BAB II Akre PUSKESMAS

PENERIMAAN P
PELA
Tanggal : 01 Maret 2019

KUNJUNGAN BPG
NO NAMA NO.KARCIS UMUR L /P POLI UMUM
B L UMUM
1 M.Yasir nugroho 9464-000383 24thn L √ Rp 15,000

2 Anggita cahya 9465-000386 22thn P √ Rp 15,000
3 Riko april.w 9466-000382 26thn L √ Rp 15,000
4 Gusti made 9467-000384 23thn L √ Rp 15,000
5 Septin marisa 9468 29thn P √ Rp 15,000
6 Liong soen 9469 70thn P √ Rp 15,000
7 Siti nuryanti 9470 14thn P √ Rp 15,000
8 Mahfiatul arfiah 9471-000381 14thn P √ Rp 15,000
9 Masyani 000380 25thn P √
10 Anggita azizi 9472 6thn P √ Rp 15,000
11 M.Akhdan.f 9473 4thn P √
12 Nova rizki 9474 9thn P √ Rp 15,000
13 Azka naufal 9475 4thn L √
14 Ruslinawati 9476 69thn P √ Rp 15,000
15 Ryan rhamadani 9477-000390 19thn L √ Rp 15,000
16 Ferdi wibowo 9478-000389 18thn L √ Rp 15,000
17 Rossehlly rustam 9479-000388 56thn P √ Rp 15,000
18 Benlia susanti 000385 43thn P √
19 Ir.Lenardi 9480 63thn L √ Rp 15,000
20 Rian aji 000387 22thn L √
21 Jahra salsabila 9481 17thn P √ Rp 15,000
22 Sri rezeki 9482 27thn P √ Rp 15,000
23 Suparmahadi 9483-000397 50thn L √ Rp 15,000
24 Mardiana 9484 54thn P √ Rp 15,000
25 Felicia dominica 9485 13bln P √
26 Parjeto 9486 39thn L √ Rp 15,000
27 Yulianto 9487 2,7thn L √
28 Abdul mukti 000391 24thn L √
29 Ahmad wibowo 000392 24thn L √
30 Faqih hasan 000393 26thn L √
31 Lutfi khaidira 9488-000395 6thn P √ Rp 15,000
32 Eko kurnianto 9489 31thn L √ Rp 15,000
33 Wirda ningsih 000394 47thn P √
34 Habsy pratama 9490 7thn P √ Rp 15,000
35 Sa'ad malik 9491 2,5thn L √
36 Ayu kurnia 9492-000398 23thn P √ Rp 15,000
37 Adittya nugraha 9493 9thn P √ Rp 15,000
38 Kiki anita sari 9494-000399 32thn P √ Rp 15,000
39 Apriliansyah 000396 27thn L √
40 Mayasari 9495 35thn P √ Rp 15,000
41 Yanti 000400 39thn P √
42 Rantika fitriyana 000401 22thn P √
43 Aji anugrah 9496 25thn L √
44 Gusti nilawati 000402 62thn P √
45 Yosepha viktoria 9497 29thn P √ Rp 15,000
46 Rahmat jhoni 9498 21thn L √ Rp 15,000
L P
TOTAL 19 27 46 Rp 255,000 Rp 180,000
Mengetahui :
Kepala Puskesmas Rawat Inap Kedaton
dr. Marisa Anggraini

NIP. 19730520 200212 2 003
RIMAAN PELAYANAN KESEHATAN DASAR PUSKESMAS RAWAT INAP KEDATON
.......................TAHUN......................
PELAYANAN KESEHATAN DAN BESARAN TARIF SESUAI PERDA
BPG TINDAKAN
PAPSMEAR
KIA/ MTBS LAB CATEN/TDS/KB MEDICO LEGAL
TINDAKAN UGD DAN IVA
Rp 27,500
Rp 30,000
Rp 27,500
Rp 27,500
Rp 42,500
Rp 15,000
Rp 15,000
Rp 15,000
Rp 130,000
Rp 65,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 20,000
Rp 15,000
Rp 125,000
Rp 15,000
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 27,500
Rp 25,000
Rp 15,000
Rp 377,500 Rp 75,000 Rp 105,000 Rp 42,500 Rp 120,000 Rp 25,000 Rp 125,000
Pejabat Teknik Fungsional
dr. Eko Budi Susanto

NIP. 19770120 200804 1 001
PERSALINAN
RAWAT INAP HAJI KET
UMUM
46.CHKM+CEIVITRON
51.61.PST.EXO
GI
ARSEN+TS
GI
SCALING
SCALING 1/2
HB
CHKM+TS
HB
GDS
DL.WIDAL
DEPO
KB SPIRAL
GDS
Rp - Rp - Rp - Rp 1,305,000
PENERIMAAN P
PELA

KUNJUNGAN BPG
B L UMUM
1 Anis nafisatul 000403 14thn P √

2 Awal adi visha 9499-000405 18thn L √ Rp 15,000
3 Helda purwaningsih 9500-000406 26thn P √ Rp 15,000
4 Zainuddin 000404 67thn L √
5 Caca tria 9501-000407 14thn P √ Rp 15,000
6 Okta pradita 9502 31thn P √ Rp 15,000
7 Ensan 9503 50thn L √ Rp 15,000
8 Nurmala 9504 44thn P √ Rp 15,000
9 Endang siskawati 000408 37thn P √
10 Retno palupi 000409 20thn P √ BPJS
11 Fathan narendra 9505 8bln L √
12 Sukri 9506-000418 70thn L √ Rp 15,000
13 Bagus rizki.r 9507 7thn L √ Rp 15,000
14 Carolin aqila.d 9508-000410 7thn P √ Rp 15,000
15 Juriyah 9509 24thn P √ Rp 15,000
16 Fitri fitasari 9510-000415 25thn P √ Rp 15,000
17 Nurmala Dewi 000411 34th P √
18 Fresca dwi anjani 9511-000413 18thn P √ Rp 15,000
19 Deby 9512-000414 5,7thn P √ Rp 15,000
20 Triyania 000412 24thn P √
21 Arka 9512 2thn L √
22 Alzam syafiq 9513 14bln L √
23 Supriyantini 000416 41thn P √
24 Paini 9514-000428 56thn P √ Rp 15,000
25 Wahyu ramadhani 000417 18thn L √
26 Rio armanda 9515-000420 18thn L √ Rp 15,000
27 Dony takha yasya 000419 24thn L √
28 M.Kahfi bakas 000421 14thn L √
29 Meidiyani edi 9517 40thn L √ Rp 15,000
30 Shendy ismurandar 000422 23thn L √
31 Alfa rizal 9517-000423 16thn L √ Rp 15,000
32 Bayu dion susanto 9518-000426 19thn P √ Rp 15,000
33 Jaka wardana 000424 19thn L √
34 Dewa rizki 000425 18thn L √
35 Kurniansyah boby 9519 23thn L √ Rp 15,000
36 Bambang 9522 34thn L √
37 Open 9523 24thn L √
38 Farida 000427 18thn P √
L P
TOTAL 20 18 38 Rp 195,000 Rp 90,000
Mengetahui :

NIP. 19730520 200212 2 003
NERIMAAN PELAYANAN KESEHATAN DASAR PUSKESMAS RAWAT INAP KEDATON
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
Rp 10,000
Rp 27,500
Rp 20,000
Rp 30,000
Rp 10,000
Rp 130,000
Rp 15,000
Rp 27,500 Rp 15,000
Rp 10,000
Rp 130,000
Rp 20,000
Rp 35,000
Rp 35,000
Rp 15,000
Rp 15,000
25000
Rp 65,000
Rp 15,000
Rp 130,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 10,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 25,000
Rp 475,000 Rp 45,000 Rp 220,000 Rp 20,000 Rp 100,000 Rp 50,000 Rp 25,000

NIP. 19770120 200804 1 001
PERSALINAN
RAWAT INAP HAJI KET
UMUM
BTW
EXO
URIN.L
Rp 100,000 HAJI
CASIL+BASIS+TS
PPTEST
SACLLING
GDS+26.EXO
VCT
SCALLING
CYCLO
DL.WIDAL
DL.WIDAL
BTL BLM WAKTUNTA KB IMPLANT
KOLEST.GDS.ASAM.U
SCALLING
VCT
HB
Rp 360,000 RANAP 3 HARI
Rp 360,000 Rp - Rp 100,000 Rp 1,680,000

PENERIMAAN PELAY
PELAYANA

KUNJUNGAN BPG
B L UMUM
1 M. Rahman Kelvin 009520 19 L √ Rp 15,000

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
L P
TOTAL 1 0 1 Rp 15,000 Rp -
Mengetahui :
NIP. 19730520 200212 2 003
AN PELAYANAN KESEHATAN DASAR PUSKESMAS RAWAT INAP KEDATON
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
KIA/ MTBS LAB CATEN/TDS/KB MEDICO LEGAL RAWAT INAP
Rp - Rp - Rp - Rp - Rp - Rp - Rp - Rp -
Petugas : Eka Pejabat Teknik Fungsional

NIP. 19770120 200804 1 001
PERSALINAN
HAJI KET
UMUM
Rp - Rp - Rp 15,000
PENERIMAAN PEL
PELAYA

KUNJUNGAN BPG
B L UMUM
1 Ipan 9521-000429 8thn L √ Rp 15,000

2 Rima 9524 19thn P √ Rp 15,000
3 Faeyza fakta 9525 5thn P √ Rp 15,000
4 Siti zaenab 9526-000130 58thn P √ Rp 15,000
5 Slamet suito 9527 52thn L √ Rp 15,000
6 Aira arsha 9528 11bln L √
7 Hana 9529-000437 10thn P √ Rp 15,000
8 Ahmad riza.wijaya 9530 2thn L √
9 Desy putri 9531-000433 21thn P √ Rp 15,000
10 Muhammad rofi efendi 000431 51thn L √
11 M.Nurdin 000432 46thn L √
12 Junani 000434 49thn L √
13 Aisyah inayah.a 9532-000436 10bln P √
14 Noval 000435 16thn L √
15 Erlina 9533 52thn P √ Rp 15,000
16 Hariyanto 9534 48thn L √ Rp 15,000
17 Annisa mutiara.s 9535 16thn P √ Rp 15,000
18 Esti susanti 9536-000441 36thn P √
19 Sri handayani 9537 35thn P √ Rp 15,000
20 Norma 9538 28thn P √
21 Aqila farisa 9539 1,10thn P √
22 Zubaidah 000438 37thn P √
23 Ervika aprilia 9540 4,11thn P √
24 Mutiara 9541 17thn P √ Rp 15,000
25 Farid nanda syanur 000439 24thn L √
26 Ayu seftiani 000440 22thn P √
27 Yusuf m.azhar 9542 8thn L √ Rp 15,000
28 Adi warsidi 9543 50thn L √ Rp 15,000
29 Tri ratih 9544 24thn P √ Rp 15,000
30 Firman putra 000442 34thn L √
31 Isriono 000443 49thn L √
32 M.Alan febrian 000444 24thn L √
33 Inna nur 9545 22thn P √ Rp 15,000
34 Reza ardian sanusi 9546-000452 21thn L √ Rp 15,000
35 Herman 000445 32thn L √
36 Defi may ranti 9547-000449 22thn P √
37 Kurniawati 000446-9557 47thn P √ Rp 15,000
38 Trimurni handajani 000447 65thn P √
39 Sara antar nuja 9548 10thn P √
40 Galang denofan 9549 4,3thn L √
41 Desi mas winarni 000448 25thn P √
42 M.Darsono 000450 26thn L √
43 Subandi 000451 65thn L √
44 RM.Zainudin 9550-000454 62thn L √ Rp 15,000
45 Leni narulita 9551 25thn P √ Rp 15,000
46 Nafisah dhiya 9552 1thn P √
47 Popy silviana 9553 24thn P √
48 Tati 9554 20thn P √ Rp 15,000
49 Rosshelly rustam 9555 56thn P √ Rp 15,000
50 Revi azahra 000453 16thn P √
51 Siti nuryanti 9556 15thn P √ Rp 15,000
52 Jesi ayu putri 000455 17thn P √
53 Sulasi agung 9558 47thn P √ Rp 15,000
54 Nur hamid 000456 29thn L √
55 M.Irwan budi 000457 30thn L √
56 Rosmeri 000458 38thn P √
57 Taufik 000459 39thn L √
58 Reihan 9561 8thn L √
59 Patra 9562 1,5thn L √
60 Wahyu 9563 18thn L √
61 Rohana 9564 34thn P √
62 Widia 9565 20thn P √
63 Rifqi 9566 32thn L √
64 Yufinus 9567 61thn L √
L P
TOTAL 29 35 64 Rp 285,000 Rp 75,000
Mengetahui :

