Format Perhitungan Remunerasi Berupa Insentif dan Gaji Jasa Pelayanan Yang Bersumber dari Dana Kapitasi, Non

Kapitasi dan Tarif Umum Serta Sumber Sah Lainnya

NAMA PUSKESMAS
BESARAN KAPITASI

JABATAN/RANGKAP TUGAS POIN VARIABEL KETIDAK HADIRAN POIN VARIABEL RESIKO JASA PELAYANAN NO

DARURATAN
PENERIMAAN

KEGAWAT
JML POIN
POIN MASA JML HARI JML HARI POIN PER JML
JUMLAH KETIDAKHADIR TOTAL POIN JASA
NO NAMA PEGAWAI KERJA POIN TENAGA JUMLAH KERJA KETIDAKHADIRAN HARI (i/j) (k x l) HUKUM/ JUMLAH PEGAWAI PELAYANAN JASA
Ka.Puskes Bendahara Kepala TU/PJ. PJ AN (i-m) PENYAKIT KEUANGAN (o + p)
KAPITASI RUJUKAN
Penatausahaa Upaya/Koordinator
n Keuangan Kegiatan
a b c d e f g h i j k l m n o p q r s t u
1
2
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
0
JASA PELAYANAN NON KAPITASI JASA PELAYANAN TARIF UMUM
PENERIMAAN
IURAN
JASA TOTAL REMONERASI YANG DI
JASA PEL PELAYANAN JASA JASA PEL RAWAT PENERIMAAN GAJI REMONERISASI KEPESERTAAN PAJAK TERIMA
PERSALINAN PERSALINAN JASA (1%)
RAWAT INAP NON KAP RUJUKAN INAP
PELAYANAN
UMUM
v w x y z aa ab ac ad ae af ag
Format Perhitungan Remunerasi Berupa Insentif dan Gaji Jasa Pelayanan Yang Ber
PUSKESMAS LANGKAPLANCAR
JUMLAH PESERTA
BESARAN KAPITASI 70000000
ALOKASI JASA PELAYANAN SESUAI KEPUTUSAN 42000000
JABATAN/RANGKAP TUGAS

POIN MASA
NO NAMA PEGAWAI POIN TENAGA
KERJA Ka.Puskes

a b c d e
1 Yana Taryana, S.Kep.,Ners. 25 100 200
2 Dudung Sutiandi, S.Kep.Ners 25 100
4 Iis Istikomah, Amd.Keb 25 60
5 Nunung Nurfauziah, AMKG 25 60
6 Miftah Fahmi, S.Kep.Ners 10 100
7 Andi Susana Hendayana, S.Kep.Ners 15 100
8 drg. Henang Agniya 5 150
9 Kusmiati 10 100
10 dr. Fiqri Fahrurozia Rizky 2 150
11 Firrizqi Adam, Apt 2 100
12 Anna Rostiana, Am.Keb 15 60
13 Evi Kustianti, Am.Keb 10 60
14 Wida Koesdiawaty, Am.Keb 10 60
15 Iin Mugiarti, Am.Keb 10 60
16 Yeni Maryani, Amd. Kep 5 60
17 Aat Ayanti, Am.Keb 5 60
18 Eulis Puspitasari, Amd.Keb 5 60
19 Neng Ani Mulyani, Amd.Keb 5 60
20 Ridwan Firmansyah,AMd.Farm 2 60
21 Rendri Soleh Makmur, Amd.Kep 2 60
22 Kunti Widyastuti,AMd.Gz 2 60
23 dr. Eris Abdul Ajiz 2 150
24 Venny Nur'aeni, Amd.Keb 2 60
25 Widi Purwanti, A.Md.Kep. 2 60
26 Dini Puspita, Amd.Keb. 2 60
27 Handri Firmansyah, Amd.Ft 2 60
28 Adik Permana Saputra 2 25
29 Diana Mariana Zenab, AMK 2 60
30 Ahmad Nurul JH 2 60
31 Titin AndrianiI, A.Md.Keb 2 60
32 Fitria Sukma, S.Tr.Kes 2 80
33 Eka Kurniawati, S.K.M 2 80
34 Ria Raisandi, A.Md 2 60
35 Yustina Wahda Nisa, A.Md.Ak. 2 60
36 Atika Deliana Azhari, S.KM 2 80
37 Wina Lestari, A.Md.Gz 2 60
38 Zuraida Bestari, A.Md.Kes 2 60
39 Ajeng Rahayu, A.Md.Keb 2 60
40 Enur Nurul Wulan, AM.Keb 2 60
41 Clintomi, S.K.M 2 80
42 Deni Tri Hartanto,Apt 2 100
43 Febriana, A.Md. Kep 2 60
44 Dudi Maulana Yusuf, A.Md. Kep. 2 60
45 Aprilia Nurhayati, Amd.Keb 2 60
46 Nena Nurhayati, S.Kep,Ners 2 100
47 Iqbal Mohammad Awliya, AMKL 2 60
48 dr. Bhakti fadzilah Nugraha 2 150
49 Chaerul, A.Md.KL 2 60
50 Jemasih Suryaningsih,Am.Keb 2 60
51 Aleh Hermawan 15 25
52 Romi Nugraha, AMK 15 60
53 Erika Sari, AMK 15 60
54 Risna Anggraeni, S.Kep 15 80
55 Ade Leni Suherti, S.Kep.Ners 10 100
56 Atik Kurniasih. Am.Keb 10 60
57 Farid Nawawi 10 25
58 Eneng Dian Nugrahani, Am.Keb 10 60
59 Apipudin 5 25
60 Yuyun Yuniar, S.Kep.Ners 5 100
61 Erni Sri Widaningsih, Am. Keb 5 60
62 Jumiyati, Am. Keb 5 60
63 Rizki Gusti Andani, S.Tr.A.K 5 80
64 Santi Sulastri, S.Tr. Keb 5 80
65 Cita Nur, Am. Keb 5 60
66 Rena Ratnasari, SE 2 50
67 Pipin Pakualam 2 25
68 Fida Fauziyyah Ilhami, Amd.Keb 2 60
69 Taufik Ramdani, Amd.RMIK 2 60
70 Aris Prima Yoga 2 25
71 Asep Septian Azwan Ma'ruf, S.Kep 2 80
72 Iman Abdulrahman 2 25
73 Roni Nugraha Permana 2 25
74 Dendi Darussaleh 2 25
75 Nita Arianti 2 25
76 Hera Sova Wahyuni, A.Md.Ak 2 60
77 Ade Nurliawati 2 25
78 Ali Mahfud Rosadi 2 25
79 Saepul Nurajiz 2 25
80 Ratna Yuliani Solihah, Amd.KG 2 60
81 Marwan Ependi 2 20
82 Dodi Supriadi 2 25
83 Rika Mudrikah Ramdan, S.Fam 2 80
84 Yalis Agustiana,S.Kep.,Ners 2 100
85 Reni Trisnawati Dewi 2 25
86 Hanna Gresiyana,S.Kep,Ners 2 100
87 Agung Purnama Muhaemin, S.Kep,Ners 2 100
88 Eneng Risa Apriliani, A.Md.Keb 2 60
89 Itasari 2 60
90 Delsi Sri Wahyuni,S.Tr.Keb 2 80
91 Maulida Zaqiah 2 25
92 Ismal Wafa Asfihani 2 25
93 Yusman Nurjaman 2 25
94 Sofi Damayanti,Amd.Keb 2 60
95 Rida Nurhajah Drajat, S.Pd 2 50
96 Asep Anwar Nasihin 2 25
97 Ajeng Sri Agustin,Amd.Kes 2 60
98 Yuliani Rahman,Amd.KG 2 60
99 Deni, S.Kep.,Ners 2 100
asa Pelayanan Yang Bersumber dari Dana Kapitasi, Non Kapitasi dan Tarif Umum Serta Sum

