Kepada : Fahmi Basa/ Muhamad Fatoni (JOB Tomori Area QHSE Superintendent)

dr. Amirullah (JOB Tomori OHIH Section Head)

Tembusan : dr. Bernie Piet (JOB Tomori OH Analyst)
Sonia Kartika Hapsari (JOB Tomori IH Analyst)
Irin Meiningsih (JOB Tomori IH Analyst)
Dari : dr. A Gunawan/dr. Kosasih (MP Field Coordinator Doctor - Site)
Deni Setiawan (MP IH Officer - Site)
dr. Ferdy N/dr. Enrico L (MP Field Doctor - Site)
Rahmat/ Richard/ Haryono/ Zulfaisal (MP Paramedik - Site)
Perihal : Laporan Mingguan
Periode : 1 - 7 APRIL 2019
CENTRAL PROCESSING PLANT SENORO JOB PERTAMINA MEDCO E&P TOMORI SULAWESI
RINGKASAN LAPORAN KLINIK MINGGUAN
TOTAL KUNJUNGAN Periode: 1 - 7 April 2019
Jumlah Kunjungan 26 Jumlah Evakuasi Medis 1
Jumlah Rujukan 1 Jumlah Rawat Observasi 0
Jumlah Kecelakaan 0

JOB Kontraktor Tamu RASIO KUNJUNGAN

TOTAL
1st Visit Follow Up 1st Visit Follow Up 1st Visit Follow Up JOB 14 53.85%
14 0 11 1 0 0 Kontraktor 12 46.15%
26
14 12 0 Tamu 0 0.00%

10 (SEPULUH) BESAR DIAGNOSIS

NO CODE ICD DIAGNOSIS TOTAL PERSENTASE
1 J00.9 Common cold (Flu) 4 15.38%
2 L50.0 Urticaria (Biduran) 2 7.69%
3 M79.1 Myalgia (Nyeri Otot) 2 7.69%
4 M25.561 Pain in right knee 2 7.69%
5 R51.9 Headache (Sakit Kepala) 2 7.69%
6 K02.9 Dental Caries (Sakit Gigi) 2 7.69%
7 H01.9 Eye Irritation (Iritasi Mata) 1 3.85%
8 I10.9 Essential (primary) hypertension 1 3.85%
9 L30.9 Dermatitis, unspecified ( Infeksi Kulit) 1 3.85%
10 J06.9 Acute upper respiratory infection, unspecified ( ISPA) 1 3.85%

KASUS KECELAKAAN
PERUSAH LOKASI
NO NAMA JABATAN AAN
DIAGNOSIS CLASS* TINDAKAN HASIL KETERANGAN
CEDERA

* FAC: First Aid Case; MTC: Medical Treatment Case; LTI: Loss Time Injury; FTL: Fatality
PROGRAM K3 TANGGAL KETERANGAN
93 orang Pemeriksaan Kesehatan Datang
(ref: 3.1 HS (Tiba dilokasi))
1 orang 7 hari/Pekerja Risiko Tinggi
(ref: 3.2 HS (7 hari))
Pemeriksaan Kesehatan (Health Surveillance) 1 - 7 April 2019 251 orang Pekerjaan berisiko tinggi
(ref: 3.3 HS (Pekerjaan Risiko Tinggi))
1 orang >14 hari kerja/Roster kerja
(ref: 3.4 (HS (>14 hari,Roster))

Inspeksi mobil ambulans 7-Apr-19 Laik Jalan (ref: 9. Inspeksi Ambulance)

Dilaksanakan tanggal 23/03/19 bersama tim

Inspeksi Hygiene Sanitasi N/A GDSK, HSE, OHIH, dan GS
(ref: 10. OHIH Inspection)

Dilaksanakan di wilayah CPP Senoro

Inspeksi kotak P3K 3 & 4 April 2019
(ref. Lap. Bulanan)

Hazard Observation Card (HOC) 1 - 7 April 2019 3 Kartu (ref: 16. HOC)
Dilaksanakan Workshop Maintenance dan
Penyuluhan kesehatan: GERD,Hipoglikemia Friday, April 05, 2019 MCB CPP Senoro
(ref: 11. Health Awareness)
Terakhir dilaksanakan tanggal 31/03/2019 di
Penyuluhan jasa boga: N/A Messhall dan diikuti 24 Karyawan GDSK
(ref: 12. Food Session)

Didistribusikan diwilayah kerja CPP Senoro

Buletin kesehatan: GERD Saturday, April 06, 2019
(ref: 13. Buletin Kesehatan)

Terakhir diilaksanakan 05/03/18 di wilayah

Emergency drill: - N/A Condensate Tank CPP Senoro
(ref: 15. DRILL)

Dilaksanakan di Mess Hall CPP Senoro

Latihan penyegaran petugas P3K: FAT lv 1 (karyawan GDSK) Saturday, April 06, 2019
(ref: 14. FAT)

Upgrade Skill Terakhir dilaksanakan 31

Lainnya: Upgrade Skill : N/A
Maret 2019 di klinik CPP

Disiapkan oleh Diperiksa oleh

dr. Ferdy/ Pr. Rahmat/ Pr. Richard dr. A. Gunawan S/ Deni Setiawan
MP Emergency Medical Team (Site) MP Coordinator Doktor / OH-IH Senior (Site)
 WEEKLY REPORT
PERIODE :
LOKASI : CPP Senoro

