FORM 1.

RUMAH SAKIT/PUSKESMAS/DOKTER KELUARGA/BIDAN PRAKTEK…..

KABUPATEN PANDEGLANG
BULAN JANUARI 2018

PUSKESMAS DTP SAKETI

JENIS RUJUKAN
JENIS RUJUKAN
PENGETAH NAMA FASILITAS JUMLAH
NO SPESIALISASI NAMA PASIEN DIAGNOSA RUJUKAN RUJUKAN RUJUKAN
UAN/ RUJUKAN RUJUKAN
RUJUKAN PASIEN SPESIMEN ALAT
KONSULTA
SI

1 Peny.Dalam ETIN LATIFAH Non-insulin-dependent diabetes mellitus with peripheral circulatory complications √ RSUD BERKAH PDG 1
H. NURHASAN Atherosclerotic heart disease √ RSUD BERKAH PDG 1
SOLEH MIRSYAD Diabetic mononeuropathy √ RSUD BERKAH PDG 1
ROBI Hemiplegia √ RSUD BERKAH PDG 1
ABDUL GAPUR Other urethritis √ RSUD BERKAH PDG 1
SOBARI Chronic viral hepatitis, unspecified √ RSUD BERKAH PDG 1
MUHAMAD DAYAT Atherosclerotic heart disease √ RSUD BERKAH PDG 1
ETI SUHAETI Insulin-dependent diabetes mellitus with other specified complications √ RSUD BERKAH PDG 1
SUKARTI Non-insulin-dependent diabetes mellitus √ RSUD BERKAH PDG 1
INE HERVIANA Retention of urine √ RSUD BERKAH PDG 1
OMAN Retention of urine √ RSUD BERKAH PDG 1
AYUB Chronic viral hepatitis, unspecified √ RSUD BERKAH PDG 1
RIO Other iron deficiency anaemias √ RSUD BERKAH PDG 1
EMAH Non-insulin-dependent diabetes mellitus with peripheral circulatory complications √ RSUD BERKAH PDG 1
HASANUDIN Non-insulin-dependent diabetes mellitus with other specified complications √ RSUD BERKAH PDG 1
HASANAH Gastritis, unspecified √ RSUD BERKAH PDG 1
ITA Asthma √ RSUD BERKAH PDG 1
RUSYDI Adverse effects in the therapeutic use of other diuretics √ RSUD BERKAH PDG 1
OMAN Retention of urine √ RSUD BERKAH PDG 1
ITA Other chronic obstructive pulmonary disease √ RSUD BERKAH PDG 1
ANWAR SANUSI Atherosclerotic heart disease √ RSUD BERKAH PDG 1
A. JUHDI Heart failure, unspecified √ RSUD BERKAH PDG 1
ASMAH Non-insulin-dependent diabetes mellitus with unspecified complications √ RSUD BERKAH PDG 1
SAEPUDIN Asthma √ RSUD BERKAH PDG 1
YULIA Gastritis, unspecified √ RSUD BERKAH PDG 1
SANTARIP HASANUDDIN Hepatomegaly and splenomegaly, not elsewhere classified √ RSUD BERKAH PDG 1
ENENG SUARSIH Essential (primary) hypertension √ RSUD BERKAH PDG 1
ACIK Nonallergic asthma √ RSUD BERKAH PDG 1
EEM Acute posthaemorrhagic anaemia √ RSUD BERKAH PDG 1
ENAR SUNARSIH NY Heart failure, unspecified √ RSUD BERKAH PDG 1
TATU LINGGA WATI Angina pectoris √ RSUD BERKAH PDG 1
SULASMI Non-insulin-dependent diabetes mellitus with peripheral circulatory complications √ RSUD BERKAH PDG 1
NARTI Non-insulin-dependent diabetes mellitus with multiple complications √ RSUD BERKAH PDG 1
ADIAH Retention of urine √ RSUD BERKAH PDG 1
SUKARTI Non-insulin-dependent diabetes mellitus with peripheral circulatory complications √ RSUD BERKAH PDG 1
MA'MUN Melaena √ RSUD BERKAH PDG 1
SADIAH Viral pneumonia, unspecified √ RSUD BERKAH PDG 1
MAEMUNAH Heart failure, unspecified √ RSUD BERKAH PDG 1
