FORM SELF ASSESSMENT

REVIEW DIAGNOSA NON SPESIALISTIK LAYANAN PRIMER

Nama FKTP Klinik Umum dan Bersalin Ramlah Parjib 2

Waktu Assessment 11 Maret 2019 tanggal/bulan/tahun 11 Maret 2019

Kode Keterangan Kendala

Diagnosa (Kompetensi) Berdasar 1. Tidak ada 2. Tidak ada 3. Tidak ada 4. Tidak ada 5. Kompetensi
obat alkes Lab/RO Nakes
No Non Nama Diagnosa Non Spesialistik (ICD 10) Permenkes Dapat Tuntas Ditangani (sebutkan (sebutkan (sebutkan sarana lain (Mampu/Tida
Mampu
Spesialistik 5/2014 dan di Faskes Saudara jenisnya) jenisnya) detail) (sebutkan) sebutkan)
(ICD 10) Kepmenkes 514/2015
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 4A

infectious origin √

4 A15.0 Respiratory tuberculosis, bacteriologically and 4A

histologically confirmed √ √ √

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 √ √

10 A91 Dengue haemorrhagic fever 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 A 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
(chronic)
√
46 D50.9 Iron deficiency anaemia, unspecified 4A √ √
47 E11.9 Non-insulin-dependent diabetes mellitus without 4A
complications
√
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 4A
arthritis+tophaceous dis
√ √
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 4A
inflamm
√ √
79 I84.0 Internal thrombosed haemorrhoids 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 4A √
oesophagitis √
99 K29.7 Gastritis, unspecified 4A √
100 K90.4 Malabsorption due to intolerance, not elsewhere 4A
classified
√
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 other 4A
sites
√
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 4A
medicaments
√ √
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 Gout 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, 4A
unspecified
√ √
129 O03.9 Spontaneous abortion, Complete or unspecified, 4A
without complication
√
130 O70.0 First degree perineal laceration during delivery 4A
√
131 O80.9 Single spontaneous delivery, unspecified 4A
√
132 O92.0 Retracted nipple associated with childbirth 4A
√
133 P38 Omphalitis of newborn with or without mild 4A
haemorrhage
√
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 [HIV] 4A
infection status
√

Kesimpulan:
1 Jumlah Diagnosa yang mampu ditangani 91
2 Jumlah Diagnosa yang tidak mampu ditangani 54
3 Jumlah Alasan dengan: 33
1. Tidak ada obat 7
2. Tidak ada alkes 13
3. Tidak ada Lab/RO 7
4. Tidak ada sarana lain 13
5. Kompetensi Nakes 3
6. Lainnya 0