I. A KLINIK
Senoro Tiaka HOC Input
No Aktifitas Total
*P *K Total *P *K Total Jumlah Pekerja OHIH
1 POB Jumlah HOC
2 Kunjungan Klinik
3 Rujukan
4 Evakuasi Medis
5 Susp. Occ. Illness
Health Surveillance (HS)
6
HS. Risiko Tinggi
7 % Kunjungan Klinik

8 % Health Surveillance
*P : Permanen
*K : Kontraktor
B Data Morbiditas
No ICD X Diagnosis Senoro Tiaka
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

C Incident
No Tgl. Kejadian Nama Perusahaan Pekerjaan Diagnosa Tindakan Lokasi
1
2
3

D Kegiatan OHIH
No Jenis Kegiatan Tanggal Lokasi Keterangan:
1 Health Promotion Judul
  Health Talk Senoro

  Bulletin Senoro
2 Higiene and Saniatation Inspection

3 Pest Control

4 Inspeksi Ambulance

5 Medical Emergency (Medivac) Drill

6 Refreshing First Aid

7 Senoro

9 Senoro

Prepared by Review by Knowledge

dr. Ferdy/dr. Enrico dr. Gunawan/ dr. Kosasih Muhamad Fatoni/Fahmi Basa
Field Doctor Field Doctor Coordinator Area HSE Superintendent
 CL
IE
PROJECT DRILLING NT
SENORO #14 & #15
LAPORAN KUNJUNGAN LOPASIEN MINGGUAN
PERIODEG :
O
Sen Sel Rab Kam Jum Sab Mgg Sub Total
DEPARTEMEN Total
1st FU 1st FU 1st FU 1st FU 1st FU 1st FU 1st FU 1st FU
QHSE
Operation
Maintenance
Project
SCM
BS
TPD
Finance
CEP
Elnusa
Mentari Line
SBL/Sea Hound/Sea Husky
JIRE
Bone Buya
Gatras
Medika Plaza
Sinar Prapanca
Latunrung
POLRI/TNI AL
MTS Indonesia
GDSK
/
TOTAL 0 0 0 0 0 0 0 0 0
 Afebris
PROJECT DRILLING SENORO #14 & #15
PEMANTAUAN KESEHATAN (TIBA DILOKASI KERJA)
(HEALTH SURVEILLANCE)
PERIODE :

Total 93

Pemeriksaan Kesehatan (Tiba di Lokasi kerja)

Keterangan
Tekanan Gula Tes Kesehatan (Anamnesis, Riwayat Penyakit, Obat- Status Fitness
Tanggal No Nama Perusahaan Umur Posisi Area kerja Nadi Respirasi Suhu
Darah Darah* (g NAPZA* Spesifik** (Tes obatan)
(x/mnt) (x/mnt) (°C)
(mmHg) %) Balance, Romberg)

S D
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
 PROJECT DRILLING SENORO #14 & #15
PEMANTAUAN KESEHATAN (SETELAH 7 HARI/PEKERJA RISIKO TINGGI)
(HEALTH SURVEILLANCE)
PERIODE :

Pemeriksaan Kesehatan (Setelah 7 hari/Pekerja Risiko Tinggi)

Keterangan
Tekanan Gula (Anamnesis, Riwayat Status Fitness
No Tanggal Nama Perusahaan Umur Posisi Area kerja Nadi Respirasi Suhu Tes Kesehatan Spesifik**
Darah Darah* (g NAPZA* Penyakit, Obat-obatan)
(x/mnt) (x/mnt) (°C) (Tes Balance, Romberg)
(mmHg) %)

S D
1

Keterangan : OHIH Team :

* Jika diperlukan
** Pekerjaan di ketinggian

Tomori-HSE-PD-09-022-L01
 PROJECT DRILLING SENORO #14 & #15
PEMANTAUAN KESEHATAN (PEKERJAAN RISIKO TINGGI)
(HEALTH SURVEILLANCE)
PERIODE :

Pemeriksaan Kesehatan (Pekerjaan berisiko tinggi)

Keterangan
Tekanan Gula (Anamnesis, Riwayat Status Fitness
No Tanggal Nama Perusahaan Umur Posisi Area kerja Nadi Respirasi Suhu Tes Kesehatan Spesifik**
Darah Darah* (g NAPZA* Penyakit, Obat-obatan)
(x/mnt) (x/mnt) (°C) (Tes Balance, Romberg)
(mmHg) %)

S D
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105

106

107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216

217

218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
 PROJECT DRILLING SENORO #14 & #15
PEMANTAUAN KESEHATAN (>14 HARI KERJA/ROSTER KERJA)
(HEALTH SURVEILLANCE)
PERIODE :

Pemeriksaan Kesehatan (>14 hari kerja/Roster kerja)

Keterangan
Tekanan Gula (Anamnesis, Riwayat Status Fitness
No Tanggal Nama Perusahaan Umur Posisi Area kerja Nadi Respirasi Suhu Tes Kesehatan Spesifik**
Darah Darah* (g NAPZA* Penyakit, Obat-obatan)
(x/mnt) (x/mnt) (°C) (Tes Balance, Romberg)
(mmHg) %)

S D
1

Keterangan : OHIH Team :

