LAPORAN BULANAN

REKAPITULASI POLI GIGI BULAN JANUARI TAHUN 2023 DI PUSKESMAS D

KABUPATEN KUPANG PUSKESMAS OEKABITI

NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1

No Elemen Data B L B L B L B L B L B L B
L P L p L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :

1 Bulan ini 6 12 1 1 1 0 1 0 0 3 0 0 0 0 0 0 2 0 0 0 1 2 0 3 0 0

2 Kumulatif s.d. Bulan lalu 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

II Kelompok Umur :

1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2 5 – 9 tahun 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

4 15 – 19 tahun 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

5 20 – 44 tahun 2 7 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0
6 45 – 54 tahun 0 2 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 2 0 2 0 0

7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0

9 > 70 tahun 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran :

1 Bumil 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3 Anak SD/MI 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

4 Lain-lain 4 9 1 1 1 0 1 0 0 3 0 0 0 0 0 0 2 0 0 0 1 2 0 3 0 0

IV Asal Pasien :

1 Datang sendiri 6 12 1 1 1 0 1 0 0 3 0 0 0 0 0 0 2 0 0 0 1 2 0 3 0 0

2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa :

1 Karies 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 2 2 0 0 1 0 0 0 0 3 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0

3 Penyakit Pulpa 1 9 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 2 0 3 0 0

4 Lain - lain 2 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1

No Elemen Data B L B L B L B L B L B L B
L P L p L P L P L P L P L P L P L P L P L P L P L P

VI Tindakan :

701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Konsultasi Dokter Gigi Diluar
702 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jam Dinas
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

707 Pencabutan gigi sulung 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 709 Uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

710 Premedikasi /Lain2 3 0 0 0 0 0 4 1 1 2 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0

VII Rujukan :

1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2 Rumah sakit 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.

Mengetahui
KEPALA PUSKESMAS OEKABITI

ADRIANA T.BETTY,S.Tr.Keb
NIP. 19730420 199212 2 001
ORAN BULANAN
ARI TAHUN 2023 DI PUSKESMAS DAN JEJARINGNYA
PANG PUSKESMAS OEKABITI

OENONI 1 OENONI 2 APREN Total TOTAL

L B L B L B L
L P L+P
L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 10 17 2 4 12 21 33

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 2 1 0 0 2 1 3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 2

0 0 0 0 0 0 0 0 0 0 3 8 0 2 3 10 13
0 0 0 0 0 0 0 0 0 0 1 5 1 2 2 7 9

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 2 1 0 0 2 1 3

0 0 0 0 0 0 0 0 0 0 1 1 1 0 2 1 3

0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 2 2

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 2 1 0 0 2 1 3

0 0 0 0 0 0 0 0 0 0 8 14 2 4 10 18 28

0 0 0 0 0 0 0 0 0 0 10 17 2 4 12 21 33

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0 0 0 5 5 0 0 5 5 10

0 0 0 0 0 0 0 0 0 0 2 11 0 5 2 16 18

0 0 0 0 0 0 0 0 0 0 2 1 1 0 3 1 4

OENONI 1 OENONI 2 APREN Total TOTAL

L B L B L B L
L P L+P
L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 2

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 5 2 4 1 9 3 12

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 2 0 0 0 2 0 2

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

OEKABITI,31 JANUARI 2023

PELAPOR

ADY IMANUEL ISMAU, A.Md.Kes

 NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1

No Elemen Data B L B L B L B L B L B L B L
L P L p L P L P L P L P L P L P L P L P L P L P L P L

VI Tindakan :

1 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Konsultasi Dokter Gigi Diluar
2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jam Dinas
3 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

4 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

5 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

6 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

7 Pencabutan gigi sulung 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

8 Pencabutan gigi permanen 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

9 Uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

10 Premidikasi/Lain2 4 9 0 0 0 0 5 4 2 1 0 0 0 2 0 0 0 1 0 0 1 1 0 0 0 0 0

VII Rujukan :

1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2 Rumah sakit 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.