NY. ROHMAH Other secondary hypertension √ RSUD BERKAH PDG 1
HJ.ENENG Family history of diabetes mellitus √ RSUD BERKAH PDG 1
SITI KHAERIAH Acute bronchitis, unspecified √ RSUD BERKAH PDG 1
MUIZ ABD AZIZ Acute myocardial infarction √ RSUD BERKAH PDG 1
MAWI SUKRAENI Chronic gastritis, unspecified √ RSUD BERKAH PDG 1
SUPRIYADI Non-insulin-dependent diabetes mellitus with unspecified complications √ RSUD BERKAH PDG 1
ACHMAD Other chronic obstructive pulmonary disease √ RSUD BERKAH PDG 1
MUHADI Thalassaemia, unspecified √ RSUD BERKAH PDG 1
JUHAENAH Calculus of kidney √ RSUD BERKAH PDG 1
KAMSI Atherosclerotic heart disease √ RSUD BERKAH PDG 1
MAEMUNAH Heart failure, unspecified √ RSUD BERKAH PDG 1
JAJA SUMARJA Diabetic retinopathy √ RSUD BERKAH PDG 1
KAMSAH Hypertensive heart disease √ RSUD BERKAH PDG 1
ENI Nephrotic syndrome, unspecified √ RSUD BERKAH PDG 1
IIS AGUSTIANI Gastritis, unspecified √ RSUD BERKAH PDG 1
BAI Non-insulin-dependent diabetes mellitus with peripheral circulatory complications √ RSUD BERKAH PDG 1
MAMAN Urinary calculus, unspecified √ RSUD BERKAH PDG 1
SARIKAH Anaemia, unspecified √ RSUD BERKAH PDG 1
ADE JUNAEDI Enterobacterial spondylitis, site unspecified √ RSUD BERKAH PDG 1
NIA SUMIATI Chronic gastritis, unspecified √ RSUD BERKAH PDG 1
SUPENDI Atherosclerotic heart disease √ RSUD BERKAH PDG 1
SITI SALSIAH Thyrotoxicosis, unspecified √ RSUD BERKAH PDG 1
MALIYAH ULFAH Typhoid fever √ RSUD BERKAH PDG 1
MUNAH Chronic gastritis, unspecified √ RSUD BERKAH PDG 1
SAMSUL. M Respiratory tuberculosis, bacteriologically and histologically confirmed √ RSUD BERKAH PDG 1
EMI SUHAEMI Secondary hypertension, unspecified √ RSUD BERKAH PDG 1
 MIMIN ATMINAH Non-insulin-dependent diabetes mellitus with other specified complications √ RSUD BERKAH PDG 1
JUMRONI Other chronic obstructive pulmonary disease √ RSUD BERKAH PDG 1
SITI AISYAH H Effects of caisson disease [decompression sickness] √ RSUD BERKAH PDG 1
2 Bedah SITI AKHMALAH Other surgical follow-up care √ RSUD BERKAH PDG 1
JUMYATI Benign neoplasm of thyroid gland √ RSUD BERKAH PDG 1
IIS RISMAWATI Benign neoplasm of thyroid gland √ RSUD BERKAH PDG 1
ILHAM Tuberculous peripheral lymphadenopathy √ RSUD BERKAH PDG 1
MOH TOLIB Tuberculous peripheral lymphadenopathy √ RSUD BERKAH PDG 1
HJ. NAFIAH BT SAKIMAN Malignant neoplasm of ovary √ RSUD BERKAH PDG 1
ISAH Malignant neoplasm of cervix uteri √ RSUD BERKAH PDG 1
DEWI SAMSIAH Neoplasm of uncertain or unknown behavior of breast √ RSUD BERKAH PDG 1
SUNIAH Haemorrhoids √ RSUD BERKAH PDG 1
ENOK HALIMAH Neoplasm of uncertain or unknown behavior of breast √ RSUD BERKAH PDG 1
SAMAH Benign neoplasm of other and unspecified sites √ RSUD BERKAH PDG 1
HJ SUMI Ganglion √ RSUD BERKAH PDG 1
MA'MUN Haemorrhoids √ RSUD BERKAH PDG 1
NAHID ACHMAD DIMYATI Acute appendicitis, unspecified √ RSUD BERKAH PDG 1
INTAN SEPTIANI Benign mammary dysplasia √ RSUD BERKAH PDG 1
