KB SUNTIK 3 BULAN PUSKESMAS BANJAREJO

BULAN JUNI TAHUN 2022

NO NAMA PESERTA No. KARTU ALAMAT NO.HP TANGGAL JENIS JUMLAH (Rp)
USIA PESERTA PELAYANAN PELAYANAN

1 NGATMI 45 TH 0000580409324 DK.GUMIRING - 02/06/2022 Rp 15,000

2 SUMIYATI 44 TH 0000580979362 DK. KARANGTALUN - 02/06/2022 Rp 15,000
3 DARWATI 34 TH 0002400507652 DK.KALIREJO - 02/06/2022 Rp 15,000
4 RUSUNA 34 TH 0000580580032 DK.GUMIRING - 03/06/2022 Rp 15,000
5 ZUMROYANI 25 TH 0000580744618 DK TAMBAKLULANG - 03/06/2022 Rp 15,000
6 KASIATI 33 TH 0000580948762 KEBUNREJO - 03/06/2022 Rp 15,000
7 WIJI LESTARI 35 TH 0002575837293 KEMBANG - 03/06/2022 Rp 15,000
8 KASRI 35 TH 0000580381762 DK.WONOSEMI - 04/06/2022 Rp 15,000
9 KISMIATI 35 TH 0000580419088 DK.GEMPOL - 04/06/2022 Rp 15,000
10 ENDANG SULASTRI 32 TH 0000580426323 DK.PILO - 04/06/2022 Rp 15,000
11 SITI NURYATUL HIKMAH 23 TH 0002002903018 DS. GEDONGSARI - 04/06/2022 Rp 15,000
12 SUPRIHATI 37 TH 0002635057664 DK GEMPOL - 04/06/2022 Rp 15,000
13 SITI SRI WAHYUNI 25 TH 0000581269386 DK. NGABLAK - 04/06/2022 KB SUNTIK 3 Rp 15,000
BULAN
14 BUNTARI 33 TH 0001698878946 KEMBANG - 06/06/2022 Rp 15,000
15 RINIPUSPITASARI 25 TH 0000580643019 GUMIRING - 06/06/2022 Rp 15,000
16 MARSINI 49 TH 0000580379141 DK. KEBONREJO - 06/06/2022 Rp 15,000
17 SITI KHOTIJAH 34 TH 0002349781716 DK. KEBONREJO - 06/06/2022 Rp 15,000
18 ISTIKOMATIL HIDAYATI 30 TH 0000580407434 DS.MOJOWETAN - 07/06/2022 Rp 15,000
19 SUWARTI 49 TH 0000581416402 DK.NGANGGIL - 07/06/2022 Rp 15,000
20 SITI MASANAH 37 TH 0000581032912 SIDOMULYO - 08/06/2022 Rp 15,000
21 NURHIDAYAH 34 TH 0000580921918 KEBONREJO - 08/06/2022 Rp 15,000
22 SITI NURUL LAILI 30 TH 0002421394209 DK. BACEM 082112174863 08/06/2022 Rp 15,000
23 VIVI DWI LESTARI 19 TH 0000580366743 DK. KEDUNG KENONGO - 09/06/2022 Rp 15,000
24 SITI MARYAM 44 TH 0000580356246 SENDANGGAYAM - 09/06/2022 Rp 15,000
25 SULASTRI 41 TH 0000580168517 DK.SAMBIREJO - 10/06/2022 Rp 15,000
26 SUPATMI 44 TH 0000581159823 DK.BANGKUK - 11/06/2022 Rp 15,000
27 SITI SULISTARI 33 TH 0000580399165 WONOSEMI - 11/06/2022 Rp 15,000
28 SRI HASTUTI 42 TH 0002349781683 DS.KEBONREJO - 11/06/2022 Rp 15,000
29 DEVI EKA NOVIYANA 25 TH 0000580374696 SUGIHAN - 11/06/2022 Rp 15,000
30 RASMI 47 TH 0000581480458 DK NGANGGIL - 13/06/2022 Rp 15,000
31 SUPARI 46 TH 0000580879978 DK KEBONREJO - 13/06/2022 Rp 15,000
32 JAMILAH 40 TH 0000581545427 DK TAMBAKLULANG - 14/06/2022 Rp 15,000
33 SUYATI 33 TH 0000581254705 DS MOJOWETAN - 14/06/2022 Rp 15,000
34 SITI KHONIAH 42 TH 0002023867089 DK WONOSEMI 085228529180 14/06/2022 Rp 15,000
35 PURWANTI 23 TH 0000581071353 DK BALONGREJO - 14/06/2022 Rp 15,000
36 SUYANTI 47 TH 0000580615119 DK BALONGSARI - 14/06/2022 Rp 15,000
37 FITRI RUPINGAH 32 TH 0000581604996 DS KEMBANG - 14/06/2022 Rp 15,000
38 WARSITI 42 TH 0000580012042 DK NGANGGIL - 15/06/2022 Rp 15,000
39 SITI SUYATNI 38 TH 0000580352319 DS WONOSEMI - 15/06/2022 Rp 15,000
40 SITI UTAMININGSIH 37 TH 0000579762257 DK WONOSEMI - 15/06/2022 Rp 15,000
41 SITI MAHMUDAH 28 TH 0000580127883 DK SUGIHAN - 15/06/2022 Rp 15,000
42 MUNASIH 53 TH 0001023845949 DK GLAGAH - 16/06/2022 Rp 15,000
43 SARMI 41 TH 0000581269318 DK GUMIRING - 16/06/2022 KB SUNTIK 3 Rp 15,000
BULAN
44 SUYATI 39 TH 0002002806099 BACEM - 16/06/2022 Rp 15,000
45 SUMARNI 44 TH 0000581126477 BANJAREJO - 16/06/2022 Rp 15,000
46 SUTANTI F 42 TH 0000581245334 DK GUMIRING - 16/06/2022 Rp 15,000
47 ST QOMARIYAH 23 TH 0000580156391 DK GUMIRING - 16/06/2022 Rp 15,000
48 SRI WAHYU IDA N 25 TH 0002596499537 TENGGER - 16/06/2022 Rp 15,000
49 KARTINI 46 TH 0000581554618 DK MOJOKULON - 17/06/2022 Rp 15,000
50 NURUN NISAK 37 TH 0000579990497 DK NGRAYUNG - 17/06/2022 Rp 15,000
51 SITI MURATI 50 TH 0000580331733 DK BANJAREJO - 17/06/2022 Rp 15,000
52 SITI SUMARI 37 TH 0000581121202 DK NGABLAK - 18/06/2022 Rp 15,000