* Jika diperlukan
** Pekerjaan di ketinggian

Tomori-HSE-PD-09-022-L01
 PROJECT DRILLING SENORO #14 & #15
LAPORAN KUNJUNGAN PASIEN
PERIODE

TIME Kategori Rujukan SKS Kecelakaan

NO JOB SITE Tanggal Badge Nama Perusahaan Posisi/Dept Umur JK Diagnosa ICD Code TREATMENT
IN OUT Diagnosa R. Jalan R. Inap Kerja

SISTEM OTOT, TULANG &

1 CPP Senoro 1-Apr-19 Taufik Ismail JOB Mechanical Tech 34 L 07.46 08.00 Myalgia M79.1 Voltaren gel 1, neurosanbe 5 √ 1st NWR
PERSENDIAN

2 CPP Senoro 1-Apr-19 Ucok Gunaldi POLRI Polisi 26 L 08.13 08.20 Dermatitis, unspecified SISTEM KULIT L30.9 Betason cream 1 √ 1st NWR

SISTEM OTOT, TULANG &

3 CPP Senoro 1-Apr-19 Prilyane Cecilia JOB Area Relation Officer 27 P 09.32 09.45 Myalgia M79.1 Voltaren gel 1, neurosanbe 5 √ 1st NWR
PERSENDIAN

SISTEM JANTUNG &

4 CPP Senoro 1-Apr-19 Andri Alfian CEP Nakhoda 42 L 08.25 08.35 Essential (primary) hypertension I10.9 Amlodipin 5 √ 1st NWR
PEMBULUH DARAH

SISTEM TELINGA, HIDUNG &

5 CPP Senoro 1-Apr-19 Hariyono Aminuddin Amir JOB Maint.Supervisor 43 L 16.54 17.01 Common cold J00.9 Paratusin 4 √ 1st NWR
TENGGOROK

SISTEM OTOT, TULANG & Voltaren Gel 1

6 CPP Senoro 2-Apr-19 Budi Permadi JOB SCM 43 L 10.01 10.17 Back pain M54.5 √ 1st NWR
PERSENDIAN Neurosanbe 5

7 CPP Senoro 2-Apr-19 Yusuf CEP HSE 24 L 10.19 10.26 Dental Caries SISTEM GIGI-GELIGI K02.9 Cataflam 6 √ 1st NWR

8 CPP Senoro 2-Apr-19 Riyadi MTS Helper 24 L 16.55 17.01 Inflammation of eyelid, unspecified SISTEM MATA H01.9 Y-Rins √ 1st NWR

9 CPP Senoro 2-Apr-19 Poltak Solmin JOB Mechanical Tech 46 L 12.49 12.53 Dental Caries SISTEM GIGI-GELIGI K02.9 Mefinal 10 √ 1st NWR

Gitas Plus 6
10 CPP Senoro 2-Apr-19 Nana Sukrima GDSK Cook 55 L 18.50 18.58 Other and unspecified abdominal pain SISTEM SALURAN CERNA R10.4 √ 1st NWR
Cipro 10

IVFD D5 drip Neurobion 1

11 CPP Senoro 2-Apr-19 Indra Afinaldi JOB Maint Planner 38 L 13.39 14.30 Syncope/collaps GEJALA & TANDA 780.2 √ 1st NWR
amp, pro referral

SISTEM OTOT, TULANG &

12 CPP Senoro 3-Apr-19 I Gusti Putu Widiana JOB Field Operator 35 L 08.36 08.45 Pain in right knee M25.561 Voltaren gel 1 √ 1st NWR
PERSENDIAN

SISTEM OTOT, TULANG &

13 CPP Senoro 3-Apr-19 I Made Manik JOB Field Operator 27 L 08.47 08.57 Pain in right knee M25.561 Voltaren gel 1 √ 1st NWR
PERSENDIAN

14 CPP Senoro 3-Apr-19 Kadek Supradana JOB Field Operator 26 L 06.00 06.15 Headache GEJALA & TANDA R51.9 pct 4 √ 1st NWR

SISTEM TELINGA, HIDUNG &

15 CPP Senoro 4-Apr-19 Usamah Achmad JOB DCS Specialist 36 L 08.36 08.50 Common cold J00.9 tuzalos 4, balsem geliga 1 √ 1st NWR
TENGGOROK

SISTEM TELINGA, HIDUNG &

16 CPP Senoro 5-Apr-19 Rachmat Mauludin JOB Marine Officer 40 L 10.30 10.45 Acute upper respiratory infection, unspecified J06.9 dextamine 6 √ 1st NWR
TENGGOROK
 SISTEM TELINGA, HIDUNG &
17 CPP Senoro 6-Apr-19 Ibnu Sina JIRE Pest Control Officer 31 L 08.57 09.10 Common cold 'J00.9 tuzalos 8 √ 1st NWR
TENGGOROK

cefadroxil 10, cendo xytrol 5,

18 CPP Senoro 6-Apr-19 Riyadi MTS Maintenancce 23 L 13.10 13.20 Conjunctivitis, acute SISTEM MATA H10.3 √ 1st NWR
cataflam 6

19 CPP Senoro 6-Apr-19 Iskandar Yusuf JOB Field Operator 47 L 01.00 01.07 Headache GEJALA & TANDA R05.9 PCT 6 √ 1st NWR

dextamine 6
20 CPP Senoro 6-Apr-19 Maharani J GDSK Nutrisionis 28 P 18.50 18.57 Urticaria SISTEM KULIT L50.0 √ 1st NWR
geliga 1

