1.

Petugas Entri
Data
REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

1 2 3 4 5 6
3 6 7 4 0 0 2 Bulan : 2021
NAMA FASKES/ PUSKESMAS PAMULANG 7 8 9 10 11 V
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

PESERTA KB JENIS TINDAKAN Kasus PENGGUNAAN SUMBER ALOKON

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
STATUS PESERTA KB

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN
ISTRI

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN
PENCABUTAN

PENCABUTAN

KEGAGALAN
PEMBERIAN/

KOMPLIKASI
NAMA SUAMI

OPERATIF/

LAINNYA
TANGGAL

MANDIRI
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

BERAT
LAHIR

(Kode)

TIDAK

APBN

APBD
DAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

01-December-
1 APDON 3 2 7 6 0 4 5 9 0 5 9 6 0 0 0 1 IIS JANISAH 19-May-1996 PAMULANG BARAT 087775622030 2 1 0 0 2 1 0 0 1 0 0 0
2021
01-December-
2 DEDE 3 3 0 4 0 6 4 6 0 7 8 4 0 0 1 1 FITRIANA 06-July-1984 PAMULANG BARAT 089649703492 3 0 0 0 2 0 0 1 1 0 0 0
2021
01-December- 11-November-
3 GINO 3 6 7 4 0 6 5 1 1 1 7 5 0 0 0 5 SITI CHASANAH PAMULANG BARAT 089652456728 3 0 0 0 2 1 0 0 1 0 0 0
2021 1975
08-December- 19-February- PAMPER A6 NO 9 PAMULANGB
4 HADI SUGANDA 3 6 7 4 0 6 5 9 0 2 8 3 0 0 0 2 CAROLINE INGGRID 3 0 0 0 2 0 0 1 1 0 0 0
2021 1983 BARAT
08-December-
5 SAPTO 3 6 7 4 0 6 6 2 0 5 8 6 0 0 0 8 CAREEN 22-May-1986 PAMULANG BARAT 087784834055 3 0 0 0 2 0 0 1 1 0 0 0
2021
15-December- 15-August-1993
6 ARIS 1 8 0 9 0 7 5 5 0 8 9 3 0 0 0 2 GUSTIARA PAMULANG BARAT 085279963976 3 0 0 0 2 1 0 0 1 0 0 0
2021
15-December- 26-February-
7 SURYA 3 6 7 4 0 6 6 6 0 3 9 3 0 0 1 8 DWI R PAMULANG BARAT 081297135977 3 0 0 0 2 0 0 1 1 0 0 0
2021 1993
22-December- 20-January-1991
8 NIKI KOSASIH 3 6 7 4 0 6 6 0 0 1 9 1 0 0 0 3 BENA ARIYANI PAMULANG PERMAI 1 BLOK A 28/8 081315877773 3 0 0 0 2 0 0 1 1 0 0 0
2021
22-December- 13-August-1985
9 SAMSUL 3 6 7 4 0 6 4 3 1 2 8 5 0 0 1 0 ANITA pamulang barat 081381602144 3 1 0 0 2 0 0 1 1 0 0 0
2021
29-December-
10 ADE HARYANTO 3 6 7 4 0 6 5 5 0 3 8 7 0 0 1 2 NURAZIZAH 15-March-1987 PAMULANG BARAT 085691091599 2 1 0 0 2 0 0 1 1 0 0 0
2021
29-December-
11 BAMBANG 3 2 7 1 0 5 6 5 0 4 0 8 0 0 0 8 RAHMI ISYA BELLA 25-April-2007 PAMULANG BARAT 085716603563 3 0 0 0 2 0 0 1 1 0 0 0
2021
29-December-
12 DIMYATI 3 3 0 3 1 4 4 2 0 4 8 4 0 0 0 1 SUNARTI 02-April-1984 PAMULANG BARAT 0821215962356 2 1 0 0 2 1 0 0 1 0 0 0
2021
29-December-
13 HERMANTO 1 6 7 3 0 1 5 0 0 9 9 1 0 0 0 1 SUSI WULANDARI 17-June-1991 PAMULANG BARAT 082279599144 3 0 0 0 2 0 0 1 1 0 0 0
2021
29-December- 07-August-1982
14 RIANTO 3 6 7 4 0 5 4 7 0 8 8 2 0 0 0 9 PATIMAH PAMULANG BARAT 3 0 0 0 2 0 0 1 1 0 0 0
2021
01-December- 06-November-
15 M. THORIQ 3 6 7 4 0 6 4 6 1 1 0 2 0 0 0 1 ARCHI SARAH PAMULANG BARAT 085693382761 1 1 1 0 3 0 0 1 1 0 0 0
2021 2002
08-December-
16 SYAFA'AT 3 6 7 4 0 6 5 4 0 7 9 4 0 0 1 1 NURANI 14-July-1994 PAMULANG BARAT 081218974559 1 1 1 0 3 0 0 1 1 0 0 0
2021
15-December-
17 DEVA 3 2 7 5 0 1 4 9 0 3 0 1 0 0 2 7 IDA HAMIDAH 09-March-2001 CIPUTAT 1 1 0 0 3 1 0 0 1 0 0 0
2021
15-December- 09-August-1996
18 SAHID 3 2 0 9 1 0 0 9 0 8 9 6 0 0 1 5 AUDIA SUCI CIPAYUNG 085893001137 3 0 0 0 3 1 0 0 1 0 0 0
2021
22-December- 02-August-1999
19 DINAR 3 1 7 4 0 7 4 2 0 8 9 9 0 0 0 6 ADILLA PUTRI PAMULANG BARAT 0895421418698 3 0 0 0 3 0 0 1 1 0 0 0
2021
22-December-
20 GANTINA 3 6 7 4 0 6 5 1 0 5 8 6 0 0 0 4 RENI JAYA 11-May-1986 PAMULANG BARAT 089630143342 3 0 0 0 3 1 0 0 1 0 0 0
2021
15-December- 23-September-
21 JAMALUDDIN 3 6 7 4 0 1 6 3 0 9 7 8 0 0 0 2 YENI SURYANI CIATER 3 0 0 0 4 0 0 1 1 0 0 0
2021 1978