53 ERMA PURWANTI 31 TH 0000580513162 DK NGRAYUNG - 18/06/2022 Rp 15,000
54 IRMA SURYANI 30 TH 0000580538946 DK KEBONREJO - 18/06/2022 Rp 15,000
55 MEITIKA DWI N 22 TH 0000581710241 DK NGRAYUNG - 18/06/2022 Rp 15,000
56 SITI FATIMAH 34 TH 0002002880698 MOJOWETAN - 18/06/2022 Rp 15,000
57 CENCIN FITRIYANI 24 TH 0000580464764 DK WONOSEMI - 18/06/2022 Rp 15,000
58 KALPIKA INTAN P S 23 TH 0000581963433 DS BANJAREJO - 18/06/2022 Rp 15,000
59 SITI NURKHOLIFAH 39 TH 0000580344769 TENGGER - 18/06/2022 Rp 15,000
60 KHOIRIN MURSIDAH 32 TH 0000581224948 DS SUMBERJO - 20/06/2022 Rp 15,000
61 LATIFAH 34 TH 0002002858086 SUMBERJO - 20/06/2022 Rp 15,000
62 SRI TUTIK 33 TH 00002349781312 DS KARANGTALUN - 20/06/2022 Rp 15,000
63 SITI MIFTAKHUL LAILI 20 TH 0000579753448 DK SUGIHAN - 20/06/2022 Rp 15,000
64 SUTRIANINGSIH 35 TH 0000579987595 DK GUMIRING - 20/06/2022 Rp 15,000
65 YATINI 42 TH 0001023849404 DK TAMBAKULANG - 20/06/2022 Rp 15,000
66 YULIANA 32 TH 0000580659884 DS MOJOWETAN - 21/06/2022 Rp 15,000
67 SUPAMININGSIH 39 TH 0000580383955 DK GUMIRING - 21/06/2022 Rp 15,000
68 KASANAH 37 TH 0000580889204 KEBONREJO - 21/06/2022 Rp 15,000
69 NGASRIATIK 43 TH 0000580383336 DS BACEM - 21/06/2022 Rp 15,000
70 INDAH SULISTIANINGSEH 28 H 0001849084661 SIDOMULYO - 21/06/2022 Rp 15,000
71 SRI SISWATI 37 TH 0000580453143 DS SIDOMULYO - 21/06/2022 Rp 15,000
72 SITI SUSWATI 51 TH 0001699425639 DK KEBONREJO - 21/06/2022 Rp 15,000
73 KALIMAH 30 TH 0000580670638 SENDANGGAYAM - 21/06/2022 Rp 15,000
74 SITI INDASAH 25 TH 0000580944971 DK NGRAYUNG - 21/06/2022 Rp 15,000
75 SUWATI 49 TH 0000580364864 DK KEDUNG KENONGO - 22/06/2022 Rp 15,000
76 SITI NURITASARI 24 TH 0000580651323 SENDANGGAYAM - 22/06/2022 KB SUNTIK 3 Rp 15,000
BULAN
77 MARYANI 40 TH 0002841168813 DK WONOSEMI - 22/06/2022 Rp 15,000
78 SITI UMAROH 38 TH 0000574528127 NGABLAK - 23/06/2022 Rp 15,000
79 JUMIATI 35 TH 0000580951495 BANJAREJO - 23/06/2022 Rp 15,000
80 SITI ROHAYATI 36 TH 0001023850034 DK SUGIHAN - 23/06/2022 Rp 15,000
81 KISWATI 44 TH 0000580201648 DK GUMIRING - 23/06/2022 Rp 15,000
82 SITI KHOLIPAH 39 TH 0001023853059 DK NGABLAK - 23/06/2022 Rp 15,000
83 SITI MARKAMAH 35 TH 0001023844419 DK BACEM - 23/06/2022 Rp 15,000
84 SITI ROPIAH 40 TH 0000581145175 DK NGRAYUNG - 23/06/2022 Rp 15,000
85 SITI PURWATI 22 TH 0000580799812 DK BANJARASEM - 23/06/2022 Rp 15,000
86 SITI MUTMAINAH 26 TH 0000581807529 DS MOJOWETAN - 23/06/2022 Rp 15,000
87 IDAWATI 27 TH 0000577136169 DS KEDUNGKRIKIL - 24/06/2022 Rp 15,000
88 SITI NURHIDAYAH 26 TH 0002176766831 BACEM - 24/06/2022 Rp 15,000
89 SUKINI 39 TH 0000580930042 DK BRINGIN - 25/06/2022 Rp 15,000
90 WARTINI 36 TH 0000580348473 DK WONOSEMI - 27/06/2022 Rp 15,000
91 WIJI LESTARI 38 TH 0000580298545 DK MOJOKULON - 27/06/2022 Rp 15,000
92 SUYATI 43 TH 0000581925971 DK MOJOKULON - 27/06/2022 Rp 15,000
93 DEWI LESTARI 34 TH 0000581216591 DK TEMBORO - 27/06/2022 Rp 15,000
94 SITI FATHONAH 29 TH 0003133386731 CEREBEK - 27/06/2022 Rp 15,000
95 ATIK NURUL H 33 TH 0000581821312 DK PULO - 27/06/2022 Rp 15,000
96 SITI SUNDARI 41 TH 0000580674756 DK GUMIRING - 28/06/2022 Rp 15,000
97 SRI WAHYUNI 31 TH 0000580596309 WONOSEMI - 28/06/2022 Rp 15,000
98 SITI DWI MARLINA 25 TH 0000581834057 KARANGTALUN - 28/06/2022 Rp 15,000
99 IDA NUR FADILAH 39 TH 0000579818992 DK PULO - 28/06/2022 KB SUNTIK 3 Rp 15,000
100 WARSIYEM 28 TH 0002002877605 KARANGTALUN - 30/06/2022 BULAN Rp 15,000
101 CHOIRUN NISAK 25 TH 0002640719913 MOJOWETAN - 30/06/2022 Rp 15,000
102 NUR SUYANTI 34 TH 0000580111075 DK PULO - 30/06/2022 Rp 15,000
103 NYAMINAH 49 TH 0000579721566 DK PULO - 30/06/2022 Rp 15,000
104 JUMIATI 41 TH 0000581606853 DK BANGKUK - 30/06/2022 Rp 15,000
105 WINARTI 32 TH 0000580347988 DK BALONGSARI - 30/06/2022 Rp 15,000
106 ST ULFATUL M 35 TH 0001023850484 DS MOJOWETAN - 30/06/2022 Rp 15,000
JUMLAH Rp 1,590,000

