L

Umur
N P
TGL JAM Nama Alamat NO. REGISTER KTP / SPM KUNJUNGAN Pekerjaan Anamnesa TD NADI RR Suhu TB BB
O

Kalianget
1 1-Aug-18 10.00 Minarniyati
Timur
54 th P 405/352/435.303.102/2018 LAMA 110/70 80 20 36.3

Kalianget
2 1-Aug-18 11.30 Moh.Miftahol
Barat
01 th L 405/1361/435.303.101/2018 102 26 36.6

Kalianget
3 1-Aug-18 12.30 Ernawati
Barat
39 th P 3529024502790001 130/90 88 20 36

Kalianget
4 2-Aug-18 10.10 Laila Nur Azizah
Barat
13 th P 3529024311040002 90/60 90 22 37.6

5 2-Aug-18 16.50 Alvin Kalimo'ok 07 th L 3529020108110001 100 22 36.6

6 3-Aug-18 17.50 indar mersiana Kertasada 02 th P 3529026805160002 100 24 36.6

Karang
7 4-Aug-18 06.40 Ageng suryo
anyar
18 th L 405/ /435.303.104/2018 100/70 88 22 36.4

Karang
8 4-Aug-18 09.10 Maimuna
anyar
54 th L 352902630650001 130/80 86 22 36.2

Kalianget
9 4-Aug-18 09.30 Jusup
Barat
51 th L 3529020101670010 120/70 80 20 36.5

Kalianget
10 4-Aug-18 11.00 Sahwiyatun
Barat
54 th P 3529027006640078 140/80 86 22

Karang
11 4-Aug-18 16.30 Andini
anyar
10 th P

12 4-Aug-18 17.00 Wildan Kertasada 08 th L 3529022812100001

Kalianget
13 4-Aug-18 19.30 Syarifa Nurfaiza
Barat
09 th P 3529024704140001

14 6-Aug-08 07.00 Haisin Kertasada 78 th L 405/554/435.303.606/2018 130/80 89 21

Karang
15 6-Aug-08 14.00 Ageng suryo
anyar
18 th L 405/435.303.104/2018 120/80 80 20

Kalianget
16 6-Aug-08 19.00 Nurul wahid
Barat
L 3529025010920019 120/80 80 20

Kalianget
17 6-Aug-08 Salamet riydi
Barat
4 th L 3529022605140001 37.9

Pinggir
18 7-Aug-28 10.15 Hosni mubarok
Papas
52 th L 3529020105880004 100/70

19 7-Aug-28 11.30 Wildan Kertasada 08 th L 405/66/435.303.106/2018

Kalianget
20 7-Aug-28 16.30 Bustanul Arifin
Barat
07 th L 3529020311090001
21 7-Aug-28 18.00 Moh. Jamaludin Kertasada 03 th L 3529021704150002

22 8-Aug-18 18.35 Wildan Kertasada 08 th L 405/66/435.303.106/2018

Kalianget
23 10-Aug-18 17:30:00 Jillah
Barat
6.5 L 3529024402120001 112 30 37.6

Kalianget
24 11-Aug-18 11:00:00 Eka novia
Barat
21 P 3529024211970003

Kalianget
25 11-Aug-18 11:15:00 Imam Bahri
Barat
58 L 352902102600001 120/70 80 20 36

26 11-Aug-18 11:20:00 Wildan Kertasada 8 L '405/66/435.303.106/2018 90 23 36;7

Marengan
27 11-Aug-18 12:00:00 Moh.Zaini
Laok
64 L 3529021208540003 140/90 80 22

Kalianget
28 12-Aug-18 17:00:00 Fitho alfiyansyah
Barat
Karang
29 13-Aug-18 7:30:00 Sadima
anyar
75 P 3529024802430001 130/80 80 20 36

30 13-Aug-18 10:00:00 Sabik kalimook 45 L 3529023006600124 120/70 82 20 36.1

Kalianget
31 13-Aug-18 13:00:00 Ferdy wiranto
Barat
11 L 3529021909070001 88 24

32 13-Aug-18 15:00:00 Indira Kertasada 2.5 P 3529026805160002 87 22 37.2

33 14-Aug-18 9:30:00 Haisin Kertasada 78 L 405/684/435.303.106/2018 140/80 80 22

Kalianget
34 14-Aug-18 15:30:00 Moh. Hari
Barat
66 L 3529022707520001 120/70 78 20

35 15-Aug-18 15:30:00 Hanimah Kertasada 47 P 3529024609720004 140/90 82 20

36 15-Aug-18 16:00:00 Rumsiati Kertasada 55 P 3529025101560001 90/60 80 20

37 15-Aug-18 20:00:00 Misnawati Kertasada 25 P 3529024006920004 110/70 82 20

Kalianget
38 16-Aug-18 12:30:00 Admi
Barat
45 P 3529026511630002 110/70 80 20

39 16-Aug-18 17:50:00 Wildan Kertasada 8 L 405/66/435.303.106/2018

40 16-Aug-18 11:30:00 Misrawti Kalimo'ok 21 P 3529026511970006 110/70 80 20

41 18-Aug-18 10.00 Miskaya Kalimo'ok 58 L 3529020107601164 BARU 130/80 82 20 38

42 18-Aug-18 14:00:00 wildan Kertasada 8 L 405/66/435.303.106/2018 112 26

 Kalianget
43 18-Aug-18 23.45 Siti Aisyah
Barat
57 P 3529024606620001 120/80 80 22

44 19-Aug-18 05.00 Haisin Kertasada 68 L 405/684/ 120/80 82 20

Kalianget
45 19-Aug-18 10.00 Suro
Timur
43 th L 110/70 80 20

Pasongsong
19-Aug-18 15:15:00 Sumayyah 24 P 3529135906940004 BARU 110/80 87 21
an

19-Aug-18 18:30:00 Yarohtok Kalimo'ok 8 L 3529021412100001 BARU 97 22 36.5

Marengan
46 22-Aug-18 9:10:00 Jihan TU
Laok
4 th 3529024910140001 BARU Muntah,Diare 98 24 36.4

47 22-Aug-18 14:10:00 Lutfi kalimook 6 th 3529020712120002 BARU Muntah,Diare 100 22 36.7 13 kg

Kalianget
48 22-Aug-18 15:00:00 Annora
Barat
26 bln 3529026706160003 BARU Muntah,Diare 120 26 36.8 10,5 kg

Kalianget
49 22-Aug-18 15:30:00 Suro
Timur
43 L LAMA Kontrol 120/80 88 20

50 22-Aug-18 15:10:00 Siti Mardiah Bandung 38 P 3273064808800009 BARU panas 120/80 87 21 38

Marengan
51 23-Aug-18 0:25:00 Faeza
Laok
5 L 3529010309130002 BARU Muntah,Diare 98 22 36

Kalianget
52 24-Aug-18 5:30:00 Aztaqirani
Barat
3 th P 3529025110150001 BARU Demam 102 24 37.6 9

Pinggir
53 24-Aug-18 8:00:00 Masruna
Papas
79 th L 3529023006390018 BARU Luka lecet

Kalianget
54 24-Aug-18 10:40:00 Dela Nura L
Timur
3 th P 3529026109150002 BARU Demam 89 24 38

Kalianget
55 25-Aug-18 8:00:00 Suro
Timur
43 th L LAMA Kontrol

Pinggir
56 25-Aug-18 9:00:00 Masruna
Papas
79 th L 3529023006390018 BARU Demam

57 25-Aug-18 20:00:00 Adiba Kertasada 03 th P 0413-994 Nyeri Kepala 13

Kalianget
58 25-Aug-18 21:20:00 Yunus Dedi
Timur
28 th L 3529021205900001 Nyeri Perut 100/60 82 20

Marengan
59 26-Aug-18 10:50:00 Sahwati
Daya
66 th P 352917006520077 Pusing 180/100 78 20

60 26-Aug-18 12:30:00 Retno Wahyudi Kertasada 36 th P 3529016903820007 Luka lecet

61 26-Aug-18 19:47:00 Amel Kalimo'ok 15 bln P

Marengan
62 26-Aug-18 23:20:00 Sunaryo
laok
51 th L 3529020107570064 Sesak 110/70 82 26

Pinggir
63 27-Aug-18 9:30:00 Masruna
Papas
79 th L 3529023006390018 Demam 120/80 80 20
 Kalianget
64 27-Aug-18 12:00:00 Misari
Timur
60 th P 3529027006580088 BARU kontrol 140/90 90 20 36.3

65 27-Aug-18 17:20:00 Sutriman Jombang 61 th L 3517033112570003 BARU 150/90 88 20 36.1

Kalianget
66 27-Aug-18 18:30:00 Awiyani
Barat
45 th P 3529024107740123 LAMA 120/80 82 20 36.7

67 28-Aug-18 8:30:00 Sittina pabian 62th P 3529017006560075 BARU 120/80 82 20 367

68 29-Aug-18 21:30:00 Sumiyati Kertasada

69 30-Aug-18 10:00:00 Alviana afifa kalimook 4th P 3529024808150001 BARU 114 27 365

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 TRIAGE
Diag. ICDX. Tindakan Obat BAGIAN MASUK KELUAR

Debridement
E 01 Gliben,metro K BDH Sendiri PS
Luka Ringan

T 01 K INT Sendiri PS

T 01 CTM,Dexa K INT Sendiri PS

R 11 Ibuprofen,Amox K INT Sendiri PS

R 50 Ibuprofen,Cefad K INT Sendiri PS

R 11 Domperidone K ANK Sendiri PS

Debridement
T01 K BDH Sendiri PS
Luka Sedang
Debridement
T01 Ibuprofen, amox K BDH Sendiri PS
Luka Sedang
Debridement
T00 K BDH Sendiri PS
Luka Ringan
ibuprofen,
R10 domperidone, K INT Sendiri PS
famotidine
ibuprofen,
R50 K INT Sendiri PS
domperidone
Debridement
T01 K BDH Sendiri PS
Luka Sedang

R50 ibuprofen syr K INT Sendiri PS

Pemasangan
dan atau
N40 K INT Sendiri PS
pencabutan
kateter urine
Debridement
T01 K BDH Sendiri PS
Luka Sedang

K INT Sendiri PS

R10 K INT Sendiri PS

R50 ibuprofen , metro K INT Sendiri PS

Debridement
T01 K BDH Sendiri PS
Luka Sedang

R50 ibuprofen K INT Sendiri PS

R10 ibuprofen K INT Sendiri PS
Debridement
T01 K BDH Sendiri PS
Luka Sedang

R50 ibuprofen syr K INT Sendiri PS

L23 CTM,Dexa K INT Sendiri PS

Debridement
TO1 ibuprofen,cipro K BDH Sendiri PS
Luka Ringan
Debridement
T01 K BDH Sendiri PS
Luka Sedang

K INT Sendiri PS

T01 Insisi abses Metro,ibubprofen k BDH Sendiri PS

Sendiri PS

Debridement
T01 Metro,ibubprofen K BDH Sendiri PS
Luka Sedang
R11 K INT Sendiri PS

Pemasangan
dan atau
N40 K INT Sendiri PS
pencabutan
kateter urine
Debridement
T01 K BDH Sendiri PS
Luka Sedang

Amlodipin, Vit
K INT Sendiri PS
BC,

Amaropo k INT Sendiri PS

GG, vit C K INT Sendiri PS

R50 Pct, Amox K INT Sendiri PS

T01 Angkat jahitan K BDH Sendiri PS

Metro,
A09 Donperidon, K INT Sendiri PS
Molagit
famotidin,amarop
R 50 K INT Sendiri PS
o
T 01 ibuprofen,amox K BDH Sendiri PS
 Metro,
A09 Ibuprofen,Pct K INT Sendiri PS

