RENCANA PENDAPATAN DAN BELANJA KAPITASI JKN Formulir

PUSKESMAS NGARGOYOSO RKA-SKPD 1

TAHUN 2014
Urusan Pemerintahan : 1 . 02 . 1 . 02 Urusan Wajib Kesehatan
Organisasi : 1 . 02 . 1 . 02 . 01 Dinas Kesehatan

Rincian Anggaran Pendapatan Satuan Kerja Perangkat Daerah

Kode Rincian Perhitungan Jumlah

Uraian
Rekening Volume Satuan Tarif/Harga (Rp)
1 2 3 4 5 6 (3x5)
Dana Kapitasi JKN
12 bulan 104,238,000 1,250,856,000
FKTP Puskesmas Ngargoyoso

Jumlah 1,250,856,000

Menyetujui: Karanganyar, 02 Januari 2014

Kepala Dinas Kesehatan
Kabupaten Karanganyar Kepala Puskesmas Ngargoyoso

dr. Cucuk Heru Kusumo, M. Kes dr. Retno Sawartuti, M. Kes

NIP. 19600105 198511 1 002 NIP. 19730314 200212 2 003

Keterangan :
Tanggal Pembahasan :
Catatan Hasil
Pembahasan :
1
2

Tim Anggaran Pemerintah Daerah

No Nama NIP Jabatan Tanda tangan
1
2
3
 RENCANA PENDAPATAN DAN BELANJA KAPITASI JKN NOMOR DPA - SKPD Formulir
FASILITAS KESEHATAN TINGKAT PERTAMA PUSKESMAS NGARGOYOSO RKA SKPD 2.2.1
KABUPATEN KARANGANYAR
TAHUN 2015
Urusan Pemerintahan : 1 . 02 . 1 . 02 Urusan Wajib Kesehatan
Organisasi : 1 . 02 . 1 . 02 . 01 Dinas Kesehatan
Program : 1 . 02 . 1 . 02 . 01 . 24 Program Jaminan Kesehatan Nasional
Kegiatan : 1 . 02 . 1 . 02 . 01 . 24 . 12 Pembiayaan Jaminan Kesehatan Nasional
Lokasi Kegiatan : Kabupaten Karanganyar
Sumber Dana : Dana Kapitasi JKN Tahun 2015

Indikator Tolok Ukur Kinerja Belanja Langsung

Indikator Tolok Ukur Kinerja Target Kinerja
Capaian Program Terlaksananya Program Jaminan Kesehatan Nasional Puskesmas Ngargoyoso
Masukan Jumlah Dana Rp 1,250,856,000.0
Keluaran Terlayaninya masyarakat dengan Program Jaminan Kesehatan Nasional Puskesmas Ngargoyoso
Hasil Meningkatnya derajat kesehatan masyarakat di Kabupaten Karanganyar 100%
Kelompok Sasaran Kegiatan: Peserta Jaminan Kesehatan Nasional
Rincian Anggaran Belanja Langsung
menurut Program dan Per Kegiatan Satuan Kerja Perangkat Daerah
Kode Rincian Perhitungan
Uraian
Rekening Volume Satuan Tarif/Harga
1 2 3 4 5
BELANJA
BELANJA LANGSUNG
Belanja Barang dan Jasa
Belanja Bahan Pakai Habis
Belanja Alat Tulis Kantor

- HVS Folio (70 gr) 72 rim 47,500

- Stopmap folio kertas 200 buah 1,100
- Stopmap plastik bertali/ berkancing 60 buah 5,000
- Snelhecter Plastik 200 buah 8,250
- Paper clips 72 dos 3,300
- Buku folio isi 300 10 buah 42,450
- Staples besar 2 buah 39,000
- Staples kecil 6 buah 14,650
- Isi staples kecil 40 dos 3,500
- Isi staples besar 10 dos 4,500
- Isolasi biasa 12 buah 1,500
- Isolasi double tape 12 buah 13,500
- Balpoint gel 144 buah 3,500
- Pensil 2 B 18 buah 3,600
- Spidol Permanent besar 60 buah 6,000
- Binder clip no 222 24 dos 17,000
- Binder clip no 223 36 dos 12,000
- Binder clip no 224 36 dos 13,000
- Binder clip no 225 36 dos 11,000
- Binder clip no 226 36 dos 9,000
- Kalkulator 12 digit 3 buah 140,000
- Amplop Merpati Kabinet 80 gr 24 dos 16,500
- Amplop besar 24 dos 12,500
- Amplop sedang 12 dos 6,500
- Ordner 36 buah 23,550
- Karbon Folio 1 dos 50,000
- Buku Tulis isi 58 lembar 20 buah 3,500
- Buku Kwitansi besar 12 buah 7,500
- Buku Kwitansi kecil 12 buah 3,500
- Pita mesin ketik rol kecil 4 buah 10,500
- Penghapus cair 8 set 13,500
- Stempel Tanggal 2 buah 8,250
- Tinta Stempel 4 buah 3,000
- Tinta Spidol Permanen 4 buah 15,000
- Stabillo Boss 10 buah 9,500
- Parporator besar 1 buah 82,500
- Parporator kecil 3 buah 28,350
- Paper Clips 24 dos 3,300
- Meterai 3000 120 lembar 3,000
- Meterai 6000 120 lembar 6,000
- Batu Baterai besar 18 buah 5,500
- Batu baterai ukuran AA 24 buah 9,600
- Kepingan VCD 60 buah 3,100
- Pisau Cutter besar 3 buah 21,300
- Isi pisau cutter besar 2 dos 4,950

