REKAM KESEHATAN DINAS KESEHATAN KABUPATEN SUMBA TIMUR

PUSKESMAS LEWA
.............................................................................................
Kode Desa Kode Dusun/Nomer Indeks Status Keluarga

Nama Pasien : L / P Tanggal Lahir: Nama Ibu/Ayah :

Agama : Pekerjaan : No Telefon yang Bisa Dihubungi :
Status Perkawainan : Kewarganegaraan : Jaminan Kesehatan
◦ Belum Kawin
◦ Kawin ◦ KIS
◦ Cerai Hidup
◦ Cerai Mati
Alamat
Jalan : ◦ Umum
Kelurahan/Desa : ◦ Lainnya
Dusun :
Kecamatan : Lewa
Kabupaten : Sumba Timur
Propinsi : Nusa Teggara Timur
Diagnosa
Tanggal Anamnesis dan Pemeriksaan Terapi
Kode ICD-10
 Kode Desa Nomor Indeks Status
REKAM KESEHATAN Keluarga

Nama Pasien : Status Perkawinan : K / BK / CM / CH

TGL Lahir / Umur : Alamat :
Jenis Kelamin : L/P No Kartu (KIS) :
Agama : Nama KK :
Pekerjaan :
Hari / Tanggal Anamnesis Diagnosa Therapi
BB :....................... TB :....................... LP :.......................

TD :....................... RR :....................... N :........... S :.............

BB ........................ TB ........................ LP ........................

TD ........................ RR ........................ N ............ S ............

BB ........................ TB ........................ LP ........................

TD ........................ RR ........................ N ............ S ............

BB ........................ TB ........................ LP ........................

TD ........................ RR ........................ N ............ S ............

KETERANGAN BB : Berat Badan TB: Tinggi Badan LP: Lingkar Perut

TD: Tekanan Darah RR: Pernafasan N: Nadi S: Suhu

 PUSKESMAS LEWA PUSKESMAS LEWA
Jln. Pakauning -Tanggamadita Jln. Pakauning -Tanggamadita
LEWA - SUMBA TIMUR LEWA - SUMBA TIMUR
Dokter 1. dr Marselyn M.L Lado,S.Ked Dokter 1. dr Marselyn M.L Lado,S.Ked
SIPD :38/SIPD/DPMPTSP/IV/2018 SIPD :38/SIPD/DPMPTSP/IV/2018
Alamat : Puskesmas Lewa Alamat : Puskesmas Lewa
HP ; 081239894986 HP ; 081239894986
2. dr Albert Umbu R.L.Awang 2. dr Albert Umbu R.L.Awang
SIPD :72/SIPD/DPMPTSP-ST/XI/2020 SIPD :72/SIPD/DPMPTSP-ST/XI/2020
Alamat : Puskesmas Lewa Alamat : Puskesmas Lewa
HP : 082247221416 HP : 082247221416
3. dr Nelson Awang 3. dr Nelson Awang
SIPD : DPMPTSP/27/SIPD/IV/2022 SIPD : DPMPTSP/27/SIPD/IV/2022
Alamat : Puskesmas Lewa Alamat : Puskesmas Lewa
HP : 085237117924 HP : 085237117924
STATUS : UMUM/BPJS STATUS : UMUM/BPJS
No. Karcis : No. Karcis :
Ruang/Unit : Ruang/Unit :
Tanggal : Tanggal :
Diagnosa : Diagnosa :
Alergi : Alergi :
R/ R/

Identitas PS : Identitas PS :
Nama : Nama :
Alamat : Alamat :
No. RM : No. RM :
Tanggal Lahir : Tanggal Lahir :
Berat Badan : Berat Badan :
Nama Dokter : Nama Dokter :

PUSKESMAS LEWA PUSKESMAS LEWA

Jln. Pakauning -Tanggamadita Jln. Pakauning -Tanggamadita
LEWA - SUMBA TIMUR LEWA - SUMBA TIMUR
Dokter : dr Marselyn M.L Lado,S.Ked Dokter : dr Marselyn M.L Lado,S.Ked
SIPD :38/SIPD/DPMPTSP/IV/2018 SIPD :38/SIPD/DPMPTSP/IV/2018
: dr Albert Umbu R.L.Awang : dr Albert Umbu R.L.Awang
SIPD :72/SIPD/DPMPTSP-ST/XI/2020 SIPD :72/SIPD/DPMPTSP-ST/XI/2020
dr Nelson Awang dr Nelson Awang
SIPD : SIPD :
STATUS : UMUM/BPJS STATUS : UMUM/BPJS
No. Karcis : No. Karcis :
Ruang/Unit : Ruang/Unit :
Tanggal : Tanggal :
Diagnosa : Diagnosa :
Alergi : Alergi :
R/ R/
Identitas PS : Identitas PS :
Nama : Nama :
Alamat : Alamat :
No. RM : No. RM :
Tanggal Lahir : Tanggal Lahir :
Berat Badan : Berat Badan :
Nama Dokter : Nama Dokter :
 Bayar jkn gratis sks t0tal petugas pendaftar
1 Januari
2
3
4 4 15 0 19 19 leni
5 2 11 13 13 leni
6 5 12 17 17 hen
7 4 8 12 12 feris = hen
8 2 8 3 13 10 feris denis
9 2 8 10 10 feris
10 0 0
11 2 15 2 19 17 yesi
12 5 9 14 14 yesi
13 1 7 8 8 yesi
14 6 10 16 16 yesi
15 4 14 18 18 yesi
16 2 12 14 14 feris
17 0 0
18 6 14 20 20 mila
19 7 11 18 18 yesi mila
20 3 23 26 26 yesi
21 3 16 19 19 mila
22 6 12 18 18 mila
23 3 10 13 13 mila
24 0 0
25 7 13 20 20 mila
26 7 11 18 18 mila yesi
27 0 14 14 14 yesi mila
28 6 8 14 14 mila
29 4 25 29 29 denis
30 4 14 18 18 denis
31 0 0
0 0
0 0
1 Pebr 6 11 17 17 mila
2 7 14 21 21 mila
3 8 11 2 21 19 mila
4 2 8 10 10 yesi
5 8 17 1 26 25 mila
6 4 20 24 24 yesi
7 0 0
8 5 29 34 34 yesi
 9 3 22 1 26 25 yesi
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
0 0
0 0
1 Maret 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 April 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
 1 Mey 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
1 Juni 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 Juli 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 Agust 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
 1 Sept 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
0 0
1 Okt 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 Nov 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
0 0
1 Des 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
 Bayar jkn gratis sks t0tal petugas pendaftar
1 Januari
2
3
4 0 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
1 Pebr 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
 9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
0 0
0 0
1 Maret 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 April 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
 1 Mey 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
1 Juni 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 Juli 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 Agust 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
 1 Sept 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
0 0
1 Okt 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 Nov 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
0 0
1 Des 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
 Jumlah hari Rawat
Bayar jkn gratis sks t0tal petugas pendaftar
1 Januari
2
3
4 0 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
1 Pebr 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
 9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
0 0
0 0
1 Maret 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 April 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
 1 Mey 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
1 Juni 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 Juli 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 Agust 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
 1 Sept 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
0 0
1 Okt 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
1 Nov 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
0 0
0 0
0 0
0 0
1 Des 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0