Mengetahui
KEPALA PUSKESMAS OEKABITI

ADRIANA TAROTJI BETY,A.Md.Keb

NIP. 19730420 199212 2 001
NONI 1 OENONI 2 APREN Total TOTAL

L B L B L B L
L P L+P
P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 1 0 1 0 2 2

0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 7 14 5 4 12 18 30

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 2 1 0 0 2 1 3

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

OEKABITI, 28 FEBRUARI 2022

PELAPOR

ADY IMANUEL ISMAU,Amd.Kes

 LAPORAN BULANAN
REKAPITULASI POLI GIGI BULAN MARET TAHUN 2022 DI PUSKESMAS DA
KABUPATEN KUPANG PUSKESMAS OEKABITI

NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1

No Elemen Data B L B L B L B L B L B L B L
L P L p L P L P L P L P L P L P L P L P L P L P L P L
I Total Kunjungan Poli Gigi :
1 Bulan ini 0 6 0 0 0 2 0 2 0 4 0 0 0 1 0 1 0 2 0 0 4 1 0 0 1 1 0
2 Kumulatif s.d. Bulan lalu 8 11 0 2 0 0 9 5 3 3 0 0 0 2 0 0 1 1 0 0 1 1 0 0 0 0 0
II Kelompok Umur :
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 2 0 0 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 2 0 0 0 0 0 0
6 45 – 54 tahun 0 1 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 2 0 0 0 1 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 1 0 2 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0
III Kelompok Sasaran :
1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 0 3 0 0 0 2 0 2 0 4 0 0 0 1 0 1 0 2 0 0 4 1 0 0 1 1 0
IV Asal Pasien :
1 Datang sendiri 0 6 0 0 0 2 0 2 0 4 0 0 0 1 0 1 0 2 0 0 4 1 0 0 1 1 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
V Diagnosa :
1 Karies 0 2 0 0 0 1 0 2 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0
2 Penyakit Gusi 0 0 0 0 0 1 0 0 0 2 0 0 0 1 0 1 0 2 0 0 4 1 0 0 0 1 0
3 Penyakit Pulpa 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1
No Elemen Data B L B L B L B L B L B L B L
L P L p L P L P L P L P L P L P L P L P L P L P L P L
VI Tindakan :
1 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Konsultasi Dokter Gigi Diluar
2 Jam Dinas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Pencabutan gigi sulung 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 8 Pencabutan gigi permanen 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Upercelectomi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Premidikasi/Lain2 0 2 0 0 0 2 0 2 0 4 0 0 0 1 0 1 0 2 0 0 4 1 0 0 1 1 0
VII Rujukan :
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.

Mengetahui
KEPALA PUSKESMAS OEKABITI

ADRIANA TAROTJI BETY,A.Md.Keb

RAN BULANAN
T TAHUN 2022 DI PUSKESMAS DAN JEJARINGNYA
ANG PUSKESMAS OEKABITI

OENONI 1 OENONI 2 APREN Total TOTAL

L B L B L B L
L P L+P
P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 5 17 0 3 5 20 25
0 0 0 0 0 0 0 0 0 13 18 9 7 22 25 47

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0 0 0 3 0 0 0 3 3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 2 4 0 2 2 6 8
0 0 0 0 0 0 0 0 0 3 3 0 0 3 3 6
0 0 0 0 0 0 0 0 0 0 2 0 0 0 2 2
0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0 0 0 3 0 1 0 4 4

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 3 0 0 0 3 3
0 0 0 0 0 0 0 0 0 5 14 0 3 5 17 22

