DAFTAR PERMINTAAN OBAT

PUSKESMAS : CURAHDAMI
TANGGAL :
NOMER :

NO NAMA OBAT SATUAN STOK AWAL PEMAKAIAN STOK AKHIR PERMINTAAN KET

MENGETAHUI
PENGELOLA OBAT KEPALA PUSKESMAS CURAHDAMI

ENDANG SULISTYOWARNI dr.AHMAD KUDLORI

NIP.19710409 200701 2 010 NIP . 19710424 200604 1 013
 DAFTAR TAGIHAN KLAIM PELAYANAN OBAT / PERESEPAN PESERTA JAMKESDA ATAU NON MASKIN DI PELAYANAN DASAR

PROPINSI : JAWATIMUR
KABUPATEN : BONDOWOSO
Kepada Yth :
Kepala Dinas Kesehatan Kabupaten Bondowoso
Di Tempat

Jenis Pelayanan obat / peresepan dan besaran tarif se

No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

1 Sucipto 3511120107720060 42 L 3/1/2017 Cephalgia Amox,Pamol,Vit C

2 Moh. In'am NIS 4350 14 L 3/1/2017 Diare Zinc,Kotrim,Pamol

3 Asmai 3511121903470004 70 L 3/1/2017 Hipertensi Kaptopril,Asmef,Amox

4 Susyana 3511125305740002 40 P 3/1/2017 Konjungtivitis Salp Mata Oxy,Amox,asmef,Dexa

5 Ernawati 3511120501780002 34 P 3/1/2017 Dispepsia B6,Ctm

6 Hilda NIS 4379 13 P 3/1/2017 Cephalgia Pamol,Kotrim,Vit BC

7 H.Kardi 3511170705030001 50 L 3/1/2017 Myalgia Asmef,Loratadin,Vit C

8 Sutrisno 3511121900720001 53 L 3/1/2017 Hipertensi Pamol,Nifed,Amox,Ctm,Vit C

9 Dwi anadia 3511124101730007 6 P 3/1/2017 Ispa Pamol,Amox,Dexa
10 Maryama 3511125607850003 28 P 01/03/2017 7 Periodontitis Amox,pamol

11 Kurnia 3511124101640004 53 P 01/03/2017 5 Periodontitis Amox,pamol

12 Zaki 3511125910750003 8 L 01/03/2017 III Persistensi Amox,pamol

13 Suhartatik 3511125507820002 39 P 01/03/2017 8 Periodontitis Amox,pamol

14 Nikolas S SMPN Wringin 15 L 01/03/2017 6 Periodontitis Amox,pamol

15 M David 3511126305810001 3,8 th L 01-03-2017 ispa Pamol,GG,Ctm

16 B. Salani 3511124501490001 68 P 01-03-2017 eks kuku Amox,Asmef V

17 Tisniyah 3511124110660002 51 P 02/03/2017 6 Hiperemi Pulpa Amox,pamol

18 Haryono 3511120905870001 30 L 02/03/2017 6 7Periodontitis Amox,pamol

19 Mulyono 351117120960002 60 L 3/2/2017 ISK Asmef,Kotrim,Vit C

20 Ervin Farida 3511125012750001 41 P 3/2/2017 Hipertensi Pamol,Amox,Nifed,Ctm

21 Miskro 3511120505770001 67 L 3/2/2017 Hipertensi Pamol,Amox,Nifed,Ctm

22 As"ad 3511121707780002 39 L 3/2/2017 Ispa Pamol,Amox,Ctm,Vit C

23 Ahmad Jupriadi 3511121101850002 32 L 3/2/2017 Ispa Amox,Asmef,GG,Ctm

24 P. Ali wapa 3511121003550005 62 L 02-03-2017 psg Dc Amox,Asmef V

25 P. Sarwi 3511122007510001 56 L 02-03-2017 insisi abses Amox,Asmef V
JUMLAH

Jenis Pelayanan obat / peresepan dan besaran tarif se

No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN

26 P. Suman 3511122905500001 57 L 02-03-2017 insisi abses Amox,Asmef V

27 Assifa 3511121112720003 3 bln P 02-03-2017 Imunisasi Pamol Syr
28 Anindita 3511109410688001 2 bln P 02-03-2017 Imunisasi Pamol Syr
29 Naufalin 3511125907870001 9 bln L 02-03-2017 Imunisasi Pamol Syr
30 Izza 3511125212800001 2 bln P 02-03-2017 Imunisasi Pamol Syr
31 Syafarina 3511120307770001 2 bln P 02-03-2017 Imunisasi Pamol Syr
32 Khilfan 3511174110850001 2 bln L 02-03-2017 Imunisasi Pamol Syr
33 Andi 3511123412050007 1 bln L 02-03-2017 Imunisasi Pamol Syr
34 Mikaila 3511124212920001 7 bln P 02-03-2017 Imunisasi Pamol Syr
35 M farhan 3511125206950003 4 bln L 02-03-2017 Imunisasi Pamol Syr
36 Ihsan 3511125904820006 1 bln L 02-03-2017 Imunisasi Pamol Syr
 37 M farel 3511157949850003 2 bln L 02-03-2017 Imunisasi Pamol Syr
38 Aurelia 3511123317760008 1 bln P 02-03-2017 Imunisasi Pamol Syr
39 Yasilah 3511125009840003 5 bln P 02-03-2017 Imunisasi Pamol Syr
40 Najwa 3511126603800001 21 bln P 02-03-2017 Imunisasi Pamol Syr
41 Raisya 3511124709840001 1 bln P 02-03-2017 Imunisasi Pamol Syr
42 Zainul 3511126605920002 2 bln L 02-03-2017 Imunisasi Pamol Syr
43 Anindya 3511124504940001 9 bln P 02-03-2017 Imunisasi Pamol Syr
44 Maulinda 3511125202870003 13 bln P 02-03-2017 Febris Pamol,Ctm,Vit BC