JABATAN/RANGKAP TUGAS POIN VARIABEL KETIDAK HADIRAN

JML HARI JML HARI POIN PER

JUMLAH KERJA KETIDAKHADIRAN HARI (i/j)
Bendahara Kepala TU/PJ. PJ
Penatausahaa Upaya/Koordinator
n Keuangan Kegiatan
f g h i j k l
325 25 0 13
125 25 0 5
30 115 25 0 4.6
85 25 0 3.4
100 210 25 0 8.4
115 25 0 4.6
155 25 0 6.2
110 25 0 4.4
152 25 0 6.08
50 152 25 0 6.08
75 25 0 3
70 25 0 2.8
70 25 0 2.8
70 25 0 2.8
65 25 0 2.6
65 25 0 2.6
65 25 0 2.6
65 25 0 2.6
50 112 25 0 4.48
62 25 0 2.48
62 25 0 2.48
30 182 25 0 7.28
30 92 25 0 3.68
62 25 0 2.48
30 92 25 0 3.68
30 92 25 0 3.68
27 25 0 1.08
62 25 0 2.48
62 25 0 2.48
62 25 0 2.48
82 25 0 3.28
82 25 0 3.28
62 25 0 2.48
62 25 0 2.48
82 25 0 3.28
62 25 0 2.48
62 25 0 2.48
62 25 0 2.48
 62 25 0 2.48
82 25 0 3.28
102 25 0 4.08
62 25 0 2.48
62 25 0 2.48
62 25 0 2.48
102 25 0 4.08
62 25 0 2.48
152 25 0 6.08
62 25 0 2.48
62 25 0 2.48
40 25 0 1.6
75 25 0 3
75 25 0 3
95 25 0 3.8
110 25 0 4.4
70 25 0 2.8
35 25 0 1.4
70 25 0 2.8
30 25 0 1.2
105 25 0 4.2
65 25 0 2.6
65 25 0 2.6
85 25 0 3.4
85 25 0 3.4
65 25 0 2.6
52 25 0 2.08
27 25 0 1.08
62 25 0 2.48
62 25 0 2.48
27 25 0 1.08
82 25 0 3.28
27 25 0 1.08
27 25 0 1.08
50 77 25 0 3.08
27 25 0 1.08
62 25 0 2.48
27 25 0 1.08
27 25 0 1.08
27 25 0 1.08
62 25 0 2.48
22 25 0 0.88
27 25 0 1.08
82 25 0 3.28
102 25 0 4.08
27 25 0 1.08
102 25 0 4.08
102 25 0 4.08
62 25 0 2.48
62 25 0 2.48
 82 25 0 3.28
27 25 0 1.08
27 25 0 1.08
27 25 0 1.08
62 25 0 2.48
52 25 0 2.08
27 25 0 1.08
62 25 0 2.48
62 25 0 2.48
102 25 0 4.08
arif Umum Serta Sumber Sah Lainnya

