LAMPIRAN 1

FORM Self Assessment

FORM SELF ASSESSMENT
REVIEW 144 DIAGNOSA LAYANAN PRIMER
Nama FKTP :
Alamat :
Jenis FKTP : Puskesmas/Klinik Pratama/DPP/RS D Pratama (lingkari salah satu)
Waktu Assessment : tanggal/bulan/tahun
KC BPJS Kesehatan :KANTOR CABANG KEDIRI

Keterangan
(Kompetensi) Berdasar Dapat Tuntas Ditangani di
No Nama Diagnosa Non Spesialistik (ICD 10) Permenkes 5/2014 dan Faskes Saudara (*mohon
Kode Diagnosa Kepmenkes 514/2015 diisi angka 1)
Non Spesialistik
(ICD 10) Ya Tidak *)
1 A01.0 Typhoid fever 4A
2 A06.0 Acute amoebic dysentery 4A
3 A09.0 Other and unspecified gastroenteritis and colitis of infectious origin 4A
4 A15.0 Respiratory tuberculosis, bacteriologically and histologically confirmed 4A
5 A27.9 Leptospirosis, unspecified 4A
6 A30.0 Indeterminate leprosy 4A
7 A35 Other tetanus 4A
8 A54.9 Gonococcal infection, unspecified 4A
9 A90 Dengue fever [classical dengue] 4A 4A
10 A91 Dengue haemorrhagic fever 4A 4A
11 B00.9 Herpesviral infection, unspecified 4A
12 B01.9 Varicella without complication 4A
13 B02.9 Zoster without complication 4A
14 B05.9 Measles without complication 4A
15 B07 Viral warts 4A
16 B08.1 Molluscum contagiosum 4A
17 B15 Acute hepatitis 4A
18 B26.0 Mumps orchitis 4A
19 B35 Dermatophytosis 4A
20 B35.0 Tinea barbae and tinea capitis 4A
21 B35.1 Tinea unguium 4A
22 B35.2 Tinea manuum 4A
23 B35.3 Tinea pedis 4A
24 B35.4 Tinea corporis 4A
25 B35.6 Tinea cruris 4A
26 B35.8 Other dermatophytoses 4A
27 B36.0 Pityriasis versicolor 4A
28 B37.9 Candidiasis, unspecified 4A
29 B54 Unspecified malaria 4A
30 B65.0 Schistosom due schis haematobium [urin schistosom] 4A
31 B65.2 Schistosomiasis due to Schistosoma japonicum 4A
32 B65.9 Schistosomiasis, unspecified 4A
33 B68.0 Taenia solium taeniasis 4A
34 B68.9 Taeniasis, unspecified 4A
35 B74.0 Filariasis due to wuchereria bancrofti 4A
36 B76.0 Ancylostomiasis 4A
37 B76.9 Hookworm disease, unspecified 4A
38 B77.9 Ascariasis, unspecified 4A
39 B78.0 Intestinal strongyloidiasis 4A
40 B78.9 Strongyloidiasis, unspecified 4A
41 B85.0 Pediculosis due to pediculus humanus capitis 4A
42 B85.3 Phthiriasis 4A
43 B86 Scabies 4A
44 D17.9 Benign lipomatous neoplasm, unspecified 4A
45 D50.0 Iron deficiency anaemia secondary to blood loss 4A
46 D50.9 Iron deficiency anaemia, unspecified 4A
47 E11.9 Non-insulin-dependent diabetes mellitus without complications 4A
48 E16.2 Hypoglycaemia, unspecified 4A
49 E46 Unspecified protein-energy malnutrition 4A
50 E66.9 Obesity, unspecified 4A
51 E78.5 Hyperlipidaemia, unspecified 4A
52 E79.0 Hyperuricaem without sign inflamm arthritis+tophaceous dis 4A
53 F45.0 Somatization disorder 4A
54 F51.0 Nonorganic insomnia 4A
55 G43.0 Migraine without aura [common migraine] 4A
56 G43.9 Migraine, unspecified 4A
57 G44.2 Tension-type headache 4A
58 G51.0 Bell's palsy 4A
59 H00.0 Hordeolum and other deep inflammation of eyelid 4A
60 H01.0 Blepharitis 4A
61 H02.0 Entropion and trichiasis of eyelid 4A
62 H04.1 Other disorders of lacrimal gland 4A
63 H10.1 Acute atopic conjunctivitis 4A
64 H10.9 Conjunctivitis, unspecified 4A
65 H15.1 Episcleritis 4A
 66 H52.0 Hypermetropia 4A
67 H52.1 Myopia 4A
68 H52.2 Astigmatism 4A
69 H52.4 Presbyopia 4A
70 H53.6 Night blindness 4A
71 H57.8 Other specified disorders of eye and adnexa 4A
72 H60.9 Otitis externa, unspecified 4A