Pemasangan
dan atau
N40 K INT Sendiri PS
pencabutan
kateter urine

T 01 pct, Amox,Ats K BDH Sendiri PS

R10 ibuprofen 3x1 K INT Sendiri PS

cotrimoks 2x1,
K INT Sendiri PS
pct syr 3x1
zinc syp,neo
A09 K ANK Sendiri PS
kaominal, pct syp
zinc syp,neo
A09 K ANK Sendiri PS
kaominal, pct syp
zinc syp,neo
A09 kaominal, Vosea K ANK Sendiri PS
syp
Debridement
T01 K BDH Sendiri PS
Luka Ringan
PCT syr 3x1,
R50 K INT Sendiri PS
Cefad 3x1
domperidon 3x1,
R11+A09 neokomial 3x1, K INT Sendiri PS
zinc 1x1
zinc 1x1,
R50 K ANK Sendiri PS
chloramp 3x1
Debridement ibupro 3x1, amox
T00 K BDH Sendiri PS
Luka Ringan 3x1

R50 ibupro, amox K ANK Sendiri PS

Debridement
T01 K BDH Sendiri PS
Luka Sedang

R50 Ibuprofen, amox K INT Sendiri PS

R10 Syr Ibupro K ANK Sendiri PS

R05 Famotidin, Ibupro K INT Sendiri PS

Amlodipin,
I10 K INT Sendiri PS
ibupro
Debridement vit. C, ibupro,
T01 K BDH Sendiri PS
Luka Sedang cipro
Ibuprofen,
L23 K ANK Sendiri PS
chloram S
Ibuprofen,
J45 famotidine,salbuta K INT Sendiri PS
mol

R50 Ibuprofen K INT Sendiri PS

E10 Ibuprofen K INT Sendiri PS

Ibuprofen, CTM K INT Sendiri PS

Ibuprofen,
K INT Sendiri PS
chloram

ibuprofen,amox K INT Sendiri PS

amox,ibupfrofen K INT Sendiri PS

 N S
L

Umur
N STATUS A U
TGL JAM Nama Alamat / NO. REGISTER RM BPJS TD RR TB BB Pekerjaan Diag. ICDX. Obat Tindakan
KELUAR
O KUNJUNGAN D H
P
I U

Debridement Luka
1 2-Aug-18 10.00 Masbullah Kertasada 67 L 1401711 02 0001706319617 LAMA 110/70 84 20 36.3 T 25 + J 45 Amino,Amox Sedang PS

2 2-Aug-18 10.30 Vira A.P kertasada 17 P 0001048905595 LAMA 100/60 82 20 37 W 55 PCT,BC,Dexa PS

3 2-Aug-18 19.00 Yati Kalianget Barat 55 P 0001048921334 LAMA 130/90 88 20 36.6 R 50 Pamol,Vit C PS

Debridement Luka
4 3-Aug-18 8:00:00 herman Kertasada 28 L 0001706277633 BARU 120/70 80 22 36.3 TO1
Sedang
PS

ibuprofen,Co
5 3-Aug-18 13.20 dodi cahya.W Kalianget Barat 6 L 0001706296847 BARU 90 26 38.1 R 50
trim PS

ibuprofen,
6 4-Aug-18 01.30 Desi Lawati Marengan Laok 29 P 0001706330079 BARU 120/80 82 20 A09 Domperidon PS
e

Metro,
7 4-Aug-18 04.30 Zainal Marengan Daya 44 L 0000780130304 BARU 130/80 86 20 K29
Molagit

Debridement Luka
8 4-Aug-18 09.00 Atminatun Kalianget Timur 52 P 0002156010232 LAMA 120/80 88 22 I10
Sedang

amox, Debridement Luka

9 4-Aug-18 10.00 R. Dhafa Kalimo'ok 11 L 0002311484185 BARU 110/80 84 22 T00
ibuprofen Ringan

tetes mata
10 4-Aug-18 15.40 Iwan dahlan Marengan Laok 27 th L 0001048903075 BARU T16 chlorampenic
ol

11 4-Aug-18 17.50 Inti Fada Marengan Laok 24 th P 0000117467008 BARU 110/80 82 R50
 ibuprofen, vit
12 4-Aug-18 18.40 Eka Sutiani Kalianget Barat 38 P 0001706280693 LAMA 110/70 R50
BC

Neokaminal,
13 5-Aug-18 09.00 Rumiyati Kertasada 32 P 0001706300223 BARU 120/80 80 20 A09
Zinc

Dhipen,
14 5-Aug-18 19.00 Hermandianto Marengan Laok 30 L 0001706332882 BARU 100/70 80 20 R50
Amaropo

Debridement Luka
15 6-Aug-18 10.00 Atminatun Kalianget Timur 52 P 0002516010232 LAMA 100/70 80 20 G10
Sedang

ibuprofen,
16 6-Aug-18 Mahmudiyah Pinggir Papas 68 P 0001048899442 120/70 80 R50 amaropo,
chloramp

17 8-Aug-18 07.40 Herman Kertasada 28 L 0001706277633 LAMA 120/80 80 20 T01 Angkat jahitan

Debridement Luka
18 8-Aug-18 08.20 Haryono Kalianget Timur 34 L 0001706352996 BARU 120/80 80 20 T01 Tetrasiklin
Sedang

19 8-Aug-18 17.00 Rohsyahniyah Kalianget Barat 43 P 0001804520474 110/70 80 20 K29

20 8-Aug-18 17.30 Susilo Kalimo'ok 63 L 0000779404421 110/80 80 20 R11+R51

Amarpo,mola
21 9-Aug-18 17.30 Sinta Suadini Karang Anyar 16 P 90/60 80 20 R50
ngit

22 9-Aug-18 21.30 Sri Yuliawati Kalimo'ok 33 P 0000780414838 120/80 80 20 R50

Cotrim
23 10-Aug-18 16:30:00 budiyanto Kalianget Barat 23 L 0001706306286 120/80 80 20
syr,cloram syr

24 6:30:00 massuryani Kertasada 56 P 0000780091738 110/80 80 21 R51

25 9:00:00 Susi amrati Marengan Laok 29 P 0002221685335 110/70 78 20 Amox,amaropo

26 11:30:00 moh alif marengan daya 5 L 0001831488039 Amox Injeksi

 Pemasangan dan
27 18:30:00 matahir Kertasada 85 L 0000779826014 atau pencabutan
kateter urine

Pemberian O² (tiap
28 Suhartini kslianget barat 49 P 0001706196983
2 jam)

ibuprofen,am
29 11-Aug-18 5:00:00 abdur rasid Kertasada 48 L 0001048908857 90/60 80 20
aropo

30 8:00:00 ningsih Kalianget Barat 40 p 0001048908339 130/80 87 20

31 9:00:00 Suhartini kalianget barat 49 P 0001706296983 90/50 87 20

32 12-Aug-18 16:00:00 Misnatun Kertasada 59 P 000048906315 160/90 80 22

33 17:00:00 fitho alfiansyah Kalianget Barat 3 L 0002217181307 90 22

34 13-Aug-18 8:00:00 andriyani Kalianget Timur 55 P 0000780335662 120/70 80 20 E10

Debridement Luka
35 16:50:00 Samsuri Kertasada 27 L 0001706275258 110/80 87 20 TO1 Metro
Sedang

Jahit luka 1 - 3
jahitan
36 17:00:00 Abd gani kalimook 54 th L 0001048913021 120/80 86 28 TO1
(Penambahan per
jahitan Rp. 5000)

Dexa,salbuta
37 14-Aug-18 6:30:00 Sunawi pamolokan 63th L 0001048935609 120/70 84 20 J45
mol

Debridement Luka
38 10:10:00 Wildan Kertasada 8 L 0001706301505 T01
Ringan
Debridement Luka
39 17:00:00 Samsuri Kertasada 27 L 0001706275258 T01
Sedang
40 15-Aug-18 10:00:00 Budiah Marengan Laok 59 P 0001706273695 120/80 80 22
Glisofulvin,
41 12:00:00 Rusmiyati Marengan Laok 32 P 0001706280006
ctm

42 12:10:00 Widya Kalianget Barat 16 P 0001706306332 90/60 80 20 Ibu, Amaropo

Glisofulvin,
43 18:30:00 Miskawan Kalianget Barat 62 L 0001905204554 120/80 81 20
Dexa
Pemberian O² (tiap
44 18:30:00 Rusmini Kalianget Barat 51 P 0001905205689 110/70 80 23 J45
2 jam)
Cotrim,IbuPr
45 16-Aug-18 8:30:00 Nur Fadila Kalianget Timur 15 L 0000780359714 100/70 80 20 T01
ofen
Debridement Luka
46 18:00:00 Syamsuri Kertasada 27 L 0001706275258 100/70 80 20 TO1
Sedang
47 17-Aug-18 9:25:00 Ach. Bayu Kalimo'ok 15 L 0001048913605 90/60 80 20 R50

48 18-Aug-18 8:00:00 Masbullah Kertasada 64 L 0001706319617 120/80 80 20 T 25

Debridement Luka
49 18-Aug-18 8:20:00 Nurfadilah A KT 15 L 0000780359714 100/70 78 20 T 00
Sedang
Jahit luka 1 - 3
Amox,ibuprof jahitan
50 18-Aug-18 9:00:00 Samaniya PP 60 P 0000117232672 120/70 80 20 T01
en (Penambahan per
jahitan Rp. 5000)
Amox,Ibuprof Debridement Luka
51 18-Aug-18 9:30:00 Halifatul Kalimook 16 P 0001048912558 120/80 80 20 T00
en Sedang
Debridement Luka
18-Aug-18 10:30:00 Tarsiadi Marengan Laok 40 L 0001895671506 130/90 87 21 T01
Sedang
PCT 3x1,
52 18-Aug-18 16:30:00 Muhammad M Kalianget Barat 10 L 0000779370208 90 20 R50
amox 3x1
Debridement Luka
53 18-Aug-18 19:00:00 Syamsuri Kertasada 26 L 0001706275258 110/90 87 21 T01
Sedang

Pct 3x1, BC
19-Aug-18 7:11:00 Ambri Rosada Pabian 18 P 0000779328606 100/60 87 20 R51
1x1

Dimperidon
19-Aug-18 18:10:00 Sevtia Kertasada 7 P 0001706291403 90 22 36.5 R11 syr 3x1, pct
syr 3x1
Debridement Luka
54 20-Aug-18 9:28:00 sanima Marengan Laok 70 P 0000778697109 130/90 87 21 T01
Ringan

detral 3x1,
20-Aug-18 16:00:00 Hasri Kalimo'ok 12 L 0000780467681 96 23 R05
cotrimok 2x1

antasida 3x1,
20-Aug-18 17:00:00 Siti Aisyah Kalimo'ok 31 P 0001706290806 120/70 87 21 R10 famotidine
2x1

Debridement Luka
21-Aug-18 9:25:00 sanima Marengan Laok 70 P 0000778697109 T01
Ringan
Debridement Luka
22-Aug-18 8:18:00 sanima Marengan Laok 70 P 0000778697109 T01
Ringan
cotrimoks
22-Aug-18 20:00:00 Ach Junaidi Kalianget Barat 2.5 L 0002156302692 98 23 36.5 R05
2x1/2
salbutamol Penanganan status
55 22-Aug-18 8:18:00 Masbullah Kertasada 64 L 0001706319617 120/80 80 29 J45
3x1 asmatikus
Debridement Luka
56 23-Aug-18 8:20:00 Samina Marengan Laok 70 th P 0000778697109 LAMA 100 T01
Sedang

57 23-Aug-18 9:00:00 Sulaiman Marengan Laok 50 th L 000170627125 BARU 160/70 80 20 T00

Debridement Luka
58 24-Aug-18 9:25:00 Samina Marengan Laok 70 th P 0000778697109 LAMA T01
Sedang
ibuprofen,
59 25-Aug-18 1:10:00 Demas D Kertasada 17 th L 000078009311 BARU 90/60 R05 Domperidon
e
 Ibuprofen, Debridement Luka
60 25-Aug-18 8:20:00 Samina Marengan Laok 70 th P 0000778697109 LAMA 100/60 80 20 T01
Amox Sedang