45 Siti Juhairiyah 3511104590785001 30 thn P 02-03-2017 ANC FE,Kalk

46 Fardawi 3511120502660002 7 L 3/3/2017 Scabies Amox,Asmef,Dexa,Ctm,Scabimite SK

47 Suhai 3511125801870001 31 P 3/3/2017 Cephalgia Kloramp,Pamol,OBH Syr

48 Siti Nur A 3511120711730001 6 P 3/3/2017 Obs Febris Pamol Syr

49 Eti 3511125001870001 41 P 3/3/2017 Diabetes Ranitidine,Amox

50 Uus Putrawati 3511125001870001 26 P 3/3/2017 Alergi Loratadin,Dexa,Beta SK

51 Aini 3511124701880001 45 P 3/3/2017 Myalgia Asmef,Meloksicam

52 Samsul Huda 3511125405700001 20 L 3/3/2017 Ispa Amox,Pamol,GG

53 Sulama 3511120301760001 55 P 3/3/2017 Hipertensi Asmef,Nifed

54 Muzainiyah 3512034511890001 27 P 03/03/2017 6 Periodontitis Amox,pamol

55 Gizela 3511124403740001 4 thn P 03-03-2017 ispa Pamol,GG,Ctm

56 Naila 3511120807080002 3,5 thn P 03-03-2017 Febris Pamol Syr,Kotrim Syr

57 Naura 3511124509860002 19 bln P 03-03-2017 ispa Pamol,GG,Ctm

58 Gisel 3511124450568001 2 bln P 03-03-2017 ispa Pamol,GG,Ctm

59 P. Soali 3511120412700007 57 L 03-03-2017 insisi abses Amox,Asmef V

JUMLAH

Pelayanan obat / peresepan dan besaran tarif se

Jenis
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN

60 B. Marhana 3511125008620001 45 P 04-03-2017 psg o2,obs<6jam Amox,Asmef V

61 Mulyani 3511125908930002 42 P 3/4/2017 Myalgia Neurodex,Asmef,Ctm

62 Umam Andrianto 3511124503780001 17 L 3/4/2017 Scabies Amox,Ctm,Pamol,Beta SK

63 Susilowati 3511124504820003 15 P 3/4/2017 Gastritis Pamol,Antasida,B6

64 Febriyanto 3511125007860001 26 L 3/4/2017 Gastritis Pamol,Antasida,B6

65 Prasetyo 3511124302590002 16 L 3/4/2017 Scabies Amox,Dexa,Ctm,Scabimite Sk

66 Zul Islami 3511124107430018 9 L 3/4/2017 Scabies Amox,Dexa,Scabimite SK

67 Mania 3511121212850001 47 P 3/4/2017 Hipertensi Amox,Asmef,Nifed

68 Moh. Garang 3511125608860001 9 L 3/4/2017 Ispa Amox,Pamol,GG

69 As'ad 3511125608860001 37 L 3/4/2017 Ispa Amox,GG,Ctm

70 Sunarmi 3511125506680001 43 P 3/4/2017 Ispa GG,Ctm,Vit C

71 Hanapi 3511124210720001 43 L 3/4/2017 Hipertensi Nifed,asmef

72 Gondriono 3511125012750001 36 L 3/4/2017 Epilepsi CPZ,B6
73 A bintang 3511121203710005 10 bln L 04-03-2017 Dermatitis Amox,pamol,Ctm
74 Dini W 3511120603780001 10 P 3/6/2017 Ispa GG,Ctm,pamol
75 Sila 3511124107810004 36 P 3/6/2017 Gastritis Antasida,B6
76 Anwari 3511121405580001 59 L 3/6/2017 Gastritis Antasida,B6
77 Rita Puspita 3511121308720001 19 P 3/6/2017 Ispa GG,Ctm,Antasida
78 Samiwar 3511121605650001 50 L 3/6/2017 Ispa Asmef,GG,Amox

79 Surinap 3511126207530001 63 P 3/6/2017 Hipertensi Nifed,B6

80 Maripa 3511124504650002 52 P 3/6/2017 Myalgia Asmef,GG,Vit Bc

81 Haryono 3511120905870001 30 L 06/03/2017 67 Gangraena Amox,pamol

82 Niza D 3511125208850003 8 P 06/03/2017 6 Periodontitis Amox,pamol

83 Kurnia 3511124101640004 53 P 06/03/2017 6 Gangraena Amox,pamol

 84 Areta Diandra M 3511125004870007 7 P 06/03/2017 I Persistensi Amox,pamol

85 Tisniyah 3511124110660002 51 P 06/03/2017 6 Gangraena Amox,pamol

86 Nabila 3511126306940002 8 bln P 06-03-2017 febris Amox,pamol,Ctm

87 Riskiatun 3511122175021003 22 thn P 06-03-2017 ANC FE,Vit C

88 Nn. Lindayani 3511124312000003 17 P 06-03-2017 insisi abses Amox,Asmef V

89 Sdr. Pipin Ari 3511122406970003 20 P 07-03-2017 eks atheron Amox,Asmef V
90 An. Lilis saputri 3511126304110002 6 P 07-03-2017 eks atheron Amox,Asmef V
91 Ny.Marhana '3511125008620001 55Th P 3/7/2017 Gastritis Antasida,B6
92 Kafia 3511125206860006 2 thn P 07-03-2017 Ispa Pamol,Ctm,GG

93 Nadine 3511126306960002 10 bln P 07-03-2017 febris Pamol Syr

JUMLAH

Jenis Pelayanan obat / peresepan dan besaran tarif se

No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN

94 Raska K N 3511126705090001 8 P 07/03/2017 I I persistensi Amox,pamol

95 Riki A 3511121411870002 5 L 07/03/2017 I Gangraena Amox,pamol

96 Sumria 3511125505770006 38 P 07/03/2017 3 Gangraena Amox,pamol

97 Eko Naono 3511121503910001 26 L 07/03/2017 6 Periodontitis Amox,pamol

98 Muzainiyah 3512034511890001 27 P 07/03/2017 6 Gangraena Amox,pamol

99 Jamilatur NIS: 584/250-1174 20 P 3/7/2017 Ispa Amox,Pamol,GG

100 B. Janan 3511120604650001 81 P 3/7/2017 Ispa Asmef,B6,Amox

101 Sumito 3511121002920002 57 L 3/7/2017 Myalgia Asmef,B6,Vit BC

102 Suwardi 3511120103720001 46 L 3/7/2017 Hipertensi Asmef,Nifed

103 Abdullah 3511124107830023 46 L 3/7/2017 Myalgia Asmef,B6,Vit BC

104 Asus Supiyadi 3511121212850001 49 L 3/7/2017 Hipertensi Loratadin,dexa

105 Halimatus 3511126702810001 37 P 3/7/2017 Myalgia Asmef,B6,Vit BC

106 Ayu 35112310230001 10 P 3/8/2017 Ispa Amox,GG,Ctm,Salp 24

107 Moh. Hisam 3511126402790001 31 L 3/8/2017 Cephalgia Pamol,Caviplex
108 Amelia 3511124307610003 17 P 3/8/2017 Diare Asmef,B6,Vit BC

109 Abdul Azir 3511126202900002 12 bln L 08-03-2017 Diare Gentian V,Beta SK,Amox,Ctm

110 M azaka 3511126205860002 9 bln L 08-03-2017 Dermatitis Amox,Ctm

111 Siti fatimah 3511125670190005 8 bln P 08-03-2017 Ispa Pamol,Vit BC

112 Aurel 3511124903710001 9 thn P 08-03-2017 Asma Pamol Syr

113 Ny.Litamarta A '3511134703940002 23Th P 3/8/2017 S.Dispepsi Antasida,B6
114 Sdr. Fikianto 3511122004920004 25 L 09-03-2017 hz5x Amox,Asmef V
115 Hasanah B 3511124406780001 7 P 09/03/2017 II Persistensi Amox,pamol

116 Meka 3511176803940001 23 thn P 09-03-2017 ANC FE,Vit C

117 Rofikin 3511120708860001 3,5 thn L 09-03-2017 Dermatitis Amox,Oxy Sk

118 Raditya 3511125206710003 3 thn L 09-03-2017 Diare Zinc,Pamol,Ctm,B6

119 Agi H 3511125206710009 8 bln L 09-03-2017 Imunisasi Pamol Syr

120 Luluk H 3511125058700006 30 thn P 09-03-2017 ANC FE,Vit C

121 Rara 3511125210970004 2 bln P 09-03-2017 Imunisasi Pamol Syr

122 Febri 3511145810740002 1 bln L 09-03-2017 Imunisasi Pamol Syr

123 Calista 3511125004930003 2 bln P 09-03-2017 Imunisasi Pamol Syr

124 Keysa 3511120706900005 2 bln L 09-03-2017 Imunisasi Pamol Syr

125 Firman 3511124919500001 2 bln L 09-03-2017 Imunisasi Pamol Syr

126 Febiola 3511125007970001 1 bln P 09-03-2017 Imunisasi Pamol Syr

127 Sholehuddin 3511125207910001 2 bln L 09-03-2017 Imunisasi Pamol Syr

JUMLAH

Pelayanan obat / peresepan dan besaran tarif se

Jenis
No.Kartu Tanda Tanggal
 Jenis
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN

128 Kevin 3511125410960001 4 bln L 09-03-2017 Imunisasi Pamol Syr

129 Kaila 3511124102910002 1 bln L 09-03-2017 Imunisasi Pamol Syr

130 Kevin H 3511124107911002 2 bln L 09-03-2017 Imunisasi Pamol Syr

131 Wanda 3511124103580001 5 bln L 09-03-2017 Imunisasi Pamol Syr

132 Zahrin 3511124108880001 5 bln L 09-03-2017 Imunisasi Pamol Syr

133 Citra 3511125509900003 6 bln P 09-03-2017 Imunisasi Pamol Syr

134 Habibul 3511125208800001 2 bln L 09-03-2017 Imunisasi Pamol Syr

135 Maulina 3511124505900001 3 bln P 09-03-2017 Imunisasi Pamol Syr

136 Balgis 3511126809820001 1 bln P 09-03-2017 Imunisasi Pamol Syr

137 Nafis 3511125109200001 10 bln P 09-03-2017 Imunisasi Pamol Syr

138 Halimatus 3511120701840001 15 bln P 09-03-2017 febris Pamol,GG,Ctm,Vit c

139 Suraji 3511122011700004 47 L 3/9/2017 Ispa Vit C,GG

140 Suki 3511121502610001 56 L 3/9/2017 Ispa Vit BC,GG

141 Sasmito 3511121708620003 55 L 3/9/2017 Alergi Amox,Asmef,Dexa

142 Wiwin K NIS: 4359 36 P 3/9/2017 Ispa Dexa,Ctm,Vit C

143 Rama 3511125905700001 7 L 3/9/2017 Alergi Amox,ctm,Dexa,Vit BC

144 Putri 3511125109930001 7 P 3/9/2017 Scabies Amox,Dexa,Vit Bc

145 Ima 3511126203770002 4 P 3/9/2017 Scabies Amox,ctm,Dexa,Vit BC,Scabimite SK

146 Risky Aditya 3511124903660001 7 L 3/9/2017 Scabies Amox,ctm,Dexa,Vit BC,Scabimite SK
147 Hafid 3511126404670001 7 P 3/9/2017 Alergi Amox,ctm,Dexa,Vit BC,Beta SK
148 Zainur Rofiq 3511126507820001 7 L 3/9/2017 Alergi Amox,ctm,Dexa,Vit BC,Beta SK
149 Nova 35111247019700001 36 P 3/9/2017 Gastritis Vit BC,Vit B6,Oxy SK

150 Sila 3511174105840001 36 P 3/9/2017 Gastritis Antasida,B6,Vit BC

151 Maripa 3511120308660001 52 P 3/9/2017 Gastritis Antasida,B6

152 Bunasar 3511121510660002 64 L 3/9/2017 Ispa GG,Ctm,Vit C

153 Dedi 3511121406860004 31 L 3/9/2017 Ispa GG,Ctm,Vit C

154 Misro 3511120505770001 60 L 3/9/2017 Ispa Pamol,Amox,Ctm,Nifed

155 M Agung 3511120203760007 14 L 3/9/2017 Cehalgia Amox,B6

156 Reni 3511121911860002 7 P 3/9/2017 Thypoid Amox Syr,Pamol,Ctm,B6

157 Ifa 3511121012950003 6 P 3/9/2017 Scabies Amox syr,Dexa,ctm,Vit BC,Scabimite SK

158 Yulianti NIS: 967/1604347 16 P 3/9/2017 Alergi Amox,Dexa

159 B. Tima 3511125612520001 80 P 3/9/2017 Ispa GG,Ctm,Vit C

160 Tn.Busiri Asjar '3511121403550001 55Th P 3/9/2017 Illius Paralitik Antasida,Rani B6

161 P. Jamal/ P. Nurul 3511120107750032 42 L 10-03-2017 eks atheron Amox,Asmef V
JUMLAH

Pelayanan obat / peresepan dan besaran tarif se

Jenis
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN

162 B. Karni 3511124707750001 42 P 10-03-2017 insisi abses Amox,Asmef V

163 M.Ronim NIS: 795/381-2063 7 L 3/10/2017 Febris Pamol,Amox,Vit BC

164 Dharo Kutni 3511124604800001 17 P 3/10/2017 Alergi Amox,dexa,Ctm,Pamol

165 Rudi Mashuri 3511124604800001 42 L 3/10/2017 Hipertensi Kaptopril,Ctm,Pamol
166 Megawati 3511126207530001 17 P 3/10/2017 Acne Beta SK

167 Hairullah 3511121412900002 27 L 10/03/2017 7 Periodontitis Amox,pamol

168 Zainiyah 3511120405940075 21 P 10/03/2017 6 Gangraena Amox,pamol

169 Diah puji 3511171088800004 29 thn P 10-03-2017 ANC FE,Vit C,Kalk

170 Zainiyah 3511120405947001 21 thn P 10-03-2017 ANC FE,Vit C,Kalk

171 Devi Eka 3511110750400001 25 thn P 10-03-2017 ANC FE,Vit C,Kalk

172 Tn.Busiri Asjar '3511121403550001 55Th L 10-03-2017 Illius Paralitik Antasida,Rani B6
173 Ny.Hiindriatus '3511124705860001 31Th P 10-03-2017 Abd.Disconfort Amox,Asmef
174 An.Rangga Adi P '3511121404160001 11Bln L 10-03-2017 Broncopnemonia Amox,Pamol,Dexa
175 Dai 3511124803930001 2 thn L 11-03-2017 Ispa pamol,GG,Ctm

176 M hamdani 3511120808740001 3 thn L 11-03-2017 Dermatitis Lacto B

177 Dwi 3511124207920001 25 thn L 11-03-2017 Febris Pamol

178 Kaila 3511124704880001 2 thn P 11-03-2017 ispa Kotrim,GG,Ctm

179 Elsi 3511121209700004 3 thn P 11-03-2017 ispa pamol,GG,Ctm

180 Abdul h 3511120708840004 7 L 3/11/2017 Cephalgia Amox,Pamol,Vit BC

181 Niman 3511121608590002 56 L 3/11/2017 Hemmoroid Antihemorroid,Kotrim,Vit C

182 M Sipul 3511121804830001 6 L 3/11/2017 Alergi Loratadin,Dexa,Vit C

183 Devi S 3511121804830001 13 L 3/11/2017 Bronkitis Amox,Pamol,GG

184 Sintia 3511124101790007 7 P 3/11/2017 Diare Pamol,Kotrim,Zinc,Oralit
185 Abd Salam NIS: 066 16 L 3/11/2017 Alergi Loratadin,Ctm,Hidro SK

186 Darman 3511120709670001 50 L 3/11/2017 Thypoid Pamol,Nifed

187 Smsul H 3511120709670001 40 L 3/11/2017 Hipertensi Nifed,asmef,Pirasetam

188 Abd Wafi NIS: 1117 11 L 3/11/2017 Alergi Amox,Ctm,Vit C,Beta SK

189 An.Hesty G '3511126112140002 26Bln P 3/11/2017 Of Pamol,Amox,Ctm

190 Ny.Nija '3511055308470001 60Th P 3/11/2017 Krisis HT Kaptopril,Asmef,B6

191 Tn.Mulyadi/Hari '3511121603500002 69Th L 3/11/2017 Of Pamol,Amox,Ctm

192 Hairullah 3511121412900002 27 L 13/03/2017 7 Periodontitis Amox,pamol

193 Nurul 3511125506880002 27 P 13/03/2017 6 Gangraena Amox,pamol

194 Slamet 3511120811600001 11 L 3/13/2017 Thypoid Pamol,GG,Vit BC,Vit C

195 Idmalul Q 3511124805800003 7 L 3/13/2017 Alergi Amox,Dexa,Ctm

JUMLAH

Pelayanan obat / peresepan dan besaran tarif se

Jenis
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN

196 Hanifah 3511125709600004 56 P 3/13/2017 Hipertensi Nifed,Vit Bc

197 Sari S 3511125667700001 32 P 3/13/2017 Myalgia Asmef,Aminofilin

198 Elsa 3511120103810004 8 P 3/13/2017 Thypoid pamol,Vit BC

199 Ervin Farida 3511125012750001 37 P 3/13/2017 Ispa Amox,Asmef,GG,Vit C

200 M zainuri 3511125409700002 1 thn L 13-03-2017 Dermatitis Amox,Aksi SK
201 A kafin 3511125305950002 17 bln L 13-03-2017 Febris Pamol,Vit BC,Ctm