Banjarejo, 30 JUNI 2022

MENGETAHUI,
KEPALA UPTD PUSKESMAS BANJAREJO

NIP.SUTRISNO,
19650418S,Kep.Ners
198812 1 001
NIP. 197301231994031002
 REKAPITULASI PELAYANAN NON KAPITASI
UPTD PUSKESMAS MEDANG
BULAN MARET 2022

KLAIM YANG DIAJUKAN REKENING

NAMA BIAYA
NO PERS NO NPWP
PUSKESMAS KB OBAT KB PRA AMBULA PENGAJUAN NAMA NOMOR
ANC ALINA PNC KB IUD ATAS NAMA
SUNTIK PRB IMPLAN RUJUKAN NCE BANK REKENING
N

Bank Bendahara
UPTD
Jateng Penerimaan 30.117.837.2
1 PUSKESMAS 26 5 5 6 3 0 4 3 3 Rp 6,400,794 2-016-13643-6
Cabang BLUD UPTD .514.000
MEDANG
Blora Pusk. Medang

MENGETAHUI,
Plt. KEPALA UPTD PUSKESMAS MEDANG
ANALIS KESEHATAN

Teguh Prasetyandaru S.KM

NIP. 19650418 198812 1 001
 REKAPITULASI PELAYANAN
AMBULANCE UPTD PUSKESMAS MEDANG
BULAN MARET 2022

FASKES
NO NAMA PASIEN USIA NOMOR PESERTA ALAMAT NO HP DIAGNOSA TINDAKAN TGL RUJUKAN JUMLAH (Rp)
PELAYANAN (KM)

Pemasangan infus RL, AMOX

1 SITI MURINA 25 TH 0001023835612 DESA TEMPURAN 085293868818 KALA 1 MEMANJANG DAN TAB 1X500 MG SWAB 12/03/2022 11 KM Rp 204,780
KETUBAN PECAH DINI ANTIGEN COVID 19

KALA 1 MEMANJANG DAN Pemasangan infus RL, AMOX

2 LINDA TAKHYANI 29 TH 0003006072099 DK. NGAWEN 082123513626 TAB 1X500 MG SWAB 28/03/2022 8 KM Rp 177,240
KETUBAN PECAH DINI ANTIGEN COVID 19