Ibuprofen, Debridement Luka

61 25-Aug-18 9:00:00 Dussamat F Kalianget Barat 30 th L 000002156302258 BARU 110/70 80 20 T01
Amox Sedang

pct syr 3x1,

62 25-Aug-18 14:30:00 Muammar Syarif Kalianget Timur 3 th L 0001841139314 BARU 100 23 38 R50
amox syr 3x1
ibuprofen
3x1,
63 25-Aug-18 16:20:00 Moh. Rifa'ie Kalimo'ok 53 th L 0000779305713 BARU 140/90 87 21 I10
amlodipin
1x1
Debridement Luka
64 26-Aug-18 09;00:00 Samina Marengan Laok 70 th P 0000778697109 LAMA 120/80 80 20 T01
Sedang
65 26-Aug-18 9:30:00 Cahya Ahafa Kalimo'ok 08 th L 0002268538525 BARU 92 37.1 R50 Amox, PCT
Debridement Luka
66 26-Aug-18 9:30:00 Dussamat F Kalianget Barat 30 th L 0002156302258 LAMA 110/80 82 36 T01
Sedang
inj. Vit b12,
67 26-Aug-18 19:00:00 Eka Suriani Kalianget Barat 38 th P 0001706280693 LAMA 100/60 82 20 R50
inj. Diphen
Debridement Luka
68 27-Aug-18 7:50:00 Supatma Kertasada 47 th P 0001706297905 120/70 80 20 36.3 T01
Sedang
ibuprofen
69 27-Aug-18 12:00:00 Rahmi Kalianget Barat 59 th P 0002429748505 100/60 82 20 R05
3x1
ibuprofen Debridement Luka
70 27-Aug-18 18:40:00 Awiyono Kertasada 29 th L 0001706283066 110/70 80 20 T01
3x1, Cipro Sedang

ibuprofen,
71 27-Aug-18 18:50:00 Osman Marengan Laok 0001706301033 120/70 80 20
salbutamol
ibuprofen Debridement Luka
72 28-Aug-18 7:30:00 Supatma Kertasada 47 th P 0001706297905 120/80 80 20
3x1 Sedang
Debridement Luka
73 28-Aug-18 10:25:00 Samina Marengan Laok 70 th P 0000778697109 120/70 80 20 T01
Sedang
Debridement Luka
74 28-Aug-18 10:30:00 Asriani Kalianget Timur 54 th P 0000780271312 110/70 80 20 T00
Sedang

Debridement Luka
75 28-Aug-18 12:03:00 Surahma Kertasada 49 th P 0001048909138 120/80 80 20 T01
Sedang

ibuprofen,
76 28-Aug-18 21:00:00 Vahrul Rosi H Kertasada 14 th L 0001706290569 100/60 80 36.1 R10
Famotidine

Pemberian O² (tiap
77 23:40:00 sulastri Marengan Laok 46th P 0001706320506 130/70 80 26 J45
2 jam)

Pemberian O² (tiap
78 29-Aug-18 2:30:00 Masbullah Kertasada 54th L 0001706319617 120/70 80 26 J06
2 jam)
79 8:40:00 Nadil ulum Kalimook 7th L 0001961607431 112 24
Debridement Luka
80 12:20:00 Jumatwan Kalianget Timur 40th L 0002480684354 120/70 80 22 R33
Ringan
 PCT tab 3x1,
81 19:00:00 Hamandianto Marengan Laok 30 th L 0001706332882 110/80 87 21 R50 vit B complex
1x1

Debridement Luka
82 30-Aug-18 8:00:00 Supatma Kertasada 47 th P 0001706297905 100/70 87 21 T01
Sedang

ibuprofen
Debridement Luka
83 30-Aug-18 8:20:00 Samina Marengan Laok 70 th P 0000778697109 110/80 80 21 T01 3x1, amox
Ringan
3x1

ibuprofen
Debridement Luka
84 30-Aug-18 9:20:00 Sunaryo Kertasada 36 th L 0001048909048 120/90 87 21 T00 3x1, amox
Ringan
3x1

Debridement Luka
85 30-Aug-18 11:00:00 Masriani Kalianget Timur 54 th P 0000780271312 130/90 87 21 E11
Ringan

ibuprofen
3x1,
86 30-Aug-18 19:00:00 Usman Raharja Kalianget Timur 31 th L 0001048924708 100/60 87 21 J06
cotrimoks
2x1

famotidin
87 30-Aug-18 23:00:00 Cahya Dhafa Kalimo'ok 8 th L 0002268538525 98 23 K29 2x1/2,
microlax

ibuprofen
Debridement Luka
88 31-Aug-18 9:30:00 Sunaryo Kertasada 36 th L 0001048909048 120/90 87 21 T00 3x1, amox
Ringan
3x1
Pemasangan dan
89 31-Aug-18 18:30:00 Matahir Kertasada 85 th L 0000779826014 140/90 87 21 N40 atau pencabutan
kateter urine
90
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 N S

TRIAGE
L

Umur
N STATUS A U
TGL JAM Nama Alamat / NO. REGISTER RM No.NIK TD RR TB BB Pekerjaan Diag. ICDX. Obat Tindakan
O KUNJUNGAN D H
P
I U

Amox, Debridement
1 3-Aug-17 10:30:00 Suparman Kalianget Barat 35 th L 08 - 1425 - 04 BARU 120/70 80 20 T01
Asmaf Luka Ringan
K

cipro,dexa, Debridement
2 10-Aug-18 2:00:00 Agus Karang anyar 16 th L 120/80 80 22 T01
b12 Luka Sedang
K

cipro,
Debridement
3 11-Aug-18 21:50:00 hairul anwar Kertasada 49 th L 120/80 80 20 T00 hufagesil, Luka Ringan
K
dexa

Debridement
4 13-Aug-18 9:10:00 Imam Buhari Kalianget Barat 58 th L 05-8813-05 BARU T01
Luka Sedang
K

Debridement
5 15-Aug-18 8:00:00 Imam Buhari Kalianget Barat 58 th L 05-8813-05 LAMA 120/80 80 20 T01
Luka Sedang
K

ibuprofen
Debridement
6 15-Aug-18 12:00:00 Bambang Kalimo'ok 09 th L BARU T00 syp, amox K
Luka Ringan
syp
Debridement
8 16-Aug-18 21:20:00 Khairul amin Kertasada 27 th L 120/60 87 20 T00
Luka Ringan
K

salbutamol,
Penanganan status
9 18-Aug-18 6:30:00 Fitri Pabian 35 th P BARU 120/80 82 24 J45 amaropo, K
asmatikus
ctm

zinc,
10 22-Aug-18 6:00:00 Haka Kalianget Barat 7 bln P BARU A09
neokaominal K

ibuprofen, Debridement
11 24-Aug-18 13:30:00 Retnowahyuni Pabian 36 th P BARU T01
tetracyclin Luka Sedang
K

12
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14

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25
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278
279
280
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301
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303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
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 B
M
A
A
G
S KELUAR
I
U
A
K
N