NIP. 19730520 200212 2 003
MAAN PELAYANAN KESEHATAN DASAR PUSKESMAS RAWAT INAP KEDATON
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
Rp 15,000
Rp 35,000
Rp 15,000
Rp 42,500
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000 Rp 35,000
Rp 20,000
Rp 15,000 Rp 10,000
Rp 25,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000 Rp 55,000
Rp 10,000
Rp 15,000
Rp 25,000
Rp 15,000
Rp 15,000
Rp 7,500 Rp 15,000
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 25,000
Rp 25,000
Rp 25,000
Rp 25,000
Rp 25,000
Rp 25,000
Rp 57,500 Rp 150,000 Rp 277,500 Rp 15,000 Rp 255,000 Rp 225,000 Rp -

NIP. 19770120 200804 1 001
PERSALINAN
RAWAT INAP HAJI KET
UMUM
EXO
HB.GDS
ACLCYL+GI
DL.WIDAL
Rp 100,000 HAJI
Rp 100,000 HAJI
DL.WIDAL
HB
PPTEST
DEPO
KS.BTW
KS.BTW
DL.WIDAL
HB.PROT.GDS
Rp 100,000 HAJI+PPTES
KS.GOL
DL.WIDAL
Rp - Rp - Rp 300,000 Rp 1,640,000
PENERIMAAN
PEL

KUNJUNGAN BPG
B L UMUM
1 Nicolaus lumen 9559-000460 5thn L √ Rp 15,000

2 Yopis linando 9560-000465 18thn L √ Rp 15,000
3 Taruar abdi 9568 28thn L √ Rp 15,000
4 Oktavia 9569-000467 23thn P √ Rp 15,000
5 Prita permatasari 000461 32thn P √
6 R.Dimas yogi 000462 29thn L √
7 Rifad 000463 8bln L √
8 Yolanda ayu 000464 26thn P √
9 Sri novianti 9570-000471 26thn P √ Rp 15,000
10 Andrio marqes 9571 4,7thn L √
11 Meti oktavia 000466 31thn P √
12 Inka aulia putri 9572 12thn P √ Rp 15,000
13 Yossi mady 9573-000469 26thn L √ Rp 15,000
14 Mesra kerdaningsih 9574-000472 20thn P √ Rp 15,000
15 Sri leni wati 000468 22thn P √
16 Dipo 9575-000475 5,5thn L √ Rp 15,000
17 Nurhasanah 000470 37thn P √
18 Octavianzi 9576 21thn P √
19 M.Iqbal pratikngo 9577-000476 8thn L √ Rp 15,000
20 Putri nuraziza 9578 13thn P √
21 Sri handayani 9579-000481 36thn P √ Rp 15,000
22 Wicco pratama 9580 28thn L √ Rp 15,000
23 Lis anisah 9581 39thn P √
24 M.Akhdan.f 9582-000474 4thn L √
25 Febrian 9583 27thn L √ Rp 15,000
26 Erdiana 000473 54thn P √
27 Wahyu ramdhani 9584-000479 18thn L √ Rp 15,000
28 Mohammad ardhes 000477 21thn L √
29 Adlin 9585 66thn L √ Rp 15,000
30 Candra saka 000478 28thn P √
31 Maria widiapuri 9586 41thn P √ Rp 15,000
32 Ms.Sayuti 000480 78thn L √
33 Arisa 9587 12thn L √
34 Carles 9588 34thn L √ Rp 15,000
35 Bela selvia 000482 22thn P √
36 Turiyati 9589 47thn P √ Rp 15,000
37 Lilis suryani 9590 66thn P √ Rp 15,000
38 M.Ibram 000483 6bln L √
39 Suyanto 9591 64thn L √
40 Refanawati 9592 50thn P √
41 M.Herman 000484 51thn L √
42 Alfina maharani 000485 18thn P √
43 Adelia ardiati 000486 17thn P √
44 Ramdhan dhanu 9593 25thn L √ Rp 15,000
45 Rizky bangkit.s 9594 7thn L √ Rp 15,000
46 Rizky desfuurandra 000487 28thn L √
47 Sudirman 000488 45thn L √
48 Rohmah fauziah 000489 23thn P √
49 Suparmi 9597 36thn P √
50 Yuli 9598 23thn P √
51 Septa tianur 9599 23thn P √
52 Fiki 9600 15thn L √
L P
TOTAL 26 26 52 Rp 195,000 Rp 120,000
Mengetahui :

NIP. 19730520 200212 2 003
RIMAAN PELAYANAN KESEHATAN DASAR PUSKESMAS RAWAT INAP KEDATON
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
Rp 30,000
Rp 27,500
Rp 27,500
Rp 15,000
Rp 15,000
Rp 7,500
Rp 125,000
Rp 92,500
Rp 15,000
Rp 15,000
Rp 35,000
Rp 157,500
Rp 7,500
Rp 30,000
Rp 27,500
Rp 15,000
Rp 30,000
Rp 25,000
Rp 65,000
Rp 15,000 Rp 35,000
Rp 15,000
Rp 15,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 15,000
Rp 7,500
Rp 25,000
Rp 25,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 25,000
Rp 25,000
Rp 82,000
Rp 460,000 Rp 60,000 Rp 112,500 Rp 42,500 Rp 195,000 Rp 257,000 Rp 125,000

NIP. 19770120 200804 1 001
PERSALINAN
RAWAT INAP HAJI KET
UMUM
EXO
ARSEN+TS
ARSEN+TS
Goldar
37.PSA+GI
DEPO
DL.WIDAL
SCALLING+46.ARSEN
GOLDAR
75.74.EUG+CEIVI
KB IMPLANT
EXO
EXO DGN PENYLIT
DL.WIDAL
###
HB
GOLDAR
UGD.HAETING 2 CM.TT
Rp - Rp - Rp - Rp 1,567,000
PENERIMAAN PEL
PELAYA

KUNJUNGAN BPG
B L UMUM
1 Suhelmi 9595 55thn P √ Rp 15,000

2 Ryan sheky 3,5thn L √
3 Adam 000490 21thn L √
4 Nizam arsiding 9651 3,5thn L √
5 Faeyza 9652-000492 5thn P √ Rp 15,000
6 Sutri handayani 9601-000494 28thn P √ Rp 15,000
7 Citra 000493 23thn P √
8 Roli 9602 49thn L √ Rp 15,000
9 Suparmahdi 9603-000499 50thn L √ Rp 15,000
10 Abhiaranto suryo 9604-000495 6thn L √ Rp 15,000
11 Arsyila romeesa 9604 1thn P √
12 Muhammad raihan 9605 2thn L √
13 Amelia fareza 9607-000500 20thn P √ √ Rp 15,000
14 Vicqy 000496 6thn L √ √
15 Meilinda sari 9608-000551 23thn P √ Rp 15,000
16 Adi suryana 000497 49thn P √
17 Wahyudi 000498 45thn L √
18 Alya nur firdaus 9609-000553 6thn L √ Rp 15,000
19 Suran afifi 9610 41thn L √ Rp 15,000
20 Eva alviani 9611 19thn P √ Rp 15,000
21 Mega suci febriyani 000552 24thn P √
22 Nurhadi 000554 22thn L √
23 Mely yudiawati 000555 46thn P √
24 Masyar 000556 82thn L √
25 Nurjanah 000557 62thn P √
26 Eka sari juwita 9612-000559 57thn P √ Rp 15,000
27 Richie dio damara 000558 25thn L √
28 Alfarizi 9613 8bln L √
29 Adinda lestari 000560 17thn P √
30 Rahmad Santosa 000561 23 thn P √
31 Abdullah Naufal 000562 18 thn L √
32 Rahmad.s 000561 23thn L √
33 Abdullah 000562 18thn L √
34 Krisbiyanto 9614 20thn L √
35 Munawaroh 9615 27thn P √ Rp 15,000
L P
TOTAL 19 16 35 Rp 75,000 Rp 120,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
Rp 15,000
Rp 15,000
Rp 15,000
Rp 35,000
Rp 130,000
Rp 15,000
Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000
Rp 130,000
Rp 7,500
Rp 130,000
Rp 15,000
Rp 15,000
Rp 30,000
Rp 15,000
Rp 20,000
Rp 15,000
Rp 55,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 517,500 Rp 75,000 Rp 62,500 Rp 15,000 Rp 165,000 Rp 25,000 Rp -

NIP. 19770120 200804 1 001
PERSALINAN
RAWAT INAP HAJI KET
UMUM
DL.WIDAL
COMPOSITE 2
27.TKF+TS
EXO
SCALLING
GOLDAR
SCALLING
EXO
CATEN
HB
Rp 100,000 HAJI
Rp 100,000 HAJI
11.12.EXO
KS.BTW
KS
KS.BTW
Rp - Rp - Rp 200,000 Rp 1,255,000
PENERIMAAN PELA
PELAYA

KUNJUNGAN BPG
B L UMUM
1 Sutarti 9616 50thn P √ Rp 15,000

2 Rahman 9617 48thn L √ Rp 15,000
3 Hasanah 9618 67thn P √ Rp 15,000
4 Destry 9619 26thn P √ Rp 15,000
5 Siti julaiha 9620 22thn P √ Rp 15,000
6 Sandri 000564 24thn L √
7 Triansyah 000565 35thn L √
8 Maifari 000566 45thn L √
9 Siti.s 000567 28thn P √
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
L P
TOTAL 4 5 9 Rp 75,000 Rp -
Mengetahui : Petugas : W
NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
KIA/ MTBS LAB CATEN/TDS/KB MEDICO LEGAL RAWAT INAP
Rp 15,000
Rp 15,000
Rp 15,000
Rp 20,000
Rp - Rp - Rp - Rp 20,000 Rp 45,000 Rp - Rp - Rp -
Petugas : Widi Astut Pejabat Teknik Fungsional

NIP. 19770120 200804 1 001
PERSALINAN
HAJI KET
UMUM
CYLO
Rp - Rp - Rp 140,000
PENERIMAAN PELA
PELAYAN

KUNJUNGAN BPG
B L UMUM
1 Wahtu rizki ramadhan 9621-000569 3,5thn L √ Rp 15,000

2 M.yasir nugroho 9622-000573 24thn L √ Rp 15,000
3 Nasywa rafifah 9623-000579 7,5thn P √ Rp 15,000
4 M.Gustiyar 9624 6bln L √
5 Haryo izas 9625 10thn L √ Rp 15,000
6 Noventy 000568 43thn P √
7 Fitri 9626 23thn P √
8 Ruli boyke hastien 9627-000592 38thn L √ Rp 15,000
9 Reko ranju 9628-000571 28thn L √ Rp 15,000
10 Yulinda amalia 9629 21thn P √ Rp 15,000
11 Yuliana 000470 27thn P √
12 M.Rafa aska 9630 11bln L √
13 Deri aditya 9631 9bln L √
14 Azahra safa 9632 7thn P √ Rp 15,000
15 Slovarisha 9633 1,1thn P √
16 Zahrul fuddi.m 9634 20thn L √ Rp 15,000
17 Aisyah azura 9635 11bln P √
18 Sifa adelia 9635-000572 7thn P √ Rp 15,000
19 Najua khaira wilda 9637 4thn P √
20 Charisha dwi.a 9638 9thn P √ Rp 15,000
21 Heni fitrianitri 9639 35thn P √
22 Rahmawati 9639-000594 40thn P √ Rp 15,000
23 Abdul aqil 9640 13thn L √ Rp 15,000
24 Msy Aisyah 9641 78thn P √ Rp 15,000
25 Resi istia.p 9642 21thn P √ Rp 15,000
26 Agus sulistiawati 9643-000589 46thn L √ Rp 15,000
27 Raja revolusi 9644 2thn L √
28 Rahmat jhoni akbar 000574 21thn L √
29 Syinthia 9645 16thn P √ Rp 15,000
30 Eni hasnawati 000575 46thn P √
31 Diyah nur 000576 24thn P √
32 Yam yani 000577 63thn P √
33 M.Raga setiawan 9646 23thn L √ Rp 15,000
34 Reihan 000578 12thn L √
35 Aninya 9647 2,3thn P √
36 Asri yuliana 000580 16thn P √
37 Hayatun nisa 000581 17thn P √
38 Sobri 000582 43thn L √
39 Nurani 000583 38thn P √
40 Abidah 000584 2thn P √
41 Selviana 9648 29thn P √ Rp 15,000
42 Nureva 000585 37thn P √
43 Ahmad sahaludin 000586 39thn P √
44 Nur aini 000587 36thn L √
45 Exel akbar 9649 4thn L √ Rp 15,000
46 Lingga 000588 3thn P √
47 Elvin saka.k 9650 22thn P √ Rp 15,000
48 Buang 9653 63thn L √ Rp 15,000
49 Eva wati elisa 9654 54thn P √ Rp 15,000
50 Amel sisilia 9655 1thn P √
51 M.Irfan 000590 41thn L √
52 Maryam anggraini 000591 28thn P √
53 Dewi 000593 43thn P √
54 Putri rahma 9658 19thn P √
55 Miftahul 9659 21thn P √
56 Romi surahto 9660 35thn L √
57 Dilla 9661 21thn P √
L P
TOTAL 21 36 57 Rp 195,000 Rp 150,000
Mengetahui :