Pemasangan infus RL, AMOX

3 KRISTINA 31 TH 0000579674709 BELIK - PARTUS MACET TAB 1X500 MG SWAB 09/03/2022 8 KM Rp 177,240
ANTIGEN COVID 19

JUMLAH Rp 559,260

Blora, 11 APRIL 2022

MENGETAHUI,
Plt. KEPALA UPTD PUSKESMAS MEDANG
ANALIS KESEHATAN

Teguh Prasetyandaru S.KM

NIP. 19650418 198812 1 001
 REKAPITULASI PELAYANAN ANC
UPTD PUSKESMAS BANJAREJO
BULAN JUNI TAHUN 2022

NO NAMA PASIEN USIA No. KARTU ALAMAT NO. HP GPA HTP TANGGAL JENIS JUMLAH (Rp)
PESERTA PELAYANAN PELAYANAN
1 SITI NINGSIH 34 TH 0000580478343 DS. BALONGREJO - G4P2A1 28/08/2022 02/06/2022 ANC 3 Rp 50,000
2 UUN KURNIASIH 20 TH 0001023848144 DK.BANJAREJO - G1P0A0 03/06/2022 02/06/2022 ANC 4 Rp 50,000
3 SUHARTIK 26 TH 0000580448777 DK.KEDAWUNG 08226723439 G3P2A0 10/08/2022 02/06/2022 ANC 3 Rp 50,000
4 LATIFATUL HUSNA 24 TH 0001023851722 DK.MOJOWETAN - G1P0A0 27/12/2022 03/06/2022 ANC 1 Rp 50,000
5 RIKA KARLINA 23 TH 0000580379804 DK.KEBONREJO - G1P0A0 18/09/2022 03/06/2022 ANC 2 Rp 50,000
6 YATMI 33 TH 0000581011277 DK.KEDUNG KENONGO - G2P1A0 14/11/2022 03/06/2022 ANC 2 Rp 50,000
7 NAILA SAKIROTUL 21 TH 0000581750357 TENGGER - G1P0A0 21/10/2022 03/06/2022 ANC 1 Rp 50,000
RISKIYAH
8 MIFTAHUS 26 TH 0000580435841 TENGGER - G2P1A0 12/10/2022 04/06/2022 ANC 2 Rp 50,000
SHOLIHAH
9 SENI WATI 25 TH 0000581418696 DK.KALISARI - G2P1A0 08/12/2022 04/06/2022 ANC 2 Rp 50,000
10 SITI KHOIRUN NISA' 20 TH 0001023839032 DS. NGRAYUNG - G1P0A0 20/07/2022 04/06/2022 ANC 3 Rp 50,000
11 MARTI'AH 34 TH 0001692499397 DK.TEMBORO - G1P0A0 01/08/2022 04/06/2022 ANC 3 Rp 50,000
12 SANITA DWI 32 TH 0000580493992 KEMBANG - G4P2A1 26/07/2022 04/06/2022 ANC 3 Rp 50,000
WIDYANINGRUM
13 SITI NUR FADILAH 35 TH 0000580400638 DK CEREBEK - G3P2A0 27/12/2022 06/06/2022 ANC 1 Rp 50,000
14 MIFTAHUL JANNAH 26 TH 0000580411574 SIDOMULYO - G2P1A0 23/09/2022 06/06/2022 ANC 2 Rp 50,000
15 SUPRAPTI 26 TH 0000579796773 DK GUMIRING - G2P1A0 12/07/2022 06/06/2022 ANC 3 Rp 50,000
16 WULANDARI 23 TH 0001023848291 DK TAMBAKLULANG - G3P1A1 02/08/2022 06/06/2022 ANC 3 Rp 50,000
17 DINA SARIYANTI 28 TH 0003262780978 DK SUMBEREJO - G2P1A0 10/06/2022 06/06/2022 ANC 3 Rp 50,000
18 ENIK NURYANTI 29 TH 0000755811178 DK TENGGER 082327197458 G4P2A1 21/06/2022 06/06/2022 ANC 3 Rp 50,000
19 ISTI ZANATUN NOR 29 TH 0000581661246 DK PULO 082328088280 G2P1A0 08/09/2022 06/06/2022 ANC 3 Rp 50,000
LAILA
20 SITI LESTARI 39 TH 0001787956953 DK JAMBE 082257516232 G2P1A0 07/07/2022 06/06/2022 ANC 3 Rp 50,000
21 SILVIANA 19 TH 0000581543965 DK BALONGSARI - G1P0A0 01/11/2022 07/06/2022 ANC 2 Rp 50,000
MUDHIROH
22 NGATMI 33 TH 0000580930481 DK WEDEK - G2P1A0 28/09/2022 07/06/2022 ANC 2 Rp 50,000
23 DIAH HESTI 23 TH 0002799533902 DK PULO - G1P0A0 05/08/2022 07/06/2022 ANC 3 Rp 50,000
PRASTYANINGRUM
24 TUTIK ALAWIYAH 25 TH 0002089886229 DK. SANTREN 085331439994 G2P0A1 20/07/2022 07/06/2022 ANC 3 Rp 50,000
25 SITI NUR INAYAH 20 TH 0000580392549 DK GUMIRING - G1P0A0 21/06/2022 07/06/2022 ANC 4 Rp 50,000
26 ARISKA 20 TH 0000580598368 KEDUNGSONO - G1P0A0 02/10/2022 09/06/2022 ANC 2 Rp 50,000
