870728 2009022002
Pendamping UKP dr Fatimah 197310012005012011

17 Selasa Mengger Pendamping ADMEN dr Vita Purnamasari 198205082010012011 Lilis Trimulyati M,P M.Kes dr Rosye A Rosdiani MT
4 September 2018 Pendamping UKM Ellya Rosa SKm MAP MH Kes 19740226 2006042000
Pendamping UKP Teti H Agustin 19730711 2005012004

18 Selasa Derwati Pendamping ADMEN Ir Dodi Rohaendi 196504092008011001 Firdawani

4 September 2018 Pendamping UKM Erlisawati,Amd Keb 19750519 1990032004
Pendamping UKP dr Deborah Johana Ratu MH Kes,MKM197303152006042016

19 Rabu Balaikota Pendamping ADMEN Etna Fatmini SKM M.Kes 19640505 198603 2 023Nia Kaniawati M.Kes
5 September 2018 Pendamping UKM Mulyani Amd Kep 198105072007012007
Pendamping UKP Kartini 196903281993032005

20 Rabu Cibolerang Pendamping ADMEN dr Budhi BM Sonjaya 197311052005011006 Nilla Avianti S.Sos MKM
5 September 2018 Pendamping UKM Siti Suwarti,SP 19750826 1994022001
Pendamping UKP dr Nitta Kurnia Sp DLP 197204282006042000

21 Rabu Liogenteng Pendamping ADMEN RR Theresia Widuri 197702082006042000 Sri Murtini S.Kep.Ners
5 September 2018 Pendamping UKM Asep Wahyu, SKM 197501112005011003
Pendamping UKP dr Erti Rostianty MH Kes SP DLP 19730921 2002122003

22 Rabu Cijagra Baru Pendamping ADMEN Eulis Yulia Amkg 19710721 1992032007 Rinjani Inez SST M.Kes
 5 September 2018 Pendamping UKM Herawati 19870728 2009022002
Pendamping UKP dr Fatimah 197310012005012011

23 Rabu Suryalaya Pendamping ADMEN dr Vita Purnamasari 198205082010012011 Lilis Trimulyati M,P M.Kes
5 September 2018 Pendamping UKM Ellya Rosa SKM., MAP MH Kes 19740226 2006042000
Pendamping UKP Teti H Agustin 19730711 2005012004

24 Rabu Cipadung Pendamping ADMEN Ir Dodi Rohaendi 196504092008011001 Firdawani

5 September 2018 Pendamping UKM Erlisawati, Amd Keb 19750519 1990032004
Pendamping UKP dr Deborah Johana Ratu MH Kes, MKM197303152006042016

25 Kamis Panyileukan Pendamping ADMEN Etna Fatmini SKM M.Kes 19640505 198603 2 023Nia Kaniawati M.Kes
6 September 2018 Pendamping UKM Mulyani Amd Kep 198105072007012007
Pendamping UKP Kartini 196903281993032005

26 Kamis Mandala mekar Pendamping ADMEN dr Budhi BM Sonjaya 197311052005011006 Siti Aisyah
6 September 2018 Pendamping UKM Nilla Avianti S.Sos MKM 197405311996032001
Pendamping UKP dr Nitta Kurnia Sp DLP 197204282006042000

27 Kamis Jatihandap Pendamping ADMEN RR Theresia Widuri 197702082006042000 Reny Kustirini S.Kep Ners
6 September 2018 Pendamping UKM Asep Wahyu, SKM 197501112005011003
Pendamping UKP dr Erti Rostianty MH Kes SP DLP 19730921 2002122003

28 Kamis A. Yani Pendamping ADMEN Eulis Yulia Amkg 19710721 1992032007 Rinjani Inez SST M.Kes
6 September 2018 Pendamping UKM Herawati 19870728 2009022002
Pendamping UKP dr Fatimah 197310012005012011

29 Kamis Taman sari Pendamping ADMEN dr Vita Purnamasari 19710721 1992032007 Lilis Trimulyati M,P M.Kes
6 September 2018 Pendamping UKM Ellya Rosa SKm MAP MH Kes 19740226 2006042000
Pendamping UKP Teti H Agustin 19730711 2005012004
30 Kamis B.Surabaya Pendamping ADMEN Ir Dodi Rohaendi 196504092008011001 Nining Supiah S,Sos dr Henny Rahayuningtyas M.Kes
6 September 2018 Pendamping UKM Erlisawati,Amd Keb 19750519 1990032004
Pendamping UKP dr Deborah Johana Ratu MH Kes,MKM197303152006042016

31 Jumat Cipaku Pendamping ADMEN Etna Fatmini SKM M.Kes 19640505 198603 2 023Nia Kaniawati M.Kes
7 September 2018 Pendamping UKM Mulyani Amd Kep 198105072007012007
Pendamping UKP Kartini 196903281993032005

32 Jumat Pasir Luyu Pendamping ADMEN dr Budhi BM Sonjaya 197311052005011006 Siti Aisyah
7 September 2018 Pendamping UKM Nilla Avianti S.Sos MKM 197405311996032001
Pendamping UKP dr Nitta Kurnia Sp DLP 197204282006042000

33 Jumat Sukahaji Pendamping ADMEN RR Theresia Widuri 197702082006042000 Reny Kustirini S.Kep Ners
7 September 2018 Pendamping UKM Asep Wahyu, SKM 197501112005011003
Pendamping UKP dr Erti Rostianty MH Kes SP DLP 19730921 2002122003