NIP. 19730520 200212 2 003
AAN PELAYANAN KESEHATAN DASAR PUSKESMAS RAWAT INAP KEDATON
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 55,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 65,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 130,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 10,000
Rp 7,500
Rp 15,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 7,500
Rp 20,000
Rp 25,000
Rp 25,000
Rp 25,000
Rp 25,000
Rp 310,000 Rp 150,000 Rp 100,000 Rp 35,000 Rp 150,000 Rp 100,000 Rp -

NIP. 19770120 200804 1 001
PERSALINAN
RAWAT INAP HAJI KET
UMUM
84.eug+ceivitron
EXO
EXO
21.22.EXO
DL.WIDAL
CATEN
61.EXO
26.COMPOSITE
URIN LENGKAP
SCALLING
pptest
GOLDAR
Rp 100,000 HAJI
Rp 100,000 HAJI
HB
GOLDAR
CYCLO
Rp - Rp - Rp 200,000 Rp 1,390,000
PENERIMAAN
PE

KUNJUNGAN BPG
B L UMUM
1 Rima 9656-000598 19thn P √ Rp 15,000

2 Kafka harjuna 9657-000596 6thn L √ Rp 15,000
3 Nurbaiti 9662 63thn P √ Rp 15,000
4 Hema novita 000595 23thn P √
5 Kahayun 9663-000602 26thn P √ Rp 15,000
6 Dimas nugroho 9664-000603 21thn L √ Rp 15,000
7 Gusti eliansyah 9665-000604 18thn L √ Rp 15,000
8 Anthoni 9666 45thn L √ Rp 15,000
9 Sultan palas 9667 1,1thn L √
10 Lilis ida 9668 36thn P √ Rp 15,000
11 Ahmad adran.r 9669 11thn L √ Rp 15,000
12 Nuraini 000597 36thn P √
13 Florencia 9670 2,9thn P √
14 Arkansyah 9671 4thn L √
15 Ika rahayu 000599 21thn P √
16 Siti rohmah 9671 19thn P √ Rp 15,000
17 Zahratun 9673-000619 17thn P √ Rp 15,000
18 Aprilia suliga 000600 22thn P √
19 Elsa 9674 16bln P √
20 Viola asyifa 9675 2thn P √
21 Muhammad khotib 000601 25thn L √
22 Ikrar firmansyah 9676 3thn L √
23 Nurhasanah 000605 30thn P √
24 Milawati 000606 63thn P √
25 M.Hasan saleh 000607 61thn L √
26 Yuliani 9677 42thn P √ Rp 15,000
27 Novita isdari 9678 29thn P √ Rp 15,000
28 Mutiara 000608 3bln P √
29 Azel neor rayyan 9679-000609 10bln P √
30 Widiastuti 9680 59thn P √ Rp 15,000
31 Rully dwi 000610 32thn L √
32 Vina aprilia 000611 27thn P √
33 Ricky yudiana 000612 31thn L √
34 Surya dewi 9681 50thn P √ Rp 15,000
35 Jeremy setiawan 000613 18thn L √
36 Mirna girsang 9682 48thn P √
37 Desi 000614 23thn P √
38 Robiensyah 000615 22thn L √
39 Rona wirda triani 9683 15thn P √ Rp 15,000
40 Reihan 9684 10thn L √ Rp 15,000
41 Keisha safira 9685 7thn P √ Rp 15,000
42 David nainggolan 000616 50thn L √
43 Tati rohayati 000617 55thn P √ BPJS
44 Evis suvia 000618 41thn P √
45 Rahelia nazwa 9686 7thn P √ Rp 15,000
46 Turlia indah 000620 19thn P √
47 Rizki dwi 9687 2,2thn L √
48 Syahrial 9691 62thn L √
L P
TOTAL 18 30 48 Rp 195,000 Rp 90,000
Mengetahui :

NIP. 19730520 200212 2 003
ENERIMAAN PELAYANAN KESEHATAN DASAR PUSKESMAS RAWAT INAP KEDATON
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
Rp 65,000
Rp 20,000
Rp 15,000
Rp 30,000
Rp 130,000
Rp 130,000
Rp 15,000
Rp 10,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 40,000
Rp 15,000
Rp 15,000 Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 130,000
Rp 47,500
Rp 15,000
Rp 15,000
Rp 25,000
Rp 512,500 Rp 120,000 Rp 120,000 Rp 107,500 Rp 150,000 Rp 50,000 Rp -

NIP. 19770120 200804 1 001
RAWAT INAP PERSALINAN HAJI KET
UMUM
EXO DGN PENYLT

URIN LENGKAP
CATEN
36.CALSIL+BASIS
SCALLING
SCALLING
PPTEST
DEPO
47.CHKM+TS
DEPO
GDS
GDS.KOLES
TINDIK BAYI
DL.WIDAL
SCALLING
LEPAS IMPLANT+CYLO
Rp - Rp - Rp - Rp 1,345,000
PENERIMAAN PELAYAN
PELAYANAN

KUNJUNGAN BPG
B L UMUM
1 Alifi akbar 9688 5thn L √ Rp 15,000

2 Muhammad sateh 9689 37thn L √ Rp 15,000
3 Indra gunawan 9690 52thn L √ Rp 15,000
4 Kaifa 9692 7thn P √
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
L P
TOTAL 3 1 4 Rp 30,000 Rp 15,000
Mengetahui :
NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
Rp 25,000
Rp - Rp - Rp - Rp - Rp - Rp 25,000 Rp -
Petugas : Muta Pejabat Teknik Fungsional

NIP. 19770120 200804 1 001
ON
PERSALINAN
RAWAT INAP HAJI KET
UMUM
Rp - Rp - Rp - Rp 70,000
PENERIMAAN PELAYA
PELAYANA

KUNJUNGAN BPG
B L UMUM
1 Kartum 9693-000628 74thn L √ Rp 15,000

2 Qurrata ayuni 9694 7thn P √ Rp 15,000
3 Suriyati 9695 47thn P Rp 15,000
4 Lia safitri 9696 38thn P √ Rp 15,000
5 Nabila huda 9697-000624 17thn P √ Rp 15,000
6 Yohana 000621 72thn P √
7 Desi achirani 9698 24thn P √ Rp 15,000
8 Nurul amira 000622 23thn P √
9 Ni wayan ayung 000623 25thn P √
10 Susanti 9699-000629 66thn P √ Rp 15,000
11 Rianti khairunisa 000625 20thn P √
12 Listya ningsih 9700-000631 22thn P √ Rp 15,000
13 Darmansyah 000626 56thn L √
14 Maysha bilqis 000627 9thn P √
15 Hasanah 9701 67thn P √ Rp 15,000
16 Shaki humaira.r 9702 1,9thn P √
17 Iqbal saputra 9703-000638 11thn L √ Rp 15,000
18 Deci 9704-000630 62thn P √ Rp 15,000
19 Khalika aliza 9705-000635 6thn P √ Rp 15,000
20 Siska 9706 24thn P √ Rp 15,000
21 Pipa fitra 9707 24thn L √ Rp 15,000
22 Acelin nathania 9708 1,5thn P √
23 Apriska feliyanti 9709 19thn P Rp 15,000
24 Saraya nisa 9710-000632 3thn P √
25 Muhammad rafesya 9711 1bln L √
26 Endah 9712 8hari P √
27 M.Nur azka 9713 3thn L √
28 Arizal pratama 9714 23thn L √ Rp 15,000
29 Kartini 9715-000633 41thn P √
30 Rosna 9716-000652 45thn P √ Rp 15,000
31 Briana nikoyoma 000634 22thn L √
32 Junaldi 9717 44thn L √ Rp 15,000
33 Putri lestari 000636 30thn P √
34 Farrel novian.s 9718 12thn P √ Rp 15,000
35 Lia fatmawati 000637 30thn P √
36 Wahyu rizki 9719 22thn L √ Rp 15,000
37 Raisa talita 9720 10thn P √ Rp 15,000
38 Felicia princes 9721 7thn P √ Rp 15,000
39 Rosshelly rustam 9722 56thn P √ Rp 15,000
40 Leni fitriani 9723-000655 22thn P √
41 Salsabila nanda 9724 18thn P √ Rp 15,000
42 Dia rafi pertiwi 9725-000649 22thn P √ Rp 15,000
43 Jovanka vridela 9726 21hr P √
44 Romadiana 9727 25thn P √
45 Muhammad rifai 000639 25thn L √
46 Galih aldi.p 9728 13thn L √ Rp 15,000
47 Suparni 000640 46thn P √
48 Laras pratiwi 000641 23thn P √
49 Triono 9729 25thn L √ Rp 15,000
50 Elyza 000642 29thn P √
51 Suci mardha fillah 000643 23thn P √
52 Julian saputra 000644 23thn L √
53 Marhayati setia 000645 22thn P √
54 Ade sugiri 000646 39thn L √
55 Dedi 000647 51thn P √
56 Dicky hermawan 000648 17thn L √
57 Arista dwi candra 000650 18thn L √
58 Robihim 000651 42thn L √
59 Bima suananda 000653 20thn L √
60 Irfan 000654 24thn L √
61 Suhelis 000656 38thn P √
62 Indra pratama 9730 47thn L √ Rp 15,000
63 Ratih Perwita Sari 9731 24 thn P √ Rp 15,000
64 Sri Ariyani 9732 44 thn P √ Rp 15,000
65 Panji Ariandinata 000657 23 thn L √
66 M. Anugrah Adi Mukti 9733 4 thn L √
67 Anang burlian 000659 20thn L √
68 Reko 000659 24thn L √
69 Eky pranata.s 000660 23thn L √
70 M.Andjoyasa 000661 22thn L √
71 Welisa fernanda 000662 22thn P √
72 Rantika 000663 21thn P √
73 Heni ayu 000664 21thn P √
74 Gerry gahara 000665 28thn L √
75 Bernanda logan 000666 27thn L √
L P
TOTAL 29 46 75 Rp 330,000 Rp 120,000
Mengetahui :

NIP. 19730520 200212 2 003
AAN PELAYANAN KESEHATAN DASAR PUSKESMAS RAWAT INAP KEDATON
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 130,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 65,000
Rp 35,000
Rp 15,000
Rp 15,000 Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 35,000 Rp 25,000
Rp 27,500
Rp 15,000
Rp 15,000
Rp 27,500
Rp 15,000 Rp 35,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 172,500 Rp 150,000 Rp 305,000 Rp 72,500 Rp 435,000 Rp 25,000 Rp -

NIP. 19770120 200804 1 001
PERSALINAN
RAWAT INAP HAJI KET
UMUM
GDS
DL.WIDAL
GDS
SCALLING
46.EUG+CEIVITRON
KOLES.GDS.ASM.U
DL.WIDAL
DL.WIDAL
DL.WIDAL
ARSEN+TS
DEPO
LEPAS IMPLANT
HB.GDS
DL.WIDAL
DEPO
DEPO
KS
KS.BTW
Rp 360,000 Rp - Rp - Rp 1,970,000
PENERIMAAN PELA
PELAYA

KUNJUNGAN BPG
B L UMUM
1 Ade gustiyawan 9734-000671 37thn L √ Rp 15,000

2 Gusti made 9735-000667 23thn L √ Rp 15,000
3 Elvin saka 9736 22thn P √ Rp 15,000
4 Kevin sadiyan 9737-000674 6thn P √ Rp 15,000
5 Ahmad aulia fadly 9738 18thn L √ Rp 15,000
6 Abduh aqil afif 9739-000668 13thn L √ Rp 15,000
7 Mesra ferdaningsih 9740-000677 20thn P √ Rp 15,000
8 Martin 000669 23thn L √
9 Dia afiat 000670 23thn P √
10 Abid atila pranata 9741 2,10thn L √
11 Wahyu pamungkas 000672 35thn L √
12 Suparmahadi 9742-000680 50thn L √ Rp 15,000
13 M.Fiqih 000673 22thn L √
14 Sutrisno 9743 35thn P √ Rp 15,000
15 Ferdinan munanda 9744-000691 24thn L √ Rp 15,000
16 Inah 9745 32thn P √
17 Retno laras palupi 000676 24thn P √
18 Sabiyan arfani 9746-000679 3thn L √
19 Fathul ghony 000678 24thn P √
20 Syabita 9747 1,6thn P √
21 Charles 9748 34thn L √ Rp 15,000
22 Manzalah aqrom 9749 19thn L √ Rp 15,000
23 Iwansyah 9750-000684 52thn L √ Rp 15,000
24 Dian ekawati 9751 45thn P √ Rp 15,000
25 Elisabeth yuliana 9752-000681 43thn P √ Rp 15,000
26 Emi susanti 9753-000704 41thn P √ Rp 15,000
27 Nur shifa khairunisa 9754 5,4thn L √ Rp 15,000
28 Depi susita 9755-000682 32thn P √
29 Poniran 9756-000683 73thn P √
30 Zia enomi 9757-000685 29thn P √
31 Lubna sova 9758-000690 8thn P √ Rp 15,000
32 Riko aditya 9759 19thn L √ Rp 15,000
33 Ahmad syahuddin 9760 73thn L √ Rp 15,000
34 M.Fawat 000686 14thn P √
35 Mardiyana zuwita 000687 22thn P √
36 Reza novitasari 000688 22thn P √
37 Wendra hardi 000689 23thn L √
38 Dita putriana 9761-000696 25thn P √
39 Adhitya m. Halbi 9762 20thn L √ Rp 15,000
40 Hesti yusfita 9763-000694 20thn P √ Rp 15,000
41 Yolanda 000692 19thn P √
42 Pinka olivia 000693 22thn P √
43 Ena 9764 62thn P √ Rp 15,000
44 Rizma yulizar 9766 20thn P √ Rp 15,000
45 Azizah khusnul 000695 23thn P √
46 Yustinus leo 9765 62thn P √
47 Nindya huda 000697 22thn P √
48 Indri yanto 000698 64thn L √
49 Nurika azkiya 000699 18thn P √
50 Ivan aloydsius 000700 24thn L √
51 Rizki yanti putri 000701 22thn P √
52 Emelya de rosalina 000702 22thn P √
53 Halimah 000703 60thn P √ BPJS
54 Albert Perdamean Pane 000705 22 thn L √
55 Oki Arisandi 9767 25 thn L √ Rp 15,000
56 Yulita 9768 53 thn P √ Rp 15,000
57 Haeruddin 000706 55 thn L √
58 Tigor Hamonangan 000707 53 thn L √
59 Bagus Lesdarno 000708 35 thn L √
60 Dede Suhendar 9769 30 thn L √
61 Galang 9770 4 thn L √
62 Ezar sinar 9771 2 thn L √
63 Bayu saputra 9772 21thn L √
64 Ita 9773 25thn P √
65 Sukasniati 9774 28thn P √
66 Ganina 9775 21bln L √
L P
TOTAL 31 35 66 Rp 195,000 Rp 195,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
Rp 20,000
Rp 27,500
Rp 30,000
Rp 15,000
Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 92,500
Rp 15,000
Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000 Rp 35,000
Rp 15,000
Rp 15,000
Rp 130,000
Rp 65,000
Rp 27,500
Rp 15,000 Rp 10,000 Rp 27,500

