Instrumen - Rakor - NSI
Instrumen - Rakor - NSI
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KABUPATEN ........................................
PROVINSI ..................................
Peta Lokasi
Untuk sampai ke Puskesmas ….., akses perjalanan dari Kabupaten hanya dapat mengunakan
transportasi Laut yaitu dengan menyewa speed boat, jika cuaca buruk harga sewa menjadi tinggi
karena jarang pengemudi speed boat yang berani menyeberang, harga sewa berkisar Rp
9.000.000 – Rp 12.000.000,- (PP). Jika cuaca bagus, harga sewa speed boat berkisar Rp 6.000.000
– 8.000.000,- (PP). Dari dermaga Marlasi Menuju Puskesmas …. bisa dilakukan dengan berjalan
kaki sejauh 200 m.
2. SK KETERPENCILAN PUSKESMAS
Berdasarkan SK Bupati Kabupaten ………… Nomor: ………………………. tentang
………………………….., masuk dalam kriteria puskesmas Terpencil/Sangat Terpencil.*)
UKM essensial
Promkes
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Kesling
KIA KB
Gizi
P2P
UKM Pengembangan
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Listrik
- Sumber listrik : PLN/Non PLN*)
- Jam operasional listrik : ..............................
Air bersih (AB)
- Sumber AB di puskesmas : .........................................
- Ketersediaan AB di puskesmas : sepanjang tahun/tidak sepanjang tahun*)
- SAB di rumah tinggal Tim NS : .........................................
- Ketersediaan AB di rumah tinggal tim NS :
sepanjang tahun/tidak sepanjang tahun*)
Jaringan telepon/HP
- Kekuatan : kuat/tidak*)
- Provider : ..................................
Jaringan internet
- Kekuatan : kuat/tidak*)
- Jam operasional : ..................................
- Provider : ..................................
- Lokasi sinyal : (radius dari puskesmas/ada spot khusus)
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- Sarana (ada/tidak)
- Pencatatan (manual/
terkomputerisasi)
- Pelaporan (tepat
waktu/tidak)
- Feedback dari Dinkes
Kabupaten
(Dilakukan/tidak)
- Supervisi dari Dinkes
Kab (ada/tidak)
2 Kesling
- Cakupan air bersih (%)
- Cakupan jamban
keluarga (%)
- Cakupan rumah sehat
(%)
- Desa ODF
- TTU diperiksa (%)
- TPM diperiksa (%)
- Konseling (Klinik
sanitasi)
- Lainnya ..........
3 KIA-KB
- K1 (%)
- K4 (%)
- Persalinan di fasilitas
(%)
- KF (%)
- KN lengkap (%)
- Cakupan KB aktif (%)
- Jumlah kematian ibu
- Jumlah kematian bayi
- Lainnya ..........
4 Gizi
- D/S
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- Kasus gizi kurang
- Kasus gizi buruk
- ASI ekslusif (%)
- Fe3 (%)
- Vit A (%)
- Konseling (Klinik gizi)
- Lainnya ..........
5 P2P
- Desa UCI
- Imunisasi dasar
lengkap (%)
- Penemuan kasus TB
BTA+ (jumlah kasus)
- Pneumonia balita
ditemukan dan
ditangani (jumlah
kasus)
- Diare ditemukan dan
ditangani (%)
- PD3I (uraikan sesuai
kasusnya)
- API malaria (per 1000)
- Cakupan pengukuran
tekanan darah (%)
- Lainnya ..........
II UKM pengembangan
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3. Stunting
PISPK
1. Sosialisasi
2. Pelatihan
3. Pendataan
4. Input data
5. Analisis data
6. Intervensi
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10. Pengelolaan dana BOK non fisik, URAIKAN
(siapa, kapan, bagaimana, bentuk kegiatan, hambatan)
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11. Kegiatan Inovasi Tim NS (uraikan)
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MASALAH & SOLUSI
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12. Menurut Tim NS, apakah Puskesmas yang menjadi tempat tugas saat ini masih layak untuk
ditempatkan kembali Tim NS (uraikan)
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13. Jika Puskesmas tidak ditempatkan kembali Tim NS, maka skala kebahagiaan (tulis 1, 2, 3, 4 atau 5,
makin besar berarti semakin bahagia) dari:
a. Kepala Puskesmas adalah: 1 - 2 - 3 - 4 - 5
b. Staf Puskesmas, adalah: 1 - 2 - 3 - 4 - 5
c. Masyarakat, adalah: 1 - 2 - 3 - 4 - 5
d. Dinas kesehatan kabupaten adalah: 1 - 2 - 3 - 4 - 5
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14. Nilai kooperatif terhadap Tim NS, dari:
a. Kepala Puskesmas adalah: 1 - 2 - 3 - 4 - 5
b. Staf Puskesmas, adalah: 1 - 2 - 3 - 4 - 5
c. Masyarakat, adalah: 1 - 2 - 3 - 4 - 5
d. Dinas kesehatan kabupaten adalah: 1 - 2 - 3 - 4 - 5
Dokumentasi
Kegiatan UKM
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