73 H61.2 Impacted cerumen 4A
74 H65.0 Acute serous otitis media 4A
75 H65.1 Other acute nonsuppurative otitis media 4A
76 H66.0 Acute suppurative otitis media 4A
77 I10 Essential (primary) hypertension 4A
78 I83.9 Varicose veins lower extremities without ulcer or inflamm 4A
79 I84.0 Internal thrombosed haemorrhoid 4A
80 I84.2 Internal haemorrhoids without complication 4A
81 I84.9 Unspecified haemorrhoids without complication 4A
82 J00 Acute nasopharyngitis [common cold] 4A
83 J02 Acute pharyngitis 4A
84 J02.9 Acute pharyngitis, unspecified 4A
85 J03 Acute tonsillitis 4A
86 J03.9 Acute tonsillitis, unspecified 4A
87 J04.0 Acute laryngitis 4A
88 J11.0 Influenza, virus not identified 4A
89 J18.0 Bronchopneumonia, unspecified 4A
90 J18.9 Pneumonia, unspecified 4A
91 J20.9 Acute bronchitis, unspecified 4A
92 J30.0 Vasomotor rhinitis 4A
93 J30.4 Allergic rhinitis, unspecified 4A
94 J34.0 Abscess, furuncle and carbuncle of nose 4A
95 J35.0 Chronic tonsillitis 4A
96 J45.9 Asthma, unspecified 4A
97 K12 Stomatitis and related lesions 4A
98 K21.9 Gastro-oesophageal reflux disease without oesophagitis 4A
99 K29.7 Gastritis, unspecified 4A
100 K90.4 Malabsorption due to intolerance, not elsewhere classified 4A
101 L01.0 Impetigo [any organism] [any site] 4A
102 L02.0 Cutaneous abscess, furuncle and carbuncle of face 4A
103 L02.2 Cutaneous abscess, furuncle and carbuncle of trunk 4A
104 L02.8 Cutaneous abscess, furuncle and carbuncle of othe sites 4A
105 L04.9 Acute lymphadenitis, unspecified 4A
106 L08.0 Pyoderma 4A
107 L08.1 Erythrasma 4A
108 L20.8 Other atopic dermatitis 4A
109 L21.0 Seborrhoea capitis 4A
110 L22 Diaper [napkin] dermatitis 4A
111 L24.0 Irritant contact dermatitis due to detergents 4A
112 L27.0 Generalized skin eruption due to drugs and medicaments 4A
113 L27.2 Dermatitis due to ingested food 4A
114 L42 Pityriasis rosea 4A
115 L50.0 Allergic urticaria 4A
116 L50.9 Atrophic disorder of skin, unspecified 4A
117 L70.0 Acne vulgaris 4A
118 L71.0 Perioral dermatitis 4A
119 L73.2 Hidradenitis suppurativa 4A
120 L74.3 Miliaria, unspecified 4A
121 L97 Ulcer of lower limb, not elsewhere classified 4A
122 M10 Gou 4A
123 N10 Acute tubulo-interstitial nephritis 4A
124 N39.0 Urinary tract infection, site not specified 4A
125 N47 Redundant prepuce, phimosis and paraphimosis 4A
126 N61 Inflammatory disorders of breast 4A
127 N76.0 Acute vaginitis 4A
128 N98.9 Complication associated with artificial fertilization, unspecified 4A
129 O03.9 Spontaneous abortion, Complete or unspecified,without complication 4A
130 O70.0 First degree perineal laceration during delivery 4A
131 O80.9 Single spontaneous delivery, unspecified 4A
132 O92.0 Single spontaneous delivery, unspecified 4A
133 P38 Omphalitis of newborn with or without mild haemorrhage 4A
134 R04.0 Epistaxis 4A
135 R42 Dizziness and giddiness 4A
136 R56.0 Febrile convulsions 4A
137 T14 Injury of unspecified body region 4A
138 T14.1 Open wound of unspecified body region 4A
139 T15.9 Foreign body on external eye, part unspecified 4A
140 T17.1 Foreign body in nostril 4A
141 T30.1 Burn of first degree, body region unspecified 4A
142 T30.2 Burn of second degree, body region unspecified 4A
143 T63.4 Venom of other arthropods 4A
144 T78.2 Anaphylactic shock, unspecified 4A
145 Z21 Asymptomatic human immunodeficiency virus infection status 4A