EL KETIDAK HADIRAN POIN VARIABEL RESIKO

DARURATAN
PENERIMAAN

KEGAWAT
JML POIN
JML TOTAL POIN JASA
JUMLAH KETIDAKHADIR
(k x l) PENYAKIT HUKUM/ JUMLAH PEGAWAI PELAYANAN
AN (i-m) KEUANGAN (o + p)
KAPITASI

m n o p q r s t
0 325 10 40 50 0 375 1,159,026
0 125 30 30 60 30 215 664,508
0 115 10 40 50 0 165 509,971
0 85 40 20 60 30 175 540,879
0 210 10 40 50 0 260 803,591
0 115 40 30 70 30 215 664,508
0 155 40 10 50 30 235 726,323
0 110 30 30 60 30 200 618,147
0 152 20 20 40 0 192 593,421
0 152 10 40 50 30 232 717,051
0 75 30 10 40 30 145 448,157
0 70 30 10 40 30 140 432,703
0 70 30 10 40 30 140 432,703
0 70 30 10 40 30 140 432,703
0 65 30 10 40 30 135 417,249
0 65 30 10 40 30 135 417,249
0 65 30 10 40 30 135 417,249
0 65 30 10 40 30 135 417,249
0 112 20 10 30 30 172 531,606
0 62 20 10 30 30 122 377,070
0 62 20 10 30 30 122 377,070
0 182 40 10 50 40 272 840,680
0 92 10 40 50 0 142 438,884
0 62 10 40 50 0 112 346,162
0 92 10 40 50 0 142 438,884
0 92 10 40 50 0 142 438,884
0 27 10 10 20 20 67 207,079
0 62 20 10 30 30 122 377,070
0 62 40 10 50 30 142 438,884
0 62 30 10 40 30 132 407,977
0 82 30 10 40 40 162 500,699
0 82 20 10 30 20 132 407,977
0 62 30 10 40 40 142 438,884
0 62 30 10 40 40 142 438,884
0 82 20 10 30 20 132 407,977
0 62 20 10 30 30 122 377,070
0 62 30 10 40 20 122 377,070
0 62 30 10 40 40 142 438,884
0 62 30 10 40 30 132 407,977
0 82 20 10 30 20 132 407,977
0 102 20 20 40 30 172 531,606
0 62 40 30 70 30 162 500,699
0 62 40 10 50 30 142 438,884
0 62 30 10 40 40 142 438,884
0 102 40 10 50 20 172 531,606
0 62 20 10 30 20 112 346,162
0 152 40 30 70 40 262 809,773
0 62 20 10 30 20 112 346,162
0 62 30 10 40 40 142 438,884
0 40 20 10 30 20 90 278,166
0 75 20 10 30 30 135 417,249
0 75 40 20 60 40 175 540,879
0 95 40 20 60 40 195 602,693
0 110 30 20 50 30 190 587,240
0 70 30 10 40 40 150 463,610
0 35 20 10 30 30 95 293,620
0 70 30 10 40 40 150 463,610
0 30 20 10 30 10 70 216,351
0 105 40 20 60 40 205 633,601
0 65 30 10 40 40 145 448,157
0 65 30 10 40 40 145 448,157
0 85 10 30 40 20 145 448,157
0 85 30 10 40 40 165 509,971
0 65 10 10 20 20 105 324,527
0 52 10 10 20 20 92 284,348
0 27 20 10 30 30 87 268,894
0 62 30 10 40 40 142 438,884
0 62 10 10 20 10 92 284,348
0 27 20 10 30 10 67 207,079
0 82 40 20 60 40 182 562,514
0 27 20 10 30 10 67 207,079
0 27 20 10 30 10 67 207,079
0 77 20 40 60 10 147 454,338
0 27 10 10 20 10 57 176,172
0 62 10 20 30 20 112 346,162
0 27 10 10 20 0 47 145,265
0 27 20 10 30 10 67 207,079
0 27 10 10 20 10 57 176,172
0 62 10 10 20 0 82 253,440
0 22 20 10 30 10 62 191,626
0 27 20 10 30 10 67 207,079
0 82 20 10 30 10 122 377,070
0 102 40 20 60 40 202 624,329
0 27 10 10 20 10 57 176,172
0 102 40 20 60 40 202 624,329
0 102 40 20 60 40 202 624,329
0 62 10 10 20 20 102 315,255
0 62 20 10 30 30 122 377,070
0 82 30 10 40 40 162 500,699
0 27 10 10 20 10 57 176,172
0 27 10 20 30 10 67 207,079
0 27 10 10 20 10 57 176,172
0 62 30 10 40 40 142 438,884
0 52 10 10 20 20 92 284,348
0 27 10 10 20 10 57 176,172
0 62 20 10 30 30 122 377,070
0 62 30 10 40 30 132 407,977
0 102 40 20 60 40 202 624,329
13589

