Surat Rujukan Baru Lagi

RUJUKAN PUSKESMAS / DOKTER KELUARGA
SURAT RUJUKAN PESERTA
No Rujukan :
Puskesmas / Dokter Keluarga : dr. ABIMAYU Kode :

Kabupaten / Kota : Kab Ktw Barat Kode :
Puskesmas / Dokter Keluarga

Kabupaten / Kota
Kepada Yth TS dr .Poli : Anak

Di RS : SULTAN IMANUDDIN PANGKALAN BUN
Mohon pemeriksaan dan penanganan lebih lanjutnpenderita
Nama : AN. REZAL FAHRIAN NOR Umur : 06 Juli 2003

No. Kartu BPJS 0001474856919 Status : T Utama / Tanggungan L
Diagnosa : Epilepsi
Telah diberikn :
Demikian atas bantuannya diucapkan terima kasih
KUMAI 06 JULI 2017
dr. A B I M A Y U
NIP. 19700526 200501 1 010
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Mohon kontrol selanjut :
Nama :
Diagnosa :
Terapi :
Tindak Lanjut yang dianjurkan
Pengobatan dengan obat - obatan Perlu rawat Inap

-......................................................
-......................................................
-...................................................... Konsultasi Selesai
Kontrol kembali ke RS tanggal :
Lain - Lain : Pangkalan Bun . .............,............................2017
Dokter RS
--------------------------------------------------------------------
1
No Rujukan :
Puskesmas / Dokter Keluarga : dr. ABIMAYU Kode :


Kabupaten / Kota
Kepada Yth TS dr .Poli : Dalam

Nama : Ny. MARIAM Umur : '23 Juli 1975

No. Kartu BPJS 00018334630001 Status : T Utama / Tanggungan P
Diagnosa :
Telah diberikn :
KUMAI 23 MEI 2017
dr. A B I M A Y U
NIP. 19700526 200501 1 010
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
1
No Rujukan :
Puskesmas / Dokter Keluarga : KUMAI Kode :


Kabupaten / Kota
Kepada Yth TS dr .Poli : DALAM

Nama : NY. JAUYAH Umur : 09 Oktober 1960

No. Jamkesmas : 0000884939512 Status : T P
Diagnosa : CHF , Dyspepsia
Telah diberikan :
KUMAI , 05 JULI 2017
KETERANGAN ; dokter Pemeriksa
Rujukan :
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
No Rujukan :
Puskesmas / Dokter Keluarga : Kode :


Kabupaten / Kota
Kepada Yth TS dr .Poli :

Nama : TN. ERNAS FARIDAEN Umur : '02 / 02 / 1962

No. Jamkesmas : 0000201107856 : U Utama / Tanggungan ( L )
Diagnosa :
Telah diberikAn :
KUMAI , 19 MEI 2017
KETERANGAN ; dokter Pemeriksa
Rujukan :
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
No Rujukan : 445 / 1587 / KI .A


Kabupaten / Kota
Kepada Yth TS dr .Poli : KULIT

Nama : TN. SUMARNO HADI Umur : 28 Februari 1938

No. Kartu BPJS : 1402040015274 Status : U Utama / Tanggungan ( L )
Diagnosa :
Telah diberikn :
KUMAI , 18 PEBRUARI 2016
dokter Pemeriksa
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
( L )
RUARI 2016
eriksa
.........................2016
RS
------------------------------
No Rujukan : 445 / 140202010414Y000164 / KI .A


Kabupaten / Kota


Diagnosa :
Telah diberikn :
dokter Pemeriksa
H. SYAMSUL ARIFIN .AMK

NIP. 19610103 198703 1 102
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
(L/P)
RUARI 2016
eriksa
IFIN .AMK
8703 1 102
.........................2016
RS
------------------------------
No Rujukan :


Kabupaten / Kota
Kepada Yth TS dr .Poli : ANAK

Nama : Ny. Umur : 31 Maret 2002

No. Kartu BPJS : 0001240789994 Status : T Utama / Tanggungan P
Diagnosa : Lipoma
Telah diberikn :
KUMAI , 30 JANUARI 2017
dokter Pemeriksa
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
UARI 2017
eriksa
.........................2017
RS
------------------------------
No Rujukan : 445 / 172 / KI .A


Kabupaten / Kota


Diagnosa :
Telah diberikn :
dokter Pemeriksa
SUPRIADI .AMK
NIP. 19710404 199011 1 001
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
(L/P)
RUARI 2016
eriksa
.AMK
9011 1 001
.........................2016
RS
------------------------------


Kabupaten / Kota
Kepada Yth TS dr .Poli : PENYAKIT DALAMMATA

Nama : ISNAWATI Umur : 67 Tahun

No. Kartu BPJS : - Status : Utama / Tanggungan P
Diagnosa : Penglihatan kabur
Telah diberikn :
KUMAI , 02 APRIL 2014
Dokter Puskesmas Kumai
MARDANI
NIP. 19721031 199303 1 005
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
(L/P)
RIL 2014
mas Kumai
NI
9303 1 005
.........................2014
RS
------------------------------


Kabupaten / Kota
Kepada Yth TS dr .Poli : BEDAH

Nama : NY. AGUSTINI Umur : 12.08.1991

No. Kartu BPJS : Status : L Utama / Tanggungan
Diagnosa :
Telah diberikn :
Bidan Puskesmas Kumai
Hj.SITI ZAKIAH
NIP. 19741001 200012 2 002
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
(L/P)
UARI 2014
as Kumai
KIAH
0012 2 002
.........................2014
RS
------------------------------
SURAT RUJUKA PESERTA


Kabupaten / Kota

Nama : TOBBY.R.R Umur : 30.12.1998

No. Kartu BPJS : 440/79/KD.B Status : Utama / Tanggungan
Diagnosa : Appendicular Infintrat
Telah diberikn :
USWATUN HASANAH .Amd Kep

NIP. 19811005 201001 2 009
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
(L/P)
UARI 2014
mas Kumai
AH .Amd Kep
1001 2 009
.........................2014
RS
------------------------------
No Rujukan : 445 / 1154 / KI .A


Kabupaten / Kota
Kepada Yth TS dr .Poli : UGD

Nama : NY. FATMAH Umur : 01.07.1962

No. Kartu BPJS : 3000318036546 Status : U Utama / Tanggungan P (L/P)
Diagnosa : Susp Gastritis Akute
Telah diberikn :
KUMAI , 12 MEI 2014
Perawat Puskesmas
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------


Kabupaten / Kota


No. Kartu BPJS : 440/79/KD.B Status : Utama / Tanggungan
Telah diberikn :
SANTRI SUTRISNO .Amd Kep

NIP. 19870610 201001 1 002
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
(L/P)
UARI 2014
mas Kumai
O .Amd Kep
1001 1 002
.........................2014
RS
------------------------------
No Rujukan : 445 / 1015 / KI .A


Kabupaten / Kota

Nama : SABARUDIN Umur : 08 September 1994

No. Kartu Jamkesda : 3000318148798 Status : U Utama / Tanggungan L
Diagnosa : Post LE + Adhesiolisis + Apenidetomi + Drainage
Telah diberikn :
KUMAI , 21 APRIL 2014
Perawat Puskesmas Kumai
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
(L/P)
RIL 2014
mas Kumai
EKA MEY WULANDARI .Amd Kep

NIP. 19880511 201001 2 009
.........................2014
RS
------------------------------
Kep
9


Kabupaten / Kota
Kepada Yth TS dr .Poli : GIGI

Nama : Tn. NEKSAN Umur : 13-Jul-62

No. Kartu BPJS : Status : L Utama / Tanggungan (L/P)
Diagnosa :
Telah diberikn :
KUMAI , 24 Februari 2014
--------------------------------------------------------------------
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Lain - Lain : Pangkalan Bun . .............,.......................................2014
Dokter RS
--------------------------------------------------------------------


Kabupaten / Kota


No. Kartu BPJS : 440/79/KD.B Status : Utama / Tanggungan (L/P)
Telah diberikn :
--------------------------------------------------------------------
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
RI 2014
Kumai
--------------------------
..........................2014
--------------------------


Kabupaten / Kota


Telah diberikn :
--------------------------------------------------------------------
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
RI 2014
Kumai
--------------------------
..........................2014
--------------------------


Kabupaten / Kota


Telah diberikn :
--------------------------------------------------------------------
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
RI 2014
Kumai
--------------------------
..........................2014
--------------------------
No Rujukan : 140202010614y000317


Kabupaten / Kota
Kepada Yth TS dr .Poli : SYARAF

Nama : MULYADI Umur : 28 - 02 1938

No. Kartu BPJS : 1312355013 Status : T Utama / Tanggungan L (L/P)
Diagnosa : HIPERTENSI HEART DISEASE
Telah diberikn :
KUMAI , 25 JUNI 2014
Perawat Puskesmas Kumai
--------------------------------------------------------------------
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
4
umai
---------------------
....................2014
---------------------


Kabupaten / Kota
Kepada Yth TS dr .Poli : DALAM


Telah diberikn :
--------------------------------------------------------------------
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
RI 2014
Kumai
--------------------------
..........................2014
--------------------------


Kabupaten / Kota


Telah diberikn :
--------------------------------------------------------------------
SURAT RUJUKAN BALIK
Teman sejawat Yth :

Nama :
Diagnosa :
Terapi :

-......................................................
-......................................................
Dokter RS
--------------------------------------------------------------------
GA
RI 2014
Kumai
--------------------------
..........................2014
--------------------------
DAFTAR NOMINATIF PEGAWAI
NAMA KANTOR PUSKESMAS KUMAI
ALAMAT KANTOR Jln. Pemuda Kumai Hilir
NOMOR KANTOR ( 0532 ) 61179
NAMA TGL ALAMAT

NO NIK JABATAN
LENGKAP LAHIR DOMINASI
1 dr. ABIMAYU 5/26/1970 Pimpinan
2 H. SYAMSUL ARIFIN,AMK 620 1010301640004 1/3/1964 Pelaksana
3 SURIANSYAH, SH 6201012701690001 1/27/1969 Pelaksana
4 RETNO WIJAYANTI,S.Farm.Apt 4/25/1982 Pelaksana
5 SUPRIADI ,AMK 6201020404710001 4/4/1971 Pelaksana
6 FRANSISCA TITIN K, AMKL 2/8/1973 Pelaksana
7 JUMIRAH 6201014612620002 12/6/1962 Pelaksana
8 SITI TATIDJAH P 6201016001680001 1/20/1968 Pelaksana
9 RAHMADI 6201021204680005 4/12/1968 Pelaksana
10 drg. DENY RAKHMAN 12/10/1985 Pelaksana
11 MARDANI 6201013110720001 10/31/1972 Pelaksana
12 M. JULIANNURAHMAN,Amd.AK 6201020807760001 7/8/1976 Pelaksana
13 MILDA NINGSIH,SKM 5/1/1986 Pelaksana
14 EKO SRI HARTATIK . S.ST 6201026707820006 1/20/1984 Pelaksana
15 H. S U H A I N I 6201011906680001 6/19/1968 Pelaksana
16 Hj. SITI ZAKIAH 6201014110740004 10/1/1974 Pelaksana
17 HESTI APRIANTI WIDYASARI, Amd Kep 6201025304840003 4/13/1984 Pelaksana
18 USWATUN HASANAH . Amd Kep 6201014510810001 10/5/1981 Pelaksana
19 SANTRI SUTRISNO,A.Md.Kep. 6/10/1987 Pelaksana
20 EKA MEY WULANDARI,A.Md.Kep. 6201025105880005 5/11/1988 Pelaksana
21 LILIAN ARDIARTI , A.Md. PK 6201025207890005 7/12/1989 Pelaksana
22 SITI SYAMSIAH 3/22/1977 Pelaksana
23 SUPARTI 6201025506740001 6/15/1974 Pelaksana
24 NORMA YUNITA 6201025108830001 8/11/1983 Pelaksana
25 dr. SRI WAHYUNI Pelaksana
26 Hj. HAMDANAH Pelaksana
27 MASDAN Pelaksana
28 H. ABDUL KAPI Pelaksana
29 RIA KUMALASARI .Amd Kep 6201014912830002 Pelaksana
30 SITI HAFSYAH ,Amd Kep 6201016101830002 Pelaksana
31 KRISMA ANJAR PRATIWI ,Amk Keb Pelaksana
32 ALMU'ALA Pelaksana
33 PUJI PURWANTO ,Amd Kep 6201010610880001 Pelaksana
34 I R LAWATI Pelaksana
35 RIBUT 62010141001720008 Pelaksana
36 WARDAH Pelaksana
37 NORHAYATI Pelaksana
38 PRIHATI BUDI UTAMI. Amd Keb Pelaksana
39 EKA NOVITASARI. Amd Keb 6201025412890002 Pelaksana
TELP
S UPARTI
19740615 200604 2 025
NORMA YUNITA
19830811 200604 2 014
dr. SRI WAHYUNI
NRPTT.15.1.0052751
DAFTAR PASIEN YANG DIRUJUK
BELUM DIBAYAR
No NAMA PASIEN BPJS/ JAMKESDA ALAMAT JLH BIAYA TANGGAL KET
1 TN. JAFAR BPJS K. HILIR RT.16 Rp. 100.000.- 20.01.2015 Blm Byr
2 TN. SAID ALI BPJS K. HULU RT.02 Rp. 50.000.- 21.01.2015 Blm Byr
3 TN. JAIS SEHAT KOBAR SEI. KAP.RT.02 Rp. 50.000.- Blm Byr
DAFTAR PERJALANAN DINAS JAMPERSAL 2016
NO JENIS KEGIATAN TANGGAL KEGIATAN JUMLAH BIAYA BBM
4 Mengantar SPJ Jampersal 20 Oktober 2016 Rp100,000

