JENIS FORMULIR

NO TGK MASUK TGL KELUAR NO.RM NAMA PASIEN DPJP

A. AWAL MEDIS IGD A. KEP. IGD TRIAGE A. RANAP (Dokter) REKOMENDASI CPPT MR.6 A. KEP. RANAP MR.8 MR.9
MR.9AMR.9B
D. P. OBAT
REKONSILIASI
MR.10 MR.11 RESUME
PRE& PASCA OPDISCHARGE
MR.14 PLANNING
PENILAIAN KEB. EDUKASI DAFTAR TILIK GC IC INFO ASUHAN GIZI Lap.op A. PRA ANASTESI CKLIS DI R. OP IC ANASTESI
NO TGK MASUK TGL KELUAR NO.RM NAMA PASIEN

1 4/7/2017 4/10/2017 044000 NURDIANA

2 4/5/2017 4/6/2017 045258 RAKEEN ALZIDAN
3 4/5/2017 4/6/2017 045295 LATONG
4 4/6/2017 4/7/2017 045317 SLAMET ANDRIYANTO
5 4/9/2017 4/11/2017 045388 HAPSAH
6 4/3/2017 4/10/2017 027174 ANTONIUS SUKUN
7 4/9/2017 4/11/2017 044243 MARKUS OLA PATI
8 4/9/2017 4/12/2017 029943 ANDI FILIA CLARINTA
9 4/3/2017 4/11/2017 027895 SUMARNO
10 4/11/2017 4/12/2017 045435 WULAN A
11 4/10/2017 4/16/2017 045419 SUKARNI
12 4/12/2017 4/16/2017 045450 ISDAYANI
13 4/8/2017 4/12/2017 042586 AMIRUDDIN
14 4/10/2017 4/12/2017 045242 MAHRITA
15 4/10/2017 4/16/2017 045418 NANANG ISHAK
16 4/16/2017 4/15/2017 045527 TIMIN
17 4/11/2017 4/14/2017 016354 TONI SAPUTRA
18 4/10/2017 4/13/2017 045402 SAKUB
19 4/12/2017 4/13/2017 045437 SAUT D SAGALA
20 4/20/2017 045593 TIRZA ,AN
21 4/18/2017 4/25/2017 045600 RINI WATI
22 4/20/2017 4/23/2017 045613 YATNO
23 4/23/2017 4/24/2017 045691 ASIKIN MUSHODIK
24 4/22/2017 4/26/2017 045712 M.PARHAN
25 4/21/2017 4/24/2017 028669 NING IDA KURNIAWATI
26 4/23/2017 4/25/2017 045718 AKHMAD IRZAN
27 4/11/2017 4/25/2017 045417 YUDI M JILAN
28 4/21/2017 4/24/2017 027044 ABDILLAH ADLI RAFIF
29 4/21/2017 4/24/2017 025953 M FAHRIZAL AKBAR
30 4/19/2017 4/22/2017 045634 HAQQI NAZALI
31 4/17/2017 4/22/2017 016898 ARYA
32 4/20/2017 4/22/2017 022920 IRVAN CAHYA M
33 4/24/2017 4/27/2017 044518 LUKMAN
34 4/18/2017 4/28/2017 045614 MARSUM
36 4/24/2017 4/25/2017 033444 AGUSTINA SALIMAH
37 4/25/2017 4/27/2017 045725 ALDFI TRIESKA
38 4/19/2017 4/20/2017 045577 MUHAMMAD HAEKAL,BY
39 4/25/2017 4/28/2017 014825 ATAYA PUTRI QOLIDA
40 4/27/2017 4/28/2017 022006 FIRMANDI
41 4/28/2017 4/30/2017 045763 INARA KAISA IRAWAN
42 4/26/2017 4/28/2017 029240 SUKANAH
43 4/24/2017 4/28/2017 042203 SUSIAMI TAMPUBOLON
44 4/27/2017 4/29/2017 025074 ANDRI WAHYONO
45 4/23/2017 4/29/2017 045713 ASMAH
 DPJP A. AWAL A. KEP. IGD TRIAGE REKOMENDASI A. RANAP (Dokter) CPPT
MEDIS IGD