202 Masfi 3511125007910001 2 thn L 13-03-2017 ispa Pamol,Ctm,GG

203 Latifatul 3511124804930001 23 thn P 13-03-2017 ANC FE,Kalk

204 M fadal 3511125303890003 1 thn L 13-03-2017 diare Kotrim Syr

205 Nurul 3511125506880002 27 thn P 13-03-2017 ANC FE,Kalk

206 Tn.Baidawi R '3511121209650001 52Th L 3/13/2017 KP D0 OAT Amox,B6

207 P. Jatem 3511121406600001 57 13-03-2017 im Amox,Asmef V
208 Afid 3511125310083003 12 bln L 14-03-2017 ispa Pamol,GG,Ctm

209 Rindi 3511125408000002 17 thn P 14-03-2017 ANC FE,Kalk

210 Miko 3511125702950002 9 bln L 14-03-2017 ispa Pamol,Ctm,GG

211 M faqih 3511125405950002 4 thn L 14-03-2017 ispa Pamol,Amox,Oxy SK

212 Erfan 3511124104740002 4 thn L 14-03-2017 ispa Pamol,Ctm,GG

213 Naila 3511125208860007 20 bln P 14-03-2017 Dermatitis Pamol,Amox,Ctm

214 Ulfatul 3511104070189001 21 thn P 14-03-2017 ANC FE,Kalk

215 Rara 3511125221470004 2 bln P 14-03-2017 Inf Telinga Kloramph TT

216 Natasya 3511126803830001 34 bln P 14-03-2017 ispa Pamol,Ctm,GG,Dexa

217 Sdr.Rafi'i '3511121007940001 23Th P 3/14/2017 Abd.Disconfort Amox,Pamol,Dexa

218 Sama 3511125405600002 57 P 3/14/2017 Myalgia Demacolin,Vit BC
219 Hari 3511120910670002 15 L 3/14/2017 Diare Kotrim,Ctm,GG,zinc
220 Misyati 3511125702680001 49 P 3/14/2017 OMA Amox,asmef,Kloramph TT

221 Jesika 3511124106900003 6 P 3/14/2017 Ispa Amox,Pamol

222 Sila 3511124107810004 36 P 3/14/2017 Gastritis Antasida,Pamol,Vit BC,B6
223 Abd Lamat 3511121902450001 63 L 3/14/2017 Hipertensi Pirasetam,Asmef,Vit B6
224 Abd Holid 35111227049500003 22 L 3/14/2017 Susp. TB Amox,GG
225 Danil 3511126803830001 34 bln L 15-03-2017 ispa Pamol,Ctm,GG
226 Nanik 3511126107920003 25 thn P 15-03-2017 ANC FE,Kalk
227 Nabil 3511120679700006 10 bln L 15-03-2017 ispa Pamol,Ctm,GG
228 Kholifah 3511147088700004 34 thn P 15-03-2017 ANC FE,Kalk
229 Raska K N 3511126705090001 8 P 15/03/2017 IV Periodontitis Amox,pamol
JUMLAH

Pelayanan obat / peresepan dan besaran tarif se

Jenis
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN

230 Ronabillah 3511126908890004 7 P 15/03/2017 I Persistensi Amox,pamol

231 M Afif 35111212078820002 17 L 3/15/2017 Thypoid Pamol,Dexa,Ctm,B6

232 Surinap 35111262075530001 64 P 3/15/2017 Hipertensi Pamol,Nifed,Ranitidin
233 Aqila Zafira 35111266111540001 3 P 3/15/2017 Pneumoni Pamol,Kotrim,Dexa,Ctm,B6
234 Dafid afrizal 35111266111540001 17 L 3/15/2017 Alergi Amox,ctm,Scabimite SK
235 Hosnan NIS: 4643 15 L 3/15/2017 Cephalgia Amox,Asmef

236 Robiyanto NIS: 775 18 L 3/15/2017 Alergi Ctm,Dexa,Kalk

237 Umam Andrianto NIS: 1312 17 L 3/15/2017 Alergi Ctm,Dexa,Kalk,Bedak Salisil

238 Nur Alim 3511124101540006 70 L 3/15/2017 Hipertensi Nifed,Asmef,Amox
239 An. Farida 3511121704820001 2 P 15-03-2017 hz5x Amox,pamol V
240 Hairullah 3511121412900002 27 L 16/03/2017 7 Gangraena Amox,pamol