016
KET
SYARAT-SYARAT UNTUK KENAIKAN PANGKAT
TAHUN 2017
SYARAT YANG
No BANYAKNYA KET
Disiapkan
1 SK CPNS 3 Rangkap
2 SK PN 3 Rangkap
3 SK Terakhir 3 Rangkap
4 Karpeg 3 Rangkap
5 Karpeg elektronik 3 Rangkap
6 Nip Baru 3 Rangkap
7 SKP 2 Tahun 3 Rangkap
8 Map Warna Kuning 3 Rangkap

LAPORAN PASIEN RUJUKAN PUSKESMAS KUMAI
BULAN JULI 2017
Tanggal TANGGAL TEMPAT RUJUKAN PEMBIAYAAN MEDICAL KEADAAN SETELAH DI RUJUK

NO NAMA LAHIR JK NO : KTP KODING Diagnosa ASRNSI KEMBALI KET
Masuk PKM RSSI R.INAP RS,LAIN BPJS UMUM RECORD SEMBUH MENINGGAL
USILA LAIN DI RAWAT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 6/3/2017 Lilis.s 1/12/1969 p E10 DM √ √
Intramural lelomyoma of √ √
2 5/10/2017 Rusita 5/25/1970 p
uterus
3 5/10/2017 Mursiman 1/14/1953 L G20 parkinson disease √ √
4 5/10/2017 Yuraida 4/24/1967 p H52.0 hypermetropia √ √
5 5/10/2017 Sri H+D31artati 3/12/2058 p I10 hypertension √ √
6 5/10/2017 Muryati 4/23/1957 p H25 senile catarac √ √
7 5/10/2017 Samsiar 12/1/2002 p F20 schizophrenia √ √
8 7/11/2017 Armiyati 8/20/1974 p H25 cataract √ √
9 7/11/2017 Lidia Sugiarto 7/6/1957 p H52.1 myopia √ √
10 7/11/2017 Siti Munawaroh 4/1/1963 p J45 Asthma √ √
11 7/11/2017 Usman Sadat 10/1/1932 L I10 hypertension √ √
12 7/11/2017 Asmuni 7/1/2017 L A015.0 Tuberculosis √ √
13 7/11/2017 M.Hatta 3/2/1955 L 150.9 CHF √ √
14 7/11/2017 Sania 5/1/1982 p I10 hypertension √ √
15 7/14/2017 Solikah 4/1/1970 P 150.9 CHF √ √
16 7/14/2017 Mahipal 6/15/1958 L I10 Hypertension √ √
Non-insulin-dependent √ √
17 7/15/2017 Salmiyah 9/2/1957 P E10
DM without co
18 7/15/2017 Usin 4/12/1948 L E10
DM without co
19 7/15/2017 Aminah 6/17/1969 P Chest pain, unspecified √ √
20 7/15/2017 Mudatsiruddin 3/20/1974 L E10,150.9 CHF, DM √ √
21 7/15/2017 Sarinten 7/5/1950 P I10 Hypertension √ √
22 7/15/2017 Rachana 2/1/2000 P I24 Caries of dentine √ √
23 7/17/2017 Tumariah 5/1/1950 P E11.5 DM Tipe II √ √
24 7/17/2017 Nurul Arifin 6/22/1995 L A015.0 Tb Paru √ √
25 7/17/2017 Marzuki 12/20/1976 L B20 HIV Aids √ √
26 7/17/2017 Ramlah 7/1/1961 P H25 Cataract, Unspecified √ √
27 7/17/2017 Tumariah 2/6/1961 P G51.0 Bell's Palsy √ √
28 7/17/2017 Tariman 5/1/1950 L E11.5 DM Tipe 2 √ √
29 7/18/2017 Fatmawati 24/)5/1967 P Benign neoplasm of ovary √ √
30 7/18/2017 Satiyah 7/1/1965 P Neoplasma of uncertain √ √
31 7/18/2017 Tajudin 7/1/1946 L Mixed asthma √ √
32 7/19/2017 Masdidi 1/1/1986 L G20 Parkinson's disease √ √
Malignant neuroleptic √ √
33 7/19/2017 Suasa 5/9/1984 P
syndrome
34 7/19/2017 Hendeny 2/2/1993 p inpartu √ Jampersal
35 7/20/2017 Antung Saadah 8/19/1944 P Cataract, Unspecified √ √
Urinary calculus, √ √
36 7/20/2017 Nordin 11/11/1974 L
Unspecified
37 7/20/2017 Suratman 3/5/1965 L Lipom √ √
Perichondritis of external √ √
38 7/20/2017 Uqaila Fahmuna Nazhi 2/4/2006 P
ear
Schizophrenia, √ √
39 7/20/2017 Himawan Sutanto 10/5/1974 L
unspecified
40 7/20/2017 Sajiman 3/10/1967 L 150.9 CHF √ √
41 7/21/2017 Naysila 1/11/2006 p Obs Febris √ √
42 7/21/2017 Alus 9/9/1966 L Other hyperlipidaemia √ √
43 7/21/2017 Mat Saleh 11/10/1976 L End-stage renal disease √ √
Acute ischaemic heart √ √
44 7/21/2017 Sugino 9/19/1955 L
disease
45 7/21/2017 Susi 10/20/1996 P Post Coital Bleeding √ √
46 7/21/2017 Salasiah 7/1/1968 P 150.9 CHF √ √
47 7/21/2017 Suyadi 8/1/1955 L 150.9 CHF √ √
48 7/21/2017 Ahmad Efendi 10/1/1968 L KOI (Infected teeth) √ √
49 7/23/2017 Wanda 1/12/2005 p Obs Febris √ √
Bronchopneumonia, √ √
50 7/24/2017 Monalisa 9/13/1998 P
unspecified
51 7/24/2017 Masniah 3/1/1977 P E10
DM without unspe
52 7/24/2017 Hj.Maulidah Mahfud 17/07/x P G20 Parkinson disease √ √
Malignant neoplasm of √ √
53 7/24/2017 Mani 7/1/1965 P
cervix uteri, unspecified
54 7/24/2017 Kamaludin 4/10/1965 L Asthma, unspecified √ √
55 7/24/2017 Nurahman 1/1/2017 L Hyperbilirubin √ √
56 7/24/2017 M.Ramadani 7/30/2012 L Obs Febris √ √
57 7/24/2017 Rizky Putra Ananda 4/17/2006 L Cough √ √
58 7/24/2017 Arbainah 3/7/1973 P Low back pain √ √
59 7/24/2017 Agustina Andriyani 8/28/1995 P
Hypertensive heart √ √
60 7/24/2017 Suriansyah 10/9/1961 L
disease
61 7/24/2017 Mei Andayani 5/25/1965 P 150.9 CHF √ √
62 7/24/2017 Endang Susilowati 10/16/1964 P
Chronic obstructive
63 7/24/2017 Supriyadi 6/14/1952 L pulmonary disease with √ √
acute I
64 7/24/2017 Dina Ramadhan 9/8/2008 P Lipoma √ √
65 7/25/2017 Salmiah 7/1/1956 P E11.5 DM Tipe II √ √
66 7/26/2017 Novi 1/26/1991 p Inpartu √ √
Mengetahui Kumai, 3 Agustus 2017
Kepala Puskesmas Kumai Pengelola Rujukan
dr.Abimayu Mardani,Amd.Kep
NIP.19700526 200501 1 011 NIP.10721031 199303 1005

PEMERINTAH KABUPATEN KOTAWARINGIN BARAT
PUSKESMAS DINAS KESEHATAN DI KUMAI
Jl.Pemuda Nomor Telephon (0532)61179-KUMAI 74181
SURAT PENGANTAR
Nomor : 445/ / KI.A
KEPADA YTH
Kepala Dinas Kesehatan
Kab. Kotawaringin Barat
Cq.Kabid Pelayanan Kesehatan
di
PANGKALAN BUN
No URAIAN BANYAKNYA KETERANGAN
1 Mengirim Laporan Rujukan Puskesmas Kumai 1 (satu ) Disampaikan dengan hormat untuk dapat
Bulan MARET 2018 Berkas diketahui dan diperiksa
Terimakasih
Kumai, 16 APRIL 2018

Kepala Puskesmas Kumai
dr. ABIMAYU
NIP.19700526 200501 1 011
TEMBUSAN
1.Pertinggal
LAPORAN PASIEN RUJUKAN PUS
BULAN JULI 201
Tanggal TANGGAL TEMPAT RUJUKAN

NO NAMA LAHIR JK NO : KTP KODING Diagnosa
Masuk PKM
USILA
1 2 3 4 5 6 7 8
1 6/3/2017 Lilis.s 1/12/1969 p E10 DM
Intramural lelomyoma of
2 5/10/2017 Rusita 5/25/1970 p
uterus
3 5/10/2017 Mursiman 1/14/1953 L G20 parkinson disease
4 5/10/2017 Yuraida 4/24/1967 p H52.0 hypermetropia
5 5/10/2017 Sri H+D31artati 3/12/2058 p I10 hypertension
6 5/10/2017 Muryati 4/23/1957 p H25 senile catarac
7 5/10/2017 Samsiar 12/1/2002 p F20 schizophrenia
8 7/11/2017 Armiyati 8/20/1974 p H25 cataract
9 7/11/2017 Lidia Sugiarto 7/6/1957 p H52.1 myopia
10 7/11/2017 Siti Munawaroh 4/1/1963 p J45 Asthma
11 7/11/2017 Usman Sadat 10/1/1932 L I10 hypertension
12 7/11/2017 Asmuni 7/1/2017 L A015.0 Tuberculosis
13 7/11/2017 M.Hatta 3/2/1955 L 150.9 CHF
14 7/11/2017 Sania 5/1/1982 p I10 hypertension
15 7/14/2017 Solikah 4/1/1970 P 150.9 CHF
16 7/14/2017 Mahipal 6/15/1958 L I10 Hypertension
Non-insulin-dependent
17 7/15/2017 Salmiyah 9/2/1957 P E10
DM without co
18 7/15/2017 Usin 4/12/1948 L E10
DM without co
19 7/15/2017 Aminah 6/17/1969 P Chest pain, unspecified

20 7/15/2017 Mudatsiruddin 3/20/1974 L E10,150.9 CHF, DM
21 7/15/2017 Sarinten 7/5/1950 P I10 Hypertension
22 7/15/2017 Rachana 2/1/2000 P I24 Caries of dentine
23 7/17/2017 Tumariah 5/1/1950 P E11.5 DM Tipe II
24 7/17/2017 Nurul Arifin 6/22/1995 L A015.0 Tb Paru
25 7/17/2017 Marzuki 12/20/1976 L B20 HIV Aids
26 7/17/2017 Ramlah 7/1/1961 P H25 Cataract, Unspecified
27 7/17/2017 Tumariah 2/6/1961 P G51.0 Bell's Palsy
28 7/17/2017 Tariman 5/1/1950 L E11.5 DM Tipe 2
29 7/18/2017 Fatmawati 24/)5/1967 P Benign neoplasm of ovary
30 7/18/2017 Satiyah 7/1/1965 P Neoplasma of uncertain
31 7/18/2017 Tajudin 7/1/1946 L Mixed asthma
32 7/19/2017 Masdidi 1/1/1986 L G20 Parkinson's disease
Malignant neuroleptic
33 7/19/2017 Suasa 5/9/1984 P
syndrome
34 7/19/2017 Hendeny 2/2/1993 p inpartu

