Anda di halaman 1dari 11

PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA

DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

SURAT KETERANGAN DAFTAR PASIEN

Yang bertanda tangan di bawah ini, Kepala Puskesmas Kelurahan Srengseng Sawah
menugaskan kepada:

Petugas : dr. Hernita Perliyani


Poli : Poli Umum Puskesmas Kelurahan Srengseng Sawah
Tanggal : Senin, 14 Mei 2018

Telah melaksanakan tugas melakukan pemeriksaan pasien rawat jalan dengan daftar sebagai
berikut:

No Nama Usia Kelamin Penyakit

1 42Th 9
ASNI ARIDA P Essential (primary) hypertension
Bln

2 42Th 9
ASNI ARIDA P Other peripheral vertigo
Bln

3 42Th 9
ASNI ARIDA P Neuralgia and neuritis, unspecified
Bln

4 74Th 4
BAMBANG SUPARDI# L Cough
Bln

5 74Th 4
BAMBANG SUPARDI# L Essential (primary) hypertension
Bln

6 42Th 4
PURWIDIANINGSIH # P Thyrotoxicosis, unspecified
Bln

7 60Th 2
PARTINI # P Tinea corporis
Bln

8 60Th 2
PARTINI # P Essential (primary) hypertension
Bln
PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA
DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

9 14Th 10 Acute upper respiratory infection,


ADHELIA MEISY P
Bln unspecified

10 60Th 4
RANTINEM L Essential (primary) hypertension
Bln

11 58Th 1
HOLID L Cataract, unspecified
Bln

12 56Th 11
AZIZAH P Status asthmaticus
Bln

13 52Th 9
DARWIASIH P Primary gonarthrosis, bilateral
Bln

14 59Th 1
TATIK MAHYUNINGSIH # L Essential (primary) hypertension
Bln

15 59Th 1
TATIK MAHYUNINGSIH # L Acute pharyngitis, unspecified
Bln

16 61Th 10
Ny Mulyihatun # P Cardiomegaly
Bln

17 58Th 7
RIDWAN L Cough
Bln

18 61Th 11
SAKIYEM # P Other peripheral vertigo
Bln

19 56Th 4 Sequelae of stroke, not specified as


Warsidi # L
Bln haemorrhage or infarction

20 73Th 2
NAPSIAH# P Essential (primary) hypertension
Bln

21 69Th 10 Hypertensive heart disease with


N.A.KOMALANINGSIH P
Bln (congestive) heart failure

22 64Th 3
TRI PERWANGSIH # P Tension-type headache
Bln

23 SUKAESIH 44Th 6 P Tinea corporis


PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA
DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

Bln

24 3Th 3
JILSA QIFAYA P Atopic dermatitis, unspecified
Bln

25 66Th 8 Hypertensive heart disease with


YULIANA P
Bln (congestive) heart failure

26 46Th 4
NUNUNG# P Polyarthritis, unspecified
Bln

27 35Th 8 Follow-up examination after surgery


KABUL SUBIYANTORO L
Bln for other conditions

28 22Th 11 Follow-up examination after other


Ilham Maulana L
Bln treatment for other conditions

29 58Th 7 Hypertensive heart disease with


SRIYANTO L
Bln (congestive) heart failure

30 38Th 5 Acute upper respiratory infection,


SUPRIATI # P
Bln unspecified

31 1Th 6 Acute nasopharyngitis [common


ARKAN KRISMAYANTO L
Bln cold]

32 9Th 6 Person injured in unspecified vehicle


IMAM JAFAR SODIK L
Bln accident

33 64Th 2
TONIH P Myalgia
Bln

34 50Th 1 Urinary tract infection, site not


Bachtiar Affandi # L
Bln specified

35 50Th 1
Bachtiar Affandi # L Essential (primary) hypertension
Bln

36 38Th 5 Acute upper respiratory infection,


RENITA P
Bln unspecified

37 68Th 2
SAIYAH P Other specified postsurgical states
Bln
PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA
DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

38 47Th 8
TUTI HERAWATI # P Essential (primary) hypertension
Bln

39 32Th 2
RATIH PURWANINGSIH P Acute pharyngitis, unspecified
Bln

40 35Th 8
YULI ANGGRAINI # P Essential (primary) hypertension
Bln

41 5Th 11
MUHAMMAD FAHMI L Impetigo [any organism] [any site]
Bln

42 MIFTHA KHAIRANI 24Th 10


P Fibroadenosis of breast
TANJUNG Bln

43 Non-insulin-dependent diabetes
60Th 10
FRANSISCUS IRIANTO L mellitus with unspecified
Bln
complications

44 24Th 10 Diarrhoea and gastroenteritis of


NADIA ALFITASARI P
Bln presumed infectious origin

45 18Th 11
nilam cahya L General medical examination
Bln

46 74Th 7
ASMAN, H. # L Congestive heart failure
Bln

47 45Th 6
NURHAYATI. P Headache
Bln

48 Person injured in collision between


17Th 2
ILHAM SAPUTRA L car and two- or three-wheeled
Bln
motor vehicle (traffic)