21 CPP Senoro 7-Apr-19 Syaril Sakrin SP Security 23 L 00.22 00.27 Blepharitis SISTEM MATA H01.0 Cendo Fenicol 1 √ 1st NWR

22 CPP Senoro 7-Apr-19 Mahmud Nawawi JOB Field Operator 27 L 07.27 07.40 Acute periodontitis SISTEM GIGI-GELIGI K05.2 cataflam 6 √ 1st NWR

23 CPP Senoro 7-Apr-19 Hendra Hamzah SP Security 41 L 07.57 08.10 Eye Irritation SISTEM MATA H01.9 Y-Rins √ 1st NWR

ciprofloxacyn 10, arcapec 8,

24 CPP Senoro 7-Apr-19 Asep Supriatman JOB Mechanical Tech 50 L 11.18 11.30 GEA SISTEM SALURAN CERNA A09.0 √ 1st NWR
pharolit 5

dextamine 4
25 CPP Senoro 7-Apr-19 Maharani J GDSK Nutrisionis 28 P 13.39 13.45 Urticaria SISTEM KULIT L50.0 √ FU NWR
betason-n 1

SISTEM TELINGA, HIDUNG &

26 CPP Senoro 7-Apr-19 Laswin SP Security 39 L 20.12 20.18 Common cold 'J00.9 tuzalos 8 √ 1st NWR
TENGGOROK
 PROJECT DRILLING SENORO #14 & #15
LAPORAN DIAGNOSTIK MINGGUAN
PERIODE :

JOB Kontraktor Tamu SUB TOTAL

NO KLASIFIKASI KODE TOTAL
1st Visit F.Up 1st Visit F. Up 1st Visit F. Up 1st Visit F. Up
I SISTEM JANTUNG & PEMBULUH DARAH
1.2 Cardiomegaly I51.7 0 0 0
1.3 Varicose veins of lower extremities with inflammation I83.1 0 0 0
1.4 Cardiac arrest 427 0 0 0
1.5 Cardiac arrhythmia 427.9 0 0 0
1.6 CHF 428.0 0 0 0
1.7 Old myocard infarction 412 0 0 0
1.8 Essential (primary) hypertension I10.9 1 1 0 1
1.9 Angina pectoris, unspecified I20.9 0 0 0
1.1 Hypotension I95 0 0 0
Orthostatic hypotension I95.1 0 0 0
Stroke, not specified as haemorrhage or infarction I64 0 0 0
Chest pain, unspecified R07.4 0 0 0
1.11 Mitral (valve) insufficiency I34.0 0 0 0
II SISTEM KULIT
2.1 Cutaneous abscess, furuncle and carbuncle, unspecified L02.9 0 0 0
2.3 Irritant contact dermatitis due to other agents L24.8 0 0 0
2.4 Pruritus, unspecified L29.9 0 0 0
2.5 Dermatitis, unspecified L30.9 1 1 0 1
2.6 Miliaria, unspecified L74.3 0 0 0
2.7 Acne L70.0 0 0 0
2.8 Allergic contact dermatitis, unspecified cause L23.9 0 0 0
2.9 Cellulitis & abcess 682 0 0 0
2.10 Impetigo 684 0 0 0
2.11 Lipoma 214.9 0 0 0
2.12 Psoriasis 696 0 0 0
2.13 Sebaceous cyst 706.2 0 0 0
2.14 Urticaria L50.0 1 1 1 1 2
2.15 Verruca (Ward) A63.0 0 0 0
2.16 Tinea Inguinalis B35.6 0 0 0
2.17 Insect Bite S90.8 0 0 0
2.18 Acute Lymphadenitis of face head and neck L04.0 0 0 0
2.19 Follicular disorder, unspecified L73.9 0 0 0
2.2 Scabies B86 0 0 0
2.21 Tinea pedis B35.3 0 0 0
2.22 Other atopic dermatitis L20.8 0 0 0
2.23 onychia and paronychia L03.0 0 0 0
2.24 Tinea barbae and tinea capitis B35.0 0 0 0
2.25 Sunburn of first degree L55.0 0 0 0
2.26 Atopic dermatitis, unspecified L20.9 0 0 0
Tinea corporis B35.4 0 0 0
Cutaneous abscess, furuncle and carbuncle of limb L02.4 0 0 0
Mumps without complication B26.9 0 0 0
Nail disorder, unspecified L60.9 0 0 0
Acute lymphadenitis of other sites L04.8 0 0 0
Pyoderma L08.0 0 0 0
Acute lymphadenitis, unspecified L04.9 0 0 0
Pityriasis versicolor B36.0 0 0 0
Ulcer of lower limb, not elsewhere classified L97 0 0 0
Pityriasis versicolor B36.0 0 0 0
2.27 Candidiasis, unspecified B37.9 0 0 0
Tinea pedis B35.3 0 0 0
Miliaria, unspecified L74.3 0 0 0
infective dermatitis  L30.3 0 0 0
Pruritus L29 0 0 0
III SISTEM TELINGA, HIDUNG & TENGGOROK
3.1 Common cold J00.9 2 2 4 0 4
Acute pharyngitis due to other specified organisms J02.8 0 0 0
3.2 Influenza, virus not identified J11.9 0 0 0
3.3 Acute Pharyngitis J02.9 0 0 0
3.4 Acute sinusitis J01.0 0 0 0
Acute Epiglottitis NOS J05.1 0 0 0
3.5 Acute tonsilitis J03.8 0 0 0
3.6 Acute treacheitis 464.1 0 0 0
3.7 Allergic rhinitis J30.4 0 0 0
3.8 Chronic laryngitis 476.0 0 0 0
3.9 Chronic nasopharyngitis 472.2 0 0 0
3.10 Chronic pharyngitis 472.1 0 0 0
3.11 Chronic rhinitis 472.0 0 0 0
3.12 Chronic sinusitis 473 0 0 0
3.13 Chronic tonsilitis J35.0 0 0 0
3.14 Deviated nasal septum 470 0 0 0