35 7/20/2017 Antung Saadah 8/19/1944 P Cataract, Unspecified
Urinary calculus,
36 7/20/2017 Nordin 11/11/1974 L
Unspecified
37 7/20/2017 Suratman 3/5/1965 L Lipom
Perichondritis of
38 7/20/2017 Uqaila Fahmun 2/4/2006 P
external ear
Schizophrenia,
39 7/20/2017 Himawan Sutan 10/5/1974 L
unspecified
40 7/20/2017 Sajiman 3/10/1967 L 150.9 CHF
41 7/21/2017 Naysila 1/11/2006 p Obs Febris
42 7/21/2017 Alus 9/9/1966 L Other hyperlipidaemia
43 7/21/2017 Mat Saleh 11/10/1976 L End-stage renal disease
Acute ischaemic heart
44 7/21/2017 Sugino 9/19/1955 L
disease
45 7/21/2017 Susi 10/20/1996 P Post Coital Bleeding
46 7/21/2017 Salasiah 7/1/1968 P 150.9 CHF
47 7/21/2017 Suyadi 8/1/1955 L 150.9 CHF
48 7/21/2017 Ahmad Efendi 10/1/1968 L KOI (Infected teeth)
49 7/23/2017 Wanda 1/12/2005 p Obs Febris
Bronchopneumonia,
50 7/24/2017 Monalisa 9/13/1998 P
unspecified
51 7/24/2017 Masniah 3/1/1977 P E10
DM without unspe
52 7/24/2017 Hj.Maulidah Ma 17/07/x P G20 Parkinson disease
Malignant neoplasm of
53 7/24/2017 Mani 7/1/1965 P
54 7/24/2017 Kamaludin 4/10/1965 L Asthma, unspecified

55 7/24/2017 Nurahman 1/1/2017 L Hyperbilirubin
56 7/24/2017 M.Ramadani 7/30/2012 L Obs Febris
57 7/24/2017 Rizky Putra An 4/17/2006 L Cough
58 7/24/2017 Arbainah 3/7/1973 P Low back pain
59 7/24/2017 Agustina Andriy 8/28/1995 P
Hypertensive heart
60 7/24/2017 Suriansyah 10/9/1961 L
disease
61 7/24/2017 Mei Andayani 5/25/1965 P 150.9 CHF
62 7/24/2017 Endang Susilow 10/16/1964 P
Chronic obstructive
63 7/24/2017 Supriyadi 6/14/1952 L pulmonary disease with
acute I
64 7/24/2017 Dina Ramadha 9/8/2008 P Lipoma

65 7/25/2017 Salmiah 7/1/1956 P E11.5 DM Tipe II
66 7/26/2017 Novi 1/26/1991 p Inpartu
Mengetahui
Kepala Puskesmas Kumai
dr.Abimayu
NIP.19700526 200501 1 011
N PASIEN RUJUKAN PUSKESMAS KUMAI
BULAN JULI 2017
TEMPAT RUJUKAN PEMBIAYAAN MEDICAL KEADAAN SETELAH DI RUJUK

ASRNSI KEMBALI
RSSI R.INAP RS,LAIN BPJS UMUM RECORD SEMBUH MENINGGAL
LAIN DI RAWAT
9 10 11 12 13 14 15 16 17 18
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Kumai, 3 Agustus 2017

Pengelola Rujukan
Mardani,Amd.Kep
NIP.10721031 199303 1005
KET
BULAN SEPTEMBER 2017

Masuk PKM RSSI R.INAP RS,LAIN BPJS UMUM RECORD SEMBUH MENINGGAL
USILA LAIN DI RAWAT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 9/28/2017 Muhammad hamdan 7/1/2005 L K40 Hernia Inguinal √ √
2 9/28/2017 Jamilan 7/1/1964 P I50.9 CHF √ √
3 9/28/2017 Siti Fatimah 8/14/1976 P H52.0 Hypermetropia √ √
4 9/29/2017 Nurbaiti 6/27/1984 p K92.1 Melena √ √
5 9/29/2017 Alpindik 1/1/1989 L F20.0 Schizophrenia √ √
6 9/27/2017 Ahmad 9/1/1936 L L23.9 Allergic Contact Dermatitis √ √
7 9/27/2017 Sampurna 5/27/1976 p A15.0 Tb Paru √ √
8 9/25/2017 Miasih 7/1/1956 p N81.4 Uterovaginal Prolapse √ √
9 9/25/2017 Mursiman 6/14/1953 L G20 Parkinson's disease √ √
10 9/25/2017 Akhmad Buhairi 12/21/2008 L G40 Epilepsi √ √
11 9/25/2017 Patina 1/1/1957 P A15.0 Tb Paru √ √
12 9/25/2017 Samsiar 12/1/1958 P F20.0 Schizophrenia √ √
13 9/23/2017 Ardiansyah 8/8/1984 L H05 Disorder of orbit √ √
14 9/22/2017 Elit sumiraha.w 10/26/1980 p I10 hypertension √ √
15 9/26/2017 Mira mariana 12/5/1983 P A15.0 Tb Paru √ √
16 9/26/2017 Jubaiti 7/1/1968 P I50.9 CHF √ √
17 9/26/2017 M.Idrus 7/1/1951 L J44.0 PPOK √ √
18 9/25/2017 Saleh 7/1/1946 L J44.0 PPOK √ √
19 9/25/2017 Merahi rohani 7/1/1962 P G50.0 Trigeminal neuralgia √ √
20 9/25/2017 Achmad bakri 8/19/1946 L N40.1 BPH √ √
21 9/25/2017 Dina ramadhan 9/8/2008 P A15.0 Tb Paru √ √
superficial injury of unspecified √ √
22 9/25/2017 Siti Munawaroh 4/1/1963 P T14.8
body regions
23 9/25/2017 Siti odjan hodjanah 8/6/1940 P H52.1 Myopi √ √
24 9/18/2017 Ernawati 2/11/1987 P vitae magistra √ √
25 9/18/2017 Jumaiyah 11/28/1952 P H25 Cataract, Unspecified √ √
26 9/20/2017 lailatul mukarromah 9/2/2005 P H60 Otitis externa √ √
27 9/20/2017 Jahrawati 6/1/2006 P N04.9 Nephrotic syndrome √ √
28 9/20/2017 Agus heriyono 8/17/1989 L E03.9 Hypothyroidism √ √
29 9/19/2017 H.Ahmad 7/13/1967 L E11.5 DM tipe II √ √
30 9/19/2017 Jama'atun 6/8/1972 P N83.2 Kista ovarium √ √
31 9/19/2017 Zahrawati 6/30/2006 P N04.9 Nephrotic syndrome √ √
32 9/19/2017 Mat saleh 11/10/1976 L N28.1 CKD √ √
33 9/19/2017 Aida 2/11/1957 P K46 Post Operasi Hernia √ √
34 9/19/2017 Ria Kumalasari 12/9/1983 p H52.4 Presbiopi √ √
35 9/19/2017 Ratnawati 9/19/1962 P H52.4 Presbiopi √ √
36 9/19/2017 Sulaiman 7/2/1981 L F20.0 Schizophrenia √ √
37 9/18/2017 Sunati 8/2/1965 P L04 Limfadenitis √ √
38 9/14/2017 Samlah 60 Tahun L H26 catarac √ √
39 9/15/2017 Misti 1/1/1962 P H26 catarac √ √
40 9/15/2017 Marmi 1/1/1943 P H26 catarac √ √
41 9/15/2017 Sri hartati 3/12/1958 p I10 Hypertension √ √
42 9/16/2017 Sisilia wati 3/1/1983 P B15.9 Hepatitis Unspecipic √ √
43 9/16/2017 Marzuki 12/20/1976 L B20 HIV √ √
44 9/18/2017 Zaitun 32 Tahun P M79.9 Post Operasi Exoir Fibro √ √
45 9/18/2017 Sadilah 10/4/1957 L J44.0 PPOK √ √
46 9/18/2017 Mita 7/10/1994 P J44.0 PPOK √ √
47 9/18/2017 Matsuki 7/6/1972 L K40 Hernia Scrotalis Sinistra √ √
48 9/18/2017 Nurhayan 11/1/1952 L H26 catarac √ √
49 9/18/2017 Merahi rohani 7/1/1962 p R07.9 Chest pain √ √
50 9/18/2017 Nismawati 9/29/1979 P E04.9 Post Operasi SNNP √ √
51 9/18/2017 Himawan 10/5/1974 L F20 Schizophrenia √ √
52 9/15/2017 Resti Yaningsih 3/8/1985 P J45 Asma √ √
53 9/15/2017 Daryah 6/25/1977 P H26 catarac √ √
54 9/14/2017 Tarmidi 60 Tahun L H26 catarac √ √
55 9/14/2017 Samlah 60 Tahun P H26 catarac √ √
56 9/14/2017 Dayang 7/1/1946 L H26 catarac √ √
57 9/14/2017 Husnul Basri 12/1/1936 L H26 catarac √ √
58 9/14/2017 Tariman 5/1/1950 L H26 catarac √ √
59 9/14/2017 Dahlia 1/9/1975 P G56.01 Carpal tunnel syndrome √ √
60 9/14/2017 Napsiah 7/1/1946 P H26 catarac √ √
61 9/14/2017 Supiani 60 Tahun P H26 catarac √ √
62 9/2/2017 Faridah 10/1/1987 P M06.9 Rheumatoid arthritis √ √
63 9/4/2017 Agustina Andriyani 8/28/1995 P N39.0 Susp ISK √ √
64 9/4/2017 Saenah 7/4/1957 P F29 Psikosis √ √
65 9/4/2017 Arbaiyah 8/12/1972 P J30.9 Rhinitis Alergi √ √
Superficial injury of √ √
66 9/2/2017 Siti Dahlia 7/1/1967 p T14.8
unspecified body region
67 9/4/2017 Suasa 5/9/1984 P N04.9 Nephrotic syndrome √ √
68 9/4/2017 Sam'ah 11/2/1964 P E11 DM Tipe II √ √
69 9/4/2017 Sadillah 10/4/1957 L A15.0 TB Paru √ √
70 9/4/2017 Siti Wasilah 6/8/1996 P N91.2 Amenorrhea sekunder √ √
71 9/4/2017 Mistyeh 3/5/1953 P I50.9 CHF √ √
72 9/15/2017 Rosalia 8/3/1985 P N42.0 Susp.Batu Ureter √ √
73 9/15/2017 Satiyah 7/1/1965 P I10 Hypertension √ √
74 9/15/2017 Liyah 7/1/1957 P H26 catarac √ √
75 9/15/2017 Sunati 7/1/1961 P I10 Hypertension √ √
76 9/15/2017 Ellin 5/29/2012 P N04.9 Nephrotic syndrome √ √
77 9/12/2017 Marsian 10/1/1955 P E11 DM Tipe II √ √
78 9/12/2017 Hatmawati 5/5/1980 P A63.0 Condyloma Akuminato √ √
79 9/12/2017 Pidayanti 21 Tahun P O48.0 Serotinus √ √
80 9/11/2017 Solikah 1/1/1970 P I50.9 CHF √ √
81 9/11/2017 Jatimah 2/6/1956 P I50.9 CHF √ √
82 9/11/2017 Asmuni 7/18/1952 L I50.9 CHF √ √
83 9/12/2017 Mahdalena 32 Tahun P I10 Hypertension √ √
84 9/12/2017 Asmat 1/1/1960 L H11.0 Pterygium √ √
85 9/12/2017 Basriah 1/1/1962 P I50.9 CHF √ √
86 9/12/2017 Arbain 9/22/1958 L E11 DM Tipe II √ √
87 9/13/2017 Ramlah 1/1/1961 P H26 catarac √ √
88 9/13/2017 Abdul Murad 9/11/1958 L K81.0 Cholecystitis √ √
89 9/13/2017 Supriadi 6/14/1952 L A15.0 TB Paru √ √
90 9/13/2017 Nismah 10/1/1960 P H26 catarac √ √
91 9/13/2017 M.Rizky Alifiandy 12/11/2010 L K81.0 Cholecystitis √ √
92 9/13/2017 Elit sumiraha w 10/28/1980 P I10 Hypertension √ √
93 9/13/2017 Abdul muis 7/1/1961 L I50.9 CHF √ √
94 9/13/2017 Ira marliana 3/12/1999 P N83.2 Susp.Kista √ √
superficial injury of unspecified √ √
95 9/13/2017 Tiroma siregar 5/20/1976 L T14.8
body regions
96 9/13/2017 Ali hasan mujtaba 9/24/2013 L J18.9 Pneumonia √ √
97 9/13/2017 Wina 12/25/2003 P H52.1 Myopia √ √
98 9/13/2017 Tarmidi 60 Tahun L H26 catarac √ √
99 9/14/2017 Rusli 53 Tahun L K30 Gastritis √ √
100 9/9/2017 Ach Dayly 12/25/1951 L I10 Hypertension √ √
101 9/9/2017 Saniyah 7/1/1974 P J40 Acute Bronchitis √ √
specific disorder of arithmetical √ √
102 9/9/2017 Juriah 6/25/1971 P F81.2
skills
103 9/9/2017 Nismawati 9/29/1978 P E21 hyperparathyroidism √ √
104 9/9/2017 M.Saleh 4/1/1958 L E88.2 lipomatosis √ √
105 9/9/2017 Mulyadi S 2/28/1938 L I50.9 CHF √ √
106 9/8/2017 Nova Luqman Afiandi 11/23/2011 L J41.0 cough √ √
107 9/8/2017 Devira 3/9/1957 P A15.0 TB Paru √ √
108 9/8/2017 Naysila 12/1/2006 P G40 epilepsy √ √
109 9/6/2017 Dedi saptana 9/1/1989 L F20 Schizophrenia √ √
110 9/6/2017 Ira marliana 3/12/1999 P N83.2 Susp.Kista √ √
111 9/7/2017 syadriah 7/12/1969 P E11 DM Tipe II √ √
112 9/7/2017 Murniati 2/28/1969 P G56.01 Carpal tunnel syndrome √ √
113 9/6/2017 Said Ucin 12/1/1939 L I50.9 CHF √ √
114 9/6/2017 Eka pratiwi 4/12/1996 P I09.9 RHD √ √
115 9/6/2017 Patina 60 Tahun P J44.0 PPOK √ √
116 9/4/2017 Teye 12/31/1946 L J44.0 PPOK √ √
117 9/4/2017 Putimah 2/15/1951 P I50.9 CHF √ √
118 9/4/2017 Maryatul Qiftiyah 9/1/1960 P G20 parkinson's disease √ √
119 9/4/2017 Amri 12/31/1961 L G20 parkinson's disease √ √
120 9/4/2017 Abdul Kohar 12/1/1965 L A15.0 TB Paru √ √
Mengetahui Kumai, 9 Oktober 2017