AEP SAEPULLAH Other appendicitis √ RSUD BERKAH PDG 1
MI'AH Benign mammary dysplasia √ RSUD BERKAH PDG 1
SUNIAH Haemorrhoids √ RSUD BERKAH PDG 1
NENENG MASTUNIATI Disruption of caesarean section wound √ RSUD BERKAH PDG 1
AEP SAEPULLAH Other appendicitis √ RSUD BERKAH PDG 1
EKA CATUR FUTU
ABDURAHMAN Thyrotoxicosis [hyperthyroidism] √ RSUD BERKAH PDG 1
MUKSIN Benign neoplasm of other and unspecified sites √ RSUD BERKAH PDG 1
HAYATUNNISA Neoplasm of uncertain or unknown behavior of breast √ RSUD BERKAH PDG 1
HJ. NAFIAH BT SAKIMAN Other and unspecified ovarian cysts √ RSUD BERKAH PDG 1
JAMILAH Endometriosis √ RSUD BERKAH PDG 1
RUMYATI Neoplasm of uncertain or unknown behavior of breas √ RSUD BERKAH PDG 1
DEDEN MUHIYAT Benign neoplasm of other and unspecified site √ RSUD BERKAH PDG 1
SITI AKHMALAH Surgical follow-up care, unspecified √ RSUD BERKAH PDG 1
DIANATUL PAJRI Benign neoplasm of thyroid gland √ RSUD BERKAH PDG 1
MASPIANI Surgical follow-up care, unspecified √ RSUD BERKAH PDG 1
julaelah Surgical follow-up care, unspecified √ RSUD BERKAH PDG 1
Yati Sumiati Surgical follow-up care, unspecified √ RSUD BERKAH PDG 1
SULISTIAWATI Neoplasm of uncertain or unknown behavior of breast √ RSUD BERKAH PDG 1
JAMHARI Corpus luteum √ RSUD BERKAH PDG 1
MUHAMMAD RAFA AZKA
PUTRA Keloid scar √ RSUD BERKAH PDG 1
3 Anak NANANG NURKAMAL Tuberculosis of lung, confirmed by sputum microscopy with or without culture √ RSUD BERKAH PDG 1
ROMI Nephrotic syndrome, unspecified √ RSUD BERKAH PDG 1
VAREZKY RAMADHANI Tuberculosis of lung, confirmed histologically √ RSUD BERKAH PDG 1
FAIZ NADIR AMIRULLAH Tuberculosis of lung, confirmed histologically √ RSUD BERKAH PDG 1
WILDAN FAWAJUL HAKY Acute sinusitis, unspecified √ RSUD BERKAH PDG 1
JIHAN KHAYLA LATIFAH Typhoid fever √ RSUD BERKAH PDG 1
MUHAMMAD AKHTAR AL
HAIDAR Unspecified chronic bronchitis √ RSUD BERKAH PDG 1
FARIZ NAUFAL MASIS Diarrhoea and gastroenteritis of presumed infectious origin √ RSUD BERKAH PDG 1
WILDAN ALDYA ARKA Tuberculosis of lung, confirmed by sputum microscopy with or without cultur √ RSUD BERKAH PDG 1
NADILATUZAHRO Ascariasis, unspecified √ RSUD BERKAH PDG 1
FAIRUZ DHABITH ARIENDA Acute upper respiratory infection, unspecified √ RSUD BERKAH PDG 1
FATHINA DZALIKA ARIENDA Typhoid fever √ RSUD BERKAH PDG 1
AKHDAN WIBI GYMNASTIAR Unspecified acute lower respiratory infection √ RSUD BERKAH PDG 1
ATHAR AZZAM MALIK Other disorders of bone development and growth √ RSUD BERKAH PDG 1
MULYANA Thalassaemia √ RSUD BERKAH PDG 1
4 BADRIAH Candidiasis of vulva and vagina √ RSUD BERKAH PDG 1
Kebidanan/
Kandungan EMA MARDIAH Antenatal screening, unspecified √ RSUD BERKAH PDG 1
RT. TUTI MULIAWATI Supervision of normal pregnancy, unspecified √ RSUD BERKAH PDG 1
UMBAYAH Antenatal screening, unspecified √ RSUD BERKAH PDG 1
MASPIANI Prolonged pregnancy √ RSUD BERKAH PDG 1