241 M khomisun 3511124403910001 5 bln L 16-03-2017 Imunisasi Pamol Syr

242 Nadine 3511126306960002 10 bln P 16-03-2017 Imunisasi Pamol Syr

243 Anindita 3511126104960001 4 bln P 16-03-2017 Imunisasi Pamol Syr

244 Adnan 3511124504870006 19 bln L 16-03-2017 Imunisasi Pamol Syr

245 Akhan 3511120511870001 1 bln L 16-03-2017 Imunisasi Pamol Syr

246 Rifki 3511126303940001 15 bln L 16-03-2017 Imunisasi Pamol Syr

247 Riskia 3511126303940001 4 bln P 16-03-2017 Imunisasi Pamol Syr

248 Fawas 3511126001770001 1 bln L 16-03-2017 Imunisasi Pamol Syr

249 Nabila 3511124404930001 3 bln P 16-03-2017 Imunisasi Pamol Syr

250 Dindi 3511125808840002 1 bln P 16-03-2017 Imunisasi Pamol Syr

251 M ahyan 3541245038700004 3 bln L 16-03-2017 Imunisasi Pamol Syr

252 Airin 3511125403890006 2 bln P 16-03-2017 Imunisasi Pamol Syr

253 M nafan 3511124802880004 1 bln L 16-03-2017 Imunisasi Pamol Syr

254 Aurelia 3511174405940002 3 bln P 16-03-2017 Imunisasi Pamol Syr

255 Alda 3511125005800003 12 bln P 16-03-2017 Imunisasi Pamol Syr

256 M fildan 3511124101852002 1 bln L 16-03-2017 Imunisasi Pamol Syr

257 Adam 3511120201930004 2 bln L 16-03-2017 Imunisasi Pamol Syr

258 Fania 3511125210870002 7 bln P 16-03-2017 Ispa Pamol,GG,Ctm

259 Naura 3511124809860002 19 bln P 16-03-2017 C cold Pamol Syr

260 Akbar 3511125911950001 10 bln L 16-03-2017 Ispa Pamol,Ctm

261 Lukman NIS: 123 17 L 3/16/2017 Alergi Amox,Dexa,Ctm

262 Friski 3511125005940004 22 P 3/16/2017 TB FDC Kat I

263 Firdatul NIS: 4410 16 P 3/16/2017 Ispa Amox,Demacolin

JUMLAH
 Jenis Pelayanan obat / peresepan dan besaran tarif se
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN
264 Suraji 3511120101590005 58 L 3/16/2017 Ispa Pamol,Amox,ranitidin
265
266 Sofyan 3511121608590002 2 L 3/16/2017 Kejang Demam Pamol,Amox,Luminal,Dexa,Ctm
267 Niman 3511121608590002 57 L 3/16/2017 Haemoroid Amox,asmef,Dexa,Ctm
268 Iksan 3511120112830006 34 L 3/16/2017 Ispa Amox,asmef,Dexa,Ctm
269 Suntono 3511661006770003 34 L 3/16/2017 Scabies Asmef,Amox,Caviplex
270 Lutfia 3511120302630001 15 P 3/16/2017 Stomatitis Amox,Dexa,Vit C
271 Dini 3511125706660001 41 P 3/16/2017 Hipertensi Asmef,Nifed,Simvastatin,Ranitidin
272 Firdania NIS: 4411 16 P 3/16/2017 Cephalgia Pamol,Kotrim,Ranitidin
273 Abd Holik 3511121407870001 28 L 3/16/2017 dispepsia Aspilet,Ranitidin
274 M Rio 3511126001910003 7 L 17/03/2017 I I persistensi Amox,pamol
275 Hosni 3511124707680001 48 P 3/17/2017 Cephalgia Amox,pamol
276 M Belgi 3511124707680001 14 L 3/17/2017 Scabies Amox,pamol,dexa
277 M Jafis 3511124805860003 7 L 3/17/2017 Alergi Amox,Dexa,Ctm
278 Idmalul Q 3511124805800003 37 P 3/17/2017 Alergi Loratadin,Dexa
279 Azahra 3511124512820001 2 P 3/17/2017 Alergi Amox,Pamol,Vit BC
280 Dani 3511122102730002 15 L 3/17/2017 Alergi Amox,Dexa
281 Ummi K 3511122003740001 17 P 3/17/2017 Ispa GG,Pamol,Ctm,Vit C
282 Siti 3511124107840008 7 bln P 17-03-2017 Dermatitis Amox,Pamol,Ctm,Dexa
283 B. Friski Dwi 3511125005940004 23 P 17-03-2017 eks kuku Amox,Asmef V
284 M Nailun 3511127001910001 6 L 3/18/2017 Bronkitis Amox,Pamol,Vit C
285 Sihat 3511122205680002 49 L 3/18/2017 Susp TB Asmef,Amox
286 Elsa N 3511120103810004 14 P 3/18/2017 Ispa Pamol,GG,Ctm,Vit C
287 Baidawi 3511120905800001 33 L 3/18/2017 dispepsia Antasida,Vit BC,B6
288 Humairoh 3511125505710001 46 P 18/03/2017 6 Abses Amox,pamol
289 Moh Jatis 3511124805800003 7 L 18/03/2017 II Persistensi Amox,pamol
290 Sumiati 3511126707780001 39 P 18/03/2017 7 Abses Amox,pamol
291 Anindia 3511124504940001 11 bln P 18-03-2017 Ispa Pamol,Ctm,GG
292 Evi 3511124101930002 24 thn P 18-03-2017 ANC FE.Kalk
293 An.Ahmad z '3511122509150001 17Bln L 3/18/2017 Of Pamol,Amox
294 Muslimatun 3511124911980001 23 thn P 20-03-2017 ANC FE.Kalk
295 M fhatan 3511125206950003 1 thn L 20-03-2017 Ispa Pamol,Ctm,GG
296 Sdr.M Adi D '3511121401980002 19Thn L 3/20/2017 Abd.Disconfort Antasida,Vit BC,B6
JUMLAH

Pelayanan obat / peresepan dan besaran tarif se

Jenis
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN
297 Tn.saniman '3511120110570007 70Thn L 3/20/2017 Anemia Gravis FE,Asmef,B6
298 Danang 3511128077900002 17 L 3/20/2017 Gastritis Kotrim,Antasida,B6
299 Ulfania NIS: 1435 16 P 3/20/2017 Konjungtivitis Amox,Asmef,Dexa,Ctm
300 Sri Hartatik 3511175009020001 15 P 3/20/2017 Cephalgia Amox,Asmef,Dexa,Ctm
301 Kanza 3511124602810003 6 P 3/20/2017 Alergi Kotrim Syr,Dexa,Ctm
302 Niman 3511121608590002 58 L 3/20/2017 Hemmoroid Amox,Asmef,Dexa,Antihemorroid
303 M Maulana 3511121010960002 5 L 3/20/2017 Ispa Pamol Syr,GG,Ctm,Dexa
304 Tri W 3511126008890003 28 P 3/20/2017 Ispa Pamol Syr,Amox Syr,B1,Ctm,Dexa
305 Dani 3511124202810001 16 L 3/20/2017 Cephalgia Pamol,Antasida
306 Abd razak 3511121363700001 40 L 3/20/2017 Cephalgia Ibu 400,B6
307 Muraji 3511122304600001 57 L 3/20/2017 Cephalgia Ibu 400,B6
308 Karim 3511121011550006 62 L 3/20/2017 Cephalgia Ibu 400,B6
309 Dahna 3511126704680001 49 P 3/20/2017 Cephalgia Ibu 400,B6
310 Fadli 3511120203590003 58 L 3/20/2017 Cephalgia Ibu 400,B6
311 Zakariya 3511120810630001 54 L 3/20/2017 Cephalgia Ibu 400,B6
312 Sahemi 3511124412750001 42 P 3/20/2017 Cephalgia Ibu 400,B6
313 Aswan 3511120802520002 65 L 3/20/2017 Cephalgia Ibu 400,B6
314 Suswanto 3511122603710001 46 L 3/20/2017 Cephalgia Ibu 400,B6
315 Muzakki 3511120806720002 47 L 3/20/2017 Cephalgia Ibu 400,B6
316 Luluk Komariyah 3511124203740003 43 P 3/20/2017 Cephalgia Ibu 400,B6
317 Saifullah 3511120603730003 44 L 3/20/2017 Cephalgia Ibu 400,B6
318 Sulasi 3511125203770003 40 P 3/20/2017 Cephalgia Ibu 400,B6
319 Misjan 3511120501680002 49 L 3/20/2017 Cephalgia Ibu 400,B6
320 Asiya 3511124506000013 57 P 3/20/2017 Cephalgia Ibu 400,B6
321 Mujiyem 3511124505560001 61 P 3/20/2017 Cephalgia Ibu 400,B6
322 Burhanuddin 3511120106550001 62 L 3/20/2017 Cephalgia Ibu 400,B6
323 Siama 3511124016770007 50 P 3/20/2017 Cephalgia Ibu 400,B6
324 Fitria 3511125210740005 43 P 3/20/2017 Cephalgia Ibu 400,B6
325 M Said 3511120602610001 56 L 3/20/2017 Cephalgia Ibu 400,B6
326 Sunasri 3511125507690001 48 P 3/20/2017 Cephalgia Ibu 400,B6
327 Marsuki 3511121803660002 49 L 3/20/2017 Cephalgia Ibu 400,B6
328 Misadin 3511120308650003 52 L 3/20/2017 Cephalgia Ibu 400,B6
329 Alim 3511122407620001 55 L 3/20/2017 Cephalgia Ibu 400,B6
JUMLAH