NIP.19700526 200501 1 011 NIP.10721031 199303 1005
DINAS KESEHATAN
PUSKESMAS KUMAI
JL. Pemuda RT 03 Kumai Hilir Kecamatan Kumai
Telp. (0532) 61179 Kode Pos 74181 Email : pkmkumai2013@gmail.com

BULAN OKTOBER 2017
Masuk PKM RSSI R.INAP RS.LAIN BPJS UMUM RECORD SEMBUH MENINGGAL
USILA LAIN DI RAWAT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 10/28/2017 Masi 11/19/1977 P N18 CKD √ √
2 10/27/2017 Haliah 6/4/1965 P I50.9 CHF √ √
3 10/27/2017 Kemo sabani 7/1/1947 L I50.9 CHF √ √
4 10/26/2017 Himawan 10/5/1974 L F20.0 Schizophrenia √ √
5 10/26/2017 Aminah 6/17/1969 P I25 IHD √ √
6 10/25/2017 Syahrani 4/17/1947 L N39.0 ISK √ √
7 10/25/2017 Jubaiti 7/1/1968 p I50.9 CHF √ √
8 10/24/2017 Devin 12/23/1985 p M54.4 Low Back Pain √ √
9 10/24/2017 Siti Munawaroh 1/1/1963 P S68.0 Post amputasi jari kaki kiri √ √
10 10/24/2017 Ibramsyah 10/24/1970 L J44.0 PPOK √ √
11 10/24/2017 Nova luqman 12/24/2011 L J11 Batuk alergi √ √
12 10/24/2017 Dewi janur 1/14/1983 P H52.1 Myopi √ √
13 10/24/2017 Akhmad arkan 2/1/2011 L H52.0 Hypermetropia √ √
14 10/24/2017 Antung halimah 7/1/1955 p J44.0 PPOK √ √
15 10/24/2017 Mira mariana 12/5/1993 P A15.0 Tb Paru √ √
16 10/24/2017 Rahmatul aulia 10/14/2003 P C85.9 Lymphosarcoma √ √
17 10/23/2017 Patina 1/7/1957 P I50.9 CHF √ √
18 10/23/2017 Siti fatmadiah 2/10/1998 P J11 Dermatitis kontak alergi √ √
19 10/23/2017 Siti Munawaroh 4/1/1963 P J45 Asma √ √
20 10/23/2017 Usin 4/12/1948 L E11.5 DM tipe II √ √
21 10/23/2017 Jumiati 5/4/1987 P K30 Gastric ulcer √ √
22 10/23/2017 Digo aliando aftahilah 8/8/2014 L S00.9 Superficial injury of head √ √
23 10/21/2017 Moh.Riki ferdiansyah 10/1/2010 L N04.9 Nephrotic syndrome √ √
Primary arthrosis of other joints, √ √
24 10/21/2017 Aminah 7/1/1958 P M19
ankle and foot
25 10/21/2017 Ilham toni 4/16/1950 L R07.9 Chest pain √ √
27 10/19/2017 Siti masitah jailani 3/8/1954 P M10.9 Gout √ √
28 10/20/2017 Matarif 3/17/1960 L J01 Acute sinusitis √ √
29 10/20/2017 Sunati 7/1/1961 P G44 Tension type headache √ √
Fasciitis, not elsewhere √ √
31 10/20/2017 Samiyah 6/5/1970 P M72.2
classified, site unspecif
32 10/18/2017 Mistyeh 3/5/1953 P I50.9 CHF √ √
33 10/18/2017 Sawirul yanti 8/29/1965 P E20.9 Hypoparathyroidism √ √
34 10/18/2017 Mahipal 6/15/1958 L E11.5 DM tipe II √ √
35 10/18/2017 M. Jumadi 4/9/1982 L K12.2 Phlegmon (Ludwig Angina) √ √
36 10/18/2017 Abdul muis 7/1/1961 L R57.9 Cardiogenic shock √ √
37 10/16/2017 M. Fardani 7/1/2008 L G40 Epilepsy √ √
38 10/14/2017 Syadriah 7/12/1969 P I50.9 CHF √ √
39 10/14/2017 Suasa 5/9/1984 P N04.9 Nephrotic syndrome √ √
40 10/13/2017 Solikah 4/1/1970 P E11.5 DM tipe II √ √
41 10/12/2017 Saprah 3/9/1956 p E11.5 DM tipe II √ √
42 10/12/2017 Maria olfah 7/1/1947 P E11.5 DM tipe II √ √
43 10/12/2017 Tajudin 7/1/1946 L G20 Parkinson's disease √ √
44 10/12/2017 Darsan 2/8/1975 L H52.0 hypermetropia √ √
45 10/11/2017 Sopiyah 1/1/1952 P M54.4 Low Back Pain √ √
46 10/11/2017 Tariman 5/1/1950 L E11.5 DM tipe II √ √
47 10/11/2017 Ach. Dayly 12/25/1951 L I50.9 CHF √ √
48 10/11/2017 Jahrawati 6/1/2006 P N04.9 Nephrotic syndrome √ √
49 10/11/2017 Solikah 4/1/1970 p J45 Asma √ √
50 10/10/2017 Mariam 8/8/1969 P M54.4 Low Back Pain √ √
Systemic Lupus erythematosus, √ √
51 10/9/2017 Yurni 10/1/1989 P M32.9
unspecified
52 10/10/2017 Yossi susilo 22/93/1963 P J40 Bronchitis √ √
53 10/9/2017 Suryati 1/1/1968 P R05 Cough √ √
54 10/9/2017 Abdul muis 7/1/1961 L I50.9 CHF √ √
55 10/9/2017 Marmi 1/1/1943 P H26 catarac √ √
56 10/9/2017 Rohana 8/1/1983 P G40 Epilepsy √ √
57 10/9/2017 Muhibah 7/2/1969 P H52.1 Myopia √ √
58 10/9/2017 Asmuni 7/18/1952 L I50.9 CHF √ √
59 10/9/2017 Surinah 9/13/1972 P M10.9 Gout √ √
60 10/6/2017 Merahi rohani 9/14/1972 P R51 Headache √ √
61 10/6/2017 Supriyadi 9/15/1972 L J44.0 PPOK √ √
62 10/7/2017 M. Saberi 9/16/1972 L K30 Gastritis Kronic √ √
63 10/7/2017 Siti sunarti 9/17/1972 P M54.4 Low Back Pain √ √
64 10/7/2017 H.Said ucin 9/18/1972 L G62.9 Neuropati √ √
65 10/7/2017 Anang amri 9/19/1972 L G20 Parkinson's disease √ √
Malignant neoplasm of cervix √ √
66 10/6/2017 Endang Susilowati 9/20/1972 p C53.9
uteri
67 10/6/2017 Mulyadi S. 2/28/1938 L I50.9 CHF √ √
68 10/6/2017 Liyah 7/1/1957 P H26 catarac √ √
69 10/6/2017 Sugino 9/19/1955 L I50.9 CHF √ √
70 10/5/2017 Marsian moncube 10/10/1955 L R05 Coug √ √
71 10/5/2017 Siti munawaroh 4/1/1963 P J45 Asma √ √
72 10/5/2017 Supriyati 7/1/1971 P S04.51 Injury of facial nerve √ √
73 10/4/2017 Supian 10/10/1980 L R07.9 Chest pain √ √
74 10/3/2017 Mariana 3/21/1977 P H52.0 Hypermetropia √ √
75 10/3/2017 Putri 8/24/1991 P K05.1 Chronic gingivitis √ √
76 10/3/2017 Wati 3/1/1980 P K02.9 Dental caries √ √
77 10/3/2017 Fatimah 10/25/1955 P D24 Benign neoplasm of breast √ √
78 10/3/2017 Inayah oktaviani 11/10/2002 P K09.9 Cyst of oral region √ √
79 10/3/2017 Saiyah 7/1/1963 P S06.9 Tekanan intra cranial serebral √ √
80 10/2/2017 Ahmad suriansyah 7/14/1992 L J03.90 Tonsilitis √ √

81 10/2/2017 Usman sadat 10/1/1932 L M54.4 Low Back pain √ √
82 10/2/2017 Mardiyah 7/1/1957 P K30 Dyspepsia √ √
83 10/2/2017 Asmuni 6/1/1945 L J45 Asma √ √
84 10/2/2017 Maryatul qiftiyah 9/1/1960 P G20 Parkinson's disease √ √
85 10/2/2017 Toyo 10/19/1947 L K40 Hernia inguinal √ √
86 10/2/2017 Rukayah 6/15/1958 P R51 Headache √ √
87 10/2/2017 Muhammad 5/5/1948 L S05 Trauma orbita √ √
88 10/2/2017 Abdul gafur 12/14/1967 L R07.9 Chest pain √ √
89 10/2/2017 Sarinten 6/14/1952 P M54.4 Low Back pain √ √
Mengetahui Kumai, 9 November 2017