42,000,000
 JASA PELAYANAN NON KAPITASI JASA PELAYANAN TARIF UMUM
PENERIMAAN
JASA
JASA JASA PEL PELAYANAN JASA
PERSALINAN PERSALINAN
RUJUKAN RAWAT INAP NON KAP RUJUKAN

u v w x y z
18,616 1,061,200 764,400 1,844,216
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 758,000 546,000 1,322,616
18,616 35,905 248,182 302,703
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 630,000 16,900 665,516
18,616 35,905 16,900 71,421
18,616 350,000 16,900 385,516
18,616 700,000 16,900 735,516
18,616 35,905 248,182 302,703
18,616 35,905 16,900 71,421
18,616 2,100,000 16,900 2,135,516
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 758,000 819,000 1,595,616
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 248,182 302,703
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
 18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
103,550 35,905 248,182 387,637
18,616 35,905 248,182 302,703
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 758,000 819,000 1,595,616
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
103,550 35,905 16,900 156,355
103,550 35,905 16,900 156,355
103,550 35,905 248,182 387,637
18,616 93,333 16,900 128,849
414,200 35,905 16,900 467,005
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
414,200 35,905 16,900 467,005
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
103,550 35,905 16,900 156,355
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
103,550 35,905 248,182 387,637
18,616 35,905 16,900 71,421
103,550 35,905 248,182 387,637
18,616 35,905 248,182 302,703
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
 18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
103,550 35,905 248,182 387,637
YANAN TARIF UMUM
IURAN
TOTAL
JASA PEL RAWAT PENERIMAAN GAJI KEPESERTAAN PAJAK
REMONERISASI
INAP JASA (1%)
PELAYANAN
UMUM
aa ab ac ad ae af
0 1,997,203 5,000,444 50,004
0 735,929 7,359
0 998,601 1,637,422 16,374
0 612,300 6,123
0 1,797,482 3,923,689 39,237
0 967,211 9,672
0 797,744 7,977
0 689,568 6,896
0 664,842 6,648
0 998,601 1,787,073 17,871
0 1,113,672 11,137
0 504,124 5,041
0 818,219 8,182
0 1,168,219 11,682
0 719,952 7,200
0 488,670 4,887
0 2,552,765 25,528
0 546,098 5,461
0 998,601 1,601,629 16,016
0 998,601 1,447,092 14,471
0 448,491 4,485
0 998,601 3,434,897 34,349
0 998,601 1,508,907 15,089
0 417,583 4,176
0 998,601 1,508,907 15,089
0 998,601 1,508,907 15,089
0 278,500 2,785
0 448,491 4,485
0 741,587 7,416
0 536,826 5,368
0 572,120 5,721
0 479,398 4,794
0 510,305 5,103
0 510,305 5,103
0 479,398 4,794
0 448,491 4,485
0 448,491 4,485
0 567,733 5,677
0 536,826 5,368
0 479,398 4,794
0 603,027 6,030
0 888,336 8,883
0 741,587 7,416
0 567,733 5,677
0 603,027 6,030
0 417,583 4,176
0 2,405,388 24,054
0 417,583 4,176
0 567,733
0 349,587
0 488,670
0 697,234
0 759,049
0 974,877
0 592,459
0 760,625
0 592,459
0 287,772
0 705,022
0 577,006
0 577,006
0 519,578
0 638,820
0 395,948
0 355,769
0 735,899
0 567,733
0 355,769
0 278,500
0 718,869
0 278,500
0 278,500
0 525,759
0 247,593
0 417,583
0 216,686
0 278,500
0 247,593
0 324,861
0 263,047
0 278,500
0 448,491
0 1,011,966
0 247,593
0 1,011,966
0 927,031
0 386,676
0 448,491
0 629,548
0 247,593
0 278,500
0 247,593
0 567,733
0 355,769
0 247,593
0 448,491
0 479,398
0 1,011,966
REMONERASI YANG DI
TERIMA

ag
6043632.883222
1334024.061149
2096424.76094
1099121.164841
4646966.806338
1565305.879331
1451475.509303
1245935.475034
1198954.895772
2432459.04208
1517038.729453
893581.1305721
1207675.867414
1557675.867414
1095500.086715
864218.2685337
2928313.005376
921646.3387091
1962653.249464
1786476.077234
787874.8272336
4191556.67523
1903927.525388
729149.1031567
1903927.525388
1903927.525388
464883.3448105
787874.8272336
1136608.093569
904028.621486
1022777.723541
846600.5513106
905326.2753875
905326.2753875
846600.5513106
787874.8272336
787874.8272336
962754.345563
 904028.621486
846600.5513106
1081503.447618
1338993.811386
1136608.093569
962754.345563
1081503.447618
729149.1031567
3134229.701153
729149.1031567
71,572,492.77 858,869,913.25

858869913.24917

864000000
544320000

544320000
962754.345562961
599952.510187434
864218.268533664
1184055.43450435
1301506.88265823
1503425.83880157
1009734.92482451
1024899.64188883
1009734.92482451
482501.062033554
1275298.33707225
980372.062786043
980372.062786043
922943.992610605
1097823.51093992
688041.096302844
611697.655002822
977919.062627273
962754.345562961
611697.655002822
464883.344810472
1225163.4413582
464883.344810472
464883.344810472
934689.137425993
406157.620733532
729149.103156702
347431.896656592
464883.344810472
406157.620733532
552971.930925882
435520.482772002
464883.344810472
787874.827233642
1573896.7076939
406157.620733532
1573896.7076939
1488962.43803098
670423.379079762
787874.827233642
1080205.79371684
406157.620733532
464883.344810472
406157.620733532
962754.345562961
611697.655002822
406157.620733532
787874.827233642
846600.551310582
1573896.7076939
41,248,834.17 494,986,010.01
494986010