0 0 0 0 0 0 0 0 0 5 17 0 3 5 20 25
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 1 4 0 2 1 6 7
0 0 0 0 0 0 0 0 0 4 8 0 1 4 9 13
0 0 0 0 0 0 0 0 0 0 2 0 0 0 2 2
0 0 0 0 0 0 0 0 0 0 3 0 0 0 3 3
OENONI 1 OENONI 2 APREN Total TOTAL
L B L B L B L
L P L+P
P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 2 0 0 0 2 2
0 0 0 0 0 0 0 0 0 0 2 0 0 0 2 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 5 13 0 3 5 16 21

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

OEKABITI, 31 MARET 2022

PELAPOR

ADY IMANUEL ISMAU,A.Md.Kes

 NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1 OENONI 2 APREN Total TOTAL
Elemen Data B L B L B L B L B L B L B L B L B L B L
L P L+P
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
V Diagnosa :
1 Karies 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 1 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 3 1 1 2 4 6
2 Penyakit Gusi 2 0 0 2 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 3 1 0 3 3 4 7
3 Penyakit Pulpa 5 3 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 3 0 0 6 3 9
4 Lain - lain 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 2

VI Tindakan :
1 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Konsultasi Dokter Gigi Diluar
2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jam Dinas
3 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Pembersihan karang gigi 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 2 2
6 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Pencabutan gigi sulung 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
8 Pencabutan gigi permanen 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 2
9 uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Premidikasi/Lain2 6 1 0 1 0 0 1 2 1 1 0 0 1 0 0 0 1 3 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 10 5 1 3 11 8 19
VII Rujukan :
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.

Mengetahui OEKABITI, 30 APRIL 2 2022

KEPALA PUSKESMAS OEKABITI PELAPOR

ADY IMANUEL ISMA,A.Md.Kes

ADRIANA TAROTJI BETY,A.Md.Keb
NIP. 19730420 199212 2 001
 NONBES OESENA KOTABES TESBATAN 1 TESBATAN 2 OENONI 1 OENONI 2 APREN Total TOTAL

No Elemen Data B L B L B L B L B L B L B L B L B L B L
L P L+P
L P L p L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
V Diagnosa :

1 Karies 0 2 0 0 0 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 1 2 1 4 5

2 Penyakit Gusi 1 3 0 2 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 4 1 3 4 7 11

3 Penyakit Pulpa 3 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 1 1 0 4 1 5

4 Lain - lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

VI Tindakan :

1 Konsultasi Dokter Gigi 4 6 1 2 0 0 2 3 0 1 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 7 3 5 9 12 21

Konsultasi Dokter Gigi Diluar
2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jam Dinas
3 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

4 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

5 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

6 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

7 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

8 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

9 Uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

10 Premidikasi/lain2 4 6 1 2 0 0 2 3 0 1 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 7 3 5 9 12 21

VII Rujukan : 0 0 0 0 0 0 0

1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.

Mengetahui OEKABITI, 30 MEI 2022

KEPALA PUSKESMAS OEKABITI PELAPOR

ADRIANA TAROTJI BETY,A.Md.Keb ADY IMANUEL ISMAU,A.Md.Kes

NIP. 19730420 199212 2 001
 NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1 OENONI 2 APREN Total TOTAL
Elemen Data B L B L B L B L B L B L B L B L B L B L
L P L+P
L P L p L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
Tindakan :
Konsultasi Dokter Gigi 4 7 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 7 0 1 3 8 11
Konsultasi Dokter Gigi Diluar Jam
Dinas
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pencabutan gigi sulung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Premidikasi/lain2 4 6 0 1 0 0 0 4 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 5 8 0 6 5 14 19
Rujukan :
Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Rumah sakit 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.
Mengetahui OEKABITI, 30 JUNI 2022
KEPALA PUSKESMAS OEKABITI PELAPOR

ADRIANA TAROTJI BETY,A.Md.Keb ADY IMANUEL ISMAU A.Md.Kes

NIP. 19730420 199212 2 001
 NONBES OESENA KOTABES PONAIN TESBATAN TESBATAN 2 OENONI OENONI 2 APREN Total TOTAL
No Elemen Data B L B L B L B L B L B L B L B L B L B L
L P L+P
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan :
Konsultasi Dokter 1 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 3 0 0 1 3 4
1 Gigi/perawat gigi
Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Jam Dinas
3 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Pencabutan gigi permanen 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1
9 Uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 premididkasi/Lain2 7 6 0 1 0 0 0 2 0 2 0 0 0 1 0 0 0 1 0 0 2 2 0 0 2 0 2 0 0 0 0 0 0 0 0 0 11 12 2 3 13 15 28
VII Rujukan :
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.