NIP.19700526 200501 1 011 NIP.10721031 199303 1005
DINAS KESEHATAN
PUSKESMAS KUMAI

BULAN NOVEMBER 2017
Masuk PKM RSSI R.INAP RS.LAIN BPJS UMUM RECORD SEMBUH MENINGGAL
USIA LAIN DI RAWAT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 11/30/2017 Nova luqman afiandi 11/23/2011 L J22 Cough √ √
2 11/30/2017 Patina 1/7/1957 P I50.9 CHF √ √
3 11/29/2017 Tini fitriani 9/22/1988 p D70.1 Susp.Kanker Serviks √ √
4 11/29/2017 Hatman 8/7/1967 L J44.0 PPOK √ √
5 11/29/2017 Arnimah 3/5/1969 P A57 Ulkus Gaster √ √
6 11/29/2017 Midhi ria abadi 7/17/1974 L N13.30 Hidronefrosis √ √
Chronic obstructive pulmonary √ √
7 11/28/2017 Halimah 6/1/1950 p J44.9
disease
8 11/28/2017 Arman 8/7/1971 L K40 Hernia inguinal √ √
9 11/25/2017 Ahmad 9/1/1936 L H16.8 Keratitis √ √
Fracture of shaft of humerus √ √
10 11/25/2017 Rudiansyah 12/1/1993 L S42.309A
close
11 11/25/2017 Erni marwiyah 5/6/1966 P M86 Osteomyelitis √ √
12 11/24/2017 Sulaiman 7/2/1988 L F20.0 Schizophrenia √ √
Fracture of lower end of tibia √ √
13 11/24/2017 Sumbriyeh 5/1/1980 P S82.301A
close
14 11/24/2017 Naufal akbar 4/28/2014 L J22 Cough √ √
15 11/24/2017 Neti 8/26/1985 P N21.0 Calculus in bladder √ √
16 11/24/2017 Yuliya ningsih 7/20/1999 P N70.1 Post operasi kista lien √ √
17 11/23/2017 Himawan susanto 10/5/1974 L F20.0 Schizophrenia √ √
18 11/22/2017 Agus heriyono 8/17/1989 L E05 Hyperthyroid √ √
19 11/22/2017 Siti Munawaroh 1/1/1963 P J45 Asma √ √
20 11/21/2017 Mira mariana 12/5/1993 P A15.0 Tubercholosis kelenjar √ √
21 11/21/2017 Sabran 7/1/1974 L I27.9 Iskemik heart disease √ √
22 11/20/2017 Arnimah 3/5/1969 P K30 Gastritis √ √
23 11/20/2017 Hatman 8/7/1967 L J45 Asma √ √
24 11/20/2017 Jamaiyah 5/1/1984 P J45 Asma √ √
25 11/20/2017 Juriah 6/25/1971 P I10 Hipertensi √ √
26 11/20/2017 Atun 7/1/1980 P S22.20XA Fracture of sternum √ √
27 11/20/2017 Sarinten 7/5/1950 P M54.4 Low Back Pain √ √
28 11/20/2017 Usin 4/12/1948 L E11 DM Tipe II √ √
29 11/20/2017 Merahi rohani 7/1/1962 P G44.209 Tention type headache √ √
30 11/20/2017 Alpindi 10/1/1990 L F20.0 Schizophrenia √ √
31 11/20/2017 Mariyam 5/1/1950 P N30.91 Cystitis unspecified √ √
32 11/20/2017 Syahrani 1/1/1953 L H26 Katarak √ √
33 11/20/2017 Halimah 6/1/1950 P J45 Asma √ √
35 11/20/2017 Toyo 10/19/1947 L K40 Hernia inguinal √ √
36 11/20/2017 Arland 12/31/1949 L L30.9 DKA √ √
Chronic obstructive pulmonary √ √
37 11/20/2017 Ahmad 9/1/1936 L J44.9
disease
Chromic ischaemic heart √ √
38 11/20/2017 Mistyeh 3/5/1953 P I25.9
disease unspecified
39 11/18/2017 Edi 6/6/1993 L J20 Bronchitis √ √
40 11/18/2017 Hesti supeni 1/12/1975 P A15.0 TB Kategori II √ √
41 11/17/2017 Masna 1/26/1900 p A15.0 TB Kategori II √ √
42 11/17/2017 Samsul 7/1/1981 L Observasi Bradikardi √ √
43 11/17/2017 Firda ayu 5/20/2004 P G40 Epilepsy √ √
Chromic ischaemic heart √ √
44 11/16/2017 Mahipal 6/15/1956 L I25.9
disease unspecified
45 11/16/2017 Mahrus alie al mubarok 5/16/2012 L H10.9 Conjunctivitis √ √
46 11/16/2017 Anang kusnal 7/1/1949 L M54.4 Low Back Pain √ √
47 11/16/2017 Jainun 7/1/1965 P A15.0 TB Paru berulang √ √
48 11/15/2017 Sri harmini 12/27/1961 P N30.91 Cystitis √ √
Superficial injury of unspecified √ √
49 11/15/2017 Tiroma siregar 5/20/1976 L T14.8
body region
50 11/15/2017 Nismah 10/1/1960 P I50.9 CHF √ √
51 11/15/2017 Edi saptana 9/1/1989 L F20.0 Schizophrenia √ √
52 11/15/2017 Nuraini 11/3/2002 P H52.0 Hypermetropia √ √
53 11/15/2017 Saunan 8/14/1956 P M86 Osteomyelitis √ √
55 11/15/2017 Purkan 8/3/1975 L O71.9 Trauma okuli √ √
56 11/15/2017 Salasiah 6/5/1975 P Z82.3 Post Stroke Hemoraegic √ √
57 11/15/2017 Putri 8/8/2013 P O71.9 Trauma abdomen √ √
58 11/13/2017 Supriyati 7/1/1971 P S04.50XA Injury of facial nerve √ √
59 11/13/2017 Fardani 7/1/2008 L G40 Epilepsy √ √
60 11/13/2017 Jainun 8/1/1966 P A15.0 TB Paru √ √
61 11/13/2017 Kemo sabani 8/1/1947 L I10 Hipertensi √ √
62 11/11/2017 Solihin 6/4/1981 L Q04.0 Corpus alineum √ √
63 11/11/2017 Ardiansyah 8/8/1984 L H05 Disorder of orbit √ √
64 11/11/2017 Ernawati 7/7/1977 P R07.9 Chest pain √ √
65 11/11/2017 Mulyadi S 2/28/1938 L I50.9 CHF √ √
66 11/11/2017 HJ.Mahdayang 5/14/1956 p F03 Dementia √ √
67 11/10/2017 Mahdalena 10/5/1985 P D64.9 Anemia gravis √ √
68 11/10/2017 Sri hartati 3/12/1958 P I10 Hipertensi √ √
69 11/10/2017 Syawaludin 6/5/1991 L M54.4 Low Back pain √ √
70 11/10/2017 Solikah 1/1/1970 P I25+E11 IHD + DM Tipe II √ √
71 11/9/2017 Sawda 3/10/1980 P K30 Dyspepsia √ √
72 11/9/2017 Mila 5/28/1994 P G1 P0 A0 dengan serotinus √ √
Benign neoplasm of unspecified √ √
73 11/9/2017 Santewi 7/1/1945 P D36.9
site
74 11/7/2017 Amri 12/31/1961 L G20 Parkinson's disease √ √
75 11/7/2017 Mat saleh 11/10/1976 L D30.00 Benign neoplasm of kidney √ √
76 11/7/2017 Nuramsyah 8/7/1972 L N45.2 Orchitis √ √
77 11/7/2017 Tajudin 7/1/1946 L G20 Parkinson's disease √ √
78 11/7/2017 Murniati 2/28/1969 P D24.9 Benign neoplasm of breast √ √
79 11/6/2017 Fauziah 7/22/2009 P J22 Cough √ √
80 11/6/2017 Nur hasanah 3/8/1977 P D30.00 Benign neoplasm of kidney √ √
81 11/6/2017 Salmiyah 9/2/1957 P I10 Hipertensi √ √
82 11/6/2017 Jahrah 9/15/1966 P G70.0 Myasthenia gravis √ √
83 11/6/2017 Asmat 1/1/1960 L H26 katarak √ √
84 11/6/2017 Ruminie 8/21/1955 P D30.00 Benign neoplasm of kidney √ √
85 11/6/2017 Elit sumiraha. W 10/26/1980 P I10 Hipertensi √ √
86 11/4/2017 Suhartini 5/1/1983 P D24.9 Benign neoplasm of breast √ √
87 11/4/2017 Rohana 8/1/1983 P G40 Epilepsy √ √
88 11/2/2017 Siti aminah 2/1/2008 P H70.90 Mastoiditis √ √
89 11/2/2017 Defin setyana 12/23/1985 P M54.4 Low Back pain √ √
Mengetahui Kumai, 11 Desember 2017

NIP.19700526 200501 1 011 NIP.10721031 199303 1005
DINAS KESEHATAN
PUSKESMAS KUMAI

BULAN DESEMBER 2017
TANGGAL TEMPAT RUJUKAN PEMBIAYAAN KEADAAN SETELAH DI RUJUK
TANGGAL MEDICAL
MASUK PKM RSSI R.INAP RS.LAIN BPJS UMUM RECORD SEMBUH MENINGGAL
USIA LAIN DI RAWAT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
OTHER AND UNSPECIFIED √

1 12/30/2017 WATI 3/1/1980 P N83.20 √
OVARIAN CYSTS
2 12/30/2017 EMI RUDIYASTUTI 8/22/1977 P M54.4 LBP √ √

3 12/30/2017 MUDATSIRUDDIN 3/20/1974 L M54.4 LBP √ √
4 12/22/2017 HADIJAH 6/24/1984 P O02.0 G3 P2 A0 BLIGHTED OVUM √ √
5 12/29/2017 ADINDA 1/12/2001 P H54.51 LOW VISION √ √
6 12/28/2017 SATIYAH 7/1/1965 P E11 DM Tipe II √ √
7 12/28/2017 WATINI 9/5/1987 p R51 HEADACHE √ √
8 12/27/2017 ALFINDO 1/4/2009 L J45.991 BATUK ALERGI √ √
9 12/27/2017 JURIAH 6/25/1971 P I10 HIPERTENSI GR II √ √
10 12/27/2017 BUDIANSYAH 3/28/1990 L KISTA ATEROMA √ √
11 23/12.2017 MURSIMAN 6/14/1953 L G20 PARKINSON'S DISEASE √ √
12 23/12.2017 Hj. MAHDAYANG 5/14/1956 P F03 DIMENSIA √ √
13 12/22/2017 BARLIAN 8/28/1968 L H26 KATARAK √ √
Chronic Obstructive Pulmonary √ √

14 12/22/2017 SADILLAH 10/4/1957 L J44
Diseanse, Unspecified
15 12/22/2017 SULAIMAN 7/2/1988 L F20.0 Paranoid Schizophrenia √ √
G3 P0 A2 Susp. KPD (Ketuban √ √

16 12/21/2017 RAFIKA 12/9/2000 L O42.01
Pecah Dini)
17 12/21/2017 H. MARTOYO 5/2/1949 L I50.9 CHF √ √
18 12/21/2017 IMAM MUSTOFA 12/17/1977 L H66.9 Otitis Media, Unspecified √ √
19 11/20/2017 RATMI 12/15/1984 P H54.51 Low Vision, One eye √ √
20 11/20/2017 FIRDA AYU PRADITHA 5/27/2004 P G40 EPILEPSY √ √
21 12/11/2017 UTIN HAJENAH 5/20/1960 P H52.10 MYOPIA √ √
22 12/20/2017 MIRA MARIANA 12/5/1993 P A15.0 TB KELENJAR √ √
23 12/20/2017 NURIAH 4/4/1987 P KISTA ATEROMA √ √
24 12/20/2017 SITI FATMADIAH 2/10/1998 P A30 MORBUS HANSEN √ √
25 12/20/2017 NURLELA 2/1/1992 P LETSU √ √
26 12/20/2017 SITI NOERJENAH 12/28/1943 P H26 KATARAK √ √
27 12/20/2017 RUSDIANSYAH 12/20/1980 L H11.009 PTERYGIUM √ √
Other and unspecified √ √
28 12/20/2017 MUHAMAD SABERI 6/22/1962 L R10.9
abdominal pain
29 12/20/2017 SITI MUNAWAROH 4/1/1963 P J45 ASTHMA √ √

30 12/19/2017 SILTA OKTAVIANI 10/15/1999 P L72.0 EPIDERMAL CYST √ √
31 12/19/2017 ASMAWATI 5/6/1973 P I50.9 Congestive heart fallure √ √
Stroke, not specified as √ √
32 12/19/2017 SRI HARTATI 3/12/1958 P I63.9
haemorrhage or infarction
Non-insulin-dependent diabtes √ √
33 12/18/2017 USIN 4/12/1948 L E11
mellitus without co
34 12/18/2017 SARINTEN 7/5/1950 P M54.4 Low Back Pain √ √
Non-insulin-dependent diabtes √ √
35 12/18/2017 SITI MUNAWAROH 01/04.1963 P E11
mellitus without co
Hypertensive heart disease with

36 12/18/2017 JAMILAH 7/1/1964 p I50.9 (congestive), Non-insulin- √ √
dependent diabetes
37 12/18/2017 RAHMAD SULDI 12/1/1984 L F20 SKIZOFRENIA √ √
38 12/18/2017 ROSMITA 7/1/1964 L H66.9 OTITIS MEDIA KRONIK √ √
39 12/18/2017 HIMAWAN 7/1/1964 L F20 SKIZOFRENIA √ √