Rp 20,000 Rp 25,000
Rp 15,000 Rp 55,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 55,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 130,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 25,000
Rp 25,000
Rp 25,000
Rp 572,500 Rp 135,000 Rp 265,000 Rp 42,500 Rp 330,000 Rp 150,000 Rp -

NIP. 19770120 200804 1 001
RAWAT PERSALINAN
HAJI KET
INAP UMUM
HB
CHKM+TS
EXO 2
EUG+CEIVITRON
46.CHKM+TS
CATEN
26.PSA+GI
BTW.KS
37.ARSEN+EUG+TS
DL.WIDAL
SCALLING
COMPOSITE
28.GI
PPTEST+KB SPIRAL
UGD+HB
HB.PROT.GDS
DL.WIDAL
HB.PROT.GDS
DL.WIDAL
SCALLING
KS
KS
KS
KS
Rp - Rp - Rp - Rp 1,885,000
PENERIMAAN PEL
PELAYA

KUNJUNGAN BPG
B L UMUM
1 Nauval aditya 9776-000709 8,5thn L v Rp 15,000

2 Djoko saputro 000710 48thn L v
3 Dian novita 000711 44thn p v
4 Dofi almula 9777-000715 22thn L v Rp 15,000
5 Mirnawati 9778 48thn P v Rp 15,000
6 Rahmadiana debora 9779 23thn P v Rp 15,000
7 Darman 000712 47thn L v BPJS
8 Oktavia 9780-000720 23thn P v Rp 15,000
9 Bilal adi surya 9781-000717 7thn L v Rp 15,000
10 Heru hermawan 000713 28thn L v
11 Kayla apara 9782-000719 6thn P v Rp 15,000
12 Yolanda 000714 27thn L v BPJS
13 Fadhil ag.ghani 9783 7thn L v Rp 15,000
14 Riska 000716 34thn P v
15 Rahmat efendi 000718 23thn L v
16 Safaras akma 9784 3thn L v
17 Adam troy 000721 56thn L v
18 Vipdiyani 000722 54thn P v
19 Mia oktafiany 9785 30thn P v
20 Jimmy schumacer 9786-000728 19thn L v Rp 15,000
21 Aprilia indriani 000723 19thn P v
22 Meilinda monetria 000724 20thn P v
23 M.Ilham prasetyo 000725 15thn L v
24 Bebby kumala.l 9788-000726 5thn P v
25 M.Ridho 9789-000727 4thn L v
26 Khaizza safa 9790 4thn P v
27 Andre geovani 9791 9hari L v
28 Khumaira arsyila 9792 6bln P v
29 Elsa ayu hasanah 9793 11thn P v Rp 15,000
30 Mayang sagita 9794 21thn P v Rp 15,000
31 Rahmah dewi 000729 48thn P v BPJS
32 Iryasti 000730 21thn P v
33 Agus tinus feri.k 9795-000737 28thn L v Rp 15,000
34 Reza tihardila 000731 24thn P v
35 Hartina 000732 55thn P v
36 Syafri 000733 61thn L v
37 Dian anggraini 000734 23thn P v
38 Syahwa novenda 000735 16thn P v
39 Hendarmin 000736 50thn L v
40 Lisa nasution 000738 22thn P v
41 Reki yuiandri 000739 22thn L v
42 Antoni 000740 24thn L v
43 Retno juniar 000741 20thn P v
44 Yullandri 000742 21thn L v
45 Arya ramadhan 000743 25thn L v
46 M.Abdul 9796 20thn L v Rp 15,000
47 Nisa vebriantika 000744 31thn P v
48 Nita lestari 000745 31thn P v
49 Cinta julia 000746 6thn P v
L P
TOTAL 23 26 49 Rp 150,000 Rp 45,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG TINDAKAN
PAPSMEAR
Rp 35,000
Rp 157,500
Rp 130,000
Rp 27,500
Rp 35,000
Rp 15,000
Rp 35,000
Rp 130,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 20,000
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 20,000
Rp 15,000 Rp 20,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 130,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 575,000 Rp 105,000 Rp 235,000 Rp 20,000 Rp 285,000 Rp - Rp -

NIP. 19770120 200804 1 001
RAWAT INAP PERSALINAN HAJI KET
UMUM
DL.WIDAL
Rp 100,000 HAJI
Rp 100,000 HAJI
SCALLING+15.ARSEN
SCALLING
37.ARSEN+CEIVITRON
DL.WIDAL
DL.WIDAL
SCALLING
CYCLO
Rp 100,000 HAJI
Rp 100,000 HAJI+HB
DL.WIDAL
HB
HB
SCALLING
BATAL TD JDCATEN
DL.WIDAL
BTW.KS
BTW.KS
Rp 120,000 Rp - Rp 400,000 Rp 1,935,000

PENERIMAAN
PE

KUNJUNGAN
B L
1 Ernifa 9797 48thn P √

2 Supriyani 9798 51thn P √ Rp 15,000
3 Nesta efriyanti 000747 24thn P √
4 M.Yusuf zikriansyah 000748 22thn L √
5 Berdi setiawan 9799-000750 26thn L √ Rp 15,000
6 Nila wati 9800 51thn P √
7 Septina 000749 24thn P √
8 Sami 9801 25thn P √
9 Puji astriawati 9802-000763 45thn P √
10 Afandi sanjaya 9803 8thn L √ Rp 15,000
11 Sally 000751 36thn L √
12 Januari tulus 000752 27thn L √
13 Meri gustina 000753 25thn P √
14 Agung yosi 9804-000765 25thn L √
15 Nurul aprilia melati 9805 17thn P √
16 Atika destia 9806-000757 20thn P √ Rp 15,000
17 Erlin gustina 9807 24thn P √
18 Aprida 000754 22thn P √
19 A.Bagus fadilah 9808 16thn L √
20 Wiwied windari 000755 24thn P √
21 Deni 000756 21thn L √
22 Mustika azahra 9809-000760 11thn P √ Rp 15,000
23 Apriska feliyanti 9810 19thn P √ Rp 15,000
25 Fatqihatul khasanah 9811 4thn P √
26 Laura anjelita 9812 15thn P √
27 Maryani 9813 38thn P √
28 Aleta 000758 21thn P √
29 Yusuf al hakim 000759 19thn L √
30 Febrina maharani 000761 25thn P √
31 Rohalni 000762 24thn P √
32 Desrita 9814 52thn P √ Rp 15,000
33 Nurhayati 000764 28thn P √
34 Surya dewi 9815 50thn P √ Rp 15,000
35 Khofifah 000766 18thn P √
36 M.Triyoga 000767 17thn L √
37 Axcels basri.w 9816 5,11thn P √ Rp 15,000
38 M.Rino 000768 20thn L √
39 Dipo rasyad 9817 5thn L √
40 P √
41 P √
42 L √
43 P √
44 P √
45 L √
46 P √
47 P √
48 L √
49 P √
50 P √
51 P √
52 L √
53 L √
54 P √
55 L √
56 P √
57 L √
58 P √
59 P √
60 P √
61 P √
62 P √
L √
L P
TOTAL Rp 135,000
Mengetahui :
NIP. 19730520 200212 2 003
PENERIMAAN PELAYANAN KESEHATAN DASAR PUSKESMAS RAWAT INAP KEDATON
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000
Rp 15,000
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 55,000
Rp 35,000
Rp 15,000
Rp 15,000 Rp 72,500
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 7,500
Rp 15,000
Rp 7,500 Rp 15,000
BPJS Rp 130,000
Rp 15,000
Rp 135,000 Rp 257,500 Rp 30,000 Rp 155,000 Rp - Rp 195,000

NIP. 19770120 200804 1 001
AT INAP KEDATON
PERDA
TINDAKAN
PAPSMEAR PERSALINAN
RAWAT INAP HAJI KET
UGD DAN IVA UMUM
DL.WIDAL
11.12.EXO
DL.WIDAL
Rp 25,000
46.ARSEN
-85
DL.WIDAL
DL.WIDAL
Rp 25,000
GOLDAR
BTW.KS
GOLDAR.KS
SCALLING
Rp 25,000 Rp 25,000 Rp - Rp - Rp - Rp 957,500
knik Fungsional
Budi Susanto
20 200804 1 001
25000 Rp -
PENERIMAA

KUNJUNGAN
B L
1 P √
2 L √
3 L √
4 P √
5 L √
6 P √
7 L √
8 P √
9 P √
10 P √
11 L √
12 P √
13 P √
14 P √
15 L √
16 P √
17 L √
18 L √
19 P √
20 P √
21 P √
22 P √
23 L √
24 P √
25 P √
26 L √
27 L √
28 P √
29 L √
30 P √
31 P √
32 L √
L P
TOTAL Rp -
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp - Rp - Rp - Rp - Rp - Rp -

NIP. 19770120 200804 1 001
AWAT INAP KEDATON
UAI PERDA
TINDAKAN
PAPSMEAR RAWAT PERSALINAN
HAJI KET
UGD DAN IVA INAP UMUM
Teknik Fungsional
ko Budi Susanto
70120 200804 1 001
-5
25000 Rp -
PENERIMAA

KUNJUNGAN
B L
1 L √
2 L √
3 P √
4 P √
5 P √
6 P √
7 P √
8 P √
9 L √
10 P √
11 P √
12 P √
13 P √
14 P √
15 P √
16 P √
17 L √
18 P √
19 P √
20 L √
21 L √
22 P √
23 P √
24 L √
25 L √
26 L √
27 L √
28 L √
29 L √
30 L √
31 P √
32 L √
33 P √
34 L √
35 P √
36 P √
37 L √
38 P √
39 L √
40 L √
41 P √
L P
TOTAL Rp -
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN

NIP. 19770120 200804 1 001
AT INAP KEDATON
PERDA
TINDAKAN
HAJI KET
knik Fungsional
udi Susanto
20 200804 1 001
25000 Rp -
PENERIMA

KUNJUNGAN
B L
1 P √
2 L √
3 P √
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
L P
TOTAL Rp -
Mengetahui :
NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Petugas: Widi astut Pejabat Teknik Fungsional

NIP. 19770120 200804 1 001
AWAT INAP KEDATON
UAI PERDA
TINDAKAN
PAPSMEAR PERSALINAN
RAWAT INAP HAJI KET
UGD DAN IVA UMUM
eknik Fungsional
Budi Susanto
120 200804 1 001
25000 Rp -
PENERIMAA

KUNJUNGAN
B L
1 L √
2 L √
3 P √
4 P √
5 L √
6 P √
7 P √
8 P √
9 P √
10 L √
11 P √
12 P √
13 P √
14 P √
15 L √
16 L √
17 L √
18 P √
19 P √
20 P √
21 P √
22 L √
23 P √
24 P √
25 P √
26 P √
27 P √
28 P √
29 L √
30 L √
31 L √
33 L √
34 P √
35 L √
36 P √
37 L √
38 L √
39 P √
40 P √
41 P √
42 P √
43 L √
44 P √
45 P √
46 P √
47 P √
48 L √
49 P √
50 P √
51 L √
52 L √
53 L √
54 P √
55 L √
L P
TOTAL Rp -
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN

NIP. 19770120 200804 1 001
AT INAP KEDATON
PERDA
TINDAKAN
PAPSMEAR PERSALINAN
RAWAT INAP HAJI KET
UGD DAN IVA UMUM
knik Fungsional
udi Susanto
20 200804 1 001
25000 Rp -
PENERIMAA
Tanggal : 19 Februari 2019

KUNJUNGAN
B L
1 Irwan 9184-000540 28thn L √

2 Rahmat putra 000537 23thn L √
3 Zhurza.n.t.a 9185-000543 30thn P √
4 Afrizan luffi lunsinan 000538 44thn L √
5 Lokosmi saba ocdita 000539 41thn P √
6 Chilla novisa 9186-000541 6thn P √ Rp 15,000
7 Ernawati 9187-000545 46thn P √ Rp 15,000
8 Endang irianingsih 9188 62thn P √ Rp 15,000
9 M.Saleh 9189 71thn L √ Rp 15,000
10 M.Ari wibowo 000542 34thn L √
11 Mei suni 9190 23thn P √ Rp 15,000
12 M.Abi saputra 9191 21thn L √ Rp 15,000
13 Suwarian 9192 42thn L √
14 Dina verdiana 9193 27thn P √ Rp 15,000
15 Boby m.safitri 000544 41thn P √
16 Bina mohar.m 9194 22thn P √ Rp 15,000
17 Vira nurdhita 9195 21thn P √
18 Maya 9196 58thn P √ Rp 15,000
19 Farida 000546 46thn P √
20 M.Yasir nugroho 9198-000157 24thn L √
21 Yayuk marlina 000546 31thn P √
22 Udin,sag 000547 47thn L √
23 Chairunnisa 9199 33thn P √
24 Asep sopriyadi 000548 30thn L √
25 Sufi yati 9200 73thn P √ Rp 15,000
26 Leny indarsari 000549 22thn P √
27 Khairuddin hasnawi 000550 56thn L √
28 Indira 000151 38thn P √
29 Suyati 000152 55thn P √
30 Nur hikmi.z 9201 21thn P √ Rp 15,000
31 Ahmad yani aslam 000153 56thn L √
32 Nino pajri irmawan 000154 29thn L √
33 Bayu arjuna 000155 19thn L √
34 Alya jazilah 9202-000160 1,8thn P √
35 Nely afrisari 000156 27thn P √
36 Desy deria 9203 48thn P √
37 Bela 000158 28thn P √
38 Nakesya 000159 2,5thn P √
39 Hariarsono 9204 24thn L √ Rp 15,000
40 Basuki sudaryanto 9205 61thn L √ Rp 15,000
41 Indri putri 9206 14thn P √
42 Ali marhak 9207 46thn L V Rp 15,000
43 Elysabeth 000161 20thn P V
44 Vini agustini 000162 23thn P V
L P
TOTAL 17 27 44 Rp 210,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000 Rp 130,000
Rp 15,000
Rp 15,000 Rp 130,000
Rp 10,000
Rp 20,000
Rp 20,000
Rp 15,000
Rp 47,500
Rp 15,000
Rp 15,000
Rp 15,000 Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
BPJS Rp 130,000
Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000 Rp 35,000
Rp 7,500 Rp 15,000
Rp 15,000
Rp 7,500
Rp 20,000
Rp 15,000
Rp 15,000
Rp 60,000 Rp 417,500 Rp 45,000 Rp 120,000 Rp 90,000 Rp 180,000

NIP. 19770120 200804 1 001
AT INAP KEDATON
PERDA
TINDAKAN
HAJI KET
SCALLING
KS.BTW
SCALLING
Rp 100,000 HAJI
Rp 100,000 HAJI+PPTEST
URIN.L
HB
Rp 25,000
LEPAS SPIRAL+CYCLO
46.CHKM+TKF
SCALLING
KB IMPLANT
Rp 100,000 HAJI
KS.BTW
DL.WIDAL
KS.GOLDAR
CATEN
GOLDAR
Rp 25,000 UGD+HB
Rp 50,000 Rp - Rp - Rp - Rp 300,000 Rp 1,472,500
knik Fungsional
Budi Susanto
20 200804 1 001
25000 Rp -
PENERIM

KUNJUNGAN
B L
1 Kurnia anggara.k 9208 27thn L √

2 Romelah 9209-000164 55thn P √ Rp 15,000
3 Humam 9210 8bln L √
4 M.Gelvin.f 9211-000169 19thn L √
5 Athariz mulya.al 9212 3thn L √
6 M.Fadhil alamsyah 9213 7thn L √
7 Ruslinawati 9214 69thn P √ Rp 15,000
8 M.Narendra alfareji 9215 6bln L √
9 Angella sri hartini 9216 61thn P √
10 Heriyanto serumpun 000165 63thn L √
11 Ahmad matin 000166 78thn L √ BPJS
12 Marcella sagita 9217 14thn P √ Rp 15,000
13 Dzakiyya talita sakti 9218-000170 3thn P √
14 Siti maimunah 000167 42thn P √
15 Yeni saria putri 000168 21thn P √
16 Fadilawi khaira 9219 10thn L √ Rp 15,000
17 Fatiah alfarita 9220 7bln P √
18 Ardyanto 000171 20thn L √
19 Rajiq alhana 9221 5thn L √
20 Mistoni 000172 49thn L √
21 Muchamad maksun 000173 37thn L √
22 Ari desmita 000174 46thn L √
23 Imanuel purwanto 000175 41thn L √
24 Ikhsan rayadi 9222-000183 24thn L √
25 Agy pangestu 000176 20thn L √
26 Agus sartono 000177 32thn L √
27 M.Zainal 0001758 44thn L √
28 Reiza rizkiawan 000179 22thn P √
29 Aji bagus sastria 000180 19thn L √
30 Reza witu.s 9223 17thn L √
31 Septina 000181 34thn P √
32 Yanuar adi purnomo 000182 25thn L √
33 Devaridho 9224 14thn L √ Rp 15,000
34 M.Lakiel al riezki 9225-000186 7thn L √
35 Turiman 9226 56thn L √
36 Elza wahyuni 9227 30thn P √ Rp 15,000
37 Nofriyanto 000184 34thn L √
38 Teresia aprida purba 000185 22thn P √
39 Priska 9228 16bln P √
40 Maety maimunah 9229 22thn P √ Rp 15,000
41 Bila anggraini 000187 20thn P √
42 Darmayu 000188 61thn P √
43 Belki 000189 77thn L √
44 M.Abizar.a 9230 10bln L √
45 Mia oktaviany 9231-000191 29thn L √
46 Bambang suparyono 000189 61thn L √
47 Iskandar 000192 45thn L √
48 Marhali 000193 46thn L √
49 Nurhayati 9235 40thn P √
50 Mumiyaniah 9236 20thn P √
51 Indira 9237-000197 36thn P √
L P
TOTAL 32 19 51 Rp 105,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000
Rp 65,000
Rp 15,000
Rp 15,000 Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 15,000 Rp 20,000
Rp 10,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 80,000
P2KM Rp 130,000
Rp 15,000
Rp 15,000
P2KM Rp 65,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 30,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 10,000
Rp 15,000
Rp 15,000
Rp 35,000
Rp 105,000 Rp 332,500 Rp 120,000 Rp 200,000 Rp - Rp 270,000

NIP. 19770120 200804 1 001
WAT INAP KEDATON
I PERDA
TINDAKAN
PAPSMEAR PERSALINAN
RAWAT INAP HAJI KET
UGD DAN IVA UMUM
KOLES.GDS.ASAM.U
26.TKF+CEIVITRON
Rp 25,000
ASAM URAT
HB
PPTEST
37.38.COMP+EUG
11.21.COMPOSITE
Rp 100,000 HAJI
36.COMPOSITE
71.81.EXO
DL.WIDAL
PPTEST
DL.WIDAL
Rp 25,000
Rp 25,000
Rp 52,500 UGD.NEBO
Rp 127,500 Rp - Rp - Rp - Rp 100,000 Rp 1,360,000
eknik Fungsional
Budi Susanto
120 200804 1 001
-20
25000 Rp -
PENERIMA

KUNJUNGAN
B L
1 Juniardi 000194 53thn L √

2 Dewi apriliana 000195 49thn P √
3 Arsyla merdeka 9232 2thn P √
4 Oktarina 9233 24thn P √
5 Desi.p 000196 26thn P √
6 Nur mahdalena 000198 32thn P √
7 Sugito 000199 56thn L √
8 Any nurhyati 000200 48thn P √
9 Rahmadiana debora.d 9234 23thn P √ Rp 15,000
10 Giono 9238-000204 64thn P √ Rp 15,000
11 Mardhi nopriyansah 9239 24thn L √
12 Kesya dariya 9240 6thn L √ Rp 15,000
13 Fakira 9241 3thn P √
14 Hudiono 000201 68thn L √ BPJS
15 Samir altiar 9242 7thn L √ Rp 15,000
16 Adiva inaka 9243-000203 3thn P √
17 Any nurhasanah 000202 45thn P √
18 T.Dewi may.s 9244 24thn P √
19 Sazir rais 000205 38thn L √
20 Rosidah ahmad 9245 47thn P √
21 Aqila 9246 4thn P √
22 Santi ayu 000206 29thn P √
23 Jovanka aurora 9247 12thn P √
24 Wardani 000207 54thn L √
25 Sriyani 000208 53thn P √
26 Salima aprina 9248-000214 19thn P √
27 M.Hamar alfarizki 9249-000212 2bln P √
28 Salsabila 000209 17thn P √
29 Ari sutejo 9250 34thn L √ Rp 15,000
30 Harun hamad 000210 64thn L √
31 Mujiati 000211 58thn P √
32 Ade putra 9251 34thn L √
33 Elisabeth yuliana 9252-000215 43thn P √
34 M.Ichwan 000213 33thn L √
35 Dewi astuti 9253 26thn P √
36 RA.Sri murniati 9254 55thn P √ Rp 15,000
37 Rania hikari 9255 3thn P √
38 M.Dimas.s 9256 3thn P √
39 Tuti 9257-000217 48thn P √ Rp 15,000
40 Mariam 9258-000216 68thn P √ Rp 15,000
41 Rowiyah 000218 89thn P √
42 Farhan 9259 6bln L √
43 Dasril 9260-000221 72thn L √ Rp 15,000
44 Fitri susanti 000219 23thn P √
45 Reno prasetyo 000220 29thn L √
46 Sherly charlina 9261 22thn P √ Rp 15,000
47 Rasya elwanda 9262 6bln L √
48 Farzan 000222 9bln L √
49 Pauji hatomi 9263 23thn L √ Rp 15,000
50 Rustiyana 000223 45thn P √
51 Nurhayati 9263-000224 18thn P √ Rp 15,000
52 Linda puspita sari 9265 21thn P √ Rp 15,000
53 Sunar 000225 16thn L √
54 Baidi rasid 9266 73thn L √ Rp 15,000
55 Azahra meydiastuti 9267-000226 4thn P √
L P
TOTAL 20 35 55 Rp 210,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 10,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 10,000
Rp 40,000
Rp 15,000
Rp 15,000
Rp 40,000
Rp 15,000 Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 20,000
Rp 15,000 Rp 42,500
Rp 15,000
Rp 15,000
Rp 15,000 Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 40,000
Rp 15,000
Rp 50,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 7,500
Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000 Rp 20,000
Rp 90,000 Rp 15,000 Rp 180,000 Rp 375,000 Rp 15,000 Rp 135,000
, Pejabat Teknik Fungsional

NIP. 19770120 200804 1 001
AT INAP KEDATON
PERDA
TINDAKAN
PAPSMEAR PERSALINAN
RAWAT INAP HAJI KET
UGD DAN IVA UMUM
Rp 100,000 HAJI
CATEN
Rp 100,000 HAJI
KOLES.GDS
ASAM.U+GDS
DL.WIDAL
Rp 100,000 HAJI
Rp 25,000
Rp 100,000 HAJI
Rp 100,000 HAJI
HB
DL.WIDAL.GOL
BTW.KS
Rp 100,000 HAJI
Rp 100,000 HAJI
EUG+CEIVITRON
ASAM.URAT
ASM.U+GDS
Rp 100,000 HAJI
ASAM.U+KOLES
GOLDAR
DL.WIDAL
HB
Rp 25,000 Rp - Rp - Rp - Rp 1,000,000 Rp 2,045,000
eknik Fungsional
Budi Susanto
120 200804 1 001
25000 Rp -
PENERIMAA