BDH Sendiri PS

BDH Sendiri PS

BDH Sendiri PS

BDH Sendiri PS

BDH Sendiri PS

BDH Sendiri PS

BDH Sendiri PS

BDH Sendiri PS

INT Sendiri PS

BDH Sendiri PS
 FORMULIR PENGAJUAN KLAIM JAMKESDA
RAWAT JALAN
UGD
BULAN AUGUST TAHUN 2018
NO TANGGAL NO. NIK / KTP NAMA UMUR L/P ALAMAT DIAGNOSE
1 1-Aug-18 405/352/435.303.102/2018 Minarniyati 54 th P Kalianget Timur E 01
2 1-Aug-18 405/1361/435.303.101/2018 Moh.Miftahol 01 th L Kalianget Barat T 01
3 1-Aug-18 3529024502790001 Ernawati 39 th P Kalianget Barat T 01
4 2-Aug-18 3529024311040002 Laila Nur Azizah 13 th P Kalianget Barat R 11
5 2-Aug-18 3529020108110001 Alvin 07 th L Kalimo'ok R 50
6 3-Aug-18 3529026805160002 indar mersiana 02 th P Kertasada R 11
7 4-Aug-18 405/ /435.303.104/2018 Ageng suryo 18 th L Karang anyar T01
8 4-Aug-18 352902630650001 Maimuna 54 th L Karang anyar T01
9 4-Aug-18 3529020101670010 Jusup 51 th L Kalianget Barat T00
10 4-Aug-18 3529027006640078 Sahwiyatun 54 th P Kalianget Barat R10
11 4-Aug-18 12/30/1899 Andini 10 th P Karang anyar R50
12 4-Aug-18 3529022812100001 Wildan 08 th L Kertasada T01
13 4-Aug-18 #REF! Syarifa Nurfaiza 09 th P Kalianget Barat R50
14 6-Aug-08 405/554/435.303.606/2018 Haisin 78 th L Kertasada N40
15 6-Aug-08 405/435.303.104/2018 Ageng suryo 18 th L Karang anyar T01
16 6-Aug-08 3529025010920019 Nurul wahid 0 L Kalianget Barat 0
17 6-Aug-08 3529022605140001 Salamet riydi 4 th L Kalianget Barat R10
18 7-Aug-28 3529020105880004 Hosni mubarok 52 th L Pinggir Papas R50
19 7-Aug-28 3529020311090001 Bustanul Arifin 08 th L Kertasada R50
20 7-Aug-28 3529021704150002 Moh. Jamaludin 07 th L Kalianget Barat R10
21 8-Aug-18 405/66/435.303.106/2018 Wildan 03 th L Kertasada T01
22 10-Aug-18 3529024402120001 Jillah 08 th L Kertasada R50
23 11-Aug-18 3529024211970003 Eka novia 6.5 L Kalianget Barat L23
24 11-Aug-18 352902102600001 Imam Bahri 21 P Kalianget Barat TO1
25 11-Aug-18 '405/66/435.303.106/2018 Wildan 58 L Kalianget Barat T01
26 11-Aug-18 3529021208540003 Moh.Zaini 8 L Kertasada 0
27 12-Aug-18 12/30/1899 Fitho alfiyansyah 64 L Marengan Laok 0
28 13-Aug-18 3529024802430001 Sadima 0 0 Kalianget Barat T01
29 13-Aug-18 3529023006600124 Sabik 75 P Karang anyar 0
30 13-Aug-18 3529021909070001 Ferdy wiranto 45 L kalimook T01
31 13-Aug-18 3529026805160002 Indira 11 L Kalianget Barat R11
32 14-Aug-18 405/684/435.303.106/2018 Haisin 2.5 P Kertasada N40
33 14-Aug-18 3529022707520001 Moh. Hari 78 L Kertasada T01
34 15-Aug-18 3529024609720004 Hanimah 66 L Kalianget Barat 0
35 15-Aug-18 3529025101560001 Rumsiati 47 P Kertasada 0
36 15-Aug-18 3529024006920004 Misnawati 55 P Kertasada 0
NO TANGGAL NO. NIK / KTP NAMA UMUR L/P ALAMAT DIAGNOSE
37 16-Aug-18 3529026511630002 Admi 25 P Kertasada R50
38 16-Aug-18 405/66/435.303.106/2018 Wildan 45 P Kalianget Barat T01
39 16-Aug-18 3529026511970006 Misrawti 8 L Kertasada A09
40 18-Aug-18 3529020107601164 Miskaya 21 P Kalimo'ok R 50
41 18-Aug-18 405/66/435.303.106/2018 wildan 58 L Kalimo'ok T 01
42 18-Aug-18 3529024606620001 Siti Aisyah 8 L Kertasada A09
43 19-Aug-18 405/684/ Haisin 57 P Kalianget Barat N40
44 19-Aug-18 12/30/1899 Suro 68 L Kertasada T 01
45 22-Aug-18 3529024910140001 Jihan TU 43 th L Kalianget Timur A09
46 22-Aug-18 3529020712120002 Lutfi 24 P Pasongsongan A09
47 22-Aug-18 3529026706160003 Annora 8 L Kalimo'ok A09
48 22-Aug-18 12/30/1899 Suro 4 th 0 Marengan Laok T01
49 22-Aug-18 3273064808800009 Siti Mardiah 6 th 0 kalimook R50
50 23-Aug-18 3529010309130002 Faeza 26 bln 0 Kalianget Barat R11+A09
51 24-Aug-18 3529025110150001 Aztaqirani 43 L Kalianget Timur R50
52 24-Aug-18 3529023006390018 Masruna 38 P Bandung T00
53 24-Aug-18 3529026109150002 Dela Nura L 5 L Marengan Laok R50
54 25-Aug-18 12/30/1899 Suro 3 th P Kalianget Barat T01
55 25-Aug-18 3529023006390018 Masruna 79 th L Pinggir Papas R50
56 25-Aug-18 12/30/1899 Adiba 3 th P Kalianget Timur R10
57 25-Aug-18 #REF! Yunus Dedi 43 th L Kalianget Timur R05
58 26-Aug-18 352917006520077 Sahwati 79 th L Pinggir Papas I10
59 26-Aug-18 3529016903820007 Retno Wahyudi 03 th P Kertasada T01
60 26-Aug-18 12/30/1899 Amel 28 th L Kalianget Timur L23
61 26-Aug-18 3529020107570064 Sunaryo 66 th P Marengan Daya J45
62 27-Aug-18 3529023006390018 Masruna 36 th P Kertasada R50
63 27-Aug-18 3529027006580088 Misari 15 bln P Kalimo'ok E10
64 27-Aug-18 3517033112570003 Sutriman 51 th L Marengan laok 0
65 27-Aug-18 3529024107740123 Awiyani 79 th L Pinggir Papas 0
66 28-Aug-18 3529017006560075 Sittina 60 th P Kalianget Timur 0
67 29-Aug-18 12/30/1899 Sumiyati 61 th L Jombang 0
68 30-Aug-18 3529024808150001 Alviana afifa 45 th P Kalianget Barat 0
69 30-Dec-99 12/30/1899 0 62th P pabian 0
70 30-Dec-99 12/30/1899 0 0 0 Kertasada 0
71 30-Dec-99 12/30/1899 0 4th P kalimook 0
72 30-Dec-99 12/30/1899 0 0 0 0 0
73 30-Dec-99 12/30/1899 0 0 0 0 0
74 30-Dec-99 12/30/1899 0 0 0 0 0
75 30-Dec-99 12/30/1899 0 0 0 0 0
76 30-Dec-99 12/30/1899 #REF! 0 0 0 0
77 30-Dec-99 12/30/1899 #REF! 0 0 0 0
78 30-Dec-99 12/30/1899 #REF! 0 0 0 0
NO TANGGAL NO. NIK / KTP NAMA UMUR L/P ALAMAT DIAGNOSE
79 30-Dec-99 #REF! #REF! 0 0 0 0
80 30-Dec-99 12/30/1899 0 0 0 0 0
81 30-Dec-99 12/30/1899 0 0 0 0 0
82 30-Dec-99 12/30/1899 0 0 0 0 0
83 30-Dec-99 12/30/1899 0 0 0 0 0
84 30-Dec-99 12/30/1899 0 0 0 0 0
85 30-Dec-99 12/30/1899 0 0 0 0 0
86 30-Dec-99 12/30/1899 0 0 0 0 0
87 30-Dec-99 12/30/1899 0 0 0 0 0
88 30-Dec-99 12/30/1899 #REF! 0 0 0 0
89 30-Dec-99 12/30/1899 #REF! 0 0 0 0
90 30-Dec-99 12/30/1899 #REF! 0 0 0 0
91 30-Dec-99 12/30/1899 #REF! 0 0 0 0
92 30-Dec-99 12/30/1899 #REF! 0 0 0 0
93 30-Dec-99 12/30/1899 #REF! 0 0 0 0
94 30-Dec-99 12/30/1899 #REF! 0 0 0 0
95 30-Dec-99 12/30/1899 #REF! 0 0 0 0
96 30-Dec-99 12/30/1899 #REF! 0 0 0 0
97 30-Dec-99 12/30/1899 #REF! 0 0 0 0
98 30-Dec-99 12/30/1899 0 0 0 0 0
99 30-Dec-99 12/30/1899 0 0 0 0 0
100 30-Dec-99 12/30/1899 0 0 0 0 0
101 30-Dec-99 12/30/1899 0 0 0 0 0
102 30-Dec-99 12/30/1899 0 0 0 0 0
103 30-Dec-99 12/30/1899 0 0 0 0 0
104 30-Dec-99 12/30/1899 0 0 0 0 0
105 30-Dec-99 12/30/1899 0 0 0 0 0
106 30-Dec-99 12/30/1899 0 0 0 0 0
107 30-Dec-99 12/30/1899 0 0 0 0 0
108 30-Dec-99 12/30/1899 0 0 0 0 0
109 30-Dec-99 12/30/1899 0 0 0 0 0
110 30-Dec-99 12/30/1899 0 0 0 0 0
111 30-Dec-99 12/30/1899 0 0 0 0 0
112 30-Dec-99 12/30/1899 0 0 0 0 0
113 30-Dec-99 12/30/1899 0 0 0 0 0
114 30-Dec-99 12/30/1899 0 0 0 0 0
115 30-Dec-99 12/30/1899 0 0 0 0 0
116 30-Dec-99 12/30/1899 0 0 0 0 0
117 30-Dec-99 12/30/1899 0 0 0 0 0
118 30-Dec-99 12/30/1899 0 0 0 0 0
119 30-Dec-99 12/30/1899 0 0 0 0 0
120 30-Dec-99 12/30/1899 0 0 0 0 0
NO TANGGAL NO. NIK / KTP NAMA UMUR L/P ALAMAT DIAGNOSE
121 30-Dec-99 12/30/1899 0 0 0 0 0
122 30-Dec-99 12/30/1899 0 0 0 0 0
123 30-Dec-99 12/30/1899 0 0 0 0 0
124 30-Dec-99 12/30/1899 0 0 0 0 0
125 30-Dec-99 12/30/1899 0 0 0 0 0
126 30-Dec-99 12/30/1899 0 0 0 0 0
127 30-Dec-99 12/30/1899 0 0 0 0 0
128 30-Dec-99 12/30/1899 0 0 0 0 0
129 30-Dec-99 12/30/1899 0 0 0 0 0
130 30-Dec-99 12/30/1899 0 0 0 0 0
131 30-Dec-99 12/30/1899 0 0 0 0 0
132 30-Dec-99 12/30/1899 0 0 0 0 0
133 30-Dec-99 12/30/1899 0 0 0 0 0
134 30-Dec-99 12/30/1899 0 0 0 0 0
135 30-Dec-99 12/30/1899 0 0 0 0 0
136 30-Dec-99 12/30/1899 0 0 0 0 0
137 30-Dec-99 12/30/1899 0 0 0 0 0
138 30-Dec-99 12/30/1899 0 0 0 0 0
139 30-Dec-99 12/30/1899 0 0 0 0 0
140 30-Dec-99 12/30/1899 0 0 0 0 0
141 30-Dec-99 12/30/1899 0 0 0 0 0
142 30-Dec-99 12/30/1899 0 0 0 0 0
143 30-Dec-99 12/30/1899 0 0 0 0 0
144 30-Dec-99 12/30/1899 0 0 0 0 0
145 30-Dec-99 12/30/1899 0 0 0 0 0