40 12/18/2017 JAMILAN 7/1/1964 P I50.9 CHF √ √
41 12/16/2017 ENDANG 10/16/1964 P H26 KATARAK √ √
42 12/16/2017 DEFIN SETYANA 12/23/1985 L M54.4 LBP √ √
43 12/16/2017 NOVA LUQMAN AFIANDI 12/24/2011 L BKB √ √
44 12/16/2017 ROHANA 8/5/1983 P G40 Epilepsy √ √
45 12/16/2017 SUGIYANTO 3/6/1993 L M19.92 POST FRAKTUR IGA √ √
46 12/16/2017 LAM'AH 7/7/1958 P E11 DM TIPE I √ √
47 12/16/2017 LISDA NINGSIH 10/21/1976 P M54.4 LBP √ √
48 12/16/2017 LUHU 6/7/1960 L G46.4 SNH √ √
49 12/16/2017 M. FARDANI 8/27/2008 L G40 Epilepsy √ √
50 12/15/2017 ANDRE H 5/4/2007 L LIFOMA √ √
51 12/15/2017 ISWANTI 3/5/1992 P G1P0A0 Dengan SIROTINUS √ √
Disorder of gingiva and √ √
52 12/15/2017 IIS SOFIANI 7/14/1992 P K06.9
edentulous alveolar ridge
G2P1A0 Dengan Abortus √ √

53 12/14/2017 SULASTRI 9/3/1990 P
Incomplit
G4P3A0 Dengan Letak √ √

54 12/14/2017 PUSPITA WARDANI 1/24/1988 P
Sungsang
DISLOKASI CALCANEOS √ √
55 12/14/2017 UMI KALSUM 7/20/2007 P Q66.1
SINISTRA
56 12/14/2017 SITI WASILAH 6/8/1996 P A56.11 Pelvic inflamatory disease √ √
57 12/13/2017 SOLIKAH 9/4/1970 P E11+I50.9 DM dan CHF √ √
58 12/13/2017 MARNINTEN 7/10/1995 L K30 DISPEPSIA √ √
59 12/13/2017 SITI FATIMAH 7/6/1989 P H11.009 PHYTERIGIUM √ √
60 12/13/2017 DEDI SAPTANA 9/1/1989 L F20 PARANOID Skizoprenia √ √
61 12/13/2017 FARIDAH 10/29/1987 P I10.9 HEMOROID Heart Disease √ √
62 12/15/2017 MASITAH 1/1/1975 P G46.4 Stroke Non Hemoregic √ √
63 12/13/2017 KARMILA 3/10/1999 P MENORAGIA √ √
64 12/13/2017 MARMINI 8/23/1979 P DISMENORHEA √ √
65 12/13/2017 RUSLI 8/28/1964 L R50 CHEPALGYA √ √
66 12/13/2017 RUDIANSYAH 12/1/1993 L M89.329 Fraktur Humerus √ √

67 12/12/2017 KUSNAH 10/10/1964 P H26 KATARAK √ √
68 12/12/2017 JUBAITI 7/1/1968 P I50.9 CHF √ √
69 12/12/2017 ANSORI 5/12/1977 L M89.329 Dislokasi Humerus Sinistra √ √
70 12/12/2017 SAIYAH 7/1/1963 P G25.6 TICS √ √
71 12/12/2017 ARDAWATI 7/24/1988 P Q62.5 SUSP. BATU URETER √ √
72 12/12/2017 HERMAN 12/15/1968 L J44.0 PPOK √ √
73 12/12/2017 ABIZAR 5/22/2014 L J03 TONSILITIS √ √
SUSP. BATU URETER/ √ √
74 12/12/2017 ARDAWATI 7/24/1988 P Q62.5
URETROLITHIASIS
75 12/11/2017 YURNI TOREN 10/10/1989 P Sistemic Lupuserythama Tosus √ √
76 12/11/2017 SAUDA 3/10/1980 P IHD √ √

77 12/11/2017 MAINI 6/1/1981 P K02 CARIES MEDIA √ √
78 12/11/2017 SANI 7/5/1941 P E11 HIPERGLIKEMIA √ √
79 12/11/2017 ARI SUPRIYADI 12/3/1995 L A15.0 TB PARU √ √
80 12/11/2017 KEMO 7/1/1947 L I50.9 CHF, HT, DM √ √
81 12/11/2017 RISALAWATI 1/13/1973 P PSIKOTIK √ √
82 12/11/2017 M. AHMAD USMAN 12/15/1964 L EKSIM √ √
83 12/11/2017 RUMINI 8/21/1955 P CKD St. V on HD √ √
84 12/11/2017 FURKAN 12/15/1964 L H10 CONJUNGTIVITIS √ √
85 12/11/2017 SURIANSYAH 12/15/1964 L R50+I10 CEFALGIA, HT Grade II √ √
86 12/9/2017 JAINUN 7/1/1965 P A15.0 TB PARU √ √
87 12/9/2017 AHMAD USMAN 9/1/1936 L H26 KATARAK √ √
88 08/12/1017 SILTA 10/15/1999 P KISTA ATEROMA √ √
89 08/12/1017 SUGINO 9/19/1955 P I50.9 CHF CC IHD √ √
90 08/12/1017 NURIAH 4/4/1987 P KISTA ATEROMA √ √
91 08/12/1017 HALIYAH 6/4/1965 P I50.9 CHF √ √
92 12/7/2017 SAPUANI 8/17/1969 L H52.1 MYOPIA √ √
93 12/7/2017 MILA YUSIFA 11/9/1976 P H52.1 MYOPIA √ √
94 12/6/2017 PUTIMAH 2/15/1951 P I50.9 CHF √ √
95 12/6/2017 MERAH IROHANI 7/1/1952 P J01.90 Sinusitis Maxilaris Dextra √ √
96 12/6/2017 JAHRAH 9/15/1966 P P94.0 MIASTENIA GRAVIS √ √
97 12/6/2017 KAMARIN 4/1/1974 L HEMOROID GR IV √ √
Penyakit Paru Obstruksi Kronik √ √
98 12/6/2017 SUPRIYADI 6/14/1952 L J44.0
& Tubercholosis
99 12/5/2017 HATIJAH 3/22/1990 P N60.2 FIBROADEMA MAMAE √ √
100 12/5/2017 SAMSIAR 1/1/1956 P PSYKOSIS √ √
Hypertensive heart disease √ √
101 12/4/2017 MARDIYAH 7/1/1957 P I50.9
without (congestive) he
Acute ischaemic heart disease, √ √
102 12/4/2017 MULYADI S 2/28/1938 L I24.9
unspecified
103 12/4/2017 MUHAMMAD 1/1/1949 L H26 KATARAK √ √
104 12/4/2017 MARSIAN MONOUBE 10/10/1955 L A15.0 TB PARU √ √
105 12/4/2017 SADILAH 10/4/1957 P K92.1 MELENA √ √

Contusion of eveball and orbital √ √
106 12/4/2017 NOASRIYANTI 2/1/1978 P S05.10XS
tissuea
107 12/4/2017 PARDI 11/11/1968 L S23 Dislokasi Sprain/ Strain Thorax √ √
108 12/4/2017 AIMATUL HIDAYAH 9/1/2006 P D17.2 Benign Lipomatous Neoplasm √ √
Mengetahui Kumai, 08 Januari 2018

NIP.19700526 200501 1 011 NIP.10721031 199303 1005
DINAS KESEHATAN
PUSKESMAS KUMAI

BULAN JANUARI 2018
TANGGAL MEDICAL
USIA LAIN DI RAWAT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 1/31/2018 LAM'AH 7/7/1958 P E11 DM Tipe II √ √
2 1/31/2018 IMAMMUDIN 7/1/1977 L J22 BATUK KRONIK BERULANG √ √
3 1/31/2018 RUDIN 12/19/1975 L R10.8 COLIC ABDOMEN √ √

4 1/31/2018 NOR RAHMAH 5/2/1959 P E11 DM Tipe II √ √
5 1/30/2018 AHMAD SURIANSYAH 5/21/1959 L J44.0 PPOK √ √
6 1/30/2018 MASNIAH 12/31/1956 P J20.9 BRONCHITIS √ √
7 1/30/2018 MARIYAM 2/17/1943 p I10 HIPERTENSI GR II √ √
8 1/30/2018 SUMBRIYEH 5/1/1980 P S82.20 FRAKTUR TIBIA √ √
FRAKTUR HUMERUS √ √
9 1/30/2018 ARLIYANI 3/8/1985 P S42.3
SINISTRA
10 1/29/2018 H.AHMAD H.S 7/1/1955 L E11 DM Tipe II √ √
11 1/29/2018 SADILLAH 10/4/1957 L A15.0 TB PARU √ √
12 1/29/2018 NURDIN BASO 7/1/1951 L R31 OB.HEMATURIA √ √
13 1/29/2018 TOMAR 7/5/1960 L E11 DM Tipe II √ √
14 1/29/2018 USUP 12/1/1950 L R31 UNSPECIFIED HEMATURIA √ √
15 1/29/2018 SULAIMAN 7/2/1988 L F20.0 Paranoid Schizophrenia √ √

16 1/29/2018 ARMAWI 11/4/1965 L E11 DM Tipe II √ √
CERVUS ALENUS √ √
17 1/27/2018 SAMSURI 1/22/1981 L
PROXIMALIS
18 1/27/2018 SALAMUN SUKRIANDI 8/6/2001 L I86.1 SCROTAL VARICES √ √

19 1/26/2018 SAILANI 7/30/1976 L LIPOM √ √
20 1/24/2018 M.ALIANSYAH 1/23/1993 L TUMOR RAHANG √ √
21 1/24/2018 SARINAH 1/23/1993 P J01 SINUSITIS √ √
CHRONIC TUBOTYMPANIC √ √
22 1/25/2018 MATARIP,H.M 5/5/1960 L H66.1
SUPPURATIVE OTITIS MEDIA
23 1/25/2018 MURSIMAN 6/14/1953 L G20 PARKINSONS DISEASE √ √

24 1/24/2018 TARIMAN 5/1/1950 L E11 DM Tipe II √ √
25 1/24/2018 ARYATI 5/7/1993 P IVA (+) √ √
26 1/24/2018 SUMANTO 7/27/1948 L I50.9 CHF √ √
27 1/24/2018 HIMAWAN 10/5/1974 L F20.0 SCHIZOFRENIA √ √
28 1/23/2018 HENDRA 11/11/1990 L NAPZA √ √
29 1/23/2018 KINANTY NUR AFRIN 7/21/2017 P H04.0 DACRYOADENITIS √ √
30 1/23/2018 SAMSIAR 12/1/1958 P F20 SCHIZOFRENIA √ √
31 1/23/2018 RUSLI 8/28/1964 L I10 HIPERTENSI GR II √ √
CEREBRAL INFARCTION, √ √
32 1/23/2018 SUTARNO PRAWIRO 2/13/1965 L I63.9
UNSPECIFIED
33 1/23/2018 PATINA 1/1/1950 P I50.9 CHF √ √
34 1/23/2018 NOVA LUQMAN AFIANDI 12/24/2015 L J45 ASMA BRONCHIALE √ √
DEFIRA ISMI NUR √ √

35 1/23/2018 12/24/2015 P J45.991 BATUK ALERGI
MAULIDA
MALIGNANT NEOPLASM OF √ √
36 1/22/2018 ENDANG SUSILOWATI 10/16/1964 p C00
CERVIX UTERI,UNSPECIFIED
37 1/22/2018 ELIT SUMIRAHA 10/26/1980 P I50.9 CHF √ √
38 1/22/2018 MULYADI.S 2/28/1938 L I50.9 CHF √ √
39 1/22/2018 ARKAN 7/1/2017 L A09 DIARE KRONIK √ √
ACUTE APICAL
40 1/22/2018 ISMI LAILA ANGRAINI 1/9/2007 P K04.4 PERIODONTITIS OF PULPAL √ √
ORIGIN
41 1/20/2018 LASMI 12/1/1975 P N60.2 FIBROADENOSIS OF BREAST √ √
42 1/19/2018 ASMUNI 7/18/1952 L I69.4 SNH √ √

43 1/19/2018 RUSDIANA 5/1/1970 P A15.0 TB PARU √ √
44 1/19/2018 MATTARIF 5/5/1966 L J44.0 PPOK √ √
45 1/19/2018 ABDUL MANAP 10/27/1957 L J44.0 PPOK √ √
46 1/17/2018 ZAILANI 3/11/1961 L A15.0 TB PARU √ √
47 1/17/2018 KERO 6/9/1962 L I50.9 CHF √ √
48 1/17/2018 SAHRINTEN 7/5/1950 P M54.4 LBP √ √
49 1/17/2018 TIROMA SIREGAR 5/20/1976 L S72 FRACTURE OF FEMUR √ √
DEFIRA ISMI NUR √ √
50 1/17/2018 12/24/2015 P R05 COUGH
MAULIDA
51 1/17/2018 NOVA L 12/24/2011 P BKB √ √
CRISTIAN PALENTINO √ √
52 1/17/2018 2/13/2008 L F03 UNSPECIFIED DEMENTIA
SINAGA
53 1/17/2018 USIN 4/12/1948 L E11 DM TIPE II √ √