49 42Th 11
WISNU MURTI ANGGORO L Acute pharyngitis, unspecified
Bln

50 42Th 11
WISNU MURTI ANGGORO L Essential (primary) hypertension
Bln

51 66Th 2
ariyanthi miranda P Congestive heart failure
Bln
PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA
DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

52 57Th 2
DJIAH # P Essential (primary) hypertension
Bln

53 71Th 3
DJUMSIAH # P Primary gonarthrosis, bilateral
Bln

54 71Th 3
DJUMSIAH # P Essential (primary) hypertension
Bln

55 SHAKILA RIZKIA 1Th 9


P Atopic dermatitis, unspecified
RAMADHANI Bln

56 Chronic obstructive pulmonary


63Th 10
NANANG RUSMANA L disease with acute lower respiratory
Bln
infection

57 CUT ASYA 16Th 1


P General medical examination
PRAMANDASARI Bln

58 33Th 0
KHALISAH P Viral conjunctivitis, unspecified
Bln

59 19Th 11
RIZKY ADE DHARMAWAN L General medical examination
Bln

60 9Th 0
PUTRI RAHMAWATI P Acute tonsillitis, unspecified
Bln

61 16Th 8
ASHIKLLA ANGGRAINI P General medical examination
Bln

62 16Th 6
EMELIA SARI P General medical examination
Bln

63 56Th 2
SOPIYAH P Essential (primary) hypertension
Bln

64 MUHAMMAD IQBAL 11Th 7


L Atopic dermatitis, unspecified
JAILANI Bln

65 84Th 5
NG HO KIAT # L Congestive heart failure
Bln
PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA
DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

66 15Th 5
Sebastian Wijaya L Acute pharyngitis, unspecified
Bln

67 52Th 9
IRA AGUSTINA P Essential (primary) hypertension
Bln

68 AULIA VERONANDA 20Th 10


P Enlarged lymph nodes, unspecified
WIDYASTUTI Bln

69 36Th 4
AMALDO L Tension-type headache
Bln

70 YULITA MAHARDINI 22Th 8


P Other atopic dermatitis
POYSANCIN Bln

71 53Th 4
SUSANTI P Atopic dermatitis, unspecified
Bln

72 22Th 6
MEGA PUJI ASTUTI# P Primary dysmenorrhoea
Bln

73 46Th 10
ABDUL MUFTI L Atopic dermatitis, unspecified
Bln

74 56Th 4
HASMUNI L Essential (primary) hypertension
Bln

75 56Th 4 Neuralgia and neuritis, unspecified,


HASMUNI L
Bln forearm

76 24Th 6
TRI HARDIANTI P General medical examination
Bln

77 38Th 1
IDA ROSDIANA P Cough
Bln

78 46Th 5
USLAN HARYANTO L Impetigo [any organism] [any site]
Bln

79 36Th 1 Acute upper respiratory infection,


PRIHANDONO L
Bln unspecified

80 AMI ZAMZAMI 20Th 4 L Follow-up examination after surgery


PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA
DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

Bln for other conditions

81 1Th 8
bayi panji newton L Epilepsy, unspecified
Bln

82 1Th 8 Acute upper respiratory infection,


bayi panji newton L
Bln unspecified

83 11Th 7
Mochamad faqih prayoga L Other gastritis
Bln

84 48Th 9 Excessive and frequent menstruation


indiah purnamasari P
Bln with regular cycle

85 SLAMET 73Th 0 Hypertensive heart disease with


L
JUDOPRAYITNO,BE# Bln (congestive) heart failure

86 26Th 11 Diarrhoea and gastroenteritis of


RIO ELBANOSA PURBA L
Bln presumed infectious origin

87 Non-insulin-dependent diabetes
59Th 0
THOHA# L mellitus with unspecified
Bln
complications

88 MUHAMMAD ALFI 25Th 6


L General medical examination
FADHOLLI Bln

89 22Th 9
IREN AYU SAPUTRA P General medical examination
Bln

90 55Th 5
NIMIH DAMAYANTI # P Myasthenia gravis
Bln

91 1Th 0 Acute nasopharyngitis [common


TANTRI P
Bln cold]

92 44Th 7
AGUS. L Cough
Bln

93 32Th 2
Desata eka rikanty P Mumps without complication
Bln

94 CUCU SUDARYAH 75Th 0 P Follow-up examination after other


PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA
DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