MARIANA, SP. S V V X V V V
SLAMET, SP. BA V V V V V V
ISHAQ, SP. U V V V V V V
MORIKO, SP. THT V V V V TDK ADA LEMBAR INI V
WAWAN, SP. B V V X V V V
MARIANA, SP. S V X V V V V
RUDY, SP. B. ONK V V X V V V
HERWINA, SP. A V V X V V V
MARIANA, SP. S V X V V V V
HERWINA, SP. A X V V V V V
WAWAN, SP. B V V X V V V
RUDY, SP. B. ONK V V V V V V
YULIANA, SP. PD V V V V V V
ISHAQ, SP. U V V V O V V
ISHAQ, SP. U X V V O X V
YULIANA, SP. PD V V V V TDK ADA LEMBAR INI V
YULIANA, SP. PD V V V V TDK ADA LEMBAR INI V
ISHAQ, SP. U V VTDK ADA LEMBAR INI V X V
NADYA, SP. BM V V V V V V
SLAMET, SP. BA V V V V V V
IRFAN,SP.OG V V V V X V
ISHAQ, SP. U V V V V V V
HENDRI PUR.SP.OT V V V V V V
SLAMET, SP. BA V V V V V V
YULIANA, SP. PD V V V V V V
YULIANA, SP. PD V V X V V V
ISHAQ, SP. U V V V V V V
HERWINA, SP. A V V X V V V
HENDRI PUR.SP.OT V V X V V V
SHERLY.SP,A V V X V V V
BASWARA.SP,M V VTDK ADA LEMBAR INI V V V
HERWINA, SP. A V V V V V V
RUDY, SP. B. ONK V V X V V V
YULIANA, SP. PD V V V V V V
YULIANA, SP. PD V V X V V V
NADYA, SP. BM V V X V V V
HERWINA, SP. A V V X O V V
SHERLY.SP,A X V X V V V
SHERLY.SP,A V V X V V V
YUDHY,SP.BP-RE V V V V X V
RUDY, SP. B. ONK V V X V V V
RUDY, SP. B. ONK V V X V V V
MARIANA, SP. S V V X V V V
YULIANA, SP. PD V X V V X V
 JENIS FORMULIR

MR.9A D. P. MR.9B
KONSULTASI MR.6 A. KEP. RANAP MR.8 MR.9 MR.10 MR.11
OBAT REKONSILIASI

O V V V V V X V V
V V V V V X X V V
O V V V V tdk dpt obat X V V
O V V V V X X V V
X V V V V X X V V
O V V V V X V V V
O V V V V X X V V
O V V V V X X V V
O V V V V X X V V
O V X V V X X V V
O V V V V X X V V
O V V V V X V V V
V V V V V X V V V
O V V V V X X V V
O V V V V X X V V
O V V V V X X V V
O V V V V X X V V
O V V V V X V V V
O V V V V X X V V
O V V V V X X V V
O V V V V V X V V
O V V V V V X V V
O V V V V V X V V
O V X V V V V V V
O V V V V V X V V
O V V V V V X V V
O V V V V V X V V
O V V V V V X V V
O V V V V V X V V
O V V V V X X V V
O V V V V V X X X
O V V V V V X V X
O V V V V X X V V
V V V V V V X V V
O V V V V V X V V
O V X V V V V V V
O V V V V V X V V
O V V V V V X V X
O V V V V V X V X
O V V V V X X V X
O V V V V X X V V
O V V V V V V V V
O V V V V V X V V
O V V V V V X V V
NIS FORMULIR