Pelayanan obat / peresepan dan besaran tarif se

Jenis
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN
330 Misadin 3511122007540001 63 L 3/20/2017 Cephalgia Ibu 400,B6
331 Paeng 3511120307540001 63 L 3/20/2017 Cephalgia Ibu 400,B6
332 M Hasan 3511120203900001 27 L 3/20/2017 Cephalgia Ibu 400,B6
333 Nasuha 3511125508490001 68 P 3/20/2017 Cephalgia Ibu 400,B6
334 Abd Syukur 3511120101560008 61 L 3/20/2017 Cephalgia Ibu 400,B6
335 Ernawati 3511124910630001 54 P 3/20/2017 Cephalgia Ibu 400,B6
336 Marlin 3511125405620001 55 P 3/20/2017 Cephalgia Ibu 400,B6
337 Abu yazid 3511121703550001 62 L 3/20/2017 Cephalgia Ibu 400,B6
338 Siama 3511124101670007 50 P 3/20/2017 Cephalgia Ibu 400,B6
339 Buhari 3511121404720003 45 L 3/20/2017 Cephalgia Ibu 400,B6
340 Elma 3511124106830002 8 P 20/03/2017 IV Periodontitis Amox,pamol
341 Saifullah 3511120607830001 34 L 20/03/2017 8 Periodontitis Amox,pamol
342 Rohama 3511125512740001 41 P 20/03/2017 8 Abses Amox,pamol
343 Kairun Niza 3511126712850103 7 P 20/03/2017 II Persistensi Amox,pamol
344 P. Andi wijaya 3511120507840004 32 L 20-03-2017 eks kuku Amox,Asmef V
345 B. Misyani 3511124611780002 39 P 20-03-2017 insisi abses Amox,Asmef V
346 Zaihol NIS: 4714 14 L 3/21/2017 dispepsia Pamol,Antasida
347 Renifa NIS: 1144 18 P 3/21/2017 Ispa Amox,pamol
348 Faisol NIS: 670-277/1174 17 L 3/21/2017 Konjungtivitis Ibu 400,Amox,Ctm
349 Suma 3511126802820002 45 P 3/21/2017 Hipertensi Nifed,Pirasetam
350 Ikmal m 3511120902820001 48 L 3/21/2017 dispepsia Pamol,Antasida,ctm
351 P. Imam hairudin 3511120105800003 37 l 21-03-2017 eks atheron Amox,Asmef V
352 Diah Putri Nis 4338 16 P 21/03/2017 6 Periodontitis Amox,pamol
353 Natasya 3511124306790001 9 P 21/03/2017 V Periodontitis Amox,pamol
354 Marima 3511125508460001 71 P 21/03/2017 2 Abses Amox,pamol
355 Sumiyati 3511126707780001 39 P 21/03/2017 1 1 Gangraena Amox,pamol
356 Abd azis 3511126202900002 1 thn L 21-03-2017 Ispa Pamol,GG,Ctm
357 M maesa 3511107510890002 1 bln L 21-03-2017 Ispa Pamol,GG,Ctm
358 Kafia 3511125206860002 27 bln P 21-03-2017 Paotitis Pamol Syr
359 Sri Wahyuningsih 3511126106750002 65 P 3/22/2017 Ispa Amox,GG,Ctm,Vit C
360 Suwarjo 3511121116720001 67 L 3/22/2017 Konjungtivitis Asmef,Amox,Dexa
361 Sulastri 3511125605786002 39 P 3/22/2017 Hipertensi Amox,Pamol,GG
362 Halimatus 3511125605760001 38 P 3/22/2017 Anemi Neurodex,B6,FE
JUMLAH

Jenis Pelayanan obat / peresepan dan besaran tarif se

No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN
363 Ainun R 3511120106750002 17 P 3/22/2017 Alergi Amox,Dexa,Ctm,Hidro SK
364 Abdullah 3511120102750009 41 L 3/22/2017 Hipertensi Pamol,Amox,Dexa,Ctm
365 Mistro 3511120505740001 66 L 3/22/2017 Hipertensi Asmef,Amox,Nifed,Antihemorroid
366 M Nur 3511120102350002 41 L 3/22/2017 HHD Aspilet,Nifed,Ranitidin
367 Ahmad F NIS: 0430 16 L 3/22/2017 Konjungtivitis Asmef,Amox,Dexa,Oxy SM
368 Sakdiya 3511121501710003 16 P 3/22/2017 Alergi Loratadin,Beta SK
369 B. Miarsi 3511124803780003 39 P 22-03-2017 hz5x Amox,Asmef V
370 Reno Wijaya Nis 670/277-1174 17 L 22/03/2017 6 Periodontitis Amox,pamol
371 Wahyu Winato SMK Wringin 18 L 22/03/2017 7 Periodontitis Amox,pamol
372 Siti Kholifah 3511125208830004 12 P 22/03/2017 I I persistensi Amox,pamol
373 Farel F 3511124107890004 8 L 22/03/2017 I I persistensi Amox,pamol
374 Zakiatul 3511120405790001 8 L 22/03/2017 III Persistensi Amox,pamol
375 Isam Nabil 3511124605780002 5 L 22/03/2017 IV Periodontitis Amox,pamol
376 Siti Amza 3511124601860001 32 P 22/03/2017 6 Gangraena Amox,pamol
377 Siti ainul 3511124601860001 37 thn P 22-03-2017 ANC FE,Kalk
378 Saifullah 3511120607830001 34 L 23/03/2017 8 Gangraena Amox,pamol
379 Emilda 3511120805890001 7 P 23/03/2017 I Persistensi Amox,pamol
380 Zhafran 3511121061109101 3 bln L 23-03-2017 Imunisasi Pamol Syr
381 Satuha 3511124510900005 1 bln P 23-03-2017 Imunisasi Pamol Syr
382 Qorina 3511125474880001 1 bln P 23-03-2017 Imunisasi Pamol Syr
383 m videndan 3511128293000001 1 bln L 23-03-2017 Imunisasi Pamol Syr
384 M izzudin 3511126010870001 1 bln L 23-03-2017 Imunisasi Pamol Syr
385 M mawatin 3511126605980001 1 bln L 23-03-2017 Imunisasi Pamol Syr
386 Atika 3511122566120006 1 bln P 23-03-2017 Imunisasi Pamol Syr
JUMLAH

Pelayanan obat / peresepan dan besaran tarif se

Jenis
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN
387 Kaila 3511120502440002 1 bln P 23-03-2017 Imunisasi Pamol Syr
388 Azalea 3511126562990003 1 bln P 23-03-2017 Imunisasi Pamol Syr
389 Rofidatul 3511121801820001 1 bln P 23-03-2017 Imunisasi Pamol Syr
390 Yuliana 3511120107580003 24 bln P 23-03-2017 Imunisasi Pamol Syr
391 Bergi 3511126306930001 18 bln P 23-03-2017 Ispa Pamol,Amox,Ctm
392 Ades 3511124301987005 3 thn L 23-03-2017 Imunisasi Pamol Syr
393 Nabila 3511122701160003 3 thn P 23-03-2017 Ispa Pamol,Ctm,GG
394 Kaila 3511124704881001 2 thn P 23-03-2017 Imunisasi Pamol Syr
395 Nabila 3511126002970002 3 thn P 23-03-2017 Imunisasi Pamol Syr
396 Rusni 3511121501810001 72 L 3/23/2017 Shizofren CPZ
397 Buhari 3511121404720003 45 L 3/23/2017 Hipertensi Kaptopril
398 Dini 3511125706660001 51 P 3/23/2017 Hipertensi Asmef,Kaptopril,Ranitidin
399 Santo 3511121211740001 43 L 3/23/2017 OMA Asmef,Amox,Dexa,ctm
400 Sri Indah 3511125709600004 23 P 3/23/2017 Ispa Pamol,Amox,Ranitidin,Ctm
401 Fatita 3511120509000001 8 P 3/23/2017 Scabies Loratadin,Ctm,Scabimite SK,Pamol
402 Marlin 3511123003560002 60 P 3/23/2017 Hipertensi Kaptopril,Ctm
403 Abd S 3511120101560008 62 L 3/23/2017 Hipertensi Amox,GG
404 Ernawati 3511124910630001 65 P 3/23/2017 Hipertensi Asmef,kaptorpil,B6
405 B. Suhaina 3511124507860001 31 P 24-03-2017 hz10x Amox,Asmef V
406 Izatun 3511121708720003 7 P 3/24/2017 Ispa Pamol,Amox,Ctm
407 Mulyono 3511171209640002 46 L 3/24/2017 dispepsia Asmef,Antasida,Vit C
408 Hasanah 3511126011930001 22 P 3/24/2017 Thypoid Demacolin,Antasida
409 Siti 3511125003800009 7 P 3/24/2017 Cephalgia Pamol,Amox,Ctm
410 Farel 3511124127890004 7 L 24/03/2017 I I persistensi Amox,pamol
411 Misbahul 3511125802770001 8 L 24/03/2017 I Persistensi Amox,pamol
412 Amil 3511125411820001 2 thn L 24-03-2017 Ispa Pamol,Ctm,GG
413 Hulillah 3511125610860001 2 thn L 24-03-2017 Ispa Pamol,Ctm,GG,Zinc
414 Nuryana 3511127808990001 17 thn P 24-03-2017 Nifas Nifedipin
415 An.Lailatul i '3511126802180001 2Thn P 3/24/2017 Of Pamol,Vit B6,Antasida
416 Niman 3511121608590002 57 L 3/25/2017 Diare Amox,pamol
417 Amir 3511124309771902 5 L 3/25/2017 Ispa Amox Syr,Pamol,B6
418 Hosni 3511124707680001 46 P 3/25/2017 dispepsia Ibu 400,Antasida,Vit B6
419 Wahyu u 3511125507681002 34 P 3/25/2017 Gastritis Ibu 400,Ranitidin,Ctm
JUMLAH