Bln treatment for other conditions

95 13Th 8
NABILA HAURA KHANZA P General medical examination
Bln

96 18Th 7
ALDI FARHANDIKA L General medical examination
Bln

97 35Th 5 Non-insulin-dependent diabetes


ARBAIN L
Bln mellitus with renal complications

98 1Th 10
GIBRAN HAIDAR RASYID L Other atopic dermatitis
Bln

99 54Th 1
SUMIYATI P Myalgia
Bln

100 54Th 1 Hypertensive heart disease with


SUMIYATI P
Bln (congestive) heart failure

101 MUHAMMAD JUNDI 9Th 0


L Varicella without complication
ASKARI Bln

102 12Th 6
NAZHIRA ZALFA RADINIA P General medical examination
Bln

103 66Th 5 Hypertensive heart disease with


MUS ANDRY # L
Bln (congestive) heart failure

104 23Th 8
DINY EKA SAPUTRI P Other specified fever
Bln

105 45Th 8
TATI P Fibroadenosis of breast
Bln

106 68Th 11
MEROH # P Essential (primary) hypertension
Bln

107 51Th 7
MOESOFFAH # P Essential (primary) hypertension
Bln

108 9Th 11
UMAIR L General medical examination
Bln
PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA
DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

109 43Th 7
SUDINI** P Myalgia
Bln

110 18Th 8 Acute nasopharyngitis [common


RERE YUNISA P
Bln cold]

111 48Th 7 Cutaneous abscess, furuncle and


YOSEFARUNA DINAR L
Bln carbuncle, unspecified

112 AIRA NAFISAH 2Th 9


P Acute pharyngitis, unspecified
GUNAWAN Bln

113 18Th 9
Rizki Damayanti P General medical examination
Bln

114 18Th 8
YULI YANIH P General medical examination
Bln

115 19Th 2
EKO ERIYANTO L General medical examination
Bln

116 19Th 2
HARIS PRATOMO L General medical examination
Bln

117 46Th 5 Acute upper respiratory infection,


SANAH P
Bln unspecified

118 ANNISA PUTRI 1Th 9 Acute nasopharyngitis [common


P
RAMADHANI Bln cold]

119 39Th 8
ROHMAN L General medical examination
Bln

120 31Th 10
WATI KARTINI P Dyspepsia
Bln

121 36Th 9 Acute nasopharyngitis [common


MOHERIK SANJAYA L
Bln cold]

122 FEBRIYANTO 18Th 1 Cutaneous abscess, furuncle and


L
NURULHUDA W Bln carbuncle, unspecified

123 SAMANI 63Th 2 P Acute pharyngitis, unspecified


PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA
DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

Bln

124 31Th 4
KHUNAENI P Dyspepsia
Bln

125 8Th 0 Cutaneous abscess, furuncle and


JEREMY MARIO WIBOWO L
Bln carbuncle, unspecified

126 66Th 6 Atherosclerotic cardiovascular


IRYANI KAMAL P
Bln disease, so described

127 21Th 1 Other acute upper respiratory


GALANG DIKA M L
Bln infections of multiple sites

128 64Th 11 Insulin-dependent diabetes mellitus


CHANDRA W L
Bln without complications

129 57Th 5
MURDIYATI # P Dyspepsia
Bln

130 57Th 5
MURDIYATI # P Essential (primary) hypertension
Bln

131 7Th 9
ULFAH KHAIRUNNISA P Acute pharyngitis, unspecified
Bln

132 RAFIF MAHAWIRA 13Th 6


L General medical examination
AYDIN Bln

133 62Th 11 Sequelae of stroke, not specified as


MUDJIANTO L
Bln haemorrhage or infarction

134 36Th 3 Acute upper respiratory infection,


EKA YUDASMARA L
Bln unspecified

135 18Th 9
FATIMAH AZZAHRA P General medical examination
Bln

136 12Th 4
AZKIA MAHARYANI P General medical examination
Bln

137 TIVANY KONITA ALYA 7Th 3 Other acute upper respiratory


P
PUTRI Bln infections of multiple sites
PEMERINTAH PROVINSI DAERAH KHUSUS IBU KOTA JAKARTA
DINAS KESEHATAN
SUKU DINAS KESEHATAN KOTA ADMINISTRASI JAKARTA SELATAN
PUSKESMAS KELURAHAN SRENGSENG SAWAH
J Jl. Batu No. 1, RT. 13/RW.09, Kel. Srengseng Sawah, Jagakarsa - Jakarta Selatan
Telp. (021) 7864707, 021-7874051, 021-78891806, Fax. (021) 7864707
Kode Pos 12640

138 13Th 10 Cutaneous abscess, furuncle and


INTAN MAULANI P
Bln carbuncle, unspecified

139 50Th 0
YULIANTI P Angina pectoris, unspecified
Bln

140 42Th 10
IKA LESTARI P Essential (primary) hypertension
Bln

141 NAUFAL SYAM ADITYA 3Th 3 Acute upper respiratory infection,


L
DARMAWAN Bln unspecified

142 31Th 7
AGUS DARMAWAN L Myalgia
Bln

143 29Th 1
FEBRI PURNAMA SARI P Other gastritis
Bln

Mengetahui,
Kepala Puskesmas Kelurahan Srengseng Sawah

drg. Indah Lestari


NIP. 196802121994032006