KUNJUNGAN
B L
1 Gusti made 9268-000234 23thn L √

2 Hana hanifatusalimah 9269 10thn P √
3 Raden putra 000227 27thn L √
4 Bhakti bagus ibrahim 9270 21thn L √ Rp 15,000
5 Damar arti 9271-000231 46thn L √ Rp 15,000
6 Sutrisno 9272-000237 81thn L √ Rp 15,000
7 Askaping 000228 65thn L √
8 Mariatul sakdiah 000229 62thn P √
9 Diki andita.k 000230 27thn P √
10 Malik alfatih 9273-000233 17bln L √
11 Saqila devina 9274 6thn P √ Rp 15,000
12 Sri novianti 9275-000239 26thn P √
13 Rahmah intan yunita 9276 22thn P √ Rp 15,000
14 Febi karneli 9277-000242 44thn P √
15 Himawan 000232 28thn L √
16 Ade pratidina 9278-000241 25thn L √
17 Sarra odelia 9279-000236 7thn P √ Rp 15,000
18 M.Saleh 9280 71thn L √ Rp 15,000
19 Sayna 000235 26thn P √
20 Dinar herdy 9281 17thn L √ Rp 15,000
21 Siti zaenab 9282 58thn P √
22 Sofi yati 9283 74thn P √
23 Rizk elkana 9284 12thn L √ Rp 15,000
24 Triska 9285-000240 16bln P √
25 Aminah 9286-000243 70thn P √ Rp 15,000
26 Rahmawati 9287-000244 51thn P √ Rp 15,000
27 Radhika kurniawan 9288 12bln L √
28 Retno ambarsari 9289 28thn P √ Rp 15,000
29 Clarissa 9290 3,8thn P √
30 Suparni 9291-000245 67thn p √ Rp 15,000
31 Dwi asyifa lestari 9292 1thn P √
32 Dwi oktafiyani 9293 28thn P √ Rp 15,000
33 Intan azizah 9294-000246 7thn P √ Rp 15,000
34 Sevi hariyati 9295 27thn P √
L P
TOTAL 13 21 34 Rp 225,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000 Rp 27,500
Rp 15,000
Rp 15,000
Rp 50,000
Rp 15,000
Rp 15,000 Rp 35,000
Rp 15,000 Rp 27,500
Rp 15,000 Rp 65,000
Rp 15,000
Rp 15,000 Rp 15,000
Rp 35,000
Rp 15,000
Rp 35,000
Rp 15,000 Rp 35,000
Rp 25,000
Rp 25,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 35,000
Rp 15,000
Rp 75,000 Rp 135,000 Rp 90,000 Rp 290,000 Rp 15,000 Rp 45,000

NIP. 19770120 200804 1 001
WAT INAP KEDATON
AI PERDA
TINDAKAN
PAPSMEAR PERSALINAN
RAWAT INAP HAJI KET
UGD DAN IVA UMUM
16.CHKM+CEIVITRON
KOLES.GDS.PPTEST
Rp 27,500 ESTRASI KUKU
Rp 100,000 HAJI
Rp 100,000 HAJI
BTW.KS
DL.WIDAL
37.CHKM+CEIVITRON
21.COMPOSITE
EUG+CEIVITRON
DL.WIDAL
DEPO
DL.WIDAL
Rp 25,000
Rp 25,000
DL.WIDAL
ASAM URAT
ASAM URAT
GDS
DL.WIDAL
Rp 77,500 Rp - Rp - Rp - Rp 200,000 Rp 1,152,500
eknik Fungsional
o Budi Susanto
0120 200804 1 001
-35
25000 Rp -
PENERIMAA

KUNJUNGAN
B L
1 Meriyanti 9296 3thn P √

2 Putri tanjung sari 9297 29thn P √ Rp 15,000
3 Tara lusiana.m 9298-000247 21thn P √
4 Muhliza 9299 61thn P √ Rp 15,000
5 Heriyanto 9300-000249 28thn L √
6 Bima adi wijaya 9301 20thn L √
7 Rudi surya 9302 24thn L √
8 Raihan chaniago 9303-000252 9thn L √
9 Lilik lamedi 9304-000248 64thn P √ Rp 15,000
10 Hasanah 9305 67thn P √ Rp 15,000
11 Adiva 9306 2thn P √
12 Yusri aldiansyah 000250 22thn L √
13 Muryanto 000251 59thn L √
14 Sriyani 9307-000257 61thn P √ Rp 15,000
15 Sudarmi 9308 39thn P √ Rp 15,000
16 Devia putri 9309 4thn P √
17 Nur aisiyah 9310 25thn P √ Rp 15,000
18 Dela saputri 9311 4hr P √
19 Leni fitriyani 9312-000253 25thn P √
20 Syabita agustina 9313 1thn P √
21 Gusnanda 9314 20thn L √ Rp 15,000
22 Meliyanti 9315 33thn P √ Rp 15,000
23 Zamaludin 9317 48thn L √ Rp 15,000
24 Kanaya 000254 4bln P √
25 Kholipah 000258 26thn P √
26 David wijaya 9317-000260 6thn L √
27 Imanuel hotman 9318 32thn L √ Rp 15,000
28 Adela ivanka 9319 18thn P √ Rp 15,000
29 Aqila azmi 000259 14thn P √
30 Sevi hariyati 000255 27thn P √
31 Novie 000256 27thn P √
32 Ester afrianti 9320 26thn P √ Rp 15,000
33 M.Thomi 9321 21thn L √ Rp 15,000
34 Nanci 000261 33thn P √
35 Junaidi 000262 51thn L √
36 Suprapti 9323 51thn P √ Rp 15,000
37 Dwi indriani 9324 50thn P √ Rp 15,000
38 Esah suheni 9325 33thn P √
41 Maya eka 9326 14thn P √ Rp 15,000
L P
TOTAL 11 30 41 Rp 255,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000
Rp 15,000 Rp 130,000
Rp 15,000 Rp 130,000
Rp 15,000
Rp 15,000 Rp 30,000
Rp 40,000
Rp 15,000
Rp 15,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 55,000
Rp 15,000
Rp 10,000
Rp 15,000 Rp 15,000
Rp 10,000
Rp 55,000
Rp 10,000
Rp 7,500
Rp 35,000
Rp 15,000
Rp 75,000 Rp 305,000 Rp 105,000 Rp 232,500 Rp - Rp 25,000

NIP. 19770120 200804 1 001
AT INAP KEDATON
PERDA
TINDAKAN
HAJI KET
SCALLING
SCALLING
BATAL
CALSIS+TS
KOLES.GDS
Rp 100,000 HAJI
HB
HB.PROT.GDS
BTL TINDIK BY
PPTEST
EXO
BTW
HB.PROT.GDS
PPTEST
GOLDAR
Rp 25,000
Rp 25,000 Rp - Rp - Rp - Rp 100,000 Rp 1,122,500
knik Fungsional
Budi Susanto
20 200804 1 001
25000 Rp -
PENERIMA

KUNJUNGAN
B L
1 Citra aulia 9327 2thn P √

2 Yuda kurniawan 9328 20thn L √ Rp 15,000
3 Zahratufus 9329 17thn P √ Rp 15,000
4 Firman sugiharto 000263 13thn L √
5 Marsiti 9334-000266 28thn P √
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
L P
TOTAL 2 3 5 Rp 30,000
Mengetahui :
NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000
Rp - Rp - Rp 15,000 Rp - Rp - Rp -
Petugas : Novi Handayani Pejabat Teknik Fungsional

NIP. 19770120 200804 1 001
AWAT INAP KEDATON
UAI PERDA
TINDAKAN
PAPSMEAR PERSALINAN
RAWAT INAP HAJI KET
UGD DAN IVA UMUM
Rp 25,000
Rp 52,500 UGD.NEBO
Rp 77,500 Rp - Rp - Rp - Rp - Rp 122,500
eknik Fungsional
Budi Susanto
120 200804 1 001
25000 Rp -
PENERIMAAN P
PELA

KUNJUNGAN
B L
1 Nabila yan warita 000264 14thn P √
2 Ida royani 000265 49thn P √
3 Riko april 9330-000271 26thn L √
4 Firman suguharto 000263 13thn P √
5 Ananta fastabiqu 9331 6thn P √
6 Karsinah 9332-000267 28thn P √
7 Indrajaya 9333 36thn L √
8 Maria widia puri 9335 41thn P √ Rp 15,000
9 M.Gelvin.f 9336-000281 19thn L √
10 Ika marantika 9337 22thn P √
11 Lucky diatnika 000268 49thn L √
12 Amadi 000269 59thn L √
13 Mariyah 000270 55thn P √
14 Fikri ahmadi 9338 34thn L √ Rp 15,000
15 Shanti 9339 22thn P √
16 Akmal kadari 9340 1thn L √
17 Mahfiatul arfiah 9341-000282 14thn P √
18 M.Azam ramdhan 9342-000273 7thn P √ Rp 15,000
19 Feri sunandar 000272 33thn L √
20 Erpan mulya 000274 33thn L √
21 Novriyadi 000275 38thn L √
22 Joni yuliansyah 9343 29thn L √ Rp 15,000
23 Riska fauziah 9344 19thn P √ Rp 15,000
24 Quinsha taqiya 9345 9thn P √ Rp 15,000
25 Irsan bima.p 9346 5bln L √
26 Rahma yunita 9347 9thn P √ Rp 15,000
27 Heri chnadra 000276 56thn L √
28 Nurlina 000277 43thn P √
29 Nurhaya 000278 63thn P √
30 Sukaini 000279 30thn L √
31 Sri hanifah 9348-000285 54thn P √ Rp 15,000
32 Ajiat mu'jizat 000280 37thn L √
33 Rahma dini 000283 17thn P √
34 Yuni rahayu 000284 29thn P √
35 Novita windria 9349 6thn P √ Rp 15,000
36 Ceisya arya.n 9350 4bln P √
37 Tasim 9351 64thn L √ Rp 15,000
38 Suci kurnia 000287 19thn P √
39 Sri suhartati 000288 49thn P √
40 Dema virnaliya 9352 35thn P √ Rp 15,000
41 Sereen dwi arya 9353 67thn P √ Rp 15,000
42 Fitri astuti 000289 25thn P √
43 Istizab 000290 27thn P √
44 Samuel enggal 000291 28thn L √
45 M.Indrajid 000292 18thn L √
46 Kiki ristiani 000293 20thn P √
47 Dini ruana 000294 23thn P √
48 Kiandra 9354 5,9thn P √ Rp 15,000
49 Zainal abidin 000295 54thn L √
50 Sri suwartati 000296 52thn P √
51 Pram mahardika 000297 41thn L √
52 Femi 000298 31thn P √
53 Siti zahriyah 9355 21thn L √
54 Khofifa indar 9356 2,6thn P √
55 Nelson rumanof 9367 56thn L √ Rp 15,000
56 Erpijal hadist 000299 28thn L √
57 Emma hfuz 000300 47thn L √
58 Dimas sutopo 000301 31thn L √
59 Erwan fahrudin 000302 36thn L √
60 M.Aarshel 9358 2,3thn P √
61 Gaffan pratama 9359 10thn L √ Rp 15,000
62 Rahmat 000303 27thn L √
L P
TOTAL 28 34 62 Rp 225,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000
Rp 15,000
Rp 15,000 Rp 15,000
Rp 15,000
Rp 15,000 Rp 10,000
Rp 15,000
Rp 15,000 Rp 92,500
Rp 15,000 Rp 222,500
Rp 7,500
Rp 15,000
Rp 15,000
Rp 15,000 Rp 15,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 65,000
Rp 15,000
Rp 7,500 Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
BPJS Rp 130,000
BPJS Rp 130,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 105,000 Rp 605,000 Rp 90,000 Rp 125,000 Rp 15,000 Rp 315,000

NIP. 19770120 200804 1 001
WAT INAP KEDATON
AI PERDA
TINDAKAN PAPSMEAR PERSALINAN

RAWAT INAP HAJI KET
UGD DAN IVA UMUM
46.EUG+CEIVITRON
PPTEST
26.PSA+GI
38.PSA+GI+SCALLING
GOLDAR
Rp 100,000 HAJI
Rp 100,000 HAJI
Eug+ceivitron
DL.WIDAL
Rp 100,000 HAJI
Rp 100,000 HAJI
Rp 100,000 HAJI
KOLES.ASM.U.GDS
KS.GOLDAR
KB DEPO
Rp 100,000 HAJI
Rp 100,000 HAJI
SCALLING
SCALLING
Rp - Rp - Rp - Rp - Rp 700,000 Rp 2,180,000
nik Fungsional HAJI. 700.000