146 30-Dec-99 12/30/1899 0 0 0 0 0
147 30-Dec-99 12/30/1899 0 0 0 0 0
148 30-Dec-99 12/30/1899 0 0 0 0 0
149 30-Dec-99 12/30/1899 0 0 0 0 0
150 30-Dec-99 12/30/1899 0 0 0 0 0
151 30-Dec-99 12/30/1899 0 0 0 0 0
152 30-Dec-99 12/30/1899 0 0 0 0 0
153 30-Dec-99 12/30/1899 0 0 0 0 0
154 30-Dec-99 12/30/1899 0 0 0 0 0
155 30-Dec-99 12/30/1899 0 0 0 0 0
156 30-Dec-99 12/30/1899 0 0 0 0 0
157 30-Dec-99 12/30/1899 0 0 0 0 0
158 30-Dec-99 12/30/1899 0 0 0 0 0
159 30-Dec-99 12/30/1899 0 0 0 0 0
160 30-Dec-99 12/30/1899 0 0 0 0 0
161 30-Dec-99 12/30/1899 0 0 0 0 0
162 30-Dec-99 12/30/1899 0 0 0 0 0
NO TANGGAL NO. NIK / KTP NAMA UMUR L/P ALAMAT DIAGNOSE
163 30-Dec-99 12/30/1899 0 0 0 0 0
164 30-Dec-99 12/30/1899 0 0 0 0 0
165 30-Dec-99 12/30/1899 0 0 0 0 0
166 30-Dec-99 12/30/1899 0 0 0 0 0
167 30-Dec-99 12/30/1899 0 0 0 0 0
168 30-Dec-99 12/30/1899 0 0 0 0 0
169 30-Dec-99 12/30/1899 0 0 0 0 0
170 30-Dec-99 12/30/1899 0 0 0 0 0
171 30-Dec-99 12/30/1899 0 0 0 0 0
172 30-Dec-99 12/30/1899 0 0 0 0 0
173 30-Dec-99 12/30/1899 0 0 0 0 0
174 30-Dec-99 12/30/1899 0 0 0 0 0
175 30-Dec-99 12/30/1899 0 0 0 0 0
176 30-Dec-99 12/30/1899 0 0 0 0 0
177 30-Dec-99 12/30/1899 0 0 0 0 0
178 30-Dec-99 12/30/1899 0 0 0 0 0
179 30-Dec-99 12/30/1899 0 0 0 0 0
180 30-Dec-99 12/30/1899 0 0 0 0 0
181 30-Dec-99 12/30/1899 0 0 0 0 0
182 30-Dec-99 12/30/1899 0 0 0 0 0
183 30-Dec-99 12/30/1899 0 0 0 0 0
184 30-Dec-99 12/30/1899 0 0 0 0 0
185 30-Dec-99 12/30/1899 0 0 0 0 0
186 30-Dec-99 12/30/1899 0 0 0 0 0
187 30-Dec-99 12/30/1899 0 0 0 0 0
188 30-Dec-99 12/30/1899 0 0 0 0 0
189 30-Dec-99 12/30/1899 0 0 0 0 0
190 30-Dec-99 12/30/1899 0 0 0 0 0
191 30-Dec-99 12/30/1899 0 0 0 0 0
192 30-Dec-99 12/30/1899 0 0 0 0 0
193 30-Dec-99 12/30/1899 0 0 0 0 0
194 30-Dec-99 12/30/1899 0 0 0 0 0
195 30-Dec-99 12/30/1899 0 0 0 0 0
196 30-Dec-99 12/30/1899 0 0 0 0 0
197 30-Dec-99 12/30/1899 0 0 0 0 0
198 30-Dec-99 12/30/1899 0 0 0 0 0
199 30-Dec-99 12/30/1899 0 0 0 0 0
200 30-Dec-99 12/30/1899 0 0 0 0 0
201 30-Dec-99 12/30/1899 0 0 0 0 0
202 30-Dec-99 12/30/1899 0 0 0 0 0
203 30-Dec-99 12/30/1899 0 0 0 0 0
204 30-Dec-99 12/30/1899 0 0 0 0 0
NO TANGGAL NO. NIK / KTP NAMA UMUR L/P ALAMAT DIAGNOSE
205 30-Dec-99 12/30/1899 0 0 0 0 0
206 30-Dec-99 12/30/1899 0 0 0 0 0
207 30-Dec-99 12/30/1899 0 0 0 0 0
208 30-Dec-99 12/30/1899 0 0 0 0 0
209 30-Dec-99 12/30/1899 0 0 0 0 0
210 30-Dec-99 12/30/1899 0 0 0 0 0
211 30-Dec-99 12/30/1899 0 0 0 0 0
212 30-Dec-99 12/30/1899 0 0 0 0 0
213 30-Dec-99 12/30/1899 0 0 0 0 0
214 30-Dec-99 12/30/1899 0 0 0 0 0
215 30-Dec-99 12/30/1899 0 0 0 0 0
216 30-Dec-99 12/30/1899 0 0 0 0 0
217 30-Dec-99 12/30/1899 0 0 0 0 0
218 30-Dec-99 12/30/1899 0 0 0 0 0
219 30-Dec-99 12/30/1899 0 0 0 0 0
220 30-Dec-99 12/30/1899 0 0 0 0 0
221 30-Dec-99 12/30/1899 0 0 0 0 0
222 30-Dec-99 12/30/1899 0 0 0 0 0
223 30-Dec-99 12/30/1899 0 0 0 0 0
224 30-Dec-99 12/30/1899 0 0 0 0 0
225 30-Dec-99 12/30/1899 0 0 0 0 0
226 30-Dec-99 12/30/1899 0 0 0 0 0
227 30-Dec-99 12/30/1899 0 0 0 0 0
228 30-Dec-99 12/30/1899 0 0 0 0 0
229 30-Dec-99 12/30/1899 0 0 0 0 0
230 30-Dec-99 12/30/1899 0 0 0 0 0
231 30-Dec-99 12/30/1899 0 0 0 0 0
232 30-Dec-99 12/30/1899 0 0 0 0 0
233 30-Dec-99 12/30/1899 0 0 0 0 0
234 30-Dec-99 12/30/1899 0 0 0 0 0
235 30-Dec-99 12/30/1899 0 0 0 0 0
236 30-Dec-99 12/30/1899 0 0 0 0 0
237 30-Dec-99 12/30/1899 0 0 0 0 0
238 30-Dec-99 12/30/1899 0 0 0 0 0
239 30-Dec-99 12/30/1899 0 0 0 0 0
240 30-Dec-99 12/30/1899 0 0 0 0 0
241 30-Dec-99 12/30/1899 0 0 0 0 0
242 30-Dec-99 12/30/1899 0 0 0 0 0
243 30-Dec-99 12/30/1899 0 0 0 0 0
244 30-Dec-99 12/30/1899 0 0 0 0 0
245 30-Dec-99 12/30/1899 0 0 0 0 0
246 30-Dec-99 12/30/1899 0 0 0 0 0
NO TANGGAL NO. NIK / KTP NAMA UMUR L/P ALAMAT DIAGNOSE
247 30-Dec-99 12/30/1899 0 0 0 0 0
248 30-Dec-99 12/30/1899 0 0 0 0 0
249 30-Dec-99 12/30/1899 0 0 0 0 0
250 30-Dec-99 12/30/1899 0 0 0 0 0
251 30-Dec-99 12/30/1899 0 0 0 0 0
252 30-Dec-99 12/30/1899 0 0 0 0 0
253 30-Dec-99 12/30/1899 0 0 0 0 0
254 30-Dec-99 12/30/1899 0 0 0 0 0
255 30-Dec-99 12/30/1899 0 0 0 0 0
256 30-Dec-99 12/30/1899 0 0 0 0 0
257 30-Dec-99 12/30/1899 0 0 0 0 0
258 30-Dec-99 12/30/1899 0 0 0 0 0
259 30-Dec-99 12/30/1899 0 0 0 0 0
260 30-Dec-99 12/30/1899 0 0 0 0 0
261 30-Dec-99 12/30/1899 0 0 0 0 0
262 30-Dec-99 12/30/1899 0 0 0 0 0
263 30-Dec-99 12/30/1899 0 0 0 0 0
264 30-Dec-99 12/30/1899 0 0 0 0 0
265 30-Dec-99 12/30/1899 0 0 0 0 0
266 30-Dec-99 12/30/1899 0 0 0 0 0
267 30-Dec-99 12/30/1899 0 0 0 0 0
268 30-Dec-99 12/30/1899 0 0 0 0 0
269 30-Dec-99 12/30/1899 0 0 0 0 0
270 30-Dec-99 12/30/1899 0 0 0 0 0
271 30-Dec-99 12/30/1899 0 0 0 0 0
272 30-Dec-99 12/30/1899 0 0 0 0 0
273 30-Dec-99 12/30/1899 0 0 0 0 0
274 30-Dec-99 12/30/1899 0 0 0 0 0
275 30-Dec-99 12/30/1899 0 0 0 0 0
276 30-Dec-99 12/30/1899 0 0 0 0 0
277 30-Dec-99 12/30/1899 0 0 0 0 0
278 30-Dec-99 12/30/1899 0 0 0 0 0
279 30-Dec-99 12/30/1899 0 0 0 0 0
280 30-Dec-99 12/30/1899 0 0 0 0 0
281 30-Dec-99 12/30/1899 0 0 0 0 0
282 30-Dec-99 12/30/1899 0 0 0 0 0
283 30-Dec-99 12/30/1899 0 0 0 0 0
284 30-Dec-99 12/30/1899 0 0 0 0 0
285 30-Dec-99 12/30/1899 0 0 0 0 0
286 30-Dec-99 12/30/1899 0 0 0 0 0
287 30-Dec-99 12/30/1899 0 0 0 0 0
288 30-Dec-99 12/30/1899 0 0 0 0 0
NO TANGGAL NO. NIK / KTP NAMA UMUR L/P ALAMAT DIAGNOSE
289 30-Dec-99 12/30/1899 0 0 0 0 0
290 30-Dec-99 12/30/1899 0 0 0 0 0
291 30-Dec-99 12/30/1899 0 0 0 0 0
292 30-Dec-99 12/30/1899 0 0 0 0 0
293 30-Dec-99 12/30/1899 0 0 0 0 0
294 30-Dec-99 12/30/1899 0 0 0 0 0
295 30-Dec-99 12/30/1899 0 0 0 0 0
296 30-Dec-99 12/30/1899 0 0 0 0 0
297 30-Dec-99 12/30/1899 0 0 0 0 0
298 30-Dec-99 12/30/1899 0 0 0 0 0
299 30-Dec-99 12/30/1899 0 0 0 0 0
300 30-Dec-99 12/30/1899 0 0 0 0 0
301 30-Dec-99 12/30/1899 0 0 0 0 0
302 30-Dec-99 12/30/1899 0 0 0 0 0
303 30-Dec-99 12/30/1899 0 0 0 0 0
304 30-Dec-99 12/30/1899 0 0 0 0 0
305 30-Dec-99 12/30/1899 0 0 0 0 0
306 30-Dec-99 12/30/1899 0 0 0 0 0
307 30-Dec-99 12/30/1899 0 0 0 0 0
308 30-Dec-99 12/30/1899 0 0 0 0 0
309 30-Dec-99 12/30/1899 0 0 0 0 0
310 30-Dec-99 12/30/1899 0 0 0 0 0
311 30-Dec-99 12/30/1899 0 0 0 0 0
312 30-Dec-99 12/30/1899 0 0 0 0 0
313 30-Dec-99 12/30/1899 0 0 0 0 0
314 30-Dec-99 12/30/1899 0 0 0 0 0
315 30-Dec-99 12/30/1899 0 0 0 0 0
316 30-Dec-99 12/30/1899 0 0 0 0 0
317 30-Dec-99 12/30/1899 0 0 0 0 0
318 30-Dec-99 12/30/1899 0 0 0 0 0
319 30-Dec-99 12/30/1899 0 0 0 0 0
320 30-Dec-99 12/30/1899 0 0 0 0 0
321 30-Dec-99 12/30/1899 0 0 0 0 0
322 30-Dec-99 12/30/1899 0 0 0 0 0
323 30-Dec-99 12/30/1899 0 0 0 0 0
324 30-Dec-99 12/30/1899 0 0 0 0 0
325 30-Dec-99 12/30/1899 0 0 0 0 0
326 30-Dec-99 12/30/1899 0 0 0 0 0
327 30-Dec-99 12/30/1899 0 0 0 0 0
328 30-Dec-99 12/30/1899 0 0 0 0 0
329 30-Dec-99 12/30/1899 0 0 0 0 0
330 30-Dec-99 12/30/1899 0 0 0 0 0
NO TANGGAL NO. NIK / KTP NAMA UMUR L/P ALAMAT DIAGNOSE
331 30-Dec-99 12/30/1899 0 0 0 0 0
332 30-Dec-99 12/30/1899 0 0 0 0 0
333 30-Dec-99 12/30/1899 0 0 0 0 0
334 30-Dec-99 12/30/1899 0 0 0 0 0
335 30-Dec-99 12/30/1899 0 0 0 0 0
336 30-Dec-99 12/30/1899 0 0 0 0 0
337 30-Dec-99 12/30/1899 0 0 0 0 0
338 30-Dec-99 12/30/1899 0 0 0 0 0
339 30-Dec-99 12/30/1899 0 0 0 0 0
340 30-Dec-99 12/30/1899 0 0 0 0 0
341 30-Dec-99 12/30/1899 0 0 0 0 0
342 30-Dec-99 12/30/1899 0 0 0 0 0
343 30-Dec-99 12/30/1899 0 0 0 0 0
344 30-Dec-99 12/30/1899 0 0 0 0 0
345 30-Dec-99 12/30/1899 0 0 0 0 0
346 30-Dec-99 12/30/1899 0 0 0 0 0
347 30-Dec-99 12/30/1899 0 0 0 0 0
348 30-Dec-99 12/30/1899 0 0 0 0 0
349 30-Dec-99 12/30/1899 0 0 0 0 0
350 30-Dec-99 12/30/1899 0 0 0 0 0
N KLAIM JAMKESDA
ALAN