RESUME PRE&OP
PASCA MR.14 DISCHARGE A. PRA
Lap.op CKLIS DI R. OP IC
PLANNING ANASTESI ANASTESI

V O V O O O O O
V X X O V V TDK ADA LEMBAR INI V
V O V O O O O O
V X V O V V TDK ADA LEMBAR INI V
X V V X O O O O
V O V O O O O O
V O V X O O O O
V O V O O O O O
V O V X O O O O
V O V O O O O O
V V V X V V X v
V V V X V V X V
X O X O O O O O
V X V O V X TDK ADA LEMBAR INI X
V X V X VTDK ADA LEMBAR
TDKINIADA LEMBAR INI X
V O V O O O O O
V O V O O O O O
V O V O O O O O
V X V O V V X V
V X X X V V X X
V V V O V V X V
V V V O VTDK ADA LEMBAR INI X X
V V V VTDK ADA LEMBAR INI X V
V X V X V V X V
V O V O O O O O
V O V O O O O O
V X V O V V V V
V O V O O O O O
V X V O V V X O
V O V O O O O O
V O V O O O O O
V O V O O O O O
V O V O O O O O
V O V O O O O O
V O V O O O O O
V V V O V V V V
V O V O O O O O
V O V O O O O O
V O V O O O O O
V V V O V X X X
V O V O O O O O
V O X O O O O O
V O V O O O O O
V O V O O O O O
PENILAIAN KEB. DAFTAR TRANSFER ASUHAN
GC IC INFO
EDUKASI TILIK INTRA RS GIZI

V V V X X V V
X V V V V V V
X X V V V V V
X V V X V X V
X V V V V V V
X V X V V V V
X V V X V X V
V X V X V O V
X V V V V V V
V X V V V V X
X X V V X V V
X V V X V V V
X X V V V V V
X V V V V X V
X V V V X X V
X V V X X V V
X V V X V V V
X V V V X V V
V V V V V V X
X V V X V V V
V V V V V V V
V X V V V V V
V V V V V V X
V X V X V V V
V V V V V V V
X X V V V X X
V X V V V V V
V V V V V V V
V V V X V X V
V X V V V V V
V V V V X V V
V O V V V V V
V V V V V X V
V X V V V V V
V V V V V V V
V V V V V V V
V V V V V V X
V X V V V V X
V X X X V V V
V V V V V V X
V V V V V V V
V V V V V V V
V X V V V V V
V X V V V V V
NO TGK MASUK TGL KELUAR NO.RM NAMA PASIEN

1 5/2/2017 5/4/2017 045894 SUKRISTYONO

2 5/1/2017 5/17/2017 045889 SYAIFFUDIN
3 5/13/2017 5/20/2017 044226 ADRIAN PRADIPTO
4 5/20/2017 5/21/2017 046318 DEWI ARUM SARI
5 5/18/2017 5/20/2017 046189 SUMARMI
6 5/15/2017 5/18/2017 043972 ALIFATUR,AN
7 17/0/2017 5/21/2017 046259 MUSANTO
8 5/17/2017 5/22/2017 046042 M KHATIM
9 5/17/2017 5/20/2017 046257 HETI PRIATINA
10 5/28/2017 5/24/2017 046284 KARNO ASRORI
11 5/22/2017 5/25/2017 046336 BELLA DESVIRANI
12 5/8/2017 5/21/2017 045948 H LAINDING
13 5/23/2017 5/25/2017 046343 SURTIANA TAMBUNAN
14 5/22/2017 5/24/2017 046296 RAMADANI
15 5/19/2017 5/23/2017 046309 RENI ANGGRAINI
16 5/15/2017 5/16/2017 046178 TOPAN DARSONO PUTRA
17 5/18/2017 5/26/2017 015420 BARIAH
18 5/23/2017 5/27/2017 046382 ANDRIYANTO
19 5/24/2017 5/25/2017 046386 ARBINAWATI
20 5/2/2017 5/6/2017 045915 HERU NUGROHO
21 5/23/2017 5/25/2017 046345 HENDRIKUS HANTUT
22 5/22/2017 5/23/2017 046334 M.AKHTAR
23 5/22/2017 5/25/2017 019160 AMALIA PUTRI
24 5/24/2017 5/28/2017 046402 IGNASIUS KAYOLA
25 5/24/2017 5/27/2017 012812 SITTI ROHANI
26 5/25/2017 5/27/2017 046421 PONISRI
27 5/25/2017 5/27/2017 011806 RAHMANIA
28 5/26/2017 5/27/2017 046442 MARLINA
29 5/27/2017 5/28/2017 046467 AFIFAH LAILATUL FITRIAH
30 5/27/2017 5/29/2017 046466 MARLIANA
31 5/27/2017 5/29/2017 046452 NG SEK FANG
32 5/30/2017 5/31/2017 046593 BAYU P
33 5/24/2017 5/30/2017 046416 SARFINA
34 5/24/2017 5/25/2017 046072 KARINA NOVITASARI
35 5/28/2017 5/31/2017 046473 DION LAWING
36
37
38
39
40
41
 DPJP A. AWAL A. KEP. TRIAGE REKOME A. RANAP KONSULT
MEDIS CPPT MR.6
IGD NDASI (Dokter) ASI
IGD

