PROVINSI :

KABUPATEN :
PUSKESMAS :
TAHUN :

NO DESA 1 2 3 4 5 6 7 8 9 10 11 12 13
P M P M P M P M P M P M P M P M P M P M P M P M P M

JUMLAH DESA...................
JUMLAH DESA YG MELAPOR.......................(..............%)
JUMLAH DESA YG MELAPORKAN TEPAT WAKTU.......................(..........%)
 LAPORAN MINGGUAN PENDERITA DIARE DI................

JUMLAH DIARE (Minggu ke )

14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
P M P M P M P M P M P M P M P M P M P M P M P M P M P M P M P M P
30 31 32 33 34 35 36 37 38 39 40 41 42
M P M P M P M P M P M P M P M P M P M P M P M P
 FORM : 12 B

42 43 44 45 46 47 48 49 50 51 52
M P M P M P M P M P M P M P M P M P M P M

..........................................
Kepala Puskesmas.........

.........................................
 FORM : 13 A

REGISTER HARIAN KUNJUNGAN LAYANAN REHIDRASI ORAL AKTIF (LROA)

KABUPATEN :
PUSKESMAS :
PUSTU :

Umur Tanggal mulai Derajat Dahidrasi Jumlah diberi Rencana Terapi

No Tanggal Nama Penderita Konseling Ket
L P sakit Tanpa dehidrasi Ringan/sedang Berat oralit Zinc A B C
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
dst...

................................., .....................................
Kepala...............................................

..............................................................
 FORM : 13 B

LAPORAN LAYANAN REHIDRASI ORAL AKTIF (LROA)

DI PUSKESMAS................
TAHUN...................

TRIWULAN :

KONDISI LROA KELENGKAPAN LOGISTIK LROA

NO JENIS FASYANKES JML KUNJUNGAN LROA KET
AKTIF TDK AKTIF LENGKAP TDK LENGKAP
1 2 3 4 5 6 7 8
1
2
3
4
5
6
7
8
9
10

Ket :
1 Tulis nomor urut fasyankes ...................................
2 Tulis jenis fasyankes pemerintah tdd : pustu, poskesdes,puskesmas KEPALA PUSKESMAS..........
3 Tulis contreng (√) jika LROA menjalankan kegiatan konseling dan
penyuluhan bagi ibu/pengasuhpenderita diare
4 Tulis contreng (√) jika LROA tidak menjalankan kegiatan konseling dan ......................................
penyuluhan bagi ibu/pengasuhpenderita diare
5 Tulis contreng (√) jika bahan dan logistik di LROA sudah lengkpat tdd : media KIE, Dispenser,
gelas, sendok, oralit, dan zink
6 Tulis contreng (√) jika bahan dan logistik di LROA tidak lengkap tdd : media KIE, Dispenser,
gelas, sendok, oralit, dan zink
7 Tulis jumlah pasien atau ibu/penasuh penderita diare yg dtg ke LROA
8 Tulis informsi yg diperlukan yang tidak ada di kolom lainnya
 BULAN : OKTOBER
TAHUN : 2021
Fasilitas Pelayanan Kesehatan
JUMLAH 0 -<6 BLN ≥6 bln - < 1 thn 1 - 4 Tahun 5 - 9 thn 10- 14 thn
NO DESA P M P M P M P M P M
PENDUDUK
L P L P L P L P L P L P L P L P L P L P
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1
Pudambu 1,287 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2
Matabondu 956 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3 Angata 510 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

4 Mataiwoi 490 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

5 Kosebo 939 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

6 Landabaro 472 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

7 Punngoni 393 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

8
Lamooso 1,072 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

9 Simbangu 688 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

10 Lamoeri 754 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

11 Puuroe 531 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

12 Sandarsi Jaya 653 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

13 Teteasa 1,184 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

14
Sandey 430 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

15 Puao 954 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

16 Puusanggula 949 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

17
Lamoen 948 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

18 Motaha 600 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

19 Pewutaa 1,074 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

20
Aopa 1,053 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

21 Puulipu 553 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

22 Langgea Indah 594 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

23
Boloso 391 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

24 Mokoau 258 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Jumlah 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
17,733
 Fasilitas Pelayanan Kesehatan
15- 19 thn > 20 tahun Jumlah Penderita diare < 5 th Diberi Penderita diare> Jumlah Pemakaian
P M P M P M Zinc 5 th Diberi Zinc
Oralit RL Oralit RL
L P L P L P L P L P L P 0-<6 bln ≥6 bln-<11 - 5 thn Oralit RL 0-<6 bln ≥6 bln-<11 - 5 thn
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47
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 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 0 0 0 0

0 0 0 0 0 1 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 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 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 0 0 1 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 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 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 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 0 0 0 0 0 0 0 0 1 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 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 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 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 0 0 0 0 0 0 0 10 TAB 0 0 0 0 0 0 10 TAB 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 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 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 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0
0 0 0 0
 Kader Total Penderita
Jumlah Fasyankes dan
0 - <1 Thn 1-4 Thn ≤ 5 Thn 5 - 9 thn 10- 14 thn 15- 19 thn > 20 tahun Jumlah Pemakaian Kader
L P L P L P L P L P L P L P L P Oralit L P
48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67
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 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 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 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 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 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 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 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 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 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

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 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 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 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 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0