KABUPATEN ENDE
PROVINSI NUSA TENGGARA TIMUR
Peta Lokasi
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... jam 4 jam
... jam
Rp ...... Rp. 25.000
Rp ....
Untuk sampai ke Puskesmas Watunggere, akses perjalanan dari Kabupaten Ende dapat
mengunakan transportasi darat yaitu dengan menggunakan angkutan desa berupa truk kayu, jika
cuaca buruk maka truk kayu tidak beroperasi. Perjalanan menuju Puskesmas Watunggere
melewati hutan, jalanan terjal yang rusak parah serta berbatu dengan tepian jurang dan rawan
longsor.
2. SK KETERPENCILAN PUSKESMAS
Berdasarkan SK Bupati Kabupaten ………… Nomor: ………………………. tentang
………………………….., masuk dalam kriteria puskesmas Sangat Terpencil.
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KATEGORI PENILAIAN (isikan di kotak yang tersedia sesuai dengan keterangan di
bawah)
1. Kategori Biasa, apabila hasil penilaian < 25%
2. Kategori Terpencil, apabila hasil penilaian mencapai 25% s.d 50%
3. Kategori Sangat Terpencil, apabila hasil penilaian mencapai lebih dari 50%
UKM essensial
Promkes
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Kesling
KIA KB
Gizi
P2P
UKM Pengembangan
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Listrik
- Sumber listrik : Non PLN
- Jam operasional listrik :-
Air bersih (AB)
- Sumber AB di puskesmas : Tidak Ada
- Ketersediaan AB di puskesmas : tidak sepanjang tahun
- SAB di rumah tinggal Tim NS : Tidak Ada
- Ketersediaan AB di rumah tinggal tim NS :
tidak sepanjang tahun
Jaringan telepon/HP
- Kekuatan : tidak
- Provider : Telkomsel
Jaringan internet
- Kekuatan : tidak
- Jam operasional : Tidak Menentu
- Provider : Telkomsel
- Lokasi sinyal : ada spot khusus
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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 ..........
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4 Gizi
- D/S
- 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
PISPK
1. Sosialisasi
2. Pelatihan
3. Pendataan
4. Input data
5. Analisis data
6. Intervensi
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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:
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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
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