YULIANA, SP. PD V V V V V V O V
Arif , SP. BTKV V V V V X V O V
HERWINA, SP. A V V V V X V V V
MARIANA, SP. S V V V V V O O V
ISHAQ, SP. U V V X V V V O V
HERWINA, SP. A V V V X V V O V
YULIANA, SP. PD V V V V V V O V
GRACE, SP . BS V V V V X V V V
HENDRI PUR.SP.OT V V X V V V O V
ISHAQ, SP. U V X X V V V O V
Andi Aliyah, Sp. B V V V V V V O V
ISHAQ, SP. U V V X V V V O V
ISHAQ, SP. U V V V V X V O V
MORIKO, SP. THT V V V V O V O V
YULIANA, SP. PD V V X V V V V V
MORIKO, SP. THT V V V V V V O V
YULIANA, SP. PD V V V V V V O V
ISHAQ, SP. U V V X V O V O V
RUDY, SP. B. ONK V V V V O V O X
HENDRI PUR.SP.OT V V V O V V O V
HENDRI PUR.SP.OT V V V V V V O V
SHERLY.SP,A V V V V O V O V
SHERLY.SP,A V V X V V V O V
HENDRI PUR.SP.OT V V V V O V O V
YULIANA, SP. PD V V X V O V O V
Andi Aliyah, Sp. B V V V V V V O V
IRFAN,SP.OG V V V O O X V V
IRFAN,SP.OG V X X V O V O V
HERWINA, SP. A V V X V O V O V
YULIANA, SP. PD V V V V X V O V
HENDRI PUR.SP.OT V V X V V V O V
YHOHAN Z T.Sp BA V V V V V V V V
SLAMET, SP. BA V V X V V V O V
IRFAN,SP.OG V V X V X V O V
ISHAQ, SP. U V X V V X V O V
 JENIS FORMULIR
MR.9B PRE&
A. KEP. MR.9A D. REKONSIL
MR.8 MR.9 MR.10 MR.11 RESUME PASCA MR.14
RANAP P. OBAT IASI OP

V V V V V V V V O V
V V V V X V V V V V
V V V V V V V X O V
V V V V X V V V O V
V V V V X V V V V V
V V V V V V V V O V
V V V V V V V V O V
V V V V X V V V V V
V V V V X V V V V V
X V V V X V V V V V
V V V V V V X V V V
V V V V X V V V V V
V V V V X V V V V V
V V V X O V V V V X
V V V V V V V V O V
V V V V V V V V V X
V V V V X V V V O V
V V V V V V V V V V
V V V V V V V V V X
V V V V V V V V V V
V V V V V V V V V X
V V V V X V V V O V
V V V V X V V V O X
X V V V V V V V V V
V V V V X V V V O X
V V V V V V V V V V
V V V V X V V V V X
V V V TDK DAPAT OBAT V V V V O V
V V V V X V V V O V
V V V V X V V V O V
V V V V X V V V V X
V V V V X V V V V V
V V V V X V V V V X
V V V V X V V V V V
V V V V X V V V V X
DISCHAR PENILAIA DAFTAR
GE A. PRA CKLIS DI IC
Lap.op N KEB. GC IC INFO
PLANNIN ANASTESI R. OP ANASTESI EDUKASI TILIK
G
O O O O O V V V V V
O V O V O V V V V V
O O O O O V X V V V
O O O O O O O V V V
O V V X V V V V V V
O O O O O V V V V V
O O O O O V V V V V
X V V X V X X V V V
O V V X V V X V V V
O V V X V V X V V V
O V O V V V X V V V
O V V X V V V V V V
O V V X V V V V V V
O V V O V V X V V V
O O O O O V V V V V
X V V X V X X V V V
O O O O O V X V V V
O V V X V V V V V V
O V V X V X X V V V
O V V X V V V V V V
O V V X V V X V V V
O O O O O V X V V V
O O O O O V X V V V
O V V X V X X V V V
O O O O O V X V V V
O V X X V V X V V V
O V V X V V X V V V
O O V O V V V V V V
O O O O O V X V V V
O O O O O V X V V V
O V V O V V X V V V
O V V X V V V V V V
O V O X O V X V V V
O V V X X V V V V V
O V O O V V X V V V
TRANSFE ASUHAN
R INTRA GIZI
RS

