< 1 TH 1 - 4 TH 5 - 14 TH 15 - 44 TH 45 - 55 TH 55 - 64 TH > 65 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas ……. Pemegang Program Kesehatan Jiwa
NIP NIP.
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.
PUS
< 1 TH 1 - 4 TH
NO ICD.10 JENIS PENYAKIT
P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
1 F00# Ggg Mental Organik 0 0 0 0 0 0 0 0 0 0
F00# Demensia 0 0 0 0 0 0 0 0 0 0
F05 Delirium 0 0 0 0 0 0 0 0 0 0
2 F10# Gangguan 0 0 0 0 0 0 0 0 0 0
Penggunaan Zat
Psikotif
F10 Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Alkohol
F11# Gangguan Penggunaan 0 0 0 0 0 0 0 0 0 0
Zat
3 F20# Skizofrenia dan G 0 0 0 0 0 0 0 0 0 0
Psikotik Lain
4 F23 G Psikotik Akut 0 0 0 0 0 0 0 0 0 0
5 F31 G Bipolar 0 0 0 0 0 0 0 0 0 0
6 F32# G Depresif 0 0 0 0 0 0 0 0 0 0
7 F40# Gangguan Neurotik 0 0 0 0 0 0 0 0 0 0
F40 G Fobik 0 0 0 0 0 0 0 0 0 0
F41.0 G Panik 0 0 0 0 0 0 0 0 0 0
F41.1 G Anxietas Menyeluruh 0 0 0 0 0 0 0 0 0 0
F41.2 G Campuran Anxietas & 0 0 0 0 0 0 0 0 0 0
Depresif
F42 G Obsesif Kompulsif 0 0 0 0 0 0 0 0 0 0
F43.2 G Penyesuaian 0 0 0 0 0 0 0 0 0 0
F45 G Somatoform 0 0 0 0 0 0 0 0 0 0
8 F50 Gangguan Makan 0 0 0 0 0 0 0 0 0 0
F50.0 Anoreksia nervosa 0 0 0 0 0 0 0 0 0 0
F50.1 Anoreksia nervosa tak 0 0 0 0 0 0 0 0 0 0
khas
F50.2 Bulimia Nervosa 0 0 0 0 0 0 0 0 0 0
F50.3 Makan berlebih yg 0 0 0 0 0 0 0 0 0 0
berhub dg ggg
psikologis lainnya
F50.4 Muntah yg berhub dg 0 0 0 0 0 0 0 0 0 0
ggg psikologis lainnya
9 F51 Gangguan Tidur Non 0 0 0 0 0 0 0 0 0 0
Organik
F51.0 Insomsia non organik 0 0 0 0 0 0 0 0 0 0
F51.1 Hipersomnia non 0 0 0 0 0 0 0 0 0 0
organik
F51.2 Gangguan jadual tidur 0 0 0 0 0 0 0 0 0 0
non organik
F51.3 Somnambulisme 0 0 0 0 0 0 0 0 0 0
(berjalan sambil
tidur/ngelindur)
F51.4 Teror tidur (terror 0 0 0 0 0 0 0 0 0 0
malam)
F51.5 Mimpi buruk 0 0 0 0 0 0 0 0 0 0
10 F52 Disfungsi Seksual 0 0 0 0 0 0 0 0 0 0
bukan Disebabkan
oleh Gangguan atau
Penyakit Organik
F52.0 Kurang atau hilangnya 0 0 0 0 0 0 0 0 0 0
nafsu seksual
F52..1 Tidak menyukai dan 0 0 0 0 0 0 0 0 0 0
tdak menikmati seks
F52.2 Kegagalan dari respons 0 0 0 0 0 0 0 0 0 0
genital
F52.3 Disfungsi organsme 0 0 0 0 0 0 0 0 0 0
F52.4 Ejakulasi dini 0 0 0 0 0 0 0 0 0 0
F52.5 Vaginismus non organik 0 0 0 0 0 0 0 0 0 0
F98.0 Enuresis 0 0 0 0 0 0 0 0 0 0
14 G40# Epilepsi 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0 0 0
Mengetahui
Kepala Puskesmas …….
NIP
LAPORAN BULANAN KESEHATAN JIWA
PUSKESMAS............................... BULAN.............................. TAHUN................
1 - 4 TH 5 - 14 TH 15 - 44 TH 45
KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
HUN................
45 - 55 TH 55 - 64 TH > 65 TH
W BARU LAMA KASUS DIRUJUK P W BARU LAMA KASUS DIRUJUK P W BARU LAMA
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NIP.
> 65 TH
KASUS DIRUJUK
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Kesehatan Jiwa
DATA PASIEN PASUNG PUSKESMAS………………………
Bulan :
Tahun :
KONDISI DAN K
JENIS
No NAMA PASIEN UMUR ALAMAT MASIH
KELAMIN
DIPASUNG
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
USKESMAS………………………
...............,.........................
Pelapor
..........................................
NIP. 19650311 198603 2 007
DATA LEMBAGA ORGANISASI/PAGUYUBAN/FORUM KOMUNIKASI/KELOMPOK SWABANTU DI BIDAN
TAHUN 2017
NAMA PUSKESMAS :
LEMBAGA
ALAMAT LEMBAGA
ORGANISASI/PAGUYUBAN/FORUM
NO ORGANISASI/PAGUYUBAN/FORUM
KOMUNIKASI/KELOMPOK
KOMUNIKASI/KELOMPOK SWABANTU
SWABANTU
1 2 3
- -
Mengetahui
Kepala Puskesmas
................................
..........................................
NIP.
MUNIKASI/KELOMPOK SWABANTU DI BIDANG KESEHATAN JIWA
HUN 2017
4 5
- -
...............,.........................
Pelapor
..........................................
NIP.