Page 10 of 25 MPFORM-WR.002 = Weekly Report Diagnostic

 JOB Kontraktor Tamu SUB TOTAL
NO KLASIFIKASI KODE TOTAL
1st Visit F.Up 1st Visit F. Up 1st Visit F. Up 1st Visit F. Up
3.15 Hearing loss 389.10 0 0 0
3.16 Nasal polyps J33.9 0 0 0
3.17 Peritonsillar abcess 475 0 0 0
3.18 URT hypersensitivity reaction 478.8 0 0 0
3.19 Otitis media H65.0 0 0 0
Acute upper respiratory infection, unspecified J06.9 1 1 0 1
3.2 Other peripheral vertigo H81.3 0 0 0
Wax Impacted H61.20 0 0 0
Benign Neoplasma of Connective and other soft tissue of head, face and neck D21.0 0 0 0
Lacrimal gland and duct D31.5 0 0 0
Acute otitis externa, noninfective H60.5 0 0 0
Abscess of external ear H60.0 0 0 0
Impacted cerumen H61.2 0 0 0
3.21 Otalgia H92.0 0 0 0
IV SISTEM ENDOKRIN
4.1 Non-insulin-dependent diabetes mellitus E11.9 0 0 0
4.1 Pure hypercholesterolaemia E78.0 0 0 0
4.3 Other specified metabolic disorders E88.8 0 0 0
4.4 Hypercholesterolemia 272.0 0 0 0
4.5 hyperlipidemia 272.4 0 0 0
4.6 Thyrotoxicosis [hyperthyroidism] E05 0 0 0
4.7 Thyromegaly 240.9 0 0 0
4.2 Hyperuricaemia without signs of inflammatory arthritis and tophaceous disease E79.0 0 0 0
4.3 Other hypoglycaemia E16.1 0 0 0
Insulin-dependent diabetes mellitus eE10 0 0 0
Essential (haemorrhagic) thrombocythaemia D47.3 0 0 0
Gout MM 10 0 0 0
4.4 Vitamin deficiency, unspecified E56.9 0 0 0
Hypercholesterolemia 272 0 0 0
Non-insulin-dependent diabetes mellitus E11.9 0 0 0
V SISTEM SALURAN CERNA
5.1 Gastro-oesophageal reflux disease without oesophagitis K21.9 0 0 0
5.2 Chronic gastritis, unspecified K29.5 0 0 0
5.3 Dyspepsia NOS K30.9 0 0 0
5.4 Noninfective gastroenteritis and colitis, unspecified K52.9 0 0 0
5.5 Other appendicitis K36.9 0 0 0
5.6 Gastritis & duodenitis K29.1 0 0 0
5.7 Appendicitis, acute 540 0 0 0
5.8 Constipation 564.0 0 0 0
5.9 Hernia, hiatal 553.3 0 0 0
5.10 Hernia, inguinal K40.3 0 0 0
5.11 Intussusception 560.0 0 0 0
5.12 Irritable bowel syndrome 564.1 0 0 0
5.13 Paralytic ileus 560.1 0 0 0
5.14 Peritonitis 567 0 0 0
5.15 Ulcerative colitis 556 0 0 0
5.16 Volvulus 560.2 0 0 0
5.17 Hemorrhoids K64.9 0 0 0
5.18 Anoreksia 0 0 0
Abdominal Colic R10.83 0 0 0
Other and unspecified gastroenteritis and colitis of infectious origin A09.0 1 1 0 1
Gastro-oesophageal reflux disease without oesophagitis K21.9 0 0 0
5.19 Other and unspecified abdominal pain R10.4 1 1 0 1
VI SISTEM SALURAN KEMIH
6.1 Calculus of kidney N20.0 0 0 0
6.2 Calculus of ureter 592.1 0 0 0
6.3 Circumcision V50.2 0 0 0
6.4 Cystitis 595 0 0 0
6.5 Hydronephrosis 591 0 0 0
6.6 Infections of kidney 590 0 0 0
6.7 Nephritis 583 0 0 0
6.8 Nephrotic syndrome 581 0 0 0
6.9 Renal failure,acute 584 0 0 0
6.10 Renal failure, chronic 585 0 0 0
6.11 UTI 599.9 0 0 0
6.1 Torsion of testis N44.9 0 0 0
Nonspecific urethritis N34.1 0 0 0
6.13 Urinary tract infection, not specified N39.0 0 0 0
Urinary tract infection, site not specified N39.0 0 0 0
VII SISTEM SALURAN HATI & EMPEDU
7.1 Chlecystitis 575.1 0 0 0
7.2 Cholelithiasis 574 0 0 0
7.3 Hepatitis,viral O70.9 0 0 0
7.4 Jaundice 782.4 0 0 0
7.5 Liver abcess 472 0 0 0
7.6 Liver cirrhosis 571.5 0 0 0
7.7 Pancreatitis, acute 577.0 0 0 0
7.8 Pancreatitis, chronic 577.1 0 0 0
Page 11 of 25 MPFORM-WR.002 = Weekly Report Diagnostic
 JOB Kontraktor Tamu SUB TOTAL
NO KLASIFIKASI KODE TOTAL
1st Visit F.Up 1st Visit F. Up 1st Visit F. Up 1st Visit F. Up
VIII IMUNISASI
8.1 Combination of Disease V09 0 0 0
8.2 Single disease V05 0 0 0
IX PENYAKIT INFEKSI
9.1 Amebiasis OO6 0 0 0
9.2 Ascariasis 127 0 0 0
9.3 Bacterial enteritis OO8.5 0 0 0
9.4 Candidiasis 112 0 0 0
9.5 Chicken pox O52 0 0 0
9.6 Dengue O61 0 0 0
9.7 Dengue hemorrhagic fever O65.4 0 0 0
9.8 Superficial mycosis, unspecified B36.9 0 0 0
9.9 Dermatophytosis 110 0 0 0
9.10 Erysipelas O35 0 0 0
9.11 Escherichia coli OO8.0 0 0 0