V V
V V
V V
V O
V O
V V
V V
V X
V X
X V
O V
O V
V X
V V
V X
V X
V V
V X
V X
V V
V X
V V
V V
V V
X V
V V
V V
V X
V X
V V
V V
V X
V V
V X
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NO TGK MASUK TGL KELUAR NO.RM NAMA PASIEN

1 5/28/2017 6/1/2017 046471 WIYONO

2 18-May 6/1/2017 040931 SELVI
3 5/31/2017 6/1/2017 046496 ARGIANTO
4 6/1/2017 6/5/2017 046528 NELI TRIANA
5 6/2/2017 6/4/2017 046259 MUSANTO
6 6/2/2017 6/4/2017 046579 HELMI HAIDIR
7 5/31/2017 6/3/2017 046521 TAZKIYAH R AQILLAH
8 6/3/2017 6/4/2017 046581 TRISTAN MAHARDIKA
9 6/3/2017 6/5/2017 046569 JAMSIAH
10 6/3/2017 6/5/2017 045993 CICI REZKI AMBO
11 6/1/2017 6/5/2017 028725 YOSEP M MELLOLO
12 5/31/2017 6/3/2017 037505 ADELIA PRITA S
13 6/6/2017 6/7/2017 019065 NANSEN LUKAS
14 6/4/2017 6/7/2017 046589 KAMILUDDIN
15 6/6/2017 6/8/2017 039689 AZZAHARA MAULIDYA
16 6/5/2017 6/7/2017 044243 MARKUS OLA PATI
17 6/7/2017 6/8/2017 046639 SUTIKAH
18 6/4/2017 6/8/2017 028976 ALBERTIN ANI
19 6/8/2017 6/10/2017 029240 SUKANAH
20 6/8/2017 6/11/2017 046663 MUHAMMAD FATURAHMAN
21 6/8/2017 6/11/2017 046659 ALYA SYIFA HUMAIRA
22 6/8/2017 6/9/2017 046668 ARBIATUN
23 6/11/2017 6/13/2017 013450 DWI NURLAILI FANTI
24 6/10/2017 6/12/2017 028305 ZEIN ELMER
25 6/1/2017 6/16/2017 040037 ISMI FAUZIA RAMADHANI
26 6/10/2017 6/14/2017 046705 DIONO
27 6/10/2017 6/16/2017 046466 MARLIANA
28 6/13/2017 6/16/2017 046748 M. YAZID ZIDAN
29 6/12/2017 6/15/2017 046723 LINDA MEITA
30 6/10/2017 6/12/2017 046694 NUR WIJAYANTI
31 6/12/2017 6/14/2017 044243 MARKUS OLA PATI
32 5/25/2017 6/15/2017 046428 JAYAN
33 6/11/2017 6/15/2017 046707 SARMI
34 6/15/2017 6/19/2017 046765 SAPRAH
35 6/18/2017 6/19/2017 033724 NOR ELLI
36 6/18/2017 6/19/2017 046815 DAVANDA TEGUH
37 6/16/2017 6/18/2017 046788 ANASTASIA MANGALLO
38 6/14/2017 6/16/2017 046755 AKBAR RAMLI
39 6/16/2017 6/18/2017 031764 NOOR ASMIDAH
40 6/16/2017 6/18/2017 046625 ESMAWATI
41 6/24/2017 6/26/2017 046905 ZAIN ABDULLAH UWAIS
42 6/16/2017 6/24/2017 017249 SUYITNO
43 6/17/2017 6/23/2017 046812 ALVIANUS YOHANES
44 6/20/2017 6/23/2017 046844 YULIANSYAH
45 6/22/2017 6/27/2017 024976 ASNI
46 6/24/2017 6/26/2017 011706 ROPIATULIYAH
47 6/21/2017 6/29/2017 046860 ASHENG
48 6/28/2017 6/30/2017 044115 SRI ANDAYANI
49 6/28/2017 6/30/2017 046939 NUR ISNANIAH
50 6/25/2017 6/28/2017 020424 JASMINE KHOIRUNNISA
 DPJP A. AWAL A. KEP. TRIAGE REKOME A. RANAP KONSULT
MEDIS CPPT
IGD NDASI (Dokter) ASI
IGD