Belanja Obat 1 paket 151,353,350

 Belanja Bahan Habis Pakai
- Belanja Bahan Habis Pakai Medis 1 paket 90,000,000
- Belanja Bahan Habis Pakai Laboratorium 1 paket 7,500,000
- Belanja Bahan Habis Pakai Gigi 1 paket 27,000,000
- Belanja Bahan Habis Pakai Pemeriksaan IVA Test 1 paket 6,000,000

Belanja Pemeliharaan Komputer

- Belanja pemeliharaan internet untuk P Care 12 paket 700,000

- Belanja pemeliharaan komputer 5 unit 500,000
- Belanja pemeliharaan printer 4 unit 250,000
- Belanja pemasangan jaringan nirkabel 1 unit 1,000,000
- Tinta refill cartridge (Black) 12 set 40,000
- Tinta refill cartridge (Color) 6 set 50,000
- Isi ulang toner printer laser 12 set 125,000
- Mouse nirkabel 4 buah 100,000
- Flash Disc 8 GB 2 buah 125,000
- PC Pentium i3, monitor LCD, Non OS 2 unit 7,750,000
- UPS 600 VA 2 buah 750,000

Belanja Operasional Pusling

- Service Rutin 6 paket 1,000,000

- Service Rutin 6 paket 1,000,000

Belanja BBM

- Pembelian BBM Pusling ELF (Solar) 1200 liter 7,500

- Pembelian BBM Pusling APV (Bensin) 600 liter 8,500

Belanja Cetak dan Penggandaan

Belanja Cetak

- Cetak Family Folder 6,000 lembar 3,000

- Cetak Resep 36 rim 80,000
- Cetak status pasien Puskesmas Induk 36 rim 80,000
- Cetak status pasien Puskesmas Pembantu dan PKD 36 set 85,000
- Cetak kartu berobat 12 set 75,000
- Cetak kartu stok obat 1 set 85,000
 Belanja Penggandaan

- Penggandaan 12,000 lembar 200

Belanja Makanan Dan Minuman

Belanja Makanan Dan Minuman Kegiatan

Belanja Konsumsi Kegiatan Promotif Penderita TB

- Snack dan Minum (1 kali x 50 orang) 50 OH 7,500
- Makan (1 kali x 40 0rang) 50 OH 17,500

Belanja Konsumsi Kegiatan Promotif Penderita DM

- Snack dan Minum (1 kali x 50 orang) 40 OH 7,500
- Makan (1 kali x 40 0rang) 40 OH 17,500

Belanja Konsumsi Kegiatan Promotif Penderita Hipertensi

- Snack dan Minum (1 kali x 40 orang) 40 OH 7,500
- Makan (1 kali x 40 0rang) 40 OH 17,500

Belanja Perjalanan Dinas

Belanja Perjalanan Dinas Dalam Daerah

Kegiatan Promotif Penderita TB

- (Peserta (1 kali x 50 orang) 50 OH 22,000

Kegiatan Promotif Penderita DM

- Peserta (1 kali x 40 orang) 40 OH 22,000

Kegiatan Promotif Penderita Hipertensi

- Peserta (1 kali x 40 orang) 40 OH 22,000

Kegiatan kunjungan rumah penderita 36 OH 22,000

- Petugas (36 kali x 1 orang)