1,353,855,923.25

63.44

319680000
Format Perhitungan Remunerasi Berupa Insentif dan Gaji Jasa Pelayanan Yang Ber
PUSKESMAS LANGKAPLANCAR
JUMLAH PESERTA
BESARAN KAPITASI 132808225
ALOKASI JASA PELAYANAN SESUAI KEPUTUSAN 79684935
JABATAN/RANGKAP TUGAS

POIN MASA
NO NAMA PEGAWAI POIN TENAGA
KERJA Ka.Puskes

a b c d e
1 Yana Taryana, S.Kep.,Ners. 25 100 200
2 Dudung Sutiandi, S.Kep.Ners 25 100
4 Iis Istikomah, Amd.Keb 25 60
5 Nunung Nurfauziah, AMKG 25 60
6 Miftah Fahmi, S.Kep.Ners 10 100
7 Andi Susana Hendayana, S.Kep.Ners 15 100
8 drg. Henang Agniya 5 150
9 Kusmiati 10 100
10 dr. Fiqri Fahrurozia Rizky 2 150
11 Firrizqi Adam, Apt 2 100
12 Anna Rostiana, Am.Keb 15 60
13 Evi Kustianti, Am.Keb 10 60
14 Wida Koesdiawaty, Am.Keb 10 60
15 Iin Mugiarti, Am.Keb 10 60
16 Yeni Maryani, Amd. Kep 5 60
17 Aat Ayanti, Am.Keb 5 60
18 Eulis Puspitasari, Amd.Keb 5 60
19 Neng Ani Mulyani, Amd.Keb 5 60
20 Ridwan Firmansyah,AMd.Farm 2 60
21 Rendri Soleh Makmur, Amd.Kep 2 60
22 Kunti Widyastuti,AMd.Gz 2 60
23 dr. Eris Abdul Ajiz 2 150
24 Venny Nur'aeni, Amd.Keb 2 60
25 Widi Purwanti, A.Md.Kep. 2 60
26 Dini Puspita, Amd.Keb. 2 60
27 Handri Firmansyah, Amd.Ft 2 60
28 Adik Permana Saputra 2 25
29 Diana Mariana Zenab, AMK 2 60
30 Ahmad Nurul JH 2 60
31 Titin AndrianiI, A.Md.Keb 2 60
32 Fitria Sukma, S.Tr.Kes 2 80
33 Eka Kurniawati, S.K.M 2 80
34 Ria Raisandi, A.Md 2 60
35 Yustina Wahda Nisa, A.Md.Ak. 2 60
36 Atika Deliana Azhari, S.KM 2 80
37 Wina Lestari, A.Md.Gz 2 60
38 Zuraida Bestari, A.Md.Kes 2 60
39 Ajeng Rahayu, A.Md.Keb 2 60
40 Enur Nurul Wulan, AM.Keb 2 60
41 Clintomi, S.K.M 2 80
42 Deni Tri Hartanto,Apt 2 100
43 Febriana, A.Md. Kep 2 60
44 Dudi Maulana Yusuf, A.Md. Kep. 2 60
45 Aprilia Nurhayati, Amd.Keb 2 60
46 Nena Nurhayati, S.Kep,Ners 2 100
47 Iqbal Mohammad Awliya, AMKL 2 60
48 dr. Bhakti fadzilah Nugraha 2 150
49 Chaerul, A.Md.KL 2 60
50 Jemasih Suryaningsih,Am.Keb 2 60
51 Aleh Hermawan 15 25
52 Romi Nugraha, AMK 15 60
53 Erika Sari, AMK 15 60
54 Risna Anggraeni, S.Kep 15 80
55 Ade Leni Suherti, S.Kep.Ners 10 100
56 Atik Kurniasih. Am.Keb 10 60
57 Farid Nawawi 10 25
58 Eneng Dian Nugrahani, Am.Keb 10 60
59 Apipudin 5 25
60 Yuyun Yuniar, S.Kep.Ners 5 100
61 Erni Sri Widaningsih, Am. Keb 5 60
62 Jumiyati, Am. Keb 5 60
63 Rizki Gusti Andani, S.Tr.A.K 5 80
64 Santi Sulastri, S.Tr. Keb 5 80
65 Cita Nur, Am. Keb 5 60
66 Rena Ratnasari, SE 2 60
67 Pipin Pakualam 2 25
68 Fida Fauziyyah Ilhami, Amd.Keb 2 60
69 Taufik Ramdani, Amd.RMIK 2 60
70 Aris Prima Yoga 2 25
71 Asep Septian Azwan Ma'ruf, S.Kep 2 80
72 Iman Abdulrahman 2 25
73 Roni Nugraha Permana 2 25
74 Dendi Darussaleh 2 25
75 Nita Arianti 2 25
76 Hera Sova Wahyuni, A.Md.Ak 2 60
77 Ade Nurliawati 2 25
78 Ali Mahfud Rosadi 2 25
79 Saepul Nurajiz 2 25
80 Ratna Yuliani Solihah, Amd.KG 2 60
81 Marwan Ependi 2 20
82 Dodi Supriadi 2 25
83 Rika Mudrikah Ramdan, S.Fam 2 80
84 Yalis Agustiana,S.Kep.,Ners 2 100
85 Reni Trisnawati Dewi 2 25
86 Hanna Gresiyana,S.Kep,Ners 2 100
87 Agung Purnama Muhaemin, S.Kep,Ners 2 100
88 Eneng Risa Apriliani, A.Md.Keb 2 60
89 Itasari 2 60
90 Delsi Sri Wahyuni,S.Tr.Keb 2 80
91 Maulida Zaqiah 2 25
92 Ismal Wafa Asfihani 2 25
93 Yusman Nurjaman 2 25
94 Sofi Damayanti,Amd.Keb 2 60
95 Rida Nurhajah Drajat, S.Pd 2 50
96 Asep Anwar Nasihin 2 25
97 Ajeng Sri Agustin,Amd.Kes 2 60
98 Yuliani Rahman,Amd.KG 2 60
99 Deni, S.Kep.,Ners 2 100
asa Pelayanan Yang Bersumber dari Dana Kapitasi, Non Kapitasi dan Tarif Umum Serta Sum