9.12 Food poisoning OO5 0 0 0
9.13 Genital herpes O54.1 0 0 0
9.14 Gonococcal infection, unspecified A54.9 0 0 0
9.15 Herpes zoster O53 0 0 0
9.16 HIV disease O42 0 0 0
9.17 Malaria O84 0 0 0
9.18 Measles O55 0 0 0
9.19 Meningoccocal infection O36 0 0 0
9.20 Mumps O72 0 0 0
9.21 Pulmonary tuberculosis O11 0 0 0
9.22 Septicemia O38 0 0 0
9.23 Shigellosis OO4 0 0 0
9.24 Early congenital syphilis, symptomatic 130 0 0 0
9.25 Trachoma A50.0 0 0 0
9.26 Typhoid & paratyphoid O02 0 0 0
9.27 Viral enteritis OO8.6 0 0 0
9.28 Pityriasis versicolor B36.0 0 0 0
9.29 Infectious mononucleosis, unspecified B27.9 0 0 0
Syphilis, unspecified A53.9 0 0 0
Measles NOS B05.9 0 0 0
9.3 Enterobiasis B80 0 0 0
Syphilis, unspecified A53.9 0 0 0
X CEDERA/TRAUMA
10.1 Foreign body or object entering through skin W45.9 0 0 0
10.2 Burns T24.0 0 0 0
10.3 Cerebral contusion 851 0 0 0
10.4 Concussion 850 0 0 0
10.5 Crushing injury 925 - 929 0 0 0
10.6 Dislocation 830 - 839 0 0 0
10.7 Fracture S02.6 0 0 0
10.8 Injury to nerve & spinal cord 950 - 957 0 0 0
10.9 Open wound of finger(s) without damage to nail S61.0 0 0 0
10.10 Sprains & Strains S03.5 0 0 0
10.11 Subarachnoid hemorrhage 852.0 0 0 0
10.12 Contusion of thorax S20.2 0 0 0
10.13 Other superficial injuries of wrist and hand S60.8 0 0 0
10.14 Open wounds involving other combinations of body regions T01.8 0 0 0
10.15 Wound puncture 0 0 0
10.16 Legal intervention involving blunt objects Y35.3 0 0 0
Superficial injury of lip and oral cavity S00.5 0 0 0
Burn of first degree of wrist and hand T23.1 0 0 0
Burn of first degree of ankle and foot T25.1 0 0 0
Anaphylactic shock, unspecified T78.2 0 0 0
Superficial injury of other parts of head S00.8 0 0 0
Other specified injuries of wrist and hand S69.8 0 0 0
Injury, unspecified T14.9 0 0 0
10.17 Other superficial injuries of ankle and foot S90.8 0 0 0
Superficial injury of ankle and foot, unspecified S90.9 0 0 0
Superficial injury of unspecified body region T14.0 0 0 0
Puncture wound with (penetrating) foreign body T14.1 0 0 0
Injury, unspecified T14.9 0 0 0
Open wound of finger(s) NOS S61.0 0 0 0
XI KESEHATAN JIWA
11.1 Alcoholism 303.9 0 0 0
11.2 Anxiety 300.0 0 0 0
11.3 Depression 311 0 0 0
11.4 Drug abuse 305.9 0 0 0
11.5 Family maladjusment V61.9 0 0 0
11.6 Sexual dysfunction 302.9 0 0 0
11.7 Situtional disturbance 309.9 0 0 0
11.8 Insomnia 0 0 0
XII SISTEM OTOT, TULANG & PERSENDIAN
12.1 Arthalgia M23.6 0 0 0
Page 12 of 25 MPFORM-WR.002 = Weekly Report Diagnostic
 JOB Kontraktor Tamu SUB TOTAL
NO KLASIFIKASI KODE TOTAL
1st Visit F.Up 1st Visit F. Up 1st Visit F. Up 1st Visit F. Up
12.2 Myalgia M79.1 2 2 0 2
Pain in right shoulder M25.511 0 0 0
Pain in limb M79.6 0 0 0
Pain in right knee M25.561 2 2 0 2
Oth symptoms and signs involving the musculoskeletal system R29.898 0 0 0
12.3 Arthritis M00.9 0 0 0
12.4 Back pain M54.5 1 1 0 1
12.5 Bursitis / tendonitis 727.3 0 0 0
12.6 Ganglion cyst 727.43 0 0 0
12.7 Haematom 0 0 0
Connective and other soft tissue of lower limb, including hip D21.2 0 0 0
Neuralgia and neuritis, unspecified M79.2 0 0 0
Torticollis M43.6 0 0 0
Cramp and spasm R25.2 0 0 0
Sprain and strain of ankle S93.4 0 0 0
Gout, unspecified M10.9 0 0 0
Soft tissue disorder, unspecified M79.9 0 0 0
Myositis M60.9 0 0 0
XIII SISTEM SARAF PUSAT & PERIFER
13.1 Tension-type Headache G44.2 0 0 0
13.2 Migraine, unspecified G43.9 0 0 0
13.3 Polyneuropathy, unspecified G62.9 0 0 0
13.4 Disorders of initiating and maintaining sleep [insomnias] G47.0 0 0 0
13.5 Bell Palsy G51.0 0 0 0
XIV SISTEM ALAT KANDUNGAN
14.1 Amenorrhea, seconday 626.0 0 0 0
14.2 Atypical PAP 795.0 0 0 0
14.3 Breast nodule 611.72 0 0 0
14.4 Cervical polyp 622.7 0 0 0
14.5 Cervicitis 616.0 0 0 0
14.6 Dysmenorrhea 625.3 0 0 0
14.7 Family planning V25.09 0 0 0
14.8 Fibrocystic breast 610.3 0 0 0