Belanja Jasa Narasumber/ Tenaga Ahli

Belanja Jasa Tenaga Ahli
- Honor Nara Sumber staf (2 kali x 1 orang) 2 OH 150,000
- Honor Nara Sumber esselon IV (2 kali x 1 orang) 2 OH 150,000
 - Uang Harian Nara Sumber staf (2 kali x 1 orang) 2 OH 44,000
- Uang Harian Nara Sumber esselon IV (2 kali x 1 orang) 2 OH 66,000

Belanja Jasa Pelayanan Kesehatan FKTP

- untuk Puskesmas 12 bulan 62,542,800

Belanja Modal
Belanja Modal Pengadaan Alat-alat Kesehatan dan Non Alat Kesehatan

Belanja Modal Pengadaan Alat-alat Kesehatan Kesehatan

- Head Lamp 2 buah 2,000,000
- Lampu Periksa Halogen 2 buah 2,450,000
- Tensi Dewasa 10 buah 1,800,000
- Stetoskop Dewasa 10 buah 1,920,000
- Stetoskop anak 2 buah 1,900,000
- Minor Set 5 set 2,011,000
- Tandu P3K 1 buah 10,000,000
- Oxygen Regulator 2 buah 1,475,000
- Timbangan bayi 3 buah 748,000
- Timbangan digital 2 buah 1,500,000
- Electrical Stimulation 1 buah 1,000,000
- Infra Red berdiri 1 buah 1,500,000
- Ultra Sound Therapy 1 buah 14,200,000
- Light Cure tambal gigi 1 buah 7,000,000
- Doppler 2 buah 2,750,000

Jumlah

Menyetujui: Karanganyar, 02 Januari 2015

Kepala Dinas Kesehatan
Kabupaten Karanganyar Kepala Puskesmas Ngargoyoso

dr. Cucuk Heru Kusumo, M. Kes dr. Retno Sawartuti, M. Kes

NIP. 19600105 198511 1 002 NIP. 19730314 200212 2 003
 Formulir
RKA SKPD 2.2.1

Target Kinerja
uskesmas Ngargoyoso
p 1,250,856,000.00
uskesmas Ngargoyoso
00%

Jumlah
(Rp)
6 = (3x5) 1 2 3 4 5 6 7 8 9

3,420,000 285,000 285,000 285,000 285,000 285,000 285,000 285,000 285,000 285,000
220,000 55,000 55,000 55,000
300,000 25,000 25,000 25,000 25,000 25,000 25,000 25,000 25,000 25,000
1,650,000 412,500 412,500 412,500
237,600 19,800 19,800 19,800 19,800 19,800 19,800 19,800 19,800 19,800
424,500 212,250 212,250
78,000 78,000
87,900 87,900
140,000 35,000 35,000 35,000
 45,000 22,500 22,500
18,000 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500
162,000 13,500 13,500 13,500 13,500 13,500 13,500 13,500 13,500 13,500
504,000 42,000 42,000 42,000 42,000 42,000 42,000 42,000 42,000 42,000
64,800 10,800 10,800 10,800 10,800
360,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000
408,000 34,000 34,000 34,000 34,000 34,000 34,000 34,000 34,000 34,000
432,000 36,000 36,000 36,000 36,000 36,000 36,000 36,000 36,000 36,000
468,000 39,000 39,000 39,000 39,000 39,000 39,000 39,000 39,000 39,000
396,000 33,000 33,000 33,000 33,000 33,000 33,000 33,000 33,000 33,000
324,000 27,000 27,000 27,000 27,000 27,000 27,000 27,000 27,000 27,000
420,000 420,000
396,000 33,000 33,000 33,000 33,000 33,000 33,000 33,000 33,000 33,000
300,000 25,000 25,000 25,000 25,000 25,000 25,000 25,000 25,000 25,000
78,000 6,500 6,500 6,500 6,500 6,500 6,500 6,500 6,500 6,500
847,800 70,650 70,650 70,650 70,650 70,650 70,650 70,650 70,650 70,650
50,000 50,000
70,000 35,000 35,000
90,000 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500 7,500
42,000 3,500 3,500 3,500 3,500 3,500 3,500 3,500 3,500 3,500
42,000 10,500 10,500 10,500
108,000 54,000 54,000
16,500 16,500
12,000 3,000 3,000 3,000
60,000 15,000 15,000 15,000
95,000 47,500 47,500
82,500 82,500
85,050 85,050
79,200 6,600 6,600 6,600 6,600 6,600 6,600 6,600 6,600 6,600
360,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000
720,000 60,000 60,000 60,000 60,000 60,000 60,000 60,000 60,000 60,000
99,000 49,500
230,400 115,200
186,000 15,500 15,500 15,500 15,500 15,500 15,500 15,500 15,500 15,500
63,900 63,900
9,900 4,950