54 1/17/2018 ABDUL MADJID 5/3/1951 L STRIKTUR URETER √ √
55 1/16/2018 TRI WAHYU WULANDARI 2/18/1993 P H54.51 LOW VISION √ √
56 1/16/2018 SITI NORIFAH 7/27/1950 P I50.9 CHF √ √
57 1/16/2018 RAHMAH 12/31/1958 P H26 KATARAK √ √
58 1/16/2018 MURDIANI 7/21/1975 P I50.9 CHF √ √
59 1/16/2018 SITI MAISYARAH 11/7/2014 P DOWN SYNDROM √ √
60 1/16/2018 SALMIYAH 7/1/1956 P E11 DM TIPE II √ √
61 1/15/2018 FARDAN 7/1/2008 L G40 EPYLEPSI √ √
62 1/15/2018 SUPRIYADI 6/14/1952 L I50.9 CHF √ √
MALIGNANT NEOPLASM OF √ √
63 1/15/2018 RIRIN NIANTI DEWI 6/20/1996 P C00.9
BREAST
64 1/15/2018 ENDANG 12/7/1987 P B20 B20 √ √
65 1/15/2018 SITI MUNAWAROH 4/1/1963 P E11 DM TIPE II √ √
BENIGN NEOPLASM OF √ √
66 1/15/2018 LASMI 12/1/1975 P D24
BREAST
67 1/13/2018 HALIPAH 10/13/2002 P H54.51 LOW VISION √ √
68 1/13/2018 ARDIANSYAH 8/8/1984 L H05.9 DISORDER OF ORBIT √ √
69 1/12/2018 HALIAH 6/4/1965 P I50.9 CHF √ √
70 1/12/2018 JAINUN 7/1/1966 P A15.0 TB PARU √ √
71 1/12/2018 RUSTIANI 8/10/1966 P H60.9 OTITIS EKTERNAL √ √
72 1/12/2018 SAPRAH 3/9/1956 L E11 DM TIPE II √ √
74 1/12/2018 RUSLI 7/1/1964 L I10.9 HIPERTENSI GR II √ √
75 1/11/2018 KEMO SABANI 7/1/1947 L I50.9 CHF √ √
76 1/10/2018 HIRI 9/1/1996 L K40 INGUINAL HERNIA √ √
77 1/10/2018 NURBAYTI 10/25/1984 P D25 LEIOMYOMA OF UTERUS √ √
78 1/10/2018 SYAHRANI 9/14/1996 L J44.0 PPOK √ √
79 1/10/2018 LIRI 9/14/1996 L K40 INGUINAL HERNIA √ √
80 1/10/2018 MASDARIYAH 3/9/1983 P L72.0 EPIDERMAL CYST √ √
81 1/9/2018 ARYATI 5/7/1993 P CERVIATIS √ √
82 1/9/2018 INDAH PERMATA SARI 20/02/200 P H66.9 OTITIS MEDIA KRONIK √ √
83 1/9/2018 BAHRUDIN 4/2/1961 L A30 MORBUS HANSEN √ √
84 1/9/2018 ARBAIYAH 11/13/1969 P ULKUS DIABETIKUM √ √
85 1/9/2018 RUDIANSYAH 12/1/1993 L S42.3 FRAKTUR HUMERUS √ √
86 1/9/2018 TASMAN MISI 7/1/1961 L SCIATICS SITE UNSPECIFIED √ √
BENIGN NEOPLASM OF √ √
87 1/9/2018 RUMINIE 8/21/1955 P D30.0
KIDNEY
88 1/9/2018 ICHA RAHMADANI 9/1/2009 P L30.9 DERMATITIS KONTAK ALERGI √ √
89 1/8/2018 USIN 4/12/1948 L H26 KATARAK √ √
90 1/8/2018 YULIANA 7/1/1966 P M12 ARTHROSIS UNSPECIFIED √ √
91 1/8/2018 SUYONO 7/5/1984 L K30 DYSPEPSIA √ √
HYPOPARATHYROIDISM, √ √
92 1/8/2018 JUNAIDI 8/18/1977 L E20.9
UNSPECIFIED
93 1/8/2018 ARMAWI 11/4/1965 L E11 DM TIPE II √ √

94 1/8/2018 DEDI SAPTANA 9/1/1989 L F20 SCHIZOPHRENIA √ √
95 1/8/2018 ASMARA 7/1/1969 L E11 DM TIPE II √ √
96 1/6/2018 USMAN SADAT 10/1/1932 L E11 DM TIPE II √ √
97 1/6/2018 MARDIYAH 7/1/1957 P I50.9 CHF √ √
98 1/6/2018 AMRI 12/31/1961 L G20 PARKINSON'S DISEASE √ √
99 1/6/2018 RESTI 3/8/1985 P J45 ASMA BRONCHIALE √ √

100 1/6/2018 SRI HARTATI 3/12/1958 P I10 HIPERTENSI GR II √ √
101 1/6/2018 RUSTIANI 8/10/1966 P H60 OTITIS EXTERNA √ √
102 1/5/2018 SUGINO 9/19/1955 L I50.9 CHF √ √
103 1/5/2018 JAHRAH P G70.0 MAESTANIA GRAVIS √ √
104 1/4/2018 SURIANSYAH 10/9/1961 L R51 HEADACHE √ √
105 1/4/2018 SITI MUNAWAROH 4/1/1963 P J45 ASMA BRONCHIALE √ √

DISLOCATION OF ANKLE √ √
106 1/4/2018 IDA JURAIDAH 8/30/1960 P S93.0
JOINT
107 1/4/2018 RAHMAD SULDI 12/1/1984 L F20 SCHIZOFHRENIA √ √
NONSPECIFIED REACTIVE √ √
108 1/3/2018 SARIFAH SALMAH 5/9/1969 P K75.2
HEPATITIS
109 1/3/2018 MARSIAN MONCUBE 10/10/1955 L E11 DM TIPE II √ √
110 1/2/2018 JOHRATAN 7/1/1970 L MDS √ √
111 1/2/2018 SYAHRANI 7/1/1968 L J44.0 PPOK √ √
112 1/2/2018 MARYATUL QIFTIYAH 9/1/1960 P G20 PARKINSON'S DISEASE √ √
113 1/2/2018 AHMAD BUKHAIRI 12/21/2008 L G40 EPYLEPSI √ √
114 1/2/2018 ALPINDI 10/1/1990 L F20 SCHIZOFHRENIA √ √
CHRONIC OBSTRUKTIVE
115 1/2/2018 HATMAN 8/1/1962 L HJ44.9 PULMONARY DISEASE WITH √ √
ACUTE I
Mengetahui Kumai, 08 Februari 2018

NIP.19700526 200501 1 011 NIP.10721031 199303 1005
DINAS KESEHATAN
PUSKESMAS KUMAI

BULAN FEBRUARI 2018
TANGGAL MEDICAL
USIA LAIN DI RAWAT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 2/3/2018 SYAKIRA 8/29/2010 P J34.1 MUCOCELE √ √
OTHER AND UNSPECIFIED √ √

2 2/3/2018 NORRAHMAH 3/10/1990 P
OVARIAN CYSTS
3 2/3/2018 SITI MUNAWAROH 4/1/1963 P J45 ASHMA √ √
4 2/3/2018 ASIAH 5/23/1958 P I50.9 CHF √ √
5 2/3/2018 NUNIEK W 12/29/1982 P H52.1 MYOPIA √ √
6 2/3/2018 ALEXANDER B.M 7/17/1989 L J20.9 FRACTURE OF CLAVICLE √ √
7 2/2/2018 KERO 6/9/1962 L I50.9 CHF √ √
8 2/2/2018 KALSUM 12/1/1941 P I50.9 CHF √ √
9 2/2/2018 SATIYAH 7/1/1965 P R07.4 CHEST PAIN √ √
10 2/2/2018 HAFSIAH 1/1/1982 P H11.0 PTERYGIUM √ √
11 2/2/2018 JUDAH 7/1/1970 P A15.0 TB PARU √ √
12 2/1/2018 RAMLI 3/25/1996 L A15.0 TB PARU √ √
13 2/1/2018 PUNADIN 3/1/1973 L R00.1 BRADYCARDIA √ √
14 2/1/2018 ELLA PUSPITASARI 7/10/2001 P KALA II LAMA √ √
15 2/1/2018 NAIMAH 4/9/1966 P E11 DM Tipe II √ √
16 2/1/2018 RINA PURNAMA S 4/4/1990 P R18 ASCITES √ √
17 2/10/2018 MURDIANI 7/1/1975 P I50.9 CHF √ √
CALCULUS OF KIDNEY AND √ √

18 2/10/2018 AHMAD SURIANSYAH 4/15/1960 L I86.1 URETER
19 2/10/2018 ALPINDI 10/1/1990 L F20.0 SCHIZOFRENIA √ √
20 2/9/2018 ANANDA DYAH 7/10/1995 P F20.0 SCHIZOFRENIA √ √
21 2/9/2018 AMINAH 6/17/1969 P I50.9 CHF √ √
22 2/9/2018 NORYANI 7/1/1965 P I10 HIPERTENSI GR II √ √
23 2/9/2018 ENCEP KAMARUDIN 6/14/1984 L I50.9 CHF √ √
24 2/8/2018 RAMLAH 7/1/1961 P H26 CATARACT √ √
25 2/8/2018 NORIMA 1/1/1981 P M54.4 LOW BACK PAIN √ √
26 2/8/2018 SYAHRANI 7/1/1968 L J44.0 PPOK √ √
27 2/7/2018 WINDA ERISKA 12/14/2000 P SEROTINUS √ √
28 2/6/2018 ZAINUN 1/1/1983 P POST OP FIBRO MAMMAE √ √
29 2/3/2018 SAMPURNA 5/5/2018 P B15 HEPATITIS B √ √
30 2/3/2018 NANI 5/20/1974 P E11 DM Tipe II √ √
31 2/3/2018 PURYADI 8/5/1980 L POST KLL √ √
32 2/13/2018 SUPRIYADI 6/14/1952 L J44.0 PPOK √ √
SYSTEMIC LUPUS √ √
33 2/13/2018 YURNI 10/1/1989 P M32.9
ERYTHEMATOSUS
HERNIA INGUINALIS LATERAL √ √

34 2/13/2018 JUANDA 4/7/1975 L K40
DEXTRA
DISLOKASI CAPUT HUMERUS √ √

35 2/13/2018 SRIYANI 12/31/1981 P
DEXTRA
36 2/12/2018 ARNIMAH 3/5/1969 p I10 HIPERTENSI GR II √ √
NONSPECIFIC
37 2/12/2018 PEBRIANTI PUTRI 2/12/2001 P I88 LYMPHADENITIS √ √
UNSPECIFIED
38 2/12/2018 NOOR RAHMAH 6/2/1959 P I63 CEREBRAL INFARCTION √ √

39 2/10/2018 DESY HERAWATI 4/4/1984 P J33.9 NASAL POLYP √ √
40 2/17/2018 ARDIANSYAH 8/8/1984 L H05.9 DISORDER OF ORBIT √ √
41 2/17/2018 SAID USIN 12/1/1939 L I10 HIPERTENSI GR II √ √
42 2/17/2018 FIRDA AYU 5/20/2004 P G40 EPYLEPSI √ √
43 2/17/2018 MATTARIF 5/5/1960 L H67.8 OTITIS MEDIA SUPURATIF √ √
44 2/17/2018 LUHU 75/06/1960 L I10 HIPERTENSI GR II √ √
MASSA REGOI OS PARIENTAL √ √