Jenis Pelayanan obat / peresepan dan besaran tarif se

No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN
420 Nadine 3511126306960003 10 bln P 25-03-2017 Ispa Pamol,GG,Ctm
421 Naura 3511125207730002 8 bln P 25-03-2017 Dermatitis Amox Syr,Pamol,Ctm
422 Tn.Wahyu umami '3511126006810001 30Thn P 3/25/2017 Dyspepsia Ibu 400,Antasida,Vit B6
423 An.Alya Nidaul 3511126308160001 6,5 Th P 3/25/2017 GEDS Kotrim,Antasida,Oralit
424 P. Saruji 3511121312910002 26 L 25-03-2017 eks atheron Amox,Asmef V
425 B. Sulasi 3511126504720012 45 P 25-03-2017 hz10x Amox,Asmef V
426 Sumiyati 3511126707780001 41 P 27/03/2017 7 Gangraena Amox,pamol
427 Miftahus 3511125012780001 11 L 27/03/2017 III Persistensi Amox,pamol
428 Nafiya 3511125802770001 40 P 27/03/2017 8 Periodontitis Amox,pamol
429 M Taufiqaur R Nis 948/141-4347 16 L 27/03/2017 6 Periodontitis Amox,pamol
430 Wahyudi Nis 965/158-4347 19 L 27/03/2017 6 Periodontitis Amox,pamol
431 Lusiyawati 3511126806780002 39 P 27/03/2017 5 Gangraena Amox,pamol
432 Yayuk 3511126810860002 31 P 27/03/2017 Kg Amox,pamol
433 Uswatun 3511128106840001 33 P 27/03/2017 Kg Amox,pamol
434 Lailatul 3511123001170002 17 P 27/03/2017 Kg Amox,pamol
435 Yuryanti 3511125208830003 34 P 27/03/2017 7 Gangraena Amox,pamol
436 Deni Rahayu 3511086801970001 20 P 27/03/2017 6 Gangraena Amox,pamol
437 Siti H 3511124103950003 22 P 27/03/2017 6 Gangraena Amox,pamol
438 Siti Kholifatus 3511124402890002 25 bln P 27-03-2017 Ispa Pamol,GG,Ctm
439 Yunyati 3511125208830003 30 thn P 27-03-2017 ANC Fe,kalk
440 Lailatul 3511123001170002 17 thn P 27-03-2017 ANC Fe,kalk
441 Deni 3511186801970001 20 thn L 27-03-2017 ANC Fe,kalk
442 Yayuk 3511126810860002 31 thn P 27-03-2017 ANC Fe,kalk
443 Fani 3511126302880001 6 bln P 27-03-2017 Ispa Pamol,GG,Ctm
444 An.Ahmad Fiqi '3511120909120001 4,5Thn L 3/27/2017 OF+Thypoid Kloramph,Antasida,B6
445 Ny.Amyani '3511124802650001 55Th P 3/27/2017 GEDS Kotrim,Antasida,Oralit
446 M. Robby NIS: 4620 15 L 3/27/2017 Cephalgia Pamol,B6
447 Tosiya 3511125001690001 48 P 3/27/2017 Cephalgia Ibu 400,Vit BC,B6'
448 Dani 3511124202810001 12 L 3/27/2017 Cephalgia GG,Vit C,Kalk
449 Mustipa 3511126116800004 37 P 3/27/2017 Alergi Ctm,Dexa,Kalk
450 Maryati 3511125701420002 75 P 3/27/2017 Alergi Ctm,Dexa,Kalk
451 Saburi 3511124305760001 42 L 3/27/2017 Myalgia Asmef,Simvastatin
452 Nulfatut 3511124305670002 25 P 3/27/2017 Alergi Amox,Dexa
JUMLAH

Pelayanan obat / peresepan dan besaran tarif se

Jenis
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN
453 Ferdi 3511124305070001 8 L 3/27/2017 Cephalgia Amox,Pamol,Dexa,Ctm
454 Rudianto 3511110309810001 36 L 3/27/2017 Cephalgia GG,Ctm,Vit C
455 Ahmad Candra 3511125003760005 12 L 29/03/2017 IV Persistensi Amox,pamol
456 Aprilia 3511121403680101 16 P 29/03/2017 6 Periodontitis Amox,pamol
457 Iqbal 3511124709840001 6 L 29/03/2017 I Persistensi Amox,pamol
458 Igafadiyah Nis 4485 14 P 29/03/2017 6 Periodontitis Amox,pamol
459 Puya 3511125112530001 65 P 3/29/2017 Myalgia Asmef,B6,GG
460 Susiyati 3511126609920002 25 P 3/29/2017 Konjungtivitis Amox,ctm
461 Surya 3511124101110003 6 P 3/29/2017 Scabies Amox,pamol,Ctm
462 Hanapi 3511121403680001 43 L 3/29/2017 Hipertensi Asmef,Kaptopril,Ctm
463 Soarmi 3511121003640003 51 L 3/29/2017 Bronkitis Asmef,GG,Vit C
464 Sofi Rahayu NIS: 963/156-4347 17 P 3/29/2017 Cephalgia Pamol,B6
465 Anisah 3511122101780001 4,5 thn P 29-03-2017 Dermatitis Amox,Pamol,Ctm,Berta SK
466 M rasid 3511125010850005 3 thn L 29-03-2017 scabies Pamol Syr,Amox,Ctm,Vit BC,Scabimite SK
467 M dzaka 3511126205860002 9 bln L 29-03-2017 Febris Pamol Syr
468 Aurel 3511124903710001 3 thn P 29-03-2017 Ispa Amox,Pamol,Ctm,Ambroxol
469 Enjel 3511124078200002 23 bln P 29-03-2017 Ispa Pamol,GG,Ctm
470 Aura 3511124405850001 4 thn P 29-03-2017 Ispa Pamol,GG,Ctm
471 Kefin 3511124405850001 2,5 thn L 29-03-2017 Ispa Pamol,GG,Ctm
472 p.luppi/p.iyud 3511120501760003 41 L 29-03-2017 hz15x Amox,Asmef V
473 An.M Zuhri '3511121907150001 21Bln L 3/29/2017 FC Amox,pamol,Luminal
474 Tn. Mistari 3511121604200001 75 Th L 3/29/2017 OF Pamol,Antasida,B6
475 An. Bella Syarifa 3511174209080001 9 Th P 3/29/2017 OF Pamol,Antasida,B7
476 Nn. Rovi Anula 3511126205980001 19 Th P 3/29/2017 OF Pamol,Antasida,B8
477 Rodi 3511120106750002 42 L 3/30/2017 Hipertensi Pamol,Nifed,Ranitidin,Amox
478 Imam S 3511082706910002 26 L 3/30/2017 Cephalgia Pamol,rani,Kotrim
479 M Nurk 3511124709830002 40 L 3/30/2017 Hipertensi Kaptopril,Asmef
480 Handri S 3511121102930004 24 L 3/30/2017 Ispa Kotrim,Pamol,Spasminal,Zinc
481 Niman 3511121608590002 55 L 3/30/2017 Diare Meta,Zinc
482 Surakmo 3511121608690001 60 L 3/30/2017 RA Ranitidin,Caviplex
483 Sunarma 3511125104670001 50 P 3/30/2017 Ispa Pamol,Gliben
484 Laysila 3511124102860006 9 P 30/03/2017 IV Persistensi Amox,pamol
485 Belgis 3511124909870001 10 P 30/03/2017 IV Persistensi Amox,pamol
JUMLAH