NURMALASARI Antenatal screening √ RSUD BERKAH PDG 1
PENTI NOVENTI Antepartum haemorrhage, unspecified √ RSUD BERKAH PDG 1
ST.RIFAATUL MUBAROKAH Secondary amenorrhoea √ RSUD BERKAH PDG 1
AAM Maternal care for disproportion due to outlet contraction of pelvis √ RSUD BERKAH PDG 1
SUKAESIH Uterovaginal prolapse, unspecified √ RSUD BERKAH PDG 1
RUMAYAH Maternal care for disproportion, unspecified √ RSUD BERKAH PDG 1
YATI SUMIATI Antenatal screening √ RSUD BERKAH PDG 1
SITI HALIMATUSAADIAH Malnutrition in pregnancy √ RSUD BERKAH PDG 1
FAHRIA SUWITA Antenatal screening, unspecified √ RSUD BERKAH PDG 1
EEM Acute posthaemorrhagic anaemi √ RSUD BERKAH PDG 1
KARSI Obstructed labour due to fetopelvic disproportion, unspecified √ RSUD BERKAH PDG 1
JULELAH Obstructed labour due to fetopelvic disproportion, unspecified √ RSUD BERKAH PDG 1
NINA Other abortion, complete or unspecified, complicated by delayed or excessive haemorrhage √ RSUD BERKAH PDG 1
HUDRIYANTI Delivery by caesarean section, unspecified √ RSUD BERKAH PDG 1
ENDAH NURSAADAH Disorder of tooth development, unspecified √ RSUD BERKAH PDG 1
JAMILAH Endometriosis √ RSUD BERKAH PDG 1
NUR AFNI PATNAWATI Antenatal screening, unspecifie √ RSUD BERKAH PDG 1
FITRI TRISNOWIYATI Retained placenta and membranes, without haemorrhage √ RSUD BERKAH PDG 1
 SUKAMAH Other complications following abortion and ectopic and molar pregnancy √ RSUD BERKAH PDG 1
SANAH Subacute and chronic vaginitis √ RSUD BERKAH PDG 1
RIKA TAULASARI Antenatal screening, unspecified √ RSUD BERKAH PDG 1
DESI ANGGRAENI DEWI Antenatal screening √ RSUD BERKAH PDG 1
5 Syaraf RASPATI Radiculopathy, cervical region √ RSUD BERKAH PDG 1
ENENG Nerve root and plexus disorder, unspecified √ RSUD BERKAH PDG 1
H. DINI Stroke, not specified as haemorrhage or infarction √ RSUD BERKAH PDG 1
MUHADI Parkinson's disease √ RSUD BERKAH PDG 1
UTIN Headache √ RSUD BERKAH PDG 1
ERUM RUMSIAH Stroke, not specified as haemorrhage or infarction √ RSUD BERKAH PDG 1
MALIHAH Stroke, not specified as haemorrhage or infarction √ RSUD BERKAH PDG 1
RODIATINI Sequelae of stroke, not specified as haemorrhage or infarction √ RSUD BERKAH PDG 1
IIF IFATUL BARIYAH, SP Headach √ RSUD BERKAH PDG 1
ENONG Polyarthritis, unspecified √ RSUD BERKAH PDG 1
HJ. ENJUN JUNARSIH Low back pain √ RSUD BERKAH PDG 1
ANIH SUMARNI Unspecified injury of head √ RSUD BERKAH PDG 1
ARINI MUAZARA ULFA Unspecified injury of head √ RSUD BERKAH PDG 1
NUR SRI HARYATI Rheumatoid arthritis, unspecified √ RSUD BERKAH PDG 1
SRI WAHYUNI Low back pain √ RSUD BERKAH PDG 1
BAI KARYAWATI Stroke, not specified as haemorrhage or infarction √ RSUD BERKAH PDG 1
HASANUDIN Scoliosis √ RSUD BERKAH PDG 1
HASANAH Postmenopausal osteoporosis √ RSUD BERKAH PDG 1
AHMAD RIFAI Stroke, not specified as haemorrhage or infarction √ RSUD BERKAH PDG 1
SUHARTI Osteophyte √ RSUD BERKAH PDG 1