27 IKA FITRIANI 28 TH 0003136584137 DK.KALIREJO 085848353346 G3P2A0 12/11/2022 09/06/2022 ANC 2 Rp 50,000
28 NANA FATMAWATI 18 TH 0000580290579 DK.TEMETES - G1P0A0 31/12/2022 09/06/2022 ANC 1 Rp 50,000
29 SITI LUPITASARI 25 TH 0000581494746 KARANGTALUN - G2P1A0 16/12/2022 10/06/2022 ANC 2 Rp 50,000
30 LIKA DWI MAYASARI 16 TH 0002349781029 JATIKLAMPOK - G1P0A0 LUPA 10/06/2022 ANC 2 Rp 50,000
31 SITI RISIYAH 31 TH 0003256900005 GEMPOL - G3P1A1 20/09/2022 10/06/2022 ANC 3 Rp 50,000
32 SRIYANA 25 TH 0001023844803 DS.BACEM - G1P0A0 11/08/2022 10/06/2022 ANC 3 Rp 50,000
33 DWI LIA ASTUTIK 23 TH 0001023849887 MOJOWETAN - G1P0A0 21/06/2022 11/06/2022 ANC 4 Rp 50,000
34 SRI NUR ELIYAWATI 33 TH 0000580649668 DK.GENEN - G2P1A0 18/07/2022 11/06/2022 ANC 3 Rp 50,000
35 RUKMIYATIN 33 TH 0002920775141 KEMBVANG G2P1A0 19/08/2022 11/06/2022 ANC 3 Rp 50,000
36 LIA LISTIANI 21 TH 0000580513397 DK KARANGTALUN - G1P0A0 17/07/2022 13/06/2022 ANC 3 Rp 50,000
NOVITASARI
37 RISKI ANI W 20 TH 0000581574868 DS SEMBONGIN - G1P0A0 04/10/2022 13/06/2022 ANC 2 Rp 50,000
38 SITI MUTIAH 21 TH 0000581455451 DK PENGKOL - G1P0A0 21/07/2022 13/06/2022 ANC 3 Rp 50,000
39 SITI JAMILAH 25 TH 0000580572617 SIDOMULYO - G2P1A0 20/09/2022 13/06/2022 ANC 3 Rp 50,000
40 MIFTAHUL JANNAH 26 TH 0000580411574 SIDOMULYO - G1P0A0 23/09/2022 13/06/2022 ANC 3 Rp 50,000
41 SITI CHOIRUNNISAK 21 TH 0000580361016 DK NGABLAK - G1P0A0 05/10/2022 13/06/2022 ANC 2 Rp 50,000
42 SETIYA EKA RINI 30 TH 0000579962452 GUMIRING - G2P1A0 27/07/2022 13/06/2022 ANC 3 Rp 50,000
43 MUNARTI 38 TH 0001023844713 DK PENGKOL - G3P2A0 18/09/2022 13/06/2022 ANC 2 Rp 50,000
44 SITI NUR HIDAYAH 27 TH 0001538343236 DK PENGKOL - G1P0A0 01/07/2022 13/06/2022 ANC 4 Rp 50,000
45 ENDANG 21 TH 0000581470424 DK BALONGSARI 085294159417 G1P0A0 01/01/2023 13/06/2022 ANC 1 Rp 50,000
SETIYAWATI
46 MUKTI BAITI 22 TH 0002944109441 DK PULO - G2P1A0 17/11/2022 13/06/2022 ANC 2 Rp 50,000
47 SISKA JAIRINI 18 TH 0000580458892 DK KEDUNG - G2P0A1 22/09/2022 14/06/2022 ANC 2 Rp 50,000
48 SITI DWI LESTARI 27 TH 0002176766853 DK. GUMIRING 088232174841 G2P1A0 19/12/2022 14/06/2022 ANC 1 Rp 50,000
49 SITI USWATUN K 22 TH 0000580951067 DK BANJARASEM - G1P0A0 16/07/2022 14/06/2022 ANC 3 Rp 50,000
50 SITI NUR HAFIFAH 19 TH 0000581474878 DS BACEM 081393060952 G1P0A0 02/07/2022 14/06/2022 ANC 4 Rp 50,000
51 MEGAWATI 30 TH 0003271292763 DK KALIREJO 085130312002 G2P1A0 07/12/2022 16/06/2022 ANC 2 Rp 50,000
52 NIA DIAN ANGGRAINI 26 TH 0000580637327 DK KESER - G2P0A1 07/09/2022 16/06/2022 ANC 2 Rp 50,000
53 HERNI ERNA SARI 21 TH 0001023852879 DK NGABLAK - G1P0A0 12/02/2023 16/06/2022 ANC 1 Rp 50,000
54 SITI MUNASIROH 28 TH 0003262914325 DS PLOSOREJO - G2P1A0 11/09/2022 17/06/2022 ANC 3 Rp 50,000
55 SITI FOROTUN K 23 TH 0001023845736 DK SAMBIRJO - G2P1A0 11/01/2023 17/06/2022 ANC 1 Rp 50,000
56 SITI ANISA 22 TH 0000580883455 DK NGLEMPUNG - G2P1A0 19/01/2023 17/06/2022 ANC 1 Rp 50,000
57 SITI KHOZINATU 21 TH 0000582230968 SENDANGGAYAM - G1P0A0 02/01/2023 17/06/2022 ANC 1 Rp 50,000
ZAIN