45 2/15/2018 LISWATI 6/16/1974 P
SINISTRA
46 2/15/2018 HALIAH 6/4/1965 P I50.9 CHF √ √
47 2/15/2018 SAMSIAR 1/1/1956 P PSIKOSIS √ √
48 2/15/2018 MURSIMAN 6/14/1953 L G20 PARKINSON'S DISEASE √ √
49 2/14/2018 TOYO 10/19/1947 L R05 COUGH √ √
50 2/14/2018 AHMAD SURIANSYAH 4/15/1960 L J44.0 PPOK √ √
51 2/14/2018 MARYATUL QIFTIYAH 9/1/1960 P G20 PARKINSON'S DISEASE √ √
52 2/14/2018 MAHIPAL 6/15/1958 L I10 HIPERTENSI GR II √ √
53 2/14/2018 ROHANA 8/1/1983 P G40 EPYLEPSI √ √
54 2/14/2018 MATARIP 5/5/1960 L J44.0 PPOK √ √
55 2/17/2018 ARLIANI 10/1/1999 P D64.9 ANEMIA √ √
56 2/17/2018 NOVA LUQMAN AFIANDI 11/23/2011 P J44.0 PPOK √ √
57 2/17/2018 DEFIN SETYANA 12/23/1985 P M43.0 SPONDYLOLYSIS √ √
58 2/17/2018 AGUS HERIYONO 8/17/1989 L E03.9 HYPOTHYROIDISM √ √
59 2/17/2018 FARIDAH 10/1/1987 P I09.9 RHEUMATIC HEART DISEASE √ √
60 2/17/2018 MAHDAYANG 5/14/1956 P R41.3 AMNESIA RETROGAT √ √
61 2/17/2018 SITI MUNAWAROH 4/1/1963 P E11 DM Tipe II √ √
62 2/17/2018 SOLIKAH 4/1/1970 P I50.9 HEART FAILURE √ √
63 2/21/2018 JUANDA 1/9/1968 L M19 OTHER ARTHROSIS √ √
64 2/21/2018 SUPRIYATI 7/1/1971 P G51 FACIAL NERVE DISORDERS √ √
66 2/20/2018 EKA PERTIWI 4/12/1996 P R07.4 CHEST PAIN √ √
67 2/19/2018 BARLIAN 8/28/1968 P H26 CATARACT √ √
68 2/19/2018 SADILLAH 10/4/1957 L J44.0 PPOK √ √
69 2/19/2018 MISNAWATI 6/5/1975 P H52.0 HYPERMETROPIA √ √
70 2/19/2018 RUSMAITA 6/8/1976 P N23 COLIC ABDOMEN √ √
71 2/19/2018 MAT SALEH 10/10/1976 L N18 CHRONIC KIDNEY DISEASE √ √
72 2/19/2018 FARDAN 7/1/2008 L G40 EPYLEPSI √ √
73 2/19/2018 NUR GIYANTI 8/14/1978 P I50.9 HEART FAILURE √ √
74 2/17/2018 SITI FATMADIYAH 2/10/1998 P A30.9 LEPROSY √ √
75 2/17/2018 HALIMAH 7/1/1950 P M54.4 LOW BACK PAIN √ √
76 2/24/2018 SUTARNO PRAWIRO 2/13/1965 L I63 CEREBRAL INFARCTION √ √
77 2/23/2018 MASNIAH 3/1/1977 P H93.1 TINNITUS √ √
78 2/23/2018 NISMAH 10/1/1960 P H26 CATARACT √ √
79 2/23/2018 NILA NADILA 6/4/1996 P N30.2 OTHER CHRONIC CYSTITIS √ √
80 2/21/2018 USIN 4/12/1948 L E11 DM Tipe II √ √
81 2/21/2018 ELIT SUMIRAHA 10/26/1980 P E11 DM Tipe II √ √
82 2/21/2018 DONNY 12/18/1997 L L91.0 KELOID √ √
83 2/26/2018 MULYADI S 2/28/1938 L H26 CATARACT √ √
DIABETIC √ √
84 2/26/2018 NOOR RAHMAH 5/2/1959 P G59.0
MONONEUROPATHY
85 2/26/2018 WARDAH 10/24/1988 P H52.1 MYOPIA √ √
86 2/26/2018 JURIAH 6/25/1971 P I10 HIPERTENSI GR II √ √
87 2/26/2018 PEBRIAN MAULANA S 3/1/2008 P G40 EPYLEPSI √ √

88 2/26/2018 NORIMA 1/1/1981 P M54.4 LOW BACK PAIN √ √
89 2/24/2018 TOMAR 7/5/1960 L E11 DM Tipe II √ √
90 2/24/2018 MARSIAN MONCUBE 10/10/1955 L A15.0 TB PARU √ √
91 2/24/2018 KHOTIMAH 8/17/1971 P H36.0 RETINOPATHY DIABETIC √ √
HERNIA INGUINALIS LATERAL √ √

92 2/28/2018 ZAISNI 4/3/1970 L K40
DEXTRA
93 2/28/2018 SITI MARLINA 5/9/1978 P R10 PELVIC PAIN √ √

94 2/26/2018 BADRIYANI 11/1/2006 P F63.2 KLEPTOMANIAL √ √
95 2/26/2018 SUPRIYADI 6/14/1952 L J44.0 PPOK √ √
96 2/26/2018 SIREN PUTRI AULIA 3/15/2012 P H52.1 MYOPIA √ √
Mengetahui Kumai, 05 Maret 2018

NIP.19700526 200501 1 011 NIP.10721031 199303 1005
DINAS KESEHATAN
PUSKESMAS KUMAI

BULAN MARET 2018
TANGGAL MEDICAL
USIA LAIN DI RAWAT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 3/31/2018 SATRI 3/5/1952 L I10 HIPERTENSI GR II √ √
2 3/31/2018 JAINAH 8/5/1970 P DERMATOPHYTOSIS √ √
3 3/31/2018 USIN 4/12/1948 L E11 DM TYPE II √ √
4 3/31/2018 LUTFIYATUL KHUSNI 8/30/2016 P PNEUMONIA √ √
5 3/31/2018 NISMAH 10/1/1960 P CATARACT √ √
6 3/31/2018 RUSLI 10/6/1964 P A15.0 TB PARU √ √
7 3/29/2018 FATTE MARIANA 12/15/1964 P I50.9 CHF √ √
8 3/29/2018 SETIANA ROMLAH 9/21/2001 P F20.0 SCHIZOFRENIA √ √
9 3/26/2018 RIZAL TAUFIK 11/24/1965 L RIWAYAT SINCOPE √ √
10 3/19/2018 NURFATIMAH 7/13/1998 P H52.1 MYOPIA √ √
11 3/19/2018 SITI MUNAWAROH 4/10/1963 P I10 HIPERTENSI GR II √ √
UNSPECIFIED VIRAL
12 3/19/2018 SAMPURNA 5/5/1966 L HEPATITIS WITHOUT HEPATIC √ √
COMA
13 3/19/2018 M.FARDAN 7/1/2008 L G40 EPYLEPSI √ √

14 3/19/2018 PATINA 1/7/1957 P I50.9 CHF √ √
15 3/16/2018 FATIMAH 7/1/1957 P I50.9 CHF √ √
16 3/16/2018 NILA NADILA 6/4/1996 P SYNDROME NEFROTIC √ √
17 3/16/2018 SEPTIYANTI RAHAYU 9/17/1988 P POST OP GANGLION √ √
18 3/16/2018 SITI ROHANI 7/2/1975 P CYSTA OVARIUM √ √
19 3/16/2018 YOGA PRATAMA 5/1/1996 L FRACTURE OF LOWER LEG √ √
20 3/16/2018 SOLIKAH 4/1/1970 P I50.9 CHF √ √
21 3/15/2018 SATIYAH 7/1/1965 P POST HERPETIC NEURALGIA √ √
22 3/15/2018 SYAMSUL BAHRIAH 1/1/1958 L H26 CATARACT √ √
23 3/15/2018 SATRI 3/1/1952 L H26 CATARACT √ √
24 3/15/2018 SETIAWAN 10/10/1986 L CYSTA ATEROMA √ √
25 3/15/2018 FITRI HANDAYANI 6/23/2013 P CYSTA ATEROMA √ √
26 3/15/2018 NOVI 12/5/1993 P ANTENATAL SCREENING √ √
27 3/15/2018 MUHAMMAD RUDY 9/1/1978 L LOW VISION OTHER EYE √ √
28 3/15/2018 AMILUDIN 7/1/1963 L H26 CATARACT √ √
29 3/15/2018 PEBRIANTI PUTRI 2/12/2001 P ENLARGED LYMPH NODES √ √
30 3/12/2018 IDA 12/1/1982 P KELAINAN SUSUNAN SARAF √ √
31 3/12/2018 SUGESTI 11/19/2003 P MENINGITIS √ √
32 3/12/2018 FARHANA HUMAIRA 8/15/2013 P J45 ASTHMA √ √
33 3/12/2018 PEBRIAN MAULANA S 3/1/2008 P G40 EPYLEPSI √ √
34 3/12/2018 MURDIANI 7/21/1975 P I10 HIPERTENSI GR II √ √
OTHER SUPERFICIAL √ √
35 3/9/2018 GATOT NURIMAN 9/1/1963 L
MYOOSES
36 3/9/2018 SUGINO 9/19/1955 L I50.9 CHF √ √

37 3/9/2018 SALMAH 10/15/1977 P PTERYGIUM √ √
38 3/9/2018 YAHYA 7/1/1927 L I50.9 CHF √ √
CALCULUS OF KIDNEY AND √ √

39 3/9/2018 ARPA'I 7/1/1975 L
URETER
40 3/9/2018 ASIAH 7/7/1968 P POLYNEUROPATHY √ √
41 3/9/2018 SYAHRANI 7/1/1968 L J44.0 PPOK √ √
42 3/9/2018 MARSIAN MONCUBE 10/10/1955 L E11 DM Tipe II √ √
43 3/9/2018 RUSLI 10/8/1964 L K30 DYSPEPSIA √ √
44 3/1/2018 HIMAWAN SUTANTO 10/5/1974 L F20.0 SCHIZOFRENIA √ √
45 3/1/2018 MURNIATI 1/28/1964 P M54.4 LBP √ √
46 3/1/2018 HUSNUL ANDINI 3/9/2011 P APPENDIKSITIS √ √
47 3/2/2018 EDY SUGITO 4/19/1957 L I10 HIPERTENSI GR II √ √
48 3/2/2018 LUSIANA FITRI 6/1/2011 P TRAUMA ORBITA √ √
POST OP EXOIR FIBRO √ √

49 3/2/2018 ZAINUN 1/5/1984 P
MAMMAE
50 3/5/2018 AMRI 12/31/1961 L G20 PARKINSON'S DISEASE √ √
GLOMERULUS NEFRITIS √ √
51 3/5/2018 NILA NADILA 6/4/1996 P
AKUT SINISTRA
52 3/5/2018 KAMALUDIN 4/10/1965 L R07.4 CHEST PAIN √ √
CONJUNCTIVAL √ √
53 3/3/2018 NADIA LIAN 3/13/2002 P
HAEMORRHAGE
54 3/5/2018 JUMIATI 12/1/1962 P PTERYGIUM √ √
55 3/5/2018 PUTIMAH 2/15/1951 P I50.9 CHF √ √
56 3/5/2018 TARIMAN 5/1/1950 L E11 DM TYPE II √ √
57 3/7/2018 JUNAIDI 8/18/1977 L HYPERTIROID √ √
58 3/7/2018 JAHARA 9/15/1966 P MAESTANIA GRAVIS √ √
Mengetahui Kumai, 07 April 2018

NIP.19700526 200501 1 011 NIP.10721031 199303 1005

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SURAT RUJUKAN PESERTA

Puskesmas / Dokter Keluarga : dr. ABIMAYU Kode :

Puskesmas / Dokter Keluarga

Kepada Yth TS dr .Poli : Anak

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Nama : AN. REZAL FAHRIAN NOR Umur : 06 Juli 2003

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SURAT RUJUKAN PESERTA

Puskesmas / Dokter Keluarga : dr. ABIMAYU Kode :

Puskesmas / Dokter Keluarga

Kepada Yth TS dr .Poli : Dalam

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Nama : Ny. MARIAM Umur : '23 Juli 1975

SURAT RUJUKAN BALIK

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Pengobatan dengan obat - obatan Perlu rawat Inap

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Puskesmas / Dokter Keluarga : KUMAI Kode :

Puskesmas / Dokter Keluarga

Kepada Yth TS dr .Poli : DALAM

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Nama : NY. JAUYAH Umur : 09 Oktober 1960

SURAT RUJUKAN BALIK

Teman sejawat Yth :

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SURAT RUJUKAN PESERTA

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Nama : TN. ERNAS FARIDAEN Umur : '02 / 02 / 1962

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No Rujukan : 445 / 1587 / KI .A

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Puskesmas / Dokter Keluarga

Kepada Yth TS dr .Poli : KULIT

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Nama : TN. SUMARNO HADI Umur : 28 Februari 1938

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No Rujukan : 445 / 140202010414Y000164 / KI .A

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Puskesmas / Dokter Keluarga

Kepada Yth TS dr .Poli : KULIT

Mohon pemeriksaan dan penanganan lebih lanjutnpenderita

Nama : TN. SUMARNO HADI Umur : 28 Februari 1938

H. SYAMSUL ARIFIN .AMK

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Teman sejawat Yth :

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