BKD. 1.250.000
udi Susanto
20 200804 1 001
25000 Rp -
PENERIMAAN P
PELA

KUNJUNGAN
B L
1 Ahmad yadi 9360-000304 31thn L √
2 Sri novianti 9361-000312 26thn P √
3 Dahrinur karlina 9362 60thn P √
4 Merlina dona 9363 22thn P √
5 Endang irianingsih 9364 62thn P √ Rp 15,000
6 Jenifer alexandria 9365-000316 11thn P √
7 Elisabeth yuliana 9366-000313 43thn P √
8 Dipa fitra.r 9367 24thn L √
9 Ratri riyana 9368-000305 30thn P √
10 Devi pratiwi 9369-000319 18thn P √
11 K.Dwi yuliani 000306 28thn P
12 Abror 000307 28thn L √
13 Novi yanti 000308 31thn P √
14 Abu na'im 000309 53thn L √
15 Suyati 000310 54thn P √
16 Firmansyah 000311 25thn L √
17 M.Fairel 9370 2,10thn L
18 Supiarni 9371 58thn P √
19 Erika dwi nanda 9372-000330 20thn P √
20 Ahmad ali reza 9373 15thn P √ Rp 15,000
21 Dimas seprianto.p 000314 20thn L √
22 Novita tri.w 000315 41thn P √
23 Hasbi sanusi 9374 30thn L √ Rp 15,000
24 Dini setyaningsih 9375 6thn P √ Rp 15,000
25 Arfan pratama 9376 9thn L √ Rp 15,000
26 Dedi warman 000317 46thn L √
27 Adi rahman 000318 30thn L √
28 M.Ridho 9377 11hr L √
29 M.Syaifuddin 000320 53thn L √
30 Naiya kharisma 9378 14thn P √ Rp 15,000
31 Hermansyah trimantara 000321 30thn L √
32 Sofiyati 9379 73thn P √ Rp 15,000
33 Eko budi riyanto 000322 57thn L √
34 Sudirman 000323 53thn L √
35 Muhammad susdi 000324 46thn L √
36 Syah kurnia 9380-000329 21thn P √ Rp 15,000
37 Felicia princes 9381 7thn P √ Rp 15,000
38 M.Husen 9382 3thn L √
39 Jony anwar 000325 53thn L √
40 Syamsu ridjar 000326-9389 65thn L √ Rp 15,000
41 Daurah 000327 60thn P √
42 M.Rahman 000328 13thn L √
43 Sulisti agustini 9383 39thn P √ Rp 15,000
44 Dasril 9384 72thn L √ Rp 15,000
45 Ediya johan 9385 33thn L √ Rp 15,000
46 Agus siswanto 9386 33thn L √ Rp 15,000
47 Ahmad ihwan 000331 35thn L √
48 Sulisna 000332 32thn P √
49 Nila 9387 38thn P √
50 Ikrom fadiansyah 9388 26thn L √ Rp 15,000
51 Hamami 000333 41thn L √
52 Wahyudi permana 000334 23thn L √
53 Efi mulansari 9390-000335 27thn P √
54 Samudra adi 9361 19thn L √ Rp 15,000
55 Hendra 000336 36thn L √
56 Rica 000337 23thn P √
57 Aidan 9392 10bln L √
58 Iyen 9393 34thn P √ Rp 15,000
59 Theresia 9394 11thn P √ Rp 15,000
60 Ahmad arya 9395 4thn L √
61 Rivaldo 9397 7thn L √
L P
TOTAL 33 28 61 Rp 270,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000 Rp 130,000
Rp 15,000 Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000 Rp 15,000
Rp 15,000 Rp 65,000
Rp 15,000
Rp 15,000 Rp 62,500
Rp 15,000 Rp 130,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 65,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 55,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 165,000 Rp 432,500 Rp 105,000 Rp 137,500 Rp - Rp 285,000

NIP. 19770120 200804 1 001
T INAP KEDATON
ERDA
TINDAKAN PAPSMEAR RAWAT PERSALINAN HAJI KET

SCALLING
37.TKF+CEIVITRON
55.PST.EXO
COMPOSITE
HB.PROT.GDS.GOL
11.12.composite
Rp 100,000 HAJI
Rp 100,000 HAJI
COMPOSITE
Rp 100,000 HAJI
Rp 100,000 HAJI
HB
Rp 100,000 HAJI
Rp 100,000 HAJI
HB.PROT.GDS
Rp 25,000
Rp 25,000 Rp - Rp - Rp - Rp 600,000 Rp 2,020,000
nik Fungsional
udi Susanto
20 200804 1 001
25000 Rp -
PENERIMAAN PE
PELAY

KUNJUNGAN
B L
1 Ibrahim 9396 85thn L √ Rp 15,000
2 Lestalia 9398 22thn P √
3 Tiara nurani 9399 9thn P √ Rp 15,000
4 Hana hanifatussalimah 9400-000340 10thn P √
5 Lismiani 000338 50thn P √
6 M.Abul fatah 000339 22thn L √
7 Nagata gibran 9401 2,8thn L √
8 Evelyn shafira 9402 19bln P √
9 Enzang 9403-000341 68thn L √ Rp 15,000
10 Nuraini 9404 27thn P √ Rp 15,000
11 Alfa azi effendar 9405-000342 21thn L √ Rp 15,000
12 Ririn yulianti 9406-000344 30thn P √
13 Winda yulita 9407-000345 26thn P √
14 Priscia hartarti 9408 5thn P √
15 Alisa delisna.p 9409 9thn P √ Rp 15,000
16 Anawati 000343 42thn P √
17 Rajiq alhana 9410 5,6thn L √
18 Anisa dwi 9411-000353 27thn P √
19 Feryanti 9412 26thn P √ Rp 15,000
20 Adzkia humaira 9413 1,2thn P √
21 Ulfah.a 9414 25thn P √ Rp 15,000
22 Rasiddan 9415 5bln L √
23 Rozani 000346 42thn L √
24 Alfaththiyatul 000347 22thn P √
25 Winarsih 000348 33thn P √
26 Zikna balqis 9416-000349 4,10thn P √
27 Khanza nopalin 9417-000350 1,3thn P √
28 Lelahati 9418 53thn P √ Rp 15,000
29 Bimo kusuma 9419-000351 4,7thn L √
30 Juriyah 9420 24thn P √ Rp 15,000
31 Clara aurelia 9421 5thn P √ Rp 15,000
32 Ivan zamorano 000352 20thn L √
33 Charisa azzalea 9422 4thn P √
34 Zahrotun rufu 9423-000354 17thn P √
35 Ahmad rasya 9424 3thn L √
36 Ade saputra 9425 24thn L √ Rp 15,000
37 Septy amelia 9426 22thn P √
L P
TOTAL 12 25 37 Rp 180,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000
Rp 15,000 Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 20,000
Rp 35,000
Rp 15,000 Rp 130,000
Rp 15,000 Rp 130,000
Rp 15,000
BPJS Rp 130,000
Rp 15,000
Rp 15,000 Rp 130,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 20,000
Rp 15,000 Rp 20,000
Rp 15,000 Rp 35,000
Rp 15,000 Rp 20,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 27,500
Rp 15,000
Rp 15,000
Rp 105,000 Rp 562,500 Rp 150,000 Rp 145,000 Rp 20,000 Rp 75,000

NIP. 19770120 200804 1 001
NAP KEDATON
DA
TINDAKAN PAPSMEAR RAWAT INAP PERSALINAN HAJI KET

UGD DAN IVA UMUM
EUG+CEIVITRON
GDS
KS.BTW
HB
DL.WIDAL
SCALLING
SCALLING
SCALLING
11.21.COMPOSITE
CYCLO
HB
DL.WIDAL
HB
47.ARSEN+CEIVITRON
Rp - Rp - Rp - Rp - Rp - Rp 1,237,500
nik Fungsional 1,100,000
udi Susanto
20 200804 1 001
25000 Rp -
PENERIMAAN PE
PELAY

KUNJUNGAN
B L
1 Suti hatiyani 000355 30thn P √
2 Wahyu nugroho 9427-000356 20thn L √
3 Tika rahmawati 9428 21thn P √ Rp 15,000
4 Rita asnani 9429 41thn P √ Rp 15,000
5 Ruli boyke hastien 9430 38thn P
6 M.Arshel 9431-000357 2,3thn L √
7 M.Ayubi al rayhan 9432-000358 4bln L
8 Mentari dwi 9433-000365 9thn P √
9 Dhenis adi wibowo 9434-000367 8thn L √
10 Bagas dwi 9435-000363 9thn L √
11 M.Pradipta 9436 1,5thn L √
12 Khairul 9437-000359 55thn L √ Rp 15,000
13 Helmizar 9438-000368 24thn L √
14 Devita habsari 000360 26thn P √
15 Jovano akhtar riski 9439 4bln L √
16 Rustina 9440 22thn P √ Rp 15,000
17 Alvero giandra.a 9441 5bln L √
18 M.Rafa azka 9442-000364 3thn L √
19 Viktor libradi 000361 47thn L √
20 Yuniarti 000362 43thn P √
21 Rukiah 000366 36thn P √
22 Ikadek genta 9443 16thn L Rp 15,000
23 Abizar nizam 9444 2thn L √
24 Wiwik 9445 35thn P √ Rp 15,000
25 Sarnah hermanahyati 9446 60thn P √ Rp 15,000
26 Syafiq fatir.a 9447 11bln L
27 Syafiqa aqila.h 9448 6thn P √
28 Irwana septiana 9449 24thn P
29 Arka leander 9450 1,3thn L √
30 Erfika aprilia 9451 4,10thn P √
31 Fitri ramadhan.s 000369 25thn P √
32 Joko kuswanto 000370 49thn L √
33 Raisya aulia.a 9452 2,7thn P √
34 Ghifahri alfarizi 9453 1thn L √
35 Firda ningrum 9454 19thn P √ Rp 15,000
36 Dewi yuliasih 9455-000373 28thn P √
37 Firdalia 000371 50thn P √
38 Muhtarjo 000372 30thn L √
39 Ratna dewi 9456 50thn P √ Rp 15,000
40 Brilian raka 9457 7thn L √
41 Armanda nazril 9458-000375 1thn L √
42 Aqila fitri 000374 35thn P √
43 Fitracia indah 000376 23thn P √
44 Suparti 000377 42thn P √
45 Adellia ayu safitri 9459 20thn P √
46 L √
47 L √
48 L √
49 P √
50 P √
51 P √
52 P √
53 P √
54 P √
55 P √
56 L √
57 L √
58 L √
59 P √
60 L √
61 L √
62 P √
P √
L P
TOTAL Rp 135,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000
Rp 15,000 Rp 130,000
Rp 15,000
Rp 15,000 Rp 35,000
Rp 15,000 Rp 35,000
Rp 15,000 Rp 15,000
Rp 15,000 Rp 27,500
Rp 15,000 Rp 15,000
Rp 15,000
Rp 40,000
Rp 15,000 Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 35,000
Rp 10,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 62,500
Rp 15,000
Rp 15,000
Rp 15,000 Rp 35,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 105,000 Rp 202,500 Rp 210,000 Rp 252,500 Rp 80,000 Rp 75,000

NIP. 19770120 200804 1 001
WAT INAP KEDATON
I PERDA

UGD DAN IVA UMUM
DEPO
SCALLING
DL.WIDAL
DL.WIDAL
EXO
GI
EXO
KOLESTROL+GDS
48.EUG+DENT
DL.WIDAL
Rp 100,000 HAJI
DEPO
Rp 25,000
CATEN
HB.PROT.GDS.GOL
Rp 25,000
DL.WIDAL
CYCLO
CATEN
Rp 25,000
Rp 75,000 Rp - Rp - Rp - Rp 200,000 Rp 1,335,000

BKD.900.000
udi Susanto
20 200804 1 001
25000 Rp -
PENERIMAAN P
PELA
Tanggal : 29 Januarir 2019

KUNJUNGAN
B L
1 Ahmad gandhi 13948 22thn L √
2 Mary amah 8688-13956 50thn P √
3 Batin strik 8689-13951 56thn L √
4 Indah murniah 8690-13955 21thn P √
5 Hifzurrahman.h 13949 23thn P √
6 Angela dixie.a 13950 22thn P √
7 Arnika safitri 8691 19thn P √ Rp 15,000
8 Syahada anggia 8692 6thn P √ Rp 15,000
9 Syahiro ainaya 8693 1thn P √
10 Meiwalia 8694 45thn P √ Rp 15,000
11 Juniro akbar 8695-13963 23thn L √ √
12 Darwin prayoga 13952 47thn L √
13 Kusmeiva 13953 45thn P √
14 Jovanka 8696 1thn P √
15 Suharmi 13954 25thn P √
16 M.Dimas saputra 8697 3thn L √
17 Edmundo caesario 13957 21thn L √
18 Fajar arum 8698-13966 26thn P √
19 Isma fadlilatus 13958 22thn P √
20 Adilah afrillia 13959 21thn P √
21 Raris meriana 8669- 38thn L √
22 Stevaro juan 8670 9thn L √
23 Hani priyanti 8701-13977 35thn P √
24 Romadhona 13960 20thn P √
25 Sri maryam 8702-13979 49thn P √
26 Dandung arif 8703-13975 24thn L √
27 Ardiansyah 13962 21thn L √
28 Edho renaldi 8704-13965 22thn P √ Rp 15,000
29 Ipah nilawati 8705 63thn P √ Rp 15,000
30 Lingga rofiani 8706-13969 15thn P √ Rp 15,000
31 Ekowati 13964 38thn P √
32 Albizar 8707 3,3thn L √
33 Angga pratama 13967 18thn L √
34 Alfia nikmah 13968 21thn P √
35 Dhea novita 13970 20thn P √
36 Luthfi aulia 13971 21thn P √
37 Arinda stefani 13972 22thn P √
38 Miswanti 8708-13974 51thn P √ Rp 15,000
39 Sarwoto 8709-13973 52thn L √ Rp 15,000
40 Toby anggara 8710 15thn L √ Rp 15,000
41 Bima anubrah 8711 7thn L √ Rp 15,000
42 Ema desmarina 8712 41thn P √ Rp 15,000
43 Yuniati 13976 29thn P √
44 Sugiyanto 8713-13980 17thn L √ Rp 15,000
45 Popy 13978 23thn P √
46 Inggrit cristina 8714 30thn P √
47 Vanesa 13981 20thn P √
48 M.Rifki 13982 21thn L √
49 Agtara liza.a 13983 21thn P √
50 Andini pramesti.n 13984 21thn P √
51 Alinta ayuningtyas 13985 22thn P √
52 Pramestha candra 13986 221thn P √
53 Alvin widya.a 13987 20thn L √
54 Romlah 8715 66thn P √
55 Ramli 13988 48thn L √
56 Melly rana 8716 22thn P √ Rp 15,000
57 Faren wira.a 8717 7thn L √ Rp 15,000
58 Ahmad ridho 8718 9thn L √ Rp 15,000
59 Mia 8720 19thn P √
L P
TOTAL 22 37 59 Rp 225,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000 Rp 65,000
Rp 15,000 Rp 27,500
Rp 15,000 Rp 55,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000 Rp 92,500
Rp 10,000
Rp 15,000
Rp 7,500
Rp 15,000
Rp 10,000
Rp 15,000 Rp 62,500
Rp 10,000
Rp 10,000
Rp 15,000 Rp 27,500
Rp 15,000
Rp 15,000 Rp 42,500
Rp 15,000
Rp 15,000 Rp 27,500
Rp 15,000 Rp 27,500
Rp 15,000
Rp 20,000
Rp 35,000
Rp 15,000
Rp 15,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 25,000
Rp 35,000
P2KM Rp 65,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 10,000
Rp 15,000
Rp 150,000 Rp 430,000 Rp 75,000 Rp 215,000 Rp 15,000 Rp 220,000