58 DEWI SRI HASTUTIK 31 TH 0000582042082 DK BANJARASEM 085643210499 G1P0A0 27/10/2022 18/06/2022 ANC 2 Rp 50,000
59 SITI WIDIYANTI 26 TH 0000580820409 DK TEMBORO - G2P1A0 20/01/2023 18/06/2022 ANC 1 Rp 50,000
60 WINARSIH 34 TH 0001023862869 SEMBONGIN - G2P1A0 27/07/2022 19/06/2022 ANC 3 Rp 50,000
61 RIRIN WIJAYANTI 32 TH 0000580707718 SEMBONGIN - G2P1A0 29/09/2022 19/06/2022 ANC 2 Rp 50,000
62 YANA DWI A 25 TH 0000580314712 DK SUGUHAN - G1P0A0 18/10/2022 20/06/2022 ANC 2 Rp 50,000
63 ENDANG L 40 TH 0001692469596 DK BALONGREJO 081311584112 G2P1A0 13/08/2022 20/06/2022 ANC 3 Rp 50,000
64 MENIK MARGIATI 27 TH 0000581737691 SEMBONGIN - G4P2A1 23/08/2022 20/06/2022 ANC 3 Rp 50,000
65 SUPARMI 24 TH 0000581257697 KEBONREJO - G1P0A0 26/11/2022 24/06/2022 ANC 2 Rp 50,000
66 SITI NUR AZIZAH 27 TH 0000581326503 DK LEMAHBANG - G2P1A0 07/03/2022 24/06/2022 ANC 2 Rp 50,000
67 KASMIYATI 31 TH 0002123957608 DK KALISARI - G4P2A1 31/01/2022 24/06/2022 ANC 1 Rp 50,000
68 SRI RAHAYU 33 TH 0000581228324 JATIKLAMPOK - G2P1A0 14/11/2022 24/06/2022 ANC 2 Rp 50,000
69 STI MUTMAINAH 32 TH 0001316074285 PLOSOREJO 082134939494 G4P2A1 09/11/2022 24/06/2022 ANC 2 Rp 50,000
70 MARIYATUN 31 TH 0000580324263 DK KEDUNGSONO - G3P1A1 15/01/2023 25/06/2022 ANC 1 Rp 50,000
71 SITI SOFIATUN 21 TH 0000581686626 DS PLOSOREJO - G1P0A0 20/07/2022 25/06/2022 ANC 3 Rp 50,000
72 WAHYU ANGGI F 21 TH 0000580384214 DK KEBONREJO 08122778261 G2P1A0 04/02/2023 22/06/2022 ANC 1 Rp 50,000
73 SRI WAHYUNI 29 TH 0002238047695 DK BOTO 083863879349 G2P1A0 24/10/2022 22/06/2022 ANC 2 Rp 50,000
74 SISWATI 34 TH 0000581474349 DK GUMIRING - G3P2A0 27/09/2022 27/06/2022 ANC 3 Rp 50,000
75 HANIK ROSIDAH 29 TH 0000581192199 DS BOTO 083866927344 G2P1A0 30/12/2022 27/06/2022 ANC 2 Rp 50,000
76 SITI LIA NUR A 20 TH 0000581436854 DK BALONGSARI 081216172390 G1P0A0 15/11/2022 27/06/2022 ANC 2 Rp 50,000
77 SITI FAJAR SUNYI 23 TH 0002874559601 SENDANGGAYAM 082145220308 G1P0A0 09/07/2022 27/06/2022 ANC 3 Rp 50,000
78 ZAZILATUL K 35 TH 0003268815693 DK PULO 081228666683 G3P2A0 12/08/2022 27/06/2022 ANC 3 Rp 50,000
79 SRI WULANDARI 22 TH 0000581400494 DK MOJOWETAN 087734647715 G1P0A0 06/10/2022 27/06/2022 ANC 3 Rp 50,000
80 DIA MARLINA U 26 TH 0000580379905 DK SUGIHAN - G2P1A0 11/08/2022 27/06/2022 ANC 3 Rp 50,000
81 SANTI WIDIA S 25 TH 0000581549872 WOTRANGKUL 082351336781 G2P1A0 03/12/2022 27/06/2022 ANC 2 Rp 50,000
82 SITI MARDIYAH 38 TH 0001023849909 DK PULO - G2P1A0 24/01/2023 27/06/2022 ANC 1 Rp 50,000
83 SITI DURROTUN 22 TH 0000582213543 DS.SENDANGGAYAM - G1P0A0 11/01/2023 27/06/2022 ANC 1 Rp 50,000
WAHIDAH
84 SULASTRI 38 TH 0001023839774 DK KEDUNG - G5P4A0 21/10/2022 27/06/2022 ANC 2 Rp 50,000
85 ISMI LUTHFI H 23 TH 0000581483518 DK PULO - G1P0A0 13/10/2022 28/06/2022 ANC 2 Rp 50,000
86 SITI USWATUN K 20 TH 0000581668705 GEDONGSARI - G1P0A0 26/09/2022 28/06/2022 ANC 3 Rp 50,000
87 NOVITA SAPTA 27 TH 0002596498378 DK NGRAYUNG 082325075818 G2P1A0 14/07/2022 28/06/2022 ANC 3 Rp 50,000
KUMALA
88 LELI ROFIATUS S 23 TH 0000581420597 DK TEMBORO - G1P0A0 12/02/2023 30/06/2022 ANC 1 Rp 50,000
JUMLAH Rp 4,400,000