SRI WAHYUNI Low back pain √ RSUD BERKAH PDG 1
ENJAH Stroke, not specified as haemorrhage or infarction √ RSUD BERKAH PDG 1
ENJAH Stroke, not specified as haemorrhage or infarction √ RSUD BERKAH PDG 1
INA HADIJAH Other specified headache syndromes √ RSUD BERKAH PDG 1
ENONG QIBTIYAH Traumatic arthropathy √ RSUD BERKAH PDG 1
MASANI Rheumatoid arthritis, unspecified, forearm √ RSUD BERKAH PDG 1
HJ. ENJUN JUNARSIH Low back pain √ RSUD BERKAH PDG 1
ENI Complicated migraine √ RSUD BERKAH PDG 1
6 THT SUMAWATI Otitis media, unspecified √ RSUD BERKAH PDG 1
NURBAETI Acute sinusitis √ RSUD BERKAH PDG 1
TIYAS RISTIYANI Acute tonsillitis √ RSUD BERKAH PDG 1
YUYUN Atrophy of thyroid (acquired) √ RSUD BERKAH PDG 1
AMINAH Suppurative and unspecified otitis media √ RSUD BERKAH PDG 1
DEDE FADILAH Nonsuppurative otitis media √ RSUD BERKAH PDG 1
 MUKLIS Other acute sinusitis √ RSUD BERKAH PDG 1
TIYAS RISTIYANI Acute tonsillitis √ RSUD BERKAH PDG 1
NADILATUZAHRO Chronic serous otitis media √ RSUD BERKAH PDG 1
KIKI MUTAQIN Acute sinusitis √ RSUD BERKAH PDG 1
ENONG NURSYAMSIAH Unspecified acute lower respiratory infection √ RSUD BERKAH PDG 1
SUPENDI Chronic sinusitis, unspecified √ RSUD BERKAH PDG 1
RASPATI Acute sinusitis, unspecified √ RSUD BERKAH PDG 1
SARWI Other chronic suppurative otitis media √ RSUD BERKAH PDG 1
SUMAWATI Otitis media, unspecified √ RSUD BERKAH PDG 1
MAHIRA FAUZIAH Acute tonsillitis √ RSUD BERKAH PDG 1
SIKA NURFADILA Chronic sinusitis √ RSUD BERKAH PDG 1
SOFIA DEWI Acute sinusitis √ RSUD BERKAH PDG 1
7 Kulit / Kelamin 0
8 Gigi dan Mulut RISNA HIDAYATI Disorders of tooth development and eruption √ RSUD BERKAH PDG 1
ADI M ROHMAWATI Disorders of tooth development and eruption √ RSUD BERKAH PDG 1
SEPTIA SULISTIYANI Diseases of pulp and periapical tissues √ RSUD BERKAH PDG 1
NINGRAT ARTI RAHAYU Pulpitis √ RSUD BERKAH PDG 1
MUHAMAD AKMALUROJI Pulpitis √ RSUD BERKAH PDG 1
9 ADE SUTISNA Sequestration of lung √ RSUD BERKAH PDG 1
Paru-paru dan
Jantung YATI Tuberculosis of lung, confirmed by sputum microscopy with or without culture √ RSUD BERKAH PDG 1
NAPIAH Angina pectoris, unspecified √ RSUD BERKAH PDG 1
KAMSI Heart failure, unspecified √ RSUD BERKAH PDG 1
SYAEFUL AZMAL Effects of caisson disease [decompression sickness] √ RSUD BERKAH PDG 1
KENEDY Heart failure √ RSUD BERKAH PDG 1
ALI SUHAERI Tuberculosis of lung, confirmed by sputum microscopy with or without culture √ RSUD BERKAH PDG 1
SANWANI Heart failure, unspecified √ RSUD BERKAH PDG 1
MOH.ARIFIN Pleural effusion, not elsewhere classified √ RSUD BERKAH PDG 1
10 Fisiotherapy 0
11 Kesehatan Jiwa 0
12 Mata ASIFAH JD MURSID Conjunctivitis √ RSUD BERKAH PDG 1
SULASMI Low vision, one eye √ RSUD BERKAH PDG 1
13 Orthopedi IDA MUGIROH Nerve root and plexus disorder, unspecified √ RSUD BERKAH PDG 1
14 Kecelakaan √ RSUD BERKAH PDG 0
RSUD BERKAH PDG 0
JUMLAH 207