151,353,350 12,099,850 13,288,600 12,885,100 12,278,900 12,929,650 11,879,650 12,731,150 12,882,600 13,691,650
90,000,000 7,500,000 7,500,000 7,500,000 7,500,000 7,500,000 7,500,000 7,500,000 7,500,000 7,500,000
7,500,000 625,000 625,000 625,000 625,000 625,000 625,000 625,000 625,000 625,000
27,000,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000
6,000,000 500,000 500,000 500,000 500,000 500,000 500,000 500,000 500,000 500,000

8,400,000 700,000 700,000 700,000 700,000 700,000 700,000 700,000 700,000 700,000
2,500,000 2,500,000
1,000,000
1,000,000 1,000,000
480,000 40,000 40,000 40,000 40,000 40,000 40,000 40,000 40,000 40,000
300,000 50,000 50,000 50,000 50,000
1,500,000 125,000 125,000 125,000 125,000 125,000 125,000 125,000 125,000 125,000
400,000 400,000
250,000 250,000
15,500,000 7,750,000 7,750,000
1,500,000 750,000 750,000

6,000,000 1,000,000 1,000,000 1,000,000 1,000,000

6,000,000 1,000,000 1,000,000 1,000,000 1,000,000 1,000,000

9,000,000 750,000 750,000 750,000 750,000 750,000 750,000 750,000 750,000 750,000
5,100,000 425,000 425,000 425,000 425,000 425,000 425,000 425,000 425,000 425,000

18,000,000 3,000,000 3,000,000 3,000,000 3,000,000 3,000,000

2,880,000 240,000 240,000 240,000 240,000 240,000 240,000 240,000 240,000 240,000
2,880,000 240,000 240,000 240,000 240,000 240,000 240,000 240,000 240,000 240,000
3,060,000 255,000 255,000 255,000 255,000 255,000 255,000 255,000 255,000 255,000
900,000 75,000 75,000 75,000 75,000 75,000 75,000 75,000 75,000 75,000
85,000 85,000
2,400,000 200,000 200,000 200,000 200,000 200,000 200,000 200,000 200,000 200,000

375,000 375,000
875,000 875,000

300,000 300,000
700,000 700,000

300,000
700,000

1,100,000 1,100,000

880,000 880,000

880,000 880,000

792,000 66,000 66,000 66,000 66,000 66,000 66,000 66,000 66,000 66,000

300,000 150,000
300,000 150,000
 88,000 44,000
132,000 66,000

750,513,600 62,542,800 62,542,800 62,542,800 62,542,800 62,542,800 62,542,800 62,542,800 62,542,800 62,542,800

4,000,000 2,000,000 2,000,000

4,900,000 2,450,000 2,450,000
18,000,000 1,800,000 1,800,000 1,800,000 1,800,000 1,800,000 1,800,000 1,800,000
19,200,000 1,920,000 1,920,000 1,920,000 1,920,000 1,920,000 1,920,000 1,920,000 1,920,000
3,800,000 1,900,000 1,900,000
10,055,000 2,011,000 2,011,000 2,011,000
10,000,000 10,000,000
2,950,000
2,244,000 2,244,000
3,000,000 1,500,000
1,000,000 1,000,000
1,500,000 1,500,000
14,200,000
7,000,000 7,000,000
5,500,000 2,750,000

1,250,856,000 104,238,000 104,238,000 104,238,000 104,238,000 104,238,000 104,238,000 104,238,000 104,238,000 104,238,000