TAHUN 2018
TINDAKAN KARCIS BIAYA TINDAKAN TOTAL BIAYA PARAF
Debridement Luka Ringan Rp 7,500 Rp 15,000 Rp 22,500
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500
Debridement Luka Ringan Rp 7,500 Rp 15,000 Rp 22,500
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500
0 Rp 7,500 #N/A #N/A
Pemasangan dan atau pencabutan kateter urine Rp 7,500 Rp 42,500 Rp 50,000
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
Debridement Luka Ringan Rp 7,500 Rp 15,000 Rp 22,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
Insisi abses Rp 7,500 Rp 25,000 Rp 32,500
0 Rp 7,500 #N/A #N/A
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500
0 Rp 7,500 #N/A #N/A
Pemasangan dan atau pencabutan kateter urine Rp 7,500 Rp 42,500 Rp 50,000
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
 TINDAKAN KARCIS BIAYA TINDAKAN TOTAL BIAYA PARAF
0 Rp 7,500 #N/A #N/A
Angkat jahitan Rp 7,500 Rp 10,000 Rp 17,500
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
Pemasangan dan atau pencabutan kateter urine Rp 7,500 Rp 42,500 Rp 50,000
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
Debridement Luka Ringan Rp 7,500 Rp 15,000 Rp 22,500
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
Debridement Luka Ringan Rp 7,500 Rp 15,000 Rp 22,500
0 Rp 7,500 #N/A #N/A
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
 TINDAKAN KARCIS BIAYA TINDAKAN TOTAL BIAYA PARAF
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 Rp - Rp 7,500
 TINDAKAN KARCIS BIAYA TINDAKAN TOTAL BIAYA PARAF
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
 TINDAKAN KARCIS BIAYA TINDAKAN TOTAL BIAYA PARAF
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
 TINDAKAN KARCIS BIAYA TINDAKAN TOTAL BIAYA PARAF
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
 TINDAKAN KARCIS BIAYA TINDAKAN TOTAL BIAYA PARAF
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
 TINDAKAN KARCIS BIAYA TINDAKAN TOTAL BIAYA PARAF
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
 TINDAKAN KARCIS BIAYA TINDAKAN TOTAL BIAYA PARAF
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 #N/A #N/A
0 Rp 7,500 Rp - Rp 7,500
Rp 1,267,500 #N/A #N/A