JABATAN/RANGKAP TUGAS POIN VARIABEL KETIDAK HADIRAN

POIN PER
JML HARI JML HARI
Bendahara JUMLAH KERJA KETIDAKHADIRAN
HARI
Kapitasi Kepala TU/PJ. PJ (D/F)
Penatausahaa Upaya/Koordinator
n Keuangan Kegiatan
f g h i j k l
325 25 0 13
125 25 0 5
50 135 25 0 5.4
85 25 0 3.4
100 210 25 0 8.4
115 25 0 4.6
155 25 0 6.2
110 25 0 4.4
152 25 0 6.08
50 152 25 0 6.08
75 25 0 3
70 25 0 2.8
70 25 0 2.8
70 25 0 2.8
65 25 0 2.6
65 25 0 2.6
65 25 0 2.6
65 25 0 2.6
50 112 25 0 4.48
50 112 25 0 4.48
62 25 0 2.48
50 202 25 0 8.08
50 112 25 0 4.48
10 72 25 0 2.88
50 112 25 0 4.48
50 112 25 0 4.48
27 25 0 1.08
10 72 25 0 2.88
62 25 0 2.48
10 72 25 0 2.88
82 25 0 3.28
82 25 0 3.28
62 25 0 2.48
62 25 0 2.48
82 25 0 3.28
62 25 0 2.48
62 25 0 2.48
62 25 0 2.48
 62 25 0 2.48
82 25 0 3.28
102 25 0 4.08
62 25 0 2.48
62 25 0 2.48
62 25 0 2.48
10 112 25 0 4.48
62 25 0 2.48
152 25 0 6.08
62 25 0 2.48
10 72 25 0 2.88
40 25 0 1.6
10 85 25 0 3.4
75 25 0 3
95 25 0 3.8
110 25 0 4.4
70 25 0 2.8
35 25 0 1.4
70 25 0 2.8
30 25 0 1.2
105 25 0 4.2
65 25 0 2.6
65 25 0 2.6
85 25 0 3.4
85 25 0 3.4
65 25 0 2.6
62 25 0 2.48
27 25 0 1.08
62 25 0 2.48
40 102 25 0 4.08
27 25 0 1.08
82 25 0 3.28
27 25 0 1.08
27 25 0 1.08
50 77 25 0 3.08
27 25 0 1.08
62 25 0 2.48
27 25 0 1.08
27 25 0 1.08
27 25 0 1.08
62 25 0 2.48
22 25 0 0.88
27 25 0 1.08
82 25 0 3.28
102 25 0 4.08
27 25 0 1.08
102 25 0 4.08
102 25 0 4.08
62 25 0 2.48
62 25 0 2.48
 82 25 0 3.28
27 25 0 1.08
50 77 25 0 3.08
27 25 0 1.08
62 25 0 2.48
52 25 0 2.08
27 25 0 1.08
62 25 0 2.48
62 25 0 2.48
102 25 0 4.08
arif Umum Serta Sumber Sah Lainnya

EL KETIDAK HADIRAN POIN VARIABEL RESIKO

DARURATAN
PENERIMAAN

KEGAWAT
JML POIN
JML TOTAL POIN JASA
JUMLAH KETIDAKHADIR
(ixj) PENYAKIT HUKUM/ JUMLAH PEGAWAI PELAYANAN
AN ( g - k ) KEUANGAN ( m + n )
KAPITASI