NIP. 19770120 200804 1 001
AT INAP KEDATON
PERDA

UGD DAN IVA UMUM
Rp 100,000 HAJI
27.exo dgn penylt
ARSEN+TS
EXO.TKF+TS
CATEN
PSA+GI
Rp 100,000 HAJI
GOLDAR
BTW
HB.PROT.GDS.GOL
BTW
BTW
GI
36.B.TMBL+GI
EXO
36.GI
HB
DL.WIDAL
Rp 25,000
BTW
BTW
BTW
BTW
ASAM URAT
DL.WIDAL
COMPOSITE
HB
BTW
BTW
BTW
BTW
BTW
BTW
Rp 25,000
Rp 25,000
Rp 50,000 Rp 25,000 Rp - Rp - Rp 300,000 Rp 1,705,000
nik Fungsional
udi Susanto
20 200804 1 001
-2500
25000 Rp -
PENERIMAAN PEL
PELAYA
Tanggal : 30 Januari 2019

KUNJUNGAN
B L
1 Jauhari rasyidin 8719-13991 37thn L √ Rp 15,000
2 Rusmin awaludin 13989 54thn L √
3 Maimunah 13990 52thn P √
4 Lilik yuniati 8721 43thn P √ Rp 15,000
5 Maya armelia 8722-13995 22thn P √
6 Vera yusnita 8723-13994 21thn P √
7 Imam 13992 43thn L √
8 Ratu alzazira 8724 6thn P √ Rp 15,000
9 Suhandi 8725 41thn L √ Rp 15,000
10 Lovely 8726 3thn P √
11 Daryadi 8727 51thn L √
12 Anya nurafifa 8728 21thn P √
13 Anya nurafifa 8729 21thn P √ Rp 15,000
14 Ernalia 13993 66thn P √
15 Zahra febri anti 8730 9thn P √ Rp 15,000
16 Wina astri 8731 17thn P √ Rp 15,000
17 Yuli kristia dewi 8732-13999 28thn P √
18 Yuliana 13996 30thn P √
19 Naufal lutfi 8733 12thn P √ Rp 15,000
20 Moushafi bellavito 13997 25thn L √
21 Yogi putra 13998 24thn L √
22 Erna safitri 14000 23thn P √
23 Indah maya sari 8734 23thn P √ Rp 15,000
24 Rike desi 14001 26thn P √
25 Azizah khaulah 8735 1,5thn P √
26 Deasy rhoma 8736 29thn P √
27 Annisa irma dewi 8737 16thn P √ Rp 15,000
28 Aan setiawan 8738 20thn L √ Rp 15,000
29 Amalia widya 14002 22thn P √
30 Arie astriani 8739-14007 29thn P √
31 Bambang hermanto 14003 55thn L √
32 Tarso 8740 76thn P √ Rp 15,000
33 Ety berliyani 14004 25thn P √
34 Andre frendrazuli 14005 22thn L √
35 Rizkia agustina 14006 24thn P √
36 Teofilus refael 8741 6,6thn L √ Rp 15,000
37 Wardatu soleh 14008 25thn L √
38 Uun hunainah 14009 39thn P √
39 Arsaka 8742 2,5thn P √
L P
TOTAL 12 27 39 Rp 195,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 35,000
Rp 15,000 Rp 15,000
Rp 15,000 Rp 130,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 25,000
Rp 15,000 Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 10,000
Rp 15,000 Rp 62,500
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 10,000
Rp 15,000
Rp 90,000 Rp 172,500 Rp 60,000 Rp 147,500 Rp 30,000 Rp 130,000

NIP. 19770120 200804 1 001
AT INAP KEDATON
PERDA

DL.WIDAL
Rp 100,000 HAJI
Rp 100,000 HAJI
EUG+TS
SCALING
GDS
KOLESTROL
GI
KB DEPO
BTW
HB.PROT.GDS.GOL
CATEN
PPTEST
Rp - Rp - Rp - Rp - Rp 200,000 Rp 1,025,000

BKD. 700.000
udi Susanto
20 200804 1 001
25000 Rp -
PENERIMAAN PEL
PELAYA
Tanggal : 31 Januari 2019

KUNJUNGAN
B L
1 Ulfa ruzaini 8743 20thn P √
2 Arisna 8744 21thn P √ Rp 15,000
3 Irham 14010 57thn L √
4 Sri purwati 14011 18thn P √
5 Muhrodi 14012 20thn L √
6 Ratu ghina 8745-14014 18thn P √
7 Kadek suprajaya 8746 18thn L
8 Jubaidah 14013 43thn P √
9 Ferido 8747 29thn L √ Rp 15,000
10 Cindy avriscka 8748-14019 33thn P √
11 Jusuf mikail 8749-14020 6thn L √
12 Doni agustoh 8750 25thn L √
13 Ruli hermalini 8751 29thn L √
14 Rendi irawan 8752 25thn L √
15 Sudarwin 8753-14031 49thn L √
16 Yumna zakiya 8754 1,2thn P √
17 Agustam 14015 53thn L √
18 Alya adriyana 8755 2thn L √
19 Ika marantika 8756-14028 21thn P √
20 Zahra azira 8757 6bln P √
21 Susiyanti 8758 56thn P √ Rp 15,000
22 Fitri 14016 30thn P √
23 Adila fitri 14017 35thn P √
24 Lisamiroh 14018 62thn P √
25 Yuli irmawati 14021 20thn P √
26 Abdul wahab 14022 50thn L √
27 M.Zaki alkahfi 8759 2,7thn L √
28 Nicholas alfa 14023 22thn L √
29 Keith sahwn 14024 23thn L √
30 Sulaiman 14024 42thn L √
31 Afrilia safitri 8760-14030 27thn P √
32 Lifa ningsih 8761 46thn P √ Rp 15,000
33 Anas saputro 8762 21thn L √ Rp 15,000
34 Bagindo zaili .f 14025 63thn L √
35 Feryatina 14026 59thn P √
36 Rusdi 14027 32thn P √
37 Novaridiba taufiq 8763 3thn P √
38 Nanda.s 14028 21thn P √
39 Fidya cahya 14029 21thn P √
40 Ade dwi 14032 22thn L √
41 Abfari 8765 2,5thn L √
42 Fizal hakim 8766 41thn L √
43 Selviana 8767 40thn P √ Rp 15,000
44 M.Andilan 8768 9thn P Rp 15,000
45
46
47
48
49
50
51
52
53
54
55
P √
P √
L P
TOTAL Rp 105,000
Mengetahui :

NIP. 19730520 200212 2 003
.......................TAHUN......................
BPG
UMUM TINDAKAN
Rp 15,000 Rp 130,000
Rp 15,000
Rp 42,500
Rp 15,000 Rp 27,500
Rp 15,000 Rp 27,500
Rp 15,000
Rp 15,000
Rp 15,000 Rp 15,000
Rp 15,000
BPJS Rp 130,000
Rp 15,000
Rp 15,000 Rp 27,500
Rp 15,000
Rp 15,000
Rp 20,000
Rp 15,000
Rp 15,000
Rp 15,000
Rp 10,000
Rp 10,000
Rp 15,000
Rp 15,000 Rp 55,000
Rp 15,000
Rp 15,000
Rp 10,000
Rp 10,000
Rp 15,000
Rp 15,000
Rp 135,000 Rp 357,500 Rp 90,000 Rp 55,000 Rp 62,500 Rp 130,000

NIP. 19770120 200804 1 001
AT INAP KEDATON
PERDA

Rp 25,000
Rp 100,000 HAJI
Rp 100,000 HAJI
Rp 100,000 HAJI
SCALLING
LEPAS IMPLANT+DEPO
TKF+CHKM
GI
Rp 25,000
EUG+TS
SCALLING
38.chkm+ceivit
KB CYCLO
Rp 100,000 HAJI
BTW
BTW
HB.PROT.GDS
Rp 100,000 HAJI
Rp 100,000 HAJI
BTW
BTW
Rp 25,000
Rp 75,000 Rp - Rp - Rp - Rp 600,000 Rp 1,610,000
nik Fungsional
udi Susanto
20 200804 1 001
25000 Rp -

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PENERIMAAN P

Tanggal : 01 Maret 2019

1 M.Yasir nugroho 9464-000383 24thn L √ Rp 15,000

dr. Marisa Anggraini

Rp 377,500 Rp 75,000 Rp 105,000 Rp 42,500 Rp 120,000 Rp 25,000 Rp 125,000

Pejabat Teknik Fungsional

dr. Eko Budi Susanto

Tanggal : 02 Maret 2019

1 Anis nafisatul 000403 14thn P √

dr. Marisa Anggraini

Rp 475,000 Rp 45,000 Rp 220,000 Rp 20,000 Rp 100,000 Rp 50,000 Rp 25,000

Pejabat Teknik Fungsional

dr. Eko Budi Susanto

Rp 360,000 Rp - Rp 100,000 Rp 1,680,000

Tanggal : 03 Maret 2019

1 M. Rahman Kelvin 009520 19 L √ Rp 15,000

Petugas : Eka Pejabat Teknik Fungsional

Tanggal : 04 Maret 2019

1 Ipan 9521-000429 8thn L √ Rp 15,000

dr. Marisa Anggraini

Rp 57,500 Rp 150,000 Rp 277,500 Rp 15,000 Rp 255,000 Rp 225,000 Rp -

Pejabat Teknik Fungsional

Tanggal : 05 Maret 2019

1 Nicolaus lumen 9559-000460 5thn L √ Rp 15,000

dr. Marisa Anggraini

Rp 460,000 Rp 60,000 Rp 112,500 Rp 42,500 Rp 195,000 Rp 257,000 Rp 125,000

Pejabat Teknik Fungsional

dr. Eko Budi Susanto

EXO DGN PENYLIT

Tanggal : 06 Maret 2019

1 Suhelmi 9595 55thn P √ Rp 15,000

dr. Marisa Anggraini

Pejabat Teknik Fungsional

dr. Eko Budi Susanto

Tanggal : 07 Maret 2019

1 Sutarti 9616 50thn P √ Rp 15,000

Petugas : Widi Astut Pejabat Teknik Fungsional

Tanggal : 08 Maret 2019

1 Wahtu rizki ramadhan 9621-000569 3,5thn L √ Rp 15,000

dr. Marisa Anggraini

Rp 310,000 Rp 150,000 Rp 100,000 Rp 35,000 Rp 150,000 Rp 100,000 Rp -

Pejabat Teknik Fungsional

dr. Eko Budi Susanto

Tanggal : 09 Maret 2019

1 Rima 9656-000598 19thn P √ Rp 15,000

dr. Marisa Anggraini

Rp 512,500 Rp 120,000 Rp 120,000 Rp 107,500 Rp 150,000 Rp 50,000 Rp -

Pejabat Teknik Fungsional

dr. Eko Budi Susanto

EXO DGN PENYLT

Tanggal : 10 Maret 2019

1 Alifi akbar 9688 5thn L √ Rp 15,000

Petugas : Muta Pejabat Teknik Fungsional

Tanggal : 11 Maret 2019

1 Kartum 9693-000628 74thn L √ Rp 15,000

dr. Marisa Anggraini

Rp 172,500 Rp 150,000 Rp 305,000 Rp 72,500 Rp 435,000 Rp 25,000 Rp -

Pejabat Teknik Fungsional

dr. Eko Budi Susanto

Rp 360,000 RANAP 3 HARI

Tanggal : 12 Maret 2019

1 Ade gustiyawan 9734-000671 37thn L √ Rp 15,000

dr. Marisa Anggraini