1) Keterangan Kode

STATUS PESERTA KB KODE JENIS ALOKON (Diisi Pada Jenis Tindakan dan Kasus)
1 : Peserta KB Baru 3 : Peserta KB Ulangan 1 : Suntikan 1 Bulanan 3 : Suntikan 3 Bulanan 5 : Pil Progestin 7 : Implan 1 Batang 9 : IUD 11 : Tubektomi
2 : Peserta KB Ganti 4 : Komplikasi 2 : Suntikan 3 Bulanan 4 : Pil Kombinasi 6 : Kondom 8 : Implan 2 Batang 10 : Vasektomi

2) SELAIN STATUS PESERTA KB, JENIS TINDAKAN DAN KASUS DIISI TANDA
 29-December- 12-October-1970
1 ENDANG 3 6 7 4 0 1 5 2 1 0 7 0 0 0 0 6 JULAEHA PAMULANG BARAT 3 0 0 0 4 0 0 1 1 0 0 0
2021
01-December- 15-January-1993
2 ROHMAN 3 5 2 1 0 1 5 5 0 1 9 3 0 0 0 1 PURWIAN HARUMI PAMULANG BARAT 081317265217 4 0 0 0 8 0 0 0 0 0 0 0
2021
15-December- 11-December-
3 HERI 3 6 7 4 0 5 5 1 1 2 8 4 0 0 0 5 HANNI H PAMULANG BARAT 1 1 1 0 8 1 0 0 1 0 0 0
2021 1984
15-December-
4 RENDI 3 2 1 6 2 0 4 3 0 5 8 6 0 0 0 3 MAILAN RUTH 13-May-1986 PAMULANG BARAT 081294433376 1 1 0 0 8 0 0 1 1 0 0 0
2021
29-December-
5 SUMONO 3 6 7 4 0 6 5 4 0 3 7 8 0 0 0 6 SRIWATI 14-March-1978 GANG HAJI MUNTIRI 4 0 0 0 8 0 0 0 0 0 0 0
2021
01-December-
6 AGUS MAULANA 3 6 7 4 0 6 5 6 0 6 8 2 0 0 0 5 YUNI SASMITA AFIATI 16-June-1982 LEMBAH PINUS RAYA A-3/97 081317826881 3 0 0 0 9 1 0 0 1 0 0 0
2021
01-December- 06-January-1993
7 CECEP ABDUL 3 2 7 6 1 1 4 6 0 1 9 3 0 0 0 1 SUMIATI PAMULANG BARAT 4 0 0 0 9 0 0 0 0 0 0 0
2021
01-December-
8 CHODIRIN 3 6 7 4 0 6 6 1 0 6 8 2 0 0 0 7 MURNIYATI 21-June-1982 GANG MUSHOLLA 2 087809842332 1 1 1 0 9 1 0 0 1 0 0 0
2021
01-December-
9 FARID 3 6 7 4 0 4 4 4 0 6 8 6 0 0 0 1 LIA TASLIMA 04-June-1986 SERUA 085776236404 4 0 0 0 9 0 0 0 0 0 0 0
2021
01-December- 26-September-
10 HANIEF 1 5 7 1 0 8 6 6 0 9 9 2 0 0 0 1 ASTI ALMIRA CIPUTAT 082383416262 1 1 1 0 9 1 0 0 1 0 0 0
2021 1992
08-December-
11 DODY 3 6 7 4 0 6 7 0 0 7 7 8 0 0 0 1 WULAN INDRI SAVITRI 30-July-1978 PAMPER 1A20/07 081280608024 4 0 0 0 9 0 0 0 0 0 0 0
2021
08-December-
12 SURANTA 3 6 0 1 0 8 5 2 0 3 0 1 0 0 0 4 MUSTAHIDAH 17-March-2001 PAMULANG BARAT 087782275775 1 1 1 0 9 1 0 0 1 0 0 0
2021
15-December- 01-January-1988
13 PUJIYONO 1 6 0 6 0 3 5 6 0 4 9 0 0 0 0 1 NUR WIDAYATI CIANJUR 1 1 0 0 9 1 0 0 1 0 0 0
2021
22-December- 27-September-
14 RIAN 3 2 0 4 1 6 6 7 0 9 9 3 0 0 0 9 SISKA WULANDARI PAMULANG BARAT 08881814504 4 0 0 0 9 0 0 0 0 0 0 0
2021 1993
22-December-
15 YANTO HERMAWAN 3 6 7 4 0 6 6 0 0 6 7 7 0 0 0 1 HERNAWATI 20-June-1977 GG ASEM 083875076500 2 1 0 0 9 1 0 0 1 0 0 0
2021
29-December- 23-August-1995
16 FARID 3 6 7 4 0 6 6 3 0 8 9 5 0 0 0 3 ADELIA JUWITA PAMULANG BARAT 1 1 1 0 9 1 0 0 1 0 0 0
2021
1. Petugas Entri Lamp.R/I/KB/20
Data LAMPIRAN R/I/KB/20 Lembar 3