m n o p q r s t
0 325 10 40 50 0 375 2,146,839
0 125 30 30 60 30 215 1,230,854
0 135 10 40 50 0 185 1,059,107
0 85 40 20 60 30 175 1,001,858
0 210 10 40 50 0 260 1,488,475
0 115 40 30 70 30 215 1,230,854
0 155 40 10 50 30 235 1,345,352
0 110 30 30 60 30 200 1,144,981
0 152 20 20 40 0 192 1,099,182
0 152 10 40 50 30 232 1,328,178
0 75 30 10 40 30 145 830,111
0 70 30 10 40 30 140 801,487
0 70 30 10 40 30 140 801,487
0 70 30 10 40 30 140 801,487
0 65 30 10 40 30 135 772,862
0 65 30 10 40 30 135 772,862
0 65 30 10 40 30 135 772,862
0 65 30 10 40 30 135 772,862
0 112 10 40 50 30 192 1,099,182
0 112 20 10 30 30 172 984,683
0 62 20 10 30 30 122 698,438
0 202 40 10 50 40 292 1,671,672
0 112 10 40 50 0 162 927,434
0 72 40 10 50 0 122 698,438
0 112 10 40 50 0 162 927,434
0 112 10 40 50 0 162 927,434
0 27 10 10 20 20 67 383,569
0 72 20 10 30 30 132 755,687
0 62 40 10 50 30 142 812,936
0 72 30 10 40 30 142 812,936
0 82 30 10 40 40 162 927,434
0 82 20 10 30 20 132 755,687
0 62 30 10 40 40 142 812,936
0 62 30 10 40 40 142 812,936
0 82 20 10 30 20 132 755,687
0 62 20 10 30 30 122 698,438
0 62 30 10 40 20 122 698,438
0 62 30 10 40 40 142 812,936
0 62 30 10 40 30 132 755,687
0 82 20 10 30 20 132 755,687
0 102 20 20 40 30 172 984,683
0 62 40 30 70 30 162 927,434
0 62 40 10 50 30 142 812,936
0 62 30 10 40 40 142 812,936
0 112 40 10 50 20 182 1,041,932
0 62 20 10 30 20 112 641,189
0 152 40 30 70 40 262 1,499,925
0 62 20 10 30 20 112 641,189
0 72 30 10 40 40 152 870,185
0 40 20 10 30 20 90 515,241
0 85 20 10 30 30 145 830,111
0 75 40 20 60 40 175 1,001,858
0 95 40 20 60 40 195 1,116,356
0 110 30 20 50 30 190 1,087,732
0 70 30 10 40 40 150 858,736
0 35 20 10 30 30 95 543,866
0 70 30 10 40 40 150 858,736
0 30 20 10 30 10 70 400,743
0 105 40 20 60 40 205 1,173,605
0 65 30 10 40 40 145 830,111
0 65 30 10 40 40 145 830,111
0 85 10 30 40 20 145 830,111
0 85 30 10 40 40 165 944,609
0 65 10 10 20 20 105 601,115
0 62 10 10 20 20 102 583,940
0 27 20 10 30 30 87 498,067
0 62 30 10 40 40 142 812,936
0 102 10 10 20 10 132 755,687
0 27 20 10 30 10 67 383,569
0 82 40 20 60 40 182 1,041,932
0 27 20 10 30 10 67 383,569
0 27 20 10 30 10 67 383,569
0 77 20 40 60 10 147 841,561
0 27 10 10 20 10 57 326,320
0 62 10 20 30 20 112 641,189
0 27 10 10 20 0 47 269,070
0 27 20 10 30 10 67 383,569
0 27 10 10 20 10 57 326,320
0 62 10 10 20 0 82 469,442
0 22 20 10 30 10 62 354,944
0 27 20 10 30 10 67 383,569
0 82 20 10 30 10 122 698,438
0 102 40 20 60 40 202 1,156,431
0 27 10 10 20 10 57 326,320
0 102 40 20 60 40 202 1,156,431
0 102 40 20 60 40 202 1,156,431
0 62 10 10 20 20 102 583,940
0 62 20 10 30 30 122 698,438
0 82 30 10 40 40 162 927,434
0 27 10 10 20 10 57 326,320
0 77 10 20 30 10 117 669,814
0 27 10 10 20 10 57 326,320
0 62 30 10 40 40 142 812,936
0 52 10 10 20 20 92 526,691
0 27 10 10 20 10 57 326,320
0 62 20 10 30 30 122 698,438
0 62 30 10 40 30 132 755,687
0 102 40 20 60 40 202 1,156,431
13919
 JASA PELAYANAN NON KAPITASI JASA PELAYANAN TARIF UMUM
PENERIMAAN
JASA
JASA JASA PEL PELAYANAN JASA
PERSALINAN PERSALINAN
RUJUKAN RAWAT INAP NON KAP RUJUKAN