Banjarejo, 30 JUNI 2022

MENGETAHUI,
KEPALA UPTD PUSKESMAS BANJAREJO

SUTRISNO, S,Kep.Ners
NIP. 197301231994031002
 REKAPITULASI PELAYANAN
PERSALINAN UPTD PUSKESMAS MEDANG
BULAN MARET TAHUN 2022

NO NAMA PASIEN USIA No. KARTU ALAMAT NO. HP GPA JENIS TANGGAL JUMLAH (Rp)
PESERTA PERSALINAN PELAYANAN

SITI MIFTACHUL Rp 700,000

1 JANAH 24 TH 0002893355818 DK. NGROJO 085713939332 G2P1A0 SPONTAN 15/03/2022
Rp 700,000
2 SITI ELIYA DEWI 24 TH 0002580171048 JEJERUK 0895603578816 G3P2A0 SPONTAN 20/03/2022
Rp 700,000
3 MAELAN PATAYANTI 27 TH 0003257579823 DK. PILANGREJO - G2P1A0 SPONTAN 30/03/2022
Rp 700,000
4 ENDANG ANDRIANY 26 TH 0003103558209 DS.TAMBAKSARI 089668142444 G2P1A0 SPONTAN 17/03/2022
Rp 700,000
5 PUJI DAMAYANTI 26 TH 0001699438239 TAMBAKSARI - G2P1A0 SPONTAN 23/03/2022
JUMLAH Rp 3,500,000