Pelayanan obat / peresepan dan besaran tarif se

Jenis
No.Kartu Tanda Tanggal
 Jenis
No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN
486 M haris 3511126405950001 7 hr L 30-03-2017 Imunisasi Pamol Syr
487 M arsyad 3513143091000004 1 bln L 30-03-2017 Imunisasi Pamol Syr
488 Anindita 3511125263039101 1 bln P 30-03-2017 Imunisasi Pamol Syr
489 Umniyati 3511127203850001 1 bln P 30-03-2017 Imunisasi Pamol Syr
490 Zherly 3511142099600002 1 bln P 30-03-2017 Imunisasi Pamol Syr
491 Ahmad 3511124407900002 1 bln L 30-03-2017 Imunisasi Pamol Syr
492 Silsa 3511121005051201 1 bln P 30-03-2017 Imunisasi Pamol Syr
493 Kholifah 3511126208080001 1 bln P 30-03-2017 Imunisasi Pamol Syr
494 Eza 3511125307960003 2 bln L 30-03-2017 Imunisasi Pamol Syr
495 Quinzy 3509064811800001 9 bln P 30-03-2017 Imunisasi Pamol Syr
496 Assifa 3511121127200003 4 bln P 30-03-2017 Imunisasi Pamol Syr
497 Sarifah 3511123370000001 1 bln P 30-03-2017 Imunisasi Pamol Syr
498 M qolby 3511126109850003 6 bln L 30-03-2017 Imunisasi Pamol Syr
499 Ahmad 3511125103910001 8 bln L 30-03-2017 Imunisasi Pamol Syr
500 Nailatul 3511122101890002 1 bln P 30-03-2017 Imunisasi Pamol Syr
501 A riski 3511124110880001 2 bln L 30-03-2017 Imunisasi Pamol Syr
502 Raihanul 3511125706920004 3 bln L 30-03-2017 Imunisasi Pamol Syr
503 Marisyatul 3512034589000001 4 bln P 30-03-2017 Imunisasi Pamol Syr
504 M farel 3511157949850003 3 bln L 30-03-2017 Imunisasi Pamol Syr
505 Adefa 3511125001880003 18 bln P 30-03-2017 Imunisasi Pamol Syr
506 Danil 3511124803910001 34 bln L 30-03-2017 Ispa Pamol,Ctm,GG
507 Riyan 3511124312820001 1 thn L 30-03-2017 Ispa Pamol,Ctm,GG
508 M zaenuri 3511125409790001 1 thn L 30-03-2017 Dermatitis Amox,Ctm,Pamol
509 Yunita 3511126205970004 10 bln P 30-03-2017 diare Kotrim,Pamol
510 Adiba 3511126008920005 9 bln L 30-03-2017 Ispa Pamol,Ctm,GG
511 Zakiyah 3511124101790001 30 thn P 30-03-2017 Aks Kb Asmef
512 Yani 3511124701860003 28 thn P 30-03-2017 ANC FE,Kalk
513 An. Moh Nurul 3511121512130001 3 Th A 3/30/2017 GEDS Kotrim,Pamol,Oralit,Zinc
514 sdr.Dulwafi 3511121111920002 25 L 30-03-2017 hz10x Amox,Asmef V
515 Ummi 3511125107780001 31 thn P 31-03-2017 ANC FE,Kalk
516 M ridho 3511174105870004 3 thn L 31-03-2017 Dermatitis Amox,Pamol,Ctm
517 Fina N D 3511125205810004 5 P 31/03/2017 I Perforasi Gingiva Amox,pamol
518 Mutiara 3511126707910001 7 P 31/03/2017 I I persistensi Amox,pamol
JUMLAH

Jenis Pelayanan obat / peresepan dan besaran tarif se

No.Kartu Tanda Tanggal
No. Nama Pasien umur Kelamin ( DIAGNOSA Poli
Penduduk Kunjungan Jenis Obat Yang Diresepkan
L/P) UGD

JUMLAH PINDAHAN
519 Sumrani 3511124809730001 44 P 31/03/2017 6 Periodontitis Amox,pamol
520 Ramadani 3511125504670001 9 L 31/03/2017 IV Persistensi Amox,pamol
521 Rima 3511125011890003 9 P 31/03/2017 IV Persistensi Amox,pamol
522 Afron 3511125302860003 9 L 31/03/2017 6 Periodontitis Amox,pamol
523 Andika 3511124262780001 10 L 31/03/2017 IV Persistensi Amox,pamol
524 Yupik 3511120402420002 25 L 3/31/2017 Scabies Amox,Dexa,Ctm
525 Roni J 3511121712420001 25 L 3/31/2017 Alergi Asmef,Amox,Dexa
526 Rorosi 3511121702530001 17 L 3/31/2017 Scabies Dexa,Ctm
527 Yul 3511120102530001 49 L 3/31/2017 Thypoid Kloramph,Pamol
528 St Fatimah 3511124109790002 38 P 3/31/2017 Ispa Amox,Pamol,B6
529 Suwardi 3511121011700013 46 L 3/31/2017 Hipertensi Asmef,Nifed,B6
JUMLAH

MENGETAHUI
KEPALA PUSKESMAS WRINGIN Pengelo

DR. Tutik Kusdarwati,M.Mkes SRI LES

NIP. 19670613 200604 2 009 NIP. 198
A ATAU NON MASKIN DI PELAYANAN DASAR

BULAN : MARET
PUSKESMAS : WRINGIN
TAHUN : 2017

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
1000
25000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

25000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
 V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
59000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

59000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
 V 1000
V 1000
V 1000
V 1000
1000
1000
1000
V 1000
V 1000
V 1000
93000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

93000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
127000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
 Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

127000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
161000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

161000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
 V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
195000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

195000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
 V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
229000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

229000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
263000
Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )
Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

263000
V 1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
296000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

296000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
 V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
329000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

329000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
V 1000
V 1000
 V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
362000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

362000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
386000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

386000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
 V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
419000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

419000
V 1000
V 1000
V 1000
V 1000
1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
 V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
452000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

452000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
485000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
 Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

485000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
1000
V 1000
V 1000
V 1000
V 1000
518000

Pelayanan obat / peresepan dan besaran tarif sesuai perda ( Rp )

Total
Poli Poli Poli Biaya
RITP
BP Gigi KIA

518000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
V 1000
 529000

Pengelola Obat

SRI LESTARI SEPTARINI

NIP. 19810912 200701 2 005