1 2 3 4 5 6
3 6 7 4 0 0 2 Bulan : 2021
NAMA FASKES/ PUSKESMAS PAMULANG 7 8 9 10 11 V
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

RINGKASAN HASIL PELAYANAN KB

PESERTA KB BARU (PB) PESERTA KB ULANGAN PELAYANAN KASUS

PEMBERIAN
PEMBERIAN INFORMED PB DAN KESERTAAN JKN INFORMED CONSENT
METODE
NO. CONSENT (Untuk Peserta KB
KONTRASEPSI
(Untuk PB) PB PASCA PB PASCA Ulangan) PELAYANAN ULANG KOMPLIKASI BERAT
GANTI CARA PENCABUTAN KEGAGALAN
PERSALINAN KEGUGURAN
PB JKN PB NON JKN TOTAL PB

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1 IUD 1 1 0 1 1 0 0 0 0 0 0 0
2 IUD 1 1 0 1 0 0 0 0 0 0 0 0
3 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0
4 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0
5 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0
6 IUD 0 0 0 0 0 0 0 0 0 1 0 0
7 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0
8 IMPLAN 1 0 0 0 0 0 0 0 0 0 0 0
9 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0
10 SUNTIKAN 1 1 0 1 0 0 0 0 0 0 0 0
11 SUNTIKAN 0 0 0 0 0 0 1 1 0 0 0 0
12 IUD 0 0 0 0 0 0 0 0 0 1 0 0
13 SUNTIKAN 0 0 0 0 0 0 1 1 0 0 0 0
14 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0
15 IMPLAN 0 0 0 0 0 0 0 0 0 1 0 0
16 IUD 1 1 0 1 1 0 0 0 0 0 0 0
17 PIL 0 0 0 0 0 0 0 0 1 0 0 0
18 PIL 0 0 0 0 0 0 0 0 1 0 0 0
19 IUD 0 0 0 0 0 0 0 0 0 1 0 0
20 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0
21 IMPLAN 1 1 0 1 1 0 0 0 0 0 0 0
22 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0

JUMLAH 10 7 0 7 7 0 5 4 17 6 0 0

Kota Tangerang Selatan, 29-December-2021

Pimpinan Faskes KB/Jaringan/Jejaring*

dr.Fitria Oriza
( .................................................................................................)
198401082009022001

NIP/NRP
* Coret yang tidak perlu

1) Keterangan Kode

STATUS PESERTA KB KODE JENIS ALOKON (Diisi Pada Jenis Tindakan dan Kasus)
1 : Peserta KB Baru 3 : Peserta KB Ulangan 1 : Suntikan 1 Bulanan 3 : Suntikan 3 Bulanan 5 : Pil Progestin 7 : Implan 1 Batang 9 : IUD 11 : Tubektomi
2 : Peserta KB Ganti 4 : Komplikasi 2 : Suntikan 3 Bulanan 4 : Pil Kombinasi 6 : Kondom 8 : Implan 2 Batang 10 : Vasektomi

2) SELAIN STATUS PESERTA KB, JENIS TINDAKAN DAN KASUS DIISI TANDA