ISHAQ, SP. U V O V V V V O
ISHAQ, SP. U V V X O X V O
ISHAQ, SP. U V V V V O V O
MARIANA, SP. S V V V V V V O
YULIANA, SP. PD V V V V V V O
IRFAN,SP.OG V V V V X V O
SLAMET, SP. BA V V X V V V V
SLAMET, SP. BA V X X V V V O
IRFAN,SP.OG V V V V X V O
IRFAN,SP.OG V V X X X V O
YULIANA, SP. PD V V V V V V O
HENDRI PUR.SP.OT V V V V V V O
HENDRI PUR.SP.OT V V X V O V O
GRACE,SP.BS V V X V O V O
HENDRI PUR.SP.OT V V V V V V O
RUDY, SP. B. ONK V V V V V V O
ISHAQ, SP. U V V X V V V O
YULIANA, SP. PD V V X V V V O
RUDY, SP. B. ONK V V V V V V O
HERWINA, SP. A V V V V V V O
HERWINA, SP. A V V V V V V O
ASHAN AZIS,SP.OG V V V V O X O
GRACE,SP.BS V V V V X V O
HERWINA, SP. A V V V V V V O
YULIANA, SP. PD V V V V V V V
YULIANA, SP. PD V V V V V V O
YULIANA, SP. PD V V V V V V O
HERWINA, SP. A V V V V V V O
NADYA,SP.BM V V X V V V O
Andi Aliyah, Sp. B V V V V V V O
RUDY, SP. B. ONK V V X V O V O
YULIANA, SP. PD V V V V X V V
Andi Aliyah, Sp. B V V V V V V V
YULIANA, SP. PD V V V V O V O
HERWINA, SP. A V V X V V V O
SHERLY.SP.A V V X V V V O
Cristiani Nadya pramasari,Sp.BM V V X V V V O
DEWI ,SP.M V V X V V V O
IRFAN,SP.OG V V V V O X O
IRFAN,SP.OG V V X V O X O
SHERLY.SP.A V V V V V V O
YULIANA, SP. PD V V X V O V V
ALIYAH,SP.B V V X V V V V
YULIANA, SP. PD V V V V O V V
FRITZ.N.SP,B V V X V X V O
YULIANA, SP. PD V V V V X V O
YULIANA, SP. PD V V X V V V O
IRFAN,SP.OG V V V V X V O
ASTRID,SP.PD V X X V V V V
FRITZ.N.SP,B V V V V V V O
 JENIS FORMULIR

MR.9B PRE&
A. KEP. MR.9A D. REKONSIL
MR.6 MR.8 MR.9 MR.10 MR.11 RESUME PASCA
RANAP P. OBAT IASI OP

V V V V V X V V V V
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 DISCHARG PENILAIA DAFTAR
A. PRA CKLIS DI IC
MR.14 E Lap.op ANASTESI N KEB. GC IC
R. OP ANASTESI EDUKASI TILIK
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 TRANSFE ASUHAN
INFO R INTRA GIZI
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