34 Jumat Sekejati Pendamping ADMEN Eulis Yulia Amkg 19710721 1992032007 Rinjani Inez SST M.Kes
7 September 2018 Pendamping UKM Herawati 19870728 2009022002
Pendamping UKP dr Fatimah 197310012005012011

35 Jumat Sukapakir Pendamping ADMEN dr Vita Purnamasari 198205082010012011 Lilis Trimulyati M, Sp. M.Kes
7 September 2018 Pendamping UKM Ellya Rosa SKm MAP MH Kes 19740226 2006042000
Pendamping UKP Teti H Agustin 19730711 2005012004

36 Jumat Cijagra lama Pendamping ADMEN Ir Dodi Rohaendi 196504092008011001 Nining Supiah S,Sos
7 September 2018 Pendamping UKM Erlisawati,Amd Keb 19750519 1990032004
Pendamping UKP dr Deborah Johana Ratu MH Kes,MKM197303152006042016
erfianty MH.Kes Sp. DLP
 lampiran 2 : Surat Tugas
Nomor :
Tanggal :

SUSUNAN ACARA PENDAMPINGAN DAN PEMBINAAN AKREDITASI PUSKESMAS

TAHUN 2018

NO URAIAN KEGIATAN PELAKSANA

I Acara Ceremonial penerimaan

Pembukaan MC
Safety Briefing Petugas
Menyanyikan Lagu Indonesia Raya Seluruh Peserta
Mars Puskesmas Staf Puskesmas
Ucapan selamat datang Kepala UPT Puskesmas
Sambutan dari Dinas Kesehatan Pimpinan Rombongan
Paparan singkat proses Akreditasi
Plt Ka UPT Puskesmas
Puskesmas
Pembacaan Doa Petugas
Penutup MC

II Pendampingan Dokumen Akreditasi

Dibagi menjadi 3 Pokja Pendamping dan masing masing Pokja (sambil
( Admen,UKM,UKP ) mencocokkan hasil SA terakhir).

III Pendampingan Tata Graha Tim Pendamping Akreditasi

Tim Pendamping (menyampaikan hasil

III Riview hasil pendampingan
dampingan nya)

CATATAN

Menghadirkan Ka UPT Puskesmas Definitif

 DATA PESERTA PELATIHAN TIM PENDAMPING AKREDITASI
TAHUN 2018
NO NAMA NIP PANGKAT/GOLONGAN JABATAN

TIM 1
1 dr. Budhi BM Sonjaya 197311052005011006 Pembina/IV a Kepala UPT Puskesmas Tamblong
2 Nilla Avianty, S.Sos MKM 197405311996032001 Penata Tk I/III d Jafung PKM Ahli Muda
3 dr Nitta Kurniati, Sp. Dlp 197204282006042009 Penata Tk I/III d Ka UPT Puskesmas Garuda

TIM II
1 RR. Theresia Widuri 197702082006042000 Penata Tk I/III d Kepala UPT Puskesmas Sukarasa
2 Lilis Trimulayati M, Sp. M.Kes 196407211992032003 Penata Tk I/III d Staf Seksi Mutu Yankes
3 Asep Kamal Sahroni, S.Farm. Apt 198603292006041001 Pengatur/II c Staf Sie SDMK

TIM III
1 dr. Vita Purnama Sari 198205082010012011 Panata/III c Kepala UPT Puskesmas Cibuntu
2 Erlisawati, AM.Keb 197505191990032004 Penata/III c Pelaksana Kebidanan

3 dr. Deborah Johana Rattu, MH.Kes, 197303152006042016 Pembina/IV a Kepala UPT Puskesmas Pagarsih
MKM

TIM IV

1 Ellya Rossa, SKM. MAP.M.H.Kes 197402262006042000 Penata Muda Tk I/III b Staf Sub Bagian Program Data dan
Informasi

2 Tati Hartati Permata 196612261995032001 Penata/III c Penyuluh Kesehatan Masyarakat Muda

3 dr. Fatimah 197310012005012011 Penata Tk I/III d Kepala UPT Puskesmas Margahayu

Raya

TIM V
1 Dodi Rohaendi, Ir 196504092008011001 Penata Muda Tk I/III b Staf Seksi Mutu Pelayanan Kesehatan

2 Siti Suarti, SP 197508261994022001 Penata Tk I/III d UPT Puskesmas Sukarasa

3 Kartini 196903281993032005 Penata Tk I/III d Staf Seksi Farmasi dan Perbekalan

Kesehatan

TIM VI
1 Mulyani, Amd. Kep. 198105072007012007 Pengatur Tk I /II d Perawat Pelaksana
2 Cucu Irawan, ST, MKM 197007141991011000 Penata Tk I/III d Kepala Seksi Yankes Rujukan
3 dr. Erti Rostiaty, MH.Kes, Sp. DLP 197309212002122003 Pembina/IV a Ka UPT Puskesmas Sukajadi

TIM VII
1 Eulis Yulia, Am.Kg 197107211992032007 Penata/III c Perawat Gigi Penyelia
2 Herawati 198707282009022002 Penata Muda/III a Bidan Puskesmas Margahayu Raya
3 dr. Teti Hendriani Agustin 197307112005012004 Penata Tk I/III d Kepala UPT Puskesmas Pasundan
KETERANGAN
(POKJA)

Adman
UKM
UKP

Adman
UKM
UKP

Adman
UKM

UKP

Adman

UKM

UKP

Admen

UKM

UKP

Adman
UKM
UKP

UKP
UKM
UKP