2 Januari 2015

mas Ngargoyoso

artuti, M. Kes
200212 2 003
10 11 12

285,000 285,000 285,000 3,420,000

55,000 220,000
25,000 25,000 25,000 300,000
412,500 1,650,000
19,800 19,800 19,800 237,600
424,500
78,000
87,900
35,000 140,000
 45,000
1,500 1,500 1,500 18,000
13,500 13,500 13,500 162,000
42,000 42,000 42,000 504,000
10,800 10800 64,800
30,000 30,000 30,000 360,000
34,000 34,000 34,000 408,000
36,000 36,000 36,000 432,000
39,000 39,000 39,000 468,000
33,000 33,000 33,000 396,000
27,000 27,000 27,000 324,000
420,000
33,000 33,000 33,000 396,000
25,000 25,000 25,000 300,000
6,500 6,500 6,500 78,000
70,650 70,650 70,650 847,800
50,000
70,000
7,500 7,500 7,500 90,000
3,500 3,500 3,500 42,000
10,500 42,000
108,000
16,500
3,000 12,000
15,000 60,000
95,000
82,500
85,050
6,600 6,600 6,600 79,200
30,000 30,000 30,000 360,000
60,000 60,000 60,000 720,000
49,500 99,000
115,200 230,400
15,500 15,500 15,500 186,000
63,900
4,950 9,900
-
12,747,900 12,538,650 11,399,650 151,353,350
7,500,000 7,500,000 7,500,000 90,000,000
625,000 625,000 625,000 7,500,000
2,250,000 2,250,000 2,250,000 27,000,000
500,000 500,000 500,000 6,000,000
-
-
-
700,000 700,000 700,000 8,400,000
2,500,000
1,000,000 1,000,000
1,000,000
40,000 40,000 40,000 480,000
50,000 50,000 300,000
125,000 125,000 125,000 1,500,000
400,000
250,000
15,500,000
1,500,000

1,000,000 1000000 6,000,000

1,000,000 6,000,000

750,000 750,000 750,000 9,000,000

425,000 425,000 425,000 5,100,000

-
-
-
3,000,000 18,000,000
240,000 240,000 240,000 2,880,000
240,000 240,000 240,000 2,880,000
255,000 255,000 255,000 3,060,000
75,000 75,000 75,000 900,000
85,000
 -
-
200,000 200,000 200,000 2,400,000
-
-
-
-
-
375,000
875,000

-
300,000
700,000
-
-
300,000 300,000
700,000 700,000
-
-
-
-

1,100,000
-
-
880,000
-
-
880,000
-
66,000 66,000 66,000 792,000
-
-
-
-
150,000 300,000
150,000 300,000
 44,000 88,000
66,000 132,000

-
62,542,800 62,542,800 62,542,800 750,513,600
-
-
-

-
4,000,000
4,900,000
3,600,000 1,800,000 18,000,000
1,920,000 1,920,000 19,200,000
3,800,000
2,011,000 2,011,000 10,055,000
10,000,000
2,950,000 2,950,000
2,244,000
1,500,000 3,000,000
1,000,000
1,500,000
14200000 14,200,000
7,000,000
2,750,000 5,500,000
-
104,238,000 104,238,000 104,238,000 1,250,856,000
 Rincian Anggaran Belanja Langsung
menurut Program dan Per Kegiatan Satuan Kerja Perangkat Daerah
Kode Anggaran
Uraian Jan Feb Mar Apr Mei Juni Juli Agustus September Oktober November Desember
Rekening Tahun Ini

5 . 2 . 2 . 01 . 01 Belanja Alat Tulis Kantor 7,964,300 1,319,100 1,244,300 1,089,100 1,244,300 876,600 1,244,300 876,600
Belanja Obat 30,587,366 3,359,500 - 8,580,198 - 9,900,646 - 8,747,022
Belanja Bahan Habis Pakai Medis 20,416,800 1,029,800 10,309,700 5,582,100 3,495,200
Belanja Sistem Informasi 8,400,000 700,000 700,000 700,000 3,200,000 1,700,000 700,000 700,000
Belanja Operasional Pusling 19,375,000 2,875,000 4,925,000 875,000 2,875,000 875,000 4,075,000 2,875,000
5 . 2 . 2 . 06 . 01 Belanja Cetak 19,712,500 2,387,500 3,137,500 3,137,500 3,137,500 3,137,500 2,387,500 2,387,500
5 . 2 . 2 .06 . 02 Belanja Penggandaan 700,000 100,000 100,000 100,000 100,000 100,000 100,000 100,000
5 . 2 . 2 . 11 . 04 Belanja Makanan Dan Minuman Kegiatan 1,250,000 - - 1,250,000 - - - -
5 . 2 . 2 . 15 . 01 Belanja Perjalanan Dinas Dalam Daerah 1,100,000 - - 1,100,000 - - - -
5 . 2 . 2 . 26 . 02 Belanja Jasa Tenaga Ahli 437,799,600 62,542,800 62,542,800 62,542,800 62,542,800 62,542,800 62,542,800 62,542,800
JUMLAH 547,305,566 74,313,700 72,649,600 89,684,298 73,099,600 84,714,646 71,049,600 81,724,122

Karanganyar, 01 Juni 2014

Kepala Puskesmas Ngargoyoso

dr. Retno Sawartuti, M. Kes

NIP. 19730314 200212 2 003
 7,894,300
30,587,366
20,416,800
8,400,000
19,375,000
19,712,500
700,000
1,250,000
1,100,000
437,799,600
547,235,566