Kalianget, 01 August 2018

KEPALA UPT PUSKESMAS KALIANGET

drg. Hj. NURUL HAYATI, M.Si

NIP. 19650919 199203 2 011
 FORMULIR PENGAJUAN KLAIM JAMKESDA
RAWAT JALAN
UGD
BULAN AUGUST TAHUN 2018
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
1 2-Aug-2018 0001706319617 Masbullah #REF! T 25 + J 45
2 2-Aug-2018 0001048905595 Vira A.P #REF! W 55
3 2-Aug-2018 0001048921334 Yati #REF! R 50
4 3-Aug-2018 0001706277633 herman #REF! TO1
5 3-Aug-2018 0001706296847 dodi cahya.W #REF! R 50
6 4-Aug-2018 0001706330079 Desi Lawati #REF! A09
7 4-Aug-2018 0000780130304 Zainal #REF! K29
8 4-Aug-2018 0002156010232 Atminatun #REF! I10
9 4-Aug-2018 0002311484185 R. Dhafa #REF! T00
10 4-Aug-2018 0001048903075 Iwan dahlan #REF! T16
11 4-Aug-2018 #REF! Inti Fada #REF! R50
12 4-Aug-2018 0001706280693 Eka Sutiani #REF! R50
13 5-Aug-2018 0001706300223 Rumiyati #REF! A09
14 5-Aug-2018 0001706332882 Hermandianto #REF! R50
15 6-Aug-2018 0002516010232 Atminatun #REF! G10
16 6-Aug-2018 0001048899442 Mahmudiyah #REF! R50
17 8-Aug-2018 0001706277633 Herman #REF! T01
18 8-Aug-2018 0001706352996 Haryono #REF! T01
19 8-Aug-2018 0001804520474 Rohsyahniyah #REF! K29
20 8-Aug-2018 0000779404421 Susilo #REF! R11+R51
21 9-Aug-2018 12/30/1899 Sinta Suadini #REF! R50
22 9-Aug-2018 0000780414838 Sri Yuliawati #REF! R50
23 10-Aug-2018 0001706306286 budiyanto #REF! 0
24 30-Dec-1899 0000780091738 massuryani #REF! R51
25 30-Dec-1899 0002221685335 Susi amrati #REF! 0
26 30-Dec-1899 0001831488039 moh alif #REF! 0
27 30-Dec-1899 0000779826014 matahir #REF! 0
28 11-Aug-2018 0001048908857 abdur rasid #REF! 0
29 #REF! #REF! #REF! #REF! 0
30 30-Dec-1899 0001048908339 ningsih #REF! 0
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
31 30-Dec-1899 0001706296983 Suhartini #REF! 0
32 12-Aug-2018 000048906315 Misnatun #REF! 0
33 30-Dec-1899 0002217181307 fitho alfiansyah #REF! 0
34 13-Aug-2018 0000780335662 andriyani #REF! E10
35 30-Dec-1899 0001706275258 Samsuri #REF! TO1
36 30-Dec-1899 0001048913021 Abd gani #REF! TO1
37 14-Aug-2018 0001048935609 Sunawi #REF! J45
38 30-Dec-1899 0001706301505 Wildan #REF! T01
39 30-Dec-1899 0001706275258 Samsuri #REF! T01
40 15-Aug-2018 0001706273695 Budiah #REF! 0
41 30-Dec-1899 0001706280006 Rusmiyati #REF! 0
42 30-Dec-1899 0001706306332 Widya #REF! 0
43 30-Dec-1899 0001905204554 Miskawan #REF! 0
44 30-Dec-1899 0001905205689 Rusmini #REF! J45
45 16-Aug-2018 0000780359714 Nur Fadila #REF! T01
46 30-Dec-1899 0001706275258 Syamsuri #REF! TO1
47 17-Aug-2018 0001048913605 Ach. Bayu #REF! R50
48 18-Aug-18 0001706319617 Masbullah #REF! T 25
49 18-Aug-18 0000780359714 Nurfadilah A #REF! T 00
50 18-Aug-18 0000117232672 Samaniya #REF! T01
51 18-Aug-18 0001048912558 Halifatul #REF! T00
52 18-Aug-18 0000779370208 Muhammad M #REF! R50
53 18-Aug-18 0001706275258 Syamsuri #REF! T01
54 20-Aug-18 0000778697109 sanima #REF! T01
55 22-Aug-2018 0001706319617 Masbullah #REF! J45
56 23-Aug-2018 0000778697109 Samina #REF! T01
57 23-Aug-2018 000170627125 Sulaiman #REF! T00
58 24-Aug-2018 0000778697109 Samina #REF! T01
59 25-Aug-2018 000078009311 Demas D #REF! R05
60 25-Aug-2018 0000778697109 Samina #REF! T01
61 25-Aug-2018 000002156302258 Dussamat F #REF! T01
62 25-Aug-2018 0001841139314 Muammar Syarif #REF! R50
63 25-Aug-2018 0000779305713 Moh. Rifa'ie #REF! I10
64 26-Aug-2018 0000778697109 Samina #REF! T01
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
65 26-Aug-2018 0002268538525 Cahya Ahafa #REF! R50
66 26-Aug-2018 0002156302258 Dussamat F #REF! T01
67 26-Aug-2018 0001706280693 Eka Suriani #REF! R50
68 27-Aug-2018 0001706297905 Supatma #REF! T01
69 27-Aug-2018 0002429748505 Rahmi #REF! R05
70 27-Aug-2018 0001706283066 Awiyono #REF! T01
71 27-Aug-2018 0001706301033 Osman #REF! 0
72 28-Aug-2018 0001706297905 Supatma #REF! 0
73 28-Aug-2018 0000778697109 Samina #REF! T01
74 28-Aug-2018 0000780271312 Asriani #REF! T00
75 28-Aug-2018 0001048909138 Surahma #REF! T01
76 28-Aug-2018 0001706290569 Vahrul Rosi H #REF! R10
77 30-Dec-1899 0001706320506 sulastri #REF! J45
78 29-Aug-2018 0001706319617 Masbullah #REF! J06
79 30-Dec-1899 0001961607431 Nadil ulum #REF! 0
80 30-Dec-1899 0002480684354 Jumatwan #REF! R33
81 30-Dec-1899 0001706332882 Hamandianto #REF! R50
82 30-Aug-18 0001706297905 Supatma #REF! T01
83 30-Aug-18 0000778697109 Samina #REF! T01
84 30-Aug-18 0001048909048 Sunaryo #REF! T00
85 30-Aug-18 0000780271312 Masriani #REF! #REF!
86 30-Aug-18 0001048924708 Usman Raharja #REF! E11
87 30-Aug-18 0002268538525 Cahya Dhafa #REF! K29
88 31-Aug-18 0001048909048 Sunaryo #REF! T00
89 31-Aug-18 0000779826014 Matahir #REF! N40
90 30-Dec-1899 12/30/1899 0 #REF! 0
91 30-Dec-1899 12/30/1899 0 #REF! 0
92 30-Dec-1899 12/30/1899 0 #REF! 0
93 30-Dec-1899 12/30/1899 0 #REF! 0
94 30-Dec-1899 12/30/1899 0 #REF! 0
95 30-Dec-1899 12/30/1899 0 #REF! 0
96 30-Dec-1899 12/30/1899 0 #REF! 0
97 30-Dec-1899 12/30/1899 0 #REF! 0
98 30-Dec-1899 12/30/1899 0 #REF! 0
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
99 30-Dec-1899 12/30/1899 0 #REF! 0
100 30-Dec-1899 12/30/1899 0 #REF! 0
101 30-Dec-1899 12/30/1899 0 #REF! 0
102 30-Dec-1899 12/30/1899 0 #REF! 0
103 30-Dec-1899 12/30/1899 0 #REF! 0
104 30-Dec-1899 12/30/1899 0 #REF! 0
105 30-Dec-1899 12/30/1899 0 #REF! 0
106 30-Dec-1899 12/30/1899 0 #REF! 0
107 30-Dec-1899 12/30/1899 0 #REF! 0
108 30-Dec-1899 12/30/1899 0 #REF! 0
109 30-Dec-1899 12/30/1899 0 #REF! 0
110 30-Dec-1899 12/30/1899 0 #REF! 0
111 30-Dec-1899 12/30/1899 0 #REF! 0
112 30-Dec-1899 12/30/1899 0 #REF! 0
113 30-Dec-1899 12/30/1899 0 #REF! 0
114 30-Dec-1899 12/30/1899 0 #REF! 0
115 30-Dec-1899 12/30/1899 0 #REF! 0
116 30-Dec-1899 12/30/1899 0 #REF! 0
117 30-Dec-1899 12/30/1899 0 #REF! 0
118 30-Dec-1899 12/30/1899 0 #REF! 0
119 30-Dec-1899 12/30/1899 0 #REF! 0
120 30-Dec-1899 12/30/1899 0 #REF! 0
121 30-Dec-1899 12/30/1899 0 #REF! 0
122 30-Dec-1899 12/30/1899 0 #REF! 0
123 30-Dec-1899 12/30/1899 0 #REF! 0
124 30-Dec-1899 12/30/1899 0 #REF! 0
125 30-Dec-1899 12/30/1899 0 #REF! 0
126 30-Dec-1899 12/30/1899 0 #REF! 0
127 30-Dec-1899 12/30/1899 0 #REF! 0
128 30-Dec-1899 12/30/1899 0 #REF! 0
129 30-Dec-1899 12/30/1899 0 #REF! 0
130 30-Dec-1899 12/30/1899 0 #REF! 0
131 30-Dec-1899 12/30/1899 0 #REF! 0
132 30-Dec-1899 12/30/1899 0 #REF! 0
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
133 30-Dec-1899 12/30/1899 0 #REF! 0
134 30-Dec-1899 12/30/1899 0 #REF! 0
135 30-Dec-1899 12/30/1899 0 #REF! 0
136 30-Dec-1899 12/30/1899 0 #REF! 0
137 30-Dec-1899 12/30/1899 0 #REF! 0
138 30-Dec-1899 12/30/1899 0 #REF! 0
139 30-Dec-1899 12/30/1899 0 #REF! 0
140 30-Dec-1899 12/30/1899 0 #REF! 0
141 30-Dec-1899 12/30/1899 0 #REF! 0
142 30-Dec-1899 12/30/1899 0 #REF! 0
143 30-Dec-1899 12/30/1899 0 #REF! 0
144 30-Dec-1899 12/30/1899 0 #REF! 0
145 30-Dec-1899 12/30/1899 0 #REF! 0
146 30-Dec-1899 12/30/1899 0 #REF! 0
147 30-Dec-1899 12/30/1899 0 #REF! 0
148 30-Dec-1899 12/30/1899 0 #REF! 0
149 30-Dec-1899 12/30/1899 0 #REF! 0
150 30-Dec-1899 12/30/1899 0 #REF! 0
151 30-Dec-1899 12/30/1899 0 #REF! 0
152 30-Dec-1899 12/30/1899 0 #REF! 0
153 30-Dec-1899 12/30/1899 0 #REF! 0
154 30-Dec-1899 12/30/1899 0 #REF! 0
155 30-Dec-1899 12/30/1899 0 #REF! 0
156 30-Dec-1899 12/30/1899 0 #REF! 0
157 30-Dec-1899 12/30/1899 0 #REF! 0
158 30-Dec-1899 12/30/1899 0 #REF! 0
159 30-Dec-1899 12/30/1899 0 #REF! 0
160 30-Dec-1899 12/30/1899 0 #REF! 0
161 30-Dec-1899 12/30/1899 0 #REF! 0
162 30-Dec-1899 12/30/1899 0 #REF! 0
163 30-Dec-1899 12/30/1899 0 #REF! 0
164 30-Dec-1899 12/30/1899 0 #REF! 0
165 30-Dec-1899 12/30/1899 #REF! #REF! 0
166 30-Dec-1899 12/30/1899 0 #REF! 0
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
167 30-Dec-1899 12/30/1899 0 #REF! 0
168 30-Dec-1899 12/30/1899 0 #REF! 0
169 30-Dec-1899 12/30/1899 0 #REF! 0
170 30-Dec-1899 12/30/1899 0 #REF! 0
171 30-Dec-1899 12/30/1899 0 #REF! 0
172 30-Dec-1899 12/30/1899 0 #REF! 0
173 30-Dec-1899 12/30/1899 0 #REF! 0
174 30-Dec-1899 12/30/1899 0 #REF! 0
175 30-Dec-1899 12/30/1899 0 #REF! 0
176 30-Dec-1899 12/30/1899 0 #REF! 0
177 30-Dec-1899 12/30/1899 0 #REF! 0
178 30-Dec-1899 12/30/1899 0 #REF! 0
179 30-Dec-1899 12/30/1899 0 #REF! 0
180 30-Dec-1899 12/30/1899 0 #REF! 0
181 30-Dec-1899 12/30/1899 0 #REF! 0
182 30-Dec-1899 12/30/1899 0 #REF! 0
183 30-Dec-1899 12/30/1899 0 #REF! 0
184 30-Dec-1899 12/30/1899 0 #REF! 0
185 30-Dec-1899 12/30/1899 0 #REF! 0
186 30-Dec-1899 12/30/1899 0 #REF! 0
187 30-Dec-1899 12/30/1899 0 #REF! 0
188 30-Dec-1899 12/30/1899 0 #REF! 0
189 30-Dec-1899 12/30/1899 0 #REF! 0
190 30-Dec-1899 12/30/1899 0 #REF! 0
191 30-Dec-1899 12/30/1899 0 #REF! 0
192 30-Dec-1899 12/30/1899 0 #REF! 0
193 30-Dec-1899 12/30/1899 0 #REF! 0
194 30-Dec-1899 12/30/1899 0 #REF! 0
195 30-Dec-1899 12/30/1899 0 #REF! 0
196 30-Dec-1899 12/30/1899 0 #REF! 0
197 30-Dec-1899 12/30/1899 0 #REF! 0
198 30-Dec-1899 12/30/1899 0 #REF! 0
199 30-Dec-1899 12/30/1899 0 #REF! 0
200 30-Dec-1899 12/30/1899 0 #REF! 0
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
201 30-Dec-1899 12/30/1899 0 #REF! 0
202 30-Dec-1899 12/30/1899 0 #REF! 0
203 30-Dec-1899 12/30/1899 0 #REF! 0
204 30-Dec-1899 12/30/1899 0 #REF! 0
205 30-Dec-1899 12/30/1899 0 #REF! 0
206 30-Dec-1899 12/30/1899 0 #REF! 0
207 30-Dec-1899 12/30/1899 0 #REF! 0
208 30-Dec-1899 12/30/1899 0 #REF! 0
209 30-Dec-1899 12/30/1899 0 #REF! 0
210 30-Dec-1899 12/30/1899 0 #REF! 0
211 30-Dec-1899 12/30/1899 0 #REF! 0
212 30-Dec-1899 12/30/1899 0 #REF! 0
213 30-Dec-1899 12/30/1899 0 #REF! 0
214 30-Dec-1899 12/30/1899 0 #REF! 0
215 30-Dec-1899 12/30/1899 0 #REF! 0
216 30-Dec-1899 12/30/1899 0 #REF! 0
217 30-Dec-1899 12/30/1899 0 #REF! 0
218 30-Dec-1899 12/30/1899 0 #REF! 0
219 30-Dec-1899 12/30/1899 0 #REF! 0
220 30-Dec-1899 12/30/1899 0 #REF! 0
221 30-Dec-1899 12/30/1899 0 #REF! 0
222 30-Dec-1899 12/30/1899 0 #REF! 0
223 30-Dec-1899 12/30/1899 0 #REF! 0
224 30-Dec-1899 12/30/1899 0 #REF! 0
225 30-Dec-1899 12/30/1899 0 #REF! 0
226 30-Dec-1899 12/30/1899 0 #REF! 0
227 30-Dec-1899 12/30/1899 0 #REF! 0
228 30-Dec-1899 12/30/1899 0 #REF! 0
229 30-Dec-1899 12/30/1899 0 #REF! 0
230 30-Dec-1899 12/30/1899 0 #REF! 0
231 30-Dec-1899 12/30/1899 0 #REF! 0
232 30-Dec-1899 12/30/1899 0 #REF! 0
233 30-Dec-1899 12/30/1899 0 #REF! 0
234 30-Dec-1899 12/30/1899 0 #REF! 0
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
235 30-Dec-1899 12/30/1899 0 #REF! 0
236 30-Dec-1899 12/30/1899 0 #REF! 0
237 30-Dec-1899 12/30/1899 0 #REF! 0
238 30-Dec-1899 12/30/1899 0 #REF! 0
239 30-Dec-1899 12/30/1899 0 #REF! 0
240 30-Dec-1899 12/30/1899 0 #REF! 0
241 30-Dec-1899 12/30/1899 0 #REF! 0
242 30-Dec-1899 12/30/1899 0 #REF! 0
243 30-Dec-1899 12/30/1899 0 #REF! 0
244 30-Dec-1899 12/30/1899 0 #REF! 0
245 30-Dec-1899 12/30/1899 0 #REF! 0
246 30-Dec-1899 12/30/1899 0 #REF! 0
247 30-Dec-1899 12/30/1899 0 #REF! 0
248 30-Dec-1899 12/30/1899 0 #REF! 0
249 30-Dec-1899 12/30/1899 0 #REF! 0
250 30-Dec-1899 12/30/1899 0 #REF! 0
251 30-Dec-1899 12/30/1899 0 #REF! 0
252 30-Dec-1899 12/30/1899 0 #REF! 0
253 30-Dec-1899 12/30/1899 0 #REF! 0
254 30-Dec-1899 12/30/1899 0 #REF! 0
255 30-Dec-1899 12/30/1899 0 #REF! 0
256 30-Dec-1899 12/30/1899 0 #REF! 0
257 30-Dec-1899 12/30/1899 0 #REF! 0
258 30-Dec-1899 12/30/1899 0 #REF! 0
259 30-Dec-1899 12/30/1899 0 #REF! 0
260 30-Dec-1899 12/30/1899 0 #REF! 0
261 30-Dec-1899 12/30/1899 0 #REF! 0
262 30-Dec-1899 12/30/1899 0 #REF! 0
263 30-Dec-1899 12/30/1899 0 #REF! 0
264 30-Dec-1899 12/30/1899 0 #REF! 0
265 30-Dec-1899 12/30/1899 0 #REF! 0
266 30-Dec-1899 12/30/1899 0 #REF! 0
267 30-Dec-1899 12/30/1899 0 #REF! 0
268 30-Dec-1899 12/30/1899 0 #REF! 0
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
269 30-Dec-1899 12/30/1899 0 #REF! 0
270 30-Dec-1899 12/30/1899 0 #REF! 0
271 30-Dec-1899 12/30/1899 0 #REF! 0
272 30-Dec-1899 12/30/1899 0 #REF! 0
273 30-Dec-1899 12/30/1899 0 #REF! 0
274 30-Dec-1899 12/30/1899 0 #REF! 0
275 30-Dec-1899 12/30/1899 0 #REF! 0
276 30-Dec-1899 12/30/1899 0 #REF! 0
277 30-Dec-1899 12/30/1899 0 #REF! 0
278 30-Dec-1899 12/30/1899 0 #REF! 0
279 30-Dec-1899 12/30/1899 0 #REF! 0
280 30-Dec-1899 12/30/1899 0 #REF! 0
281 30-Dec-1899 12/30/1899 0 #REF! 0
282 30-Dec-1899 12/30/1899 0 #REF! 0
283 30-Dec-1899 12/30/1899 0 #REF! 0
284 30-Dec-1899 12/30/1899 0 #REF! 0
285 30-Dec-1899 12/30/1899 0 #REF! 0
286 30-Dec-1899 12/30/1899 0 #REF! 0
287 30-Dec-1899 12/30/1899 0 #REF! 0
288 30-Dec-1899 12/30/1899 0 #REF! 0
289 30-Dec-1899 12/30/1899 0 #REF! 0
290 30-Dec-1899 12/30/1899 0 #REF! 0
291 30-Dec-1899 12/30/1899 0 #REF! 0
292 30-Dec-1899 12/30/1899 0 #REF! 0
293 30-Dec-1899 12/30/1899 0 #REF! 0
294 30-Dec-1899 12/30/1899 0 #REF! 0
295 30-Dec-1899 12/30/1899 0 #REF! 0
296 30-Dec-1899 12/30/1899 0 #REF! 0
297 30-Dec-1899 12/30/1899 0 #REF! 0
298 30-Dec-1899 12/30/1899 0 #REF! 0
299 30-Dec-1899 12/30/1899 0 #REF! 0
300 30-Dec-1899 12/30/1899 0 #REF! 0
301 30-Dec-1899 12/30/1899 0 #REF! 0
302 30-Dec-1899 12/30/1899 0 #REF! 0
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
303 30-Dec-1899 12/30/1899 0 #REF! 0
304 30-Dec-1899 12/30/1899 0 #REF! 0
305 30-Dec-1899 12/30/1899 0 #REF! 0
306 30-Dec-1899 12/30/1899 0 #REF! 0
307 30-Dec-1899 12/30/1899 0 #REF! 0
308 30-Dec-1899 12/30/1899 0 #REF! 0
309 30-Dec-1899 12/30/1899 0 #REF! 0
310 30-Dec-1899 12/30/1899 0 #REF! 0
311 30-Dec-1899 12/30/1899 0 #REF! 0
312 30-Dec-1899 12/30/1899 0 #REF! 0
313 30-Dec-1899 12/30/1899 0 #REF! 0
314 30-Dec-1899 12/30/1899 0 #REF! 0
315 30-Dec-1899 12/30/1899 0 #REF! 0
316 30-Dec-1899 12/30/1899 0 #REF! 0
317 30-Dec-1899 12/30/1899 0 #REF! 0
318 30-Dec-1899 12/30/1899 0 #REF! 0
319 30-Dec-1899 12/30/1899 0 #REF! 0
320 30-Dec-1899 12/30/1899 0 #REF! 0
321 30-Dec-1899 12/30/1899 0 #REF! 0
322 30-Dec-1899 12/30/1899 0 #REF! 0
323 30-Dec-1899 12/30/1899 0 #REF! 0
324 30-Dec-1899 12/30/1899 0 #REF! 0
325 30-Dec-1899 12/30/1899 0 #REF! 0
326 30-Dec-1899 12/30/1899 0 #REF! 0
327 30-Dec-1899 12/30/1899 0 #REF! 0
328 30-Dec-1899 12/30/1899 0 #REF! 0
329 30-Dec-1899 12/30/1899 0 #REF! 0
330 30-Dec-1899 12/30/1899 0 #REF! 0
331 30-Dec-1899 12/30/1899 0 #REF! 0
332 30-Dec-1899 12/30/1899 0 #REF! 0
333 30-Dec-1899 12/30/1899 0 #REF! 0
334 30-Dec-1899 12/30/1899 0 #REF! 0
335 30-Dec-1899 12/30/1899 0 #REF! 0
336 30-Dec-1899 12/30/1899 0 #REF! 0
NO TANGGAL NO. BPJS NAMA KELUHAN TB BB TD RR HR DIAGNOSA
337 30-Dec-1899 12/30/1899 0 #REF! 0
338 30-Dec-1899 12/30/1899 0 #REF! 0
339 30-Dec-1899 12/30/1899 0 #REF! 0
340 30-Dec-1899 12/30/1899 0 #REF! 0
341 30-Dec-1899 12/30/1899 0 #REF! 0
342 30-Dec-1899 12/30/1899 0 #REF! 0
343 30-Dec-1899 12/30/1899 0 #REF! 0
344 30-Dec-1899 12/30/1899 0 #REF! 0
345 30-Dec-1899 12/30/1899 0 #REF! 0
346 30-Dec-1899 12/30/1899 0 #REF! 0
347 30-Dec-1899 12/30/1899 0 #REF! 0
348 30-Dec-1899 12/30/1899 0 #REF! 0
349 30-Dec-1899 12/30/1899 0 #REF! 0
350 30-Dec-1899 12/30/1899 0 #REF! 0
 TINDAKAN RUJUK KE