Saketi, 31 Januari 2018

MENGETAHUI Penanggungjawab Laporan Rujukan
Penanggung Jawab Puskesmas Saketi UGD PUSKESMAS SAKETI

dr.KARTIRINI MUHAMAD RUHIMAT, Amd.Kep

NIP: 19750803 200501 2 004 TKS
 FORM 2.
LAPORAN PELAYANAN RUJUKAN DI SARANA PELAYANAN KESEHATAN
KABUPATEN PANDEGLANG
BULAN JANUARI 2018

PUSKESMAS DTP SAKETI

JENIS RUJUKAN NAMA FASILITAS RUJUKAN
JUMLAH
NO JENIS SPESIALISASI RUJUKAN RUJUKAN
RUJUKAN RUJUKAN RUJUKAN PKM SATELIT RS KLS C RS KLS B
PASIEN SPESIMEN PENGETAHUAN/ RUJUKAN
KONSULTASI ALAT
1 Peny.Dalam 67 √ √
2 Bedah 35 √ √
3 Anak 15 √ √
4 Kebidanan/Kandungan 27 √ √
5 Syaraf 28 √ √
6 THT 18 √ √
7 Kulit dan Kelamin √ √
8 Gigi dan Mulut 5 √ √
9 Paru-paru dan Jantung 9 √ √
10 Fisiotherapi 0 √ √
11 Kesehatan Jiwa √ √
12 Mata 2 √ √
13 Orthopedi 1 √ √
14 Kecelakaan √ √
TO 207

MENGETAHUI Saketi, 31 Januari 2018

Penanggung Jawab Puskesmas Saketi Penanggung Jawab Laporan Rujukan

dr.Kartirini MUHAMAD RUHIMAT ,Amd.Kep

NIP: 19750803 200501 2 004 TKS
 FORM 2.
AN RUJUKAN DI SARANA PELAYANAN KESEHATAN
KABUPATEN PANDEGLANG
BULAN JANUARI 2018

NAMA FASILITAS RUJUKAN

RS KLS A

Saketi, 31 Januari 2018

Penanggung Jawab Laporan Rujukan

MUHAMAD RUHIMAT ,Amd.Kep

TKS