u v w x y z
18,616 1,061,200 764,400 1,844,216
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 758,000 546,000 1,322,616
18,616 35,905 248,182 302,703
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 630,000 16,900 665,516
18,616 35,905 16,900 71,421
18,616 350,000 16,900 385,516
18,616 700,000 16,900 735,516
18,616 35,905 248,182 302,703
18,616 35,905 16,900 71,421
18,616 2,100,000 16,900 2,135,516
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 758,000 819,000 1,595,616
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 248,182 302,703
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
 18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
103,550 35,905 248,182 387,637
18,616 35,905 248,182 302,703
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 758,000 819,000 1,595,616
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
103,550 35,905 16,900 156,355
103,550 35,905 16,900 156,355
103,550 35,905 248,182 387,637
18,616 93,333 16,900 128,849
414,200 35,905 16,900 467,005
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
414,200 35,905 16,900 467,005
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
103,550 35,905 16,900 156,355
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
103,550 35,905 248,182 387,637
18,616 35,905 16,900 71,421
103,550 35,905 248,182 387,637
18,616 35,905 248,182 302,703
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
 18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 93,333 16,900 128,849
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
18,616 35,905 16,900 71,421
103,550 35,905 248,182 387,637
YANAN TARIF UMUM
IURAN
TOTAL
JASA PEL RAWAT PENERIMAAN GAJI KEPESERTAAN PAJAK
REMONERISASI
INAP JASA (1%)
PELAYANAN
UMUM
aa ab ac ad ae af
0 1,997,203 5,988,257 59,883
0 1,302,275 13,023
0 998,601 2,186,558 21,866
0 1,073,279 10,733
0 1,797,482 4,608,573 46,086
0 1,533,557 15,336
0 1,416,773 14,168
0 1,216,402 12,164
0 1,170,603 11,706
0 998,601 2,398,200 23,982
0 1,495,627 14,956
0 872,908 8,729
0 1,187,002 11,870
0 1,537,002 15,370
0 1,075,565 10,756
0 844,283 8,443
0 2,908,378 29,084
0 901,711 9,017
0 998,601 2,169,204 21,692
0 998,601 2,054,706 20,547
0 769,859 7,699
0 998,601 4,265,889 42,659
0 998,601 1,997,457 19,975
0 769,859 7,699
0 998,601 1,997,457 19,975
0 998,601 1,997,457 19,975
0 454,990 4,550
0 827,108 8,271
0 1,115,639 11,156
0 941,785 9,418
0 998,855 9,989
0 827,108 8,271
0 884,357 8,844
0 884,357 8,844
0 827,108 8,271
0 769,859 7,699
0 769,859 7,699
0 941,785 9,418
0 884,536 8,845
0 827,108 8,271
0 1,056,104 10,561
0 1,315,071 13,151
0 1,115,639 11,156
0 941,785 9,418
0 1,113,353 11,134
0 712,610 7,126
0 3,095,541 30,955
0 712,610 7,126
0 999,034
0 586,662
0 901,532
0 1,158,213
0 1,272,711
0 1,475,369
0 987,585
0 1,010,871
0 987,585
0 472,164
0 1,245,026
0 958,960
0 958,960
0 901,532
0 1,073,458
0 672,536
0 655,361
0 965,072
0 941,785
0 827,108
0 454,990
0 1,198,288
0 454,990
0 454,990
0 912,982
0 397,741
0 712,610
0 340,491
0 454,990
0 397,741
0 540,863
0 426,365
0 454,990
0 769,859
0 1,544,068
0 397,741
0 1,544,068
0 1,459,133
0 655,361
0 769,859
0 1,056,283
0 397,741
0 741,235
0 397,741
0 941,785
0 598,112
0 397,741
0 769,859
0 827,108
0 1,544,068
REMONERASI SETELAH
PAJAK

ag
6043632.883222
1334024.061149
2096424.76094
1099121.164841
4646966.806338
1565305.879331
1451475.509303
1245935.475034
1198954.895772
2432459.04208
1517038.729453
893581.1305721
1207675.867414
1557675.867414
1095500.086715
864218.2685337
2928313.005376
921646.3387091
1962653.249464
1786476.077234
787874.8272336
4191556.67523
1903927.525388
729149.1031567
1903927.525388
1903927.525388
464883.3448105
787874.8272336
1136608.093569
904028.621486
1022777.723541
846600.5513106
905326.2753875
905326.2753875
846600.5513106
787874.8272336
787874.8272336
962754.345563
 904028.621486
846600.5513106
1081503.447618
1338993.811386
1136608.093569
962754.345563
1081503.447618
729149.1031567
3134229.701153
729149.1031567
71,572,492.77 858,869,913.25

858869913.24917

864000000
544320000

544320000
962754.345562961
599952.510187434
864218.268533664
1184055.43450435
1301506.88265823
1503425.83880157
1009734.92482451
1024899.64188883
1009734.92482451
482501.062033554
1275298.33707225
980372.062786043
980372.062786043
922943.992610605
1097823.51093992
688041.096302844
611697.655002822
977919.062627273
962754.345562961
611697.655002822
464883.344810472
1225163.4413582
464883.344810472
464883.344810472
934689.137425993
406157.620733532
729149.103156702
347431.896656592
464883.344810472
406157.620733532
552971.930925882
435520.482772002
464883.344810472
787874.827233642
1573896.7076939
406157.620733532
1573896.7076939
1488962.43803098
670423.379079762
787874.827233642
1080205.79371684
406157.620733532
464883.344810472
406157.620733532
962754.345562961
611697.655002822
406157.620733532
787874.827233642
846600.551310582
1573896.7076939
41,248,834.17 494,986,010.01
494986010

1,353,855,923.25

63.44

319680000
1,997,203 1997202.5 1997202.5
1,797,482.25 1797482.25
998,601.25 998601.25
998,601.25 998601.25
998,601.25 998601.25
998,601.25 998601.25
998,601.25 998601.25
998,601.25 998601.25
998,601.25 998601.25
998,601.25 998601.25
11,783,494.75

11783494.75
rujuka persalinan RITP ritp
5442000 12950000 10920000 65% 7098000 7% 764,400.00
1300000 2210000 35% 3822000 5% 546,000.00
4142000 15160000 10,920,000.00 15% 1,638,000.00
25% 2,730,000.00
13% 1,419,600.00
35% 3,822,000.00
100% 10,920,000.00
 persalinan rujukan
kepala 80% 12128000 7% 1,061,200.00 kapus 40%
ka tu 20% 3032000 5% 758,000.00 k tu 20%
visite 0 10% 1,516,000.00 dr penenggung jawab 20%
perawat RITP 15160000 40% 6,064,000.00 bidan penolong 20%
Tenaga kesehatan lainnya 18% 2,728,800.00 tenaga kesehtan lain
MAMIN 20% 3,032,000.00
100% 12,128,000.00
 rujukan
1656800 40% 1656800 Remunerasi
828400 20% 828400 Supir
828400 20% 828400 pendamping
828400 20% 828400 Operasional
0

4142000 100% 4142000

bbm isa p s o
500000
600000
no nama pasien tarif bidan penolong dokter penanggung jawab kepala
k tu tenaga kesehatan dan lainnya