14.9 Retensio Plasenta 0 0 0
14.1 First trimester bleeding 640.9 0 0 0
14.11 Gyanecology examination V72.3 0 0 0
14.12 Irregular menstruation 626.4 0 0 0
14.13 Mastitis 611.0 0 0 0
14.14 Menopause symptoms 627.2 0 0 0
14.15 Miscarriage 634.9 0 0 0
14.16 Pelvic pain 625.9 0 0 0
14.17 PID 614.9 0 0 0
14.18 Postpart.Ex, routine V24.2 0 0 0
14.19 Pregnancy with complications 646.9 0 0 0
14.20 Premenstrual syndrome 625.4 0 0 0
14.21 Prenatal.Ex, routine V22.1 0 0 0
14.22 Previous C-section 654.2 0 0 0
Inflammatory disorders of breast N61 0 0 0
Neonatal haemorrhage, unspecified P54.9 0 0 0
14.23 Vaginitis 616.10 0 0 0
XV SISTEM MATA
15.1 Blindness & low vision 369 0 0 0
15.2 Cataract 366 0 0 0
15.3 Chalazion 373.2 0 0 0
15.4 Color vision deficiencies 368.5 0 0 0
Blepharitis H01.0 1 1 0 1
Inflammation of eyelid, unspecified H01.9 1 1 0 1
15.5 Conjunctivitis, acute H10.3 1 1 0 1
15.6 Conjunctivitis, chronic 372.1 0 0 0
15.7 Corneal abrasion 918.1 0 0 0
15.8 Glaucoma 365 0 0 0
15.9 Keratitis 370 0 0 0
15.10 Pterygium 372.4 0 0 0
15.11 Visual disturbance 368 0 0 0
15.12 Visual field defects 368.4 0 0 0
15.13 Eye Irritation H01.9 1 1 0 1
15.14 Hordeolum and other deep inflammation of eyelid H00.0 0 0 0
15.15 Disorder of refraction, unspecified H52.7 0 0 0
15.16 Disorder of eye and adnexa, unspecified H57.9 0 0 0
Asthenopia H53.1 0 0 0
Disorders of accommodation H52.5 0 0 0
15.17 Blepharitis H01.0 0 0 0
XVI SISTEM SALURAN PERNAFASAN
16.1 Asthma J45.9 0 0 0
16.2 Bronchitis, unspecified J20.9 0 0 0
16.3 COPD 496 0 0 0
16.4 Emphysema 492 0 0 0
16.5 Influenza J11.9 0 0 0
Page 13 of 25 MPFORM-WR.002 = Weekly Report Diagnostic
 JOB Kontraktor Tamu SUB TOTAL
NO KLASIFIKASI KODE TOTAL
1st Visit F.Up 1st Visit F. Up 1st Visit F. Up 1st Visit F. Up
16.6 Other bacterial pneumonia 485 0 0 0
16.7 Pleurisy 511 0 0 0
16.8 Pneumoccocal pneumonia 481 0 0 0
16.9 Pneumothorax 512 0 0 0
16.1 Respiratory arrest 799.1 0 0 0
Unspecified acute lower respiratory infection J22 0 0 0
16.11 URTI J06.9 0 0 0
Asthma, unspecified J45.9 0 0 0
16.12 Viral pneumonia 480 0 0 0
16.2 Disease of upper respiratory tract, Unspecified J39.9 0 0 0
XVII GEJALA & TANDA
17.1 Dizziness and giddiness R42.9 0 0 0
17.2 Fever, unspecified R50.9 0 0 0
Dysphonia 'R49.0 0 0 0
17.3 Malaise and fatigue R53.9 0 0 0
17.4 Abnormal glucose tolerance test R73.0 0 0 0
17.5 Gen*)Abdominal pain 789.07 0 0 0
17.6 Tinitus 0 0 0
17.7 Headache R51.9 1 1 0 1
17.8 Syncope/collaps 780.2 1 1 0 1
17.9 Nausea and vomiting R11.9 0 0 0
Disorders of initiating and maintaining sleep [insomnias] G47.0 0 0 0
Malaise and fatigue R53.9 0 0 0
Headache R51 1 1 0 1
17.1 Cough R05.9 0 0 0
Fever with chills R50.8 0 0 0
nonspecific low blood pressure reading NOS R03.1 0 0 0
Other faecal abnormalities R19.5 0 0 0
Bradycardia, unspecified R00.1 0 0 0
Abnormal results of cardiovascular function studies R94.3 0 0 0
Pain, unspecified R52.9 0 0 0
Palpitations R00.2 0 0 0
Bradycardia, unspecified R00.1 0 0 0
17.11 Somatoform disorder, unspecified F45.9 0 0 0
XVIII SISTEM GIGI-GELIGI
18.1 Dental Caries K02.9 1 1 0 1
Other forms of stomatitis K12.1 0 0 0
Dental caries K02 1 1 0 1
18.2 Acute Gingivitis K05.0 0 0 0
18.3 Recurrent oral aphthae K12.0 0 0 0
18.4 Other forms of stomatitis K12.1 0 0 0
18.5 Chronic Gingivitis 523.1 0 0 0
18.6 Periodontal disease, unspecified K05.6 0 0 0
Pulpitis K04.0 0 0 0
Acute periodontitis K05.2 1 1 0 1
18.7 Other specified disorders of teeth and supporting structures K08.8 0 0 0
XIX KERACUNAN
19.1 Angioneurotic oedema T78.3 0 0 0
19.2 Assault by Poisoning E962 0 0 0
19.3 Suicide & self-inflicted E958 0 0 0
19.4 Venomous animals & plants E905 0 0 0
XX LAIN-LAIN
20.1 Examination of blood pressure Z01.3 0 0 0
20.2 Special examination, unspecified Z01.9 0 0 0
14 0 11 1 0 0 25 1 26