Blora, 11 APRIL 2022

MENGETAHUI,
Plt. KEPALA UPTD PUSKESMAS MEDANG
ANALIS KESEHATAN

Teguh Prasetyandaru S.KM

NIP. 19650418 198812 1 001
 REKAPITULASI PELAYANAN PNC
UPTD PUSKESMAS BANJAREJO
BULAN JUNI TAHUN 2022

NO NAMA PESERTA USIA No. KARTU ALAMAT NO. HP TANGGAL TANGGAL JENIS JUMLAH (Rp)
PESERTA PERSALINAN PELAYANAN PELAYANAN

1 SITI ALFINA 20 TH 0000580666847 DK. KALISARI - 30/05/2022 02/06/2022 PNC 2 Rp 25,000

DAMAYANTI

2 IIN DWI SUHARTINI 22 TH 0000581110571 DK SUGIHAN - 31/05/2022 03/06/2022 PNC 2 Rp 25,000

3 SEPTYANA 26 TH 0000581171905 DK. BADONG KIDUL; - 31/05/2022 03/06/2022 PNC 2 Rp 25,000

SASMITHA

4 SRI HARYANTI 23 TH 0000580524682 DK GUMIRING - 31/05/2022 03/06/2022 PNC 2 Rp 25,000

5 SITI SUPRAPTI 20 TH 0000580630318 DK SENDANGGAYAM - 06/06/2022 09/06/2022 PNC 2 Rp 25,000

6 UUN KURNIASIH 20 TH 0001023848144 DK BANJAREJO - 06/06/2022 09/06/2022 PNC 2 Rp 25,000

7 PITRI LIANA 22 TH 0000581195665 DK BALONGSARI 085326540074 14/06/2022 16/06/2022 PNC 2 Rp 25,000

8 ST MUNIKA 23 TH 000580227838 DK KEDUNG - 14/06/2022 17/06/2022 PNC 2 Rp 25,000

NURDIYANTI

9 SITI SALAMATUL 31 TH 0001625282199 DK BAONG KIDUL - 16/06/2022 18/06/2022 PNC 2 Rp 25,000

UMAH

10 ENIK NURYANTI 29 TH 000075811178 DK TENGGER 082327197458 20/06/2022 23/06/2022 PNC 2 Rp 25,000

11 NIPA DENIATI 25 TH 0002742915341 DK TEMETES 082328505635 19/06/2022 23/06/2022 PNC 2 Rp 25,000

JUMLAH Rp 275,000

Banjarejo, 30 JUNI 2022

MENGETAHUI,
KEPALA UPTD PUSKESMAS BANJAREJO

SUTRISNO, S,Kep.Ners
NIP. 197301231994031002
 REKAPITULASI PELAYANAN
PRA RUJUKAN UPTD PUSKESMAS MEDANG
BULAN MARET 2022

NO NAMA PASIEN USIA NOMOR ALAMAT NO HP DIAGNOSA TINDAKAN TGL FASKES RUJUKAN JUMLAH (Rp)
PESERTA PELAYANAN

KALA 1 MEMANJANG Pemasangan infus RL, RS PKU

000102383 DESA AMOX TAB 1X500 MG
1 SITI MURINA 25 TH 5612 TEMPURAN 085293868818 DAN KETUBAN SWAB ANTIGEN COVID 12/03/2022 MUHAMMADIYYAH Rp 125,000
PECAH DINI BLORA
19

KALA 1 MEMANJANG Pemasangan infus RL,

2 LINDA TAKHYANI 29 TH 000300607 DK. NGAWEN 082123513626 DAN KETUBAN AMOX TAB 1X500 MG 28/03/2022 RS PERMATA BLORA Rp 125,000
2099 PECAH DINI SWAB ANTIGEN COVID
19
Pemasangan infus RL,
000057967 AMOX TAB 1X500 MG
3 KRISTINA 31 TH 4709 BELIK - PARTUS MACET 09/03/2022 RS PERMATA BLORA Rp 125,000
SWAB ANTIGEN COVID
19
JUMLAH Rp 375,000

Blora, 11 APRIL 2022

MENGETAHUI,
Plt. KEPALA UPTD PUSKESMAS MEDANG
ANALIS KESEHATAN

Teguh Prasetyandaru S.KM

NIP. 19650418 198812 1 001
 REKAPITULASI PELAYANAN
KB IMPLANT PUSKESMAS BANJAREJO
BULAN JUNI TAHUN 2022

NO NAMA PESERTA No. KARTU ALAMAT NO.HP TANGGAL JENIS JUMLAH (Rp)
USIA PESERTA PELAYANAN PELAYANAN

1 SRI WAHYUNI 50 TH 0000580887213 DK. KEDUNG - 22/06/2022 KB IMPLANT Rp 100,000

JUMLAH Rp 100,000

Banjarejo, 30 JUNI 2022

MENGETAHUI,
KEPALA UPTD PUSKESMAS BANJAREJO

SUTRISNO, S,Kep.Ners
NIP. 197301231994031002