Debridement Luka Sedang

0
0
Debridement Luka Sedang
0
0
0
Debridement Luka Sedang
Debridement Luka Ringan
0
0
0
0
0
Debridement Luka Sedang
0
Angkat jahitan
Debridement Luka Sedang
0
0
0
0
0
0
0
Injeksi
Pemasangan dan atau pencabutan kateter urine
Pemberian O² (tiap 2 jam)
0
0
 TINDAKAN RUJUK KE

0
0
0
0
Debridement Luka Sedang
Jahit luka 1 - 3 jahitan (Penambahan per jahitan Rp. 5000)
0
Debridement Luka Ringan
Debridement Luka Sedang
0
0
0
0
Pemberian O² (tiap 2 jam)
0
Debridement Luka Sedang
0
0
Debridement Luka Sedang
Jahit luka 1 - 3 jahitan (Penambahan per jahitan Rp. 5000)
Debridement Luka Sedang
0
Debridement Luka Sedang
Debridement Luka Ringan
Penanganan status asmatikus
Debridement Luka Sedang
0
Debridement Luka Sedang
0
Debridement Luka Sedang
Debridement Luka Sedang
0
0
Debridement Luka Sedang
 TINDAKAN RUJUK KE

0
Debridement Luka Sedang
0
Debridement Luka Sedang
0
Debridement Luka Sedang
0
Debridement Luka Sedang
Debridement Luka Sedang
Debridement Luka Sedang
Debridement Luka Sedang
0
Pemberian O² (tiap 2 jam)
Pemberian O² (tiap 2 jam)
0
Debridement Luka Ringan
0
Debridement Luka Sedang
Debridement Luka Ringan
Debridement Luka Ringan
Debridement Luka Ringan
0
0
Debridement Luka Ringan
Pemasangan dan atau pencabutan kateter urine
0
0
0
0
0
0
0
0
0
 TINDAKAN RUJUK KE

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 TINDAKAN RUJUK KE

0
0
0
0
0
0
0
0
0
#REF!
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 TINDAKAN RUJUK KE

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 TINDAKAN RUJUK KE

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 TINDAKAN RUJUK KE

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 TINDAKAN RUJUK KE

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 TINDAKAN RUJUK KE

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 TINDAKAN RUJUK KE

0
0
0
0
0
0
0
0
0
0
0
0
0
0
 RAWAT JALAN
UGD
BULAN AUGUST TAHUN 2018

NO TANGGAL NO. NIK / KTP NAMA UMUR L/P ALAMAT DIAGNOSE/TINDAKAN

1 1-Aug-18 405/352/435.303.102/2018 Minarniyati 54 th P Kalianget Timur E 01

2 1-Aug-18 405/1361/435.303.101/2018 Moh.Miftahol 01 th L Kalianget Barat T 01
3 1-Aug-18 3529024502790001 Ernawati 39 th P Kalianget Barat T 01
4 2-Aug-18 3529024311040002 Laila Nur Azizah 13 th P Kalianget Barat R 11
5 2-Aug-18 3529020108110001 Alvin 07 th L Kalimo'ok R 50
6 3-Aug-18 3529026805160002 indar mersiana 02 th P Kertasada R 11
7 4-Aug-18 405/12 /435.303.104/2018 Ageng suryo 18 th L Karang anyar T01
8 4-Aug-18 352902630650001 Maimuna 54 th L Karang anyar T01
9 4-Aug-18 3529020101670010 Jusup 51 th L Kalianget Barat T00
10 4-Aug-18 3529027006640078 Sahwiyatun 54 th P Kalianget Barat R10
11 4-Aug-18 3529022812100001 Wildan 08 th L Kertasada T01
12 6-Aug-08 405/554/435.303.606/2018 Haisin 78 th L Kertasada N40
13 6-Aug-08 405/435.303.104/2018 Ageng suryo 18 th L Karang anyar T01
14 6-Aug-08 3529025010920019 Nurul wahid 0 L Kalianget Barat 0
15 6-Aug-08 3529022605140001 Salamet riydi 4 th L Kalianget Barat R10
16 7-Aug-28 3529020105880004 Hosni mubarok 52 th L Pinggir Papas R50
17 7-Aug-28 3529020311090001 Bustanul Arifin 08 th L Kertasada R50
18 7-Aug-28 3529021704150002 Moh. Jamaludin 07 th L Kalianget Barat R10
19 8-Aug-18 405/66/435.303.106/2018 Wildan 03 th L Kertasada T01
20 10-Aug-18 3529024402120001 Jillah 08 th L Kertasada R50
21 11-Aug-18 3529024211970003 Eka novia 6.5 L Kalianget Barat L23
22 11-Aug-18 352902102600001 Imam Bahri 21 P Kalianget Barat TO1
23 11-Aug-18 '405/66/435.303.106/2018 Wildan 58 L Kalianget Barat T01
24 11-Aug-18 3529021208540003 Moh.Zaini 8 L Kertasada 0
25 13-Aug-18 3529024802430001 Sadima 0 0 Kalianget Barat T01
26 13-Aug-18 3529023006600124 Sabik 75 P Karang anyar 0
27 13-Aug-18 3529021909070001 Ferdy wiranto 45 L kalimook T01
28 13-Aug-18 3529026805160002 Indira 11 L Kalianget Barat R11
29 14-Aug-18 405/684/435.303.106/2018 Haisin 2.5 P Kertasada N40
30 14-Aug-18 3529022707520001 Moh. Hari 78 L Kertasada T01
31 15-Aug-18 3529024609720004 Hanimah 66 L Kalianget Barat 0
32 15-Aug-18 3529025101560001 Rumsiati 47 P Kertasada 0
33 15-Aug-18 3529024006920004 Misnawati 55 P Kertasada 0
34 16-Aug-18 3529026511630002 Admi 25 P Kertasada R50
35 16-Aug-18 405/66/435.303.106/2018 Wildan 45 P Kalianget Barat T01
36 16-Aug-18 3529026511970006 Misrawti 8 L Kertasada A09
 37 18-Aug-18 3529020107601164 Miskaya 21 P Kalimo'ok R 50
38 18-Aug-18 405/66/435.303.106/2018 wildan 58 L Kalimo'ok T 01
39 18-Aug-18 3529024606620001 Siti Aisyah 8 L Kertasada A09
40 22-Aug-18 3529024910140001 Jihan TU 43 th L Kalianget Timur A09
41 22-Aug-18 3529020712120002 Lutfi 24 P Pasongsongan A09
42 22-Aug-18 3529026706160003 Annora 8 L Kalimo'ok A09
43 22-Aug-18 3273064808800009 Siti Mardiah 6 th 0 kalimook R50
44 23-Aug-18 3529010309130002 Faeza 26 bln 0 Kalianget Barat R11+A09
45 24-Aug-18 3529025110150001 Aztaqirani 43 L Kalianget Timur R50
46 24-Aug-18 3529023006390018 Masruna 38 P Bandung T00
47 24-Aug-18 3529026109150002 Dela Nura L 5 L Marengan Laok R50
48 25-Aug-18 3529023006390018 Masruna 79 th L Pinggir Papas R50
49 26-Aug-18 352917006520077 Sahwati 79 th L Pinggir Papas I10
50 26-Aug-18 3529016903820007 Retno Wahyudi 03 th P Kertasada T01
51 26-Aug-18 3529020107570064 Sunaryo 66 th P Marengan Daya J45
52 27-Aug-18 3529023006390018 Masruna 36 th P Kertasada R50
53 27-Aug-18 3529027006580088 Misari 15 bln P Kalimo'ok E10
54 27-Aug-18 3517033112570003 Sutriman 51 th L Marengan laok 0
55 27-Aug-18 3529024107740123 Awiyani 79 th L Pinggir Papas 0
56 28-Aug-18 3529017006560075 Sittina 60 th P Kalianget Timur 0
57 30-Aug-18 3529024808150001 Alviana afifa 45 th P Kalianget Barat 0
58 26-Jul-18 3529020612080002 Ahmad faiz sobili 10 th L Kalianget Barat R50
### 26-Jul-18 3529020105170002 Moh Miftahol 1 th L Kalianget Barat R50
### 28-Jul-18 3529020105170002 Moh Miftahol 1 th L Kalianget Barat 0
### 28-Jul-18 3529022707760001 Rachmat H 4 th L Kalianget Barat R50
### 28-Jul-18 3529021411100001 Isnan Robbani 7 th L Kalimo'ok R50
### 28-Jul-18 3529025406840002 Marnain ningsih 34 th P Karang Anyar T01
### 29-Jul-18 405/ /435.303.104/2018 Aseng Suryo 11 th L Karang Anyar R50
### 29-Jul-18 3529025804070001 Rani hidayah 12 thn P Kalimo'ok R50
### 29-Jul-18 3529024801180001 Ufairur nur 3 th P Kalimo'ok N40
### 29-Jul-18 405/554/435.303.106/2018 Haisin 78 th L Kertasada T01
### 29-Jul-18 405/1361/435.303.101/2018 Moh Miftahol 1 th L Kalianget Barat E.10
### 29-Jul-18 405/352/435.303.102/2018 Minarniyati 54 th P Kalianget timur R50
### 29-Jul-18 3529021707770001 Salihin 4 th L Karang Anyar R50
### 29-Jul-18 3529025707810003 Yuli K 0 P Kertasada N40
### 31-Jul-18 405/554/435.303.106/2018 Haisin 78 th L Kertasada T01
### 31-Jul-18 405/ /435.303.104/2018 Aseng Suryo 11 th L Karang Anyar B 86
### 31-Jul-18 3529021604700001 Mulyono 48 th L Kalimo'ok R50
### 31-Jul-18 3529025007160001 Dwi Agraini 2 th P Kalianget Barat R 50
### 31-Jul-18 3529026601150002 Firda Aulia 3 th P Kertasada 0
###
###
###
###
###
###
###
###
###
###
###

###
###
 BIAYA
DIAGNOSE/TINDAKAN KARCIS TOTAL BIAYA PARAF
TINDAKAN
Debridement Luka Ringan Rp 7,500 Rp 15,000 Rp 22,500 Rp 22,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
Debridement Luka Ringan Rp 7,500 Rp 15,000 Rp 22,500 Rp 22,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
Pemasangan dan atau pencabutan kateter urine Rp 7,500 Rp 42,500 Rp 50,000 Rp 50,000
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Debridement Luka Ringan Rp 7,500 Rp 15,000 Rp 22,500 Rp 22,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Insisi abses Rp 7,500 Rp 25,000 Rp 32,500 Rp 32,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Pemasangan dan atau pencabutan kateter urine Rp 7,500 Rp 42,500 Rp 50,000 Rp 50,000
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Angkat jahitan Rp 7,500 Rp 10,000 Rp 17,500 Rp 17,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Debridement Luka Ringan Rp 7,500 Rp 15,000 Rp 22,500 Rp 22,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Rp - Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
Rp - Rp 7,500 Rp - Rp 7,500 Rp 7,500
Rp - Rp 7,500 Rp - Rp 7,500 Rp 7,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
Debridement Luka Ringan Rp 7,500 Rp 15,000 Rp 22,500 Rp 22,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
Debridement Luka Sedang Rp 7,500 Rp 20,000 Rp 27,500 Rp 27,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
0 Rp 7,500 Rp - Rp 7,500 Rp 7,500
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -

Rp -
Rp -
Rp 570,000 Rp 475,000 Rp 1,045,000