Page 14 of 25 MPFORM-WR.002 = Weekly Report Diagnostic

 PROJECT DRILLING SENORO #14 & #15
LAPORAN RUJUKAN UMUM
PERIODE :

NO TGL NAMA PASIEN USIA JK PERUSAHAAN JABATAN DIAGNOSIS KERJA RUJUKAN KETERANGAN

-
 PROJECT DRILLING SENORO #14 & #15
LAPORAN KECELAKAAN KERJA
PERIODE :

TEMPAT TIPE CEDERA BAGIAN JENIS KETERANGAN

NO. TGL NAMA PASIEN USIA PERUSAHAAN JABATAN PENANGANAN
KEJADIAN DIAGNOSIS CEDERA KECELAKAAN KESIMPULAN

- - - - - - - - - - - -

FAC = First aid Case RWC = Restricted Work Case FTL = Fatality
* Jenis Kecelakaan :
MTC = Medical Treatment Case LTI = Lost Time Injury
 PROJECT DRILLING SENORO #14 & #15
LAPORAN EVAKUASI MEDIS
PERIODE :

NO TGL NAMA PASIEN USIA JK PERUSAHAAN DIAGNOSIS KERJA TIM ESCORT RUMAH SAKIT TUJUAN

- - - - - - - - -
 PROJECT DRILLING SENORO #14 & #15
LAPORAN INSPEKSI KANTIN
PERIODE

Name of
Date & Time
Contractor

Location(s)

Team Members

Evidence
NO Deficiency Action Plan Pic Target Date Status
Before After

Note: This Section should be completed after inspection and send to HSE Department for update Corrective Action Tracking System
 PROJECT DRILLING SENORO #14 & #15
LAPORAN PENYULUHAN KESEHATAN
PERIODE :

DURASI JUMLAH PENDAMPING

NO TGL/JAM LOKASI TOPIK PEMBICARA
(menit) PESERTA PARAMEDIK HSE

2
 PROJECT DRILLING SENORO #14 & #15
LAPORAN PENYULUHAN JASA BOGA
PERIODE :

DURASI JUMLAH PENDAMPING

NO TGL/JAM LOKASI TOPIK PEMBICARA
(menit) PESERTA PARAMEDIK HSE

- - - - - - - - -
 PROJECT DRILLING SENORO #14 & #15
LAPORAN BULETIN KESEHATAN
PERIODE :

DISTRIBUSI
NO TGL/JAM TOPIK KORESPONDENSI
BLASTING MAIL KANTOR WORKSHOP Jetty MCB

1
 PROJECT DRILLING SENORO #14 & #15
LAPORAN LATIHAN PENYEGARAN PETUGAS P3K
PERIODE :

DURASI PENDAMPING
NO TGL/JAM LOKASI TOPIK JUMLAH PESERTA PEMBICARA
(menit) PARAMEDIK HSE

-
 PROJECT DRILLING SENORO #14 & #15
LAPORAN EKSTERNAL DAN INTERNAL DRILL
PERIODE :

DURASI JUMLAH PENDAMPING

NO TGL/JAM LOKASI TOPIK Pelaksana
(menit) PESERTA PARAMEDIK HSE

- - - - - - - - -