Mengetahui OEKABITI, 29 JULI 2022

KEPALA PUSKESMAS OEKABITI PELAPOR

ADY IMANUEL ISMAU,Amd,Kes

ADRIANA TAROTJI BETY,A.Md.Keb
NIP. 19730420 199212 2 001
 NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1 OENONI 2 APREN Total TOTAL
No Elemen Data B L B L B L B L B L B L B L B L B L B L
L P L+P
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P

Konsultasi Dokter Gigi/perawat 4 9 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 9 1 1 5 10 15

701 gigi
Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Jam Dinas
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

708 Pencabutan gigi permanen 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 2 3

709 Uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

710 Premidikasi/Lain2 4 8 0 0 1 1 3 5 0 2 0 2 0 0 0 0 0 0 0 0 1 3 0 0 1 1 0 0 0 0 0 0 0 0 0 0 7 15 3 7 10 22 32

VII Rujukan :
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2 Rumah sakit 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1

3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.
Mengetahui OEKABITI, 31 AGUSTUS 2022
KEPALA PUSKESMAS OEKABITI PELAPOR

ADRIANA TAROTJI BETY,A.Md.Keb ADY IMANUEL ISMAU,Amd.Kes

NIP. 19730420 199212 2 001
 LAPORAN BULANAN
REKAPITULASI POLI GIGI BULAN SEPTEMBER TAHUN 2022 DI PUSKESMAS DAN JEJ
KABUPATEN KUPANG PUSKESMAS OEKABITI

NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1

No Elemen Data B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L
I Total Kunjungan Poli Gigi :
1 Bulan ini 4 19 1 6 0 0 1 3 0 2 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1
2 Kumulatif s.d. Bulan lalu 36 50 4 11 8 5 9 20 1 7 0 3 3 2 3 4 4 6 1 0 8 6 2 7 4 3 2

II Kelompok Umur :
≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1
5 – 9 tahun 2 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2
10 – 14 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3
15 – 19 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4
20 – 44 tahun 0 16 0 6 0 0 0 2 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1
5
45 – 54 tahun 1 2 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6
55 – 59 tahun 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7
60 – 69 tahun 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8
> 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9

III Kelompok Sasaran :

1 Bumil 0 16 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 2 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1
4 Lain-lain 2 2 0 0 0 0 1 3 0 2 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0

IV Asal Pasien :
1 Datang sendiri 4 19 1 6 0 0 0 3 0 2 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa :
1 Karies 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 1 14 0 5 0 0 1 3 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1
3 Penyakit Pulpa 2 3 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1
No Elemen Data B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L

VI Tindakan :
Konsultasi Dokter Gigi/perawat 0 13 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
701 gigi
Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Jam Dinas
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 708 Pencabutan gigi permanen 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
710 Premidikasi/Lain2 2 6 0 1 0 0 1 3 0 2 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1
VII Rujukan :
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.

Mengetahui
KEPALA PUSKESMAS OEKABITI

ADRIANA TAROTJI BETY,A.Md.Keb

NIP. 19730420 199212 2 001
ORAN BULANAN
MBER TAHUN 2022 DI PUSKESMAS DAN JEJARINGNYA
ANG PUSKESMAS OEKABITI

OENONI 1 OENONI 2 APREN Total TOTAL

L B L B L B L
L P L+P
P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 6 21 3 9 9 30 39
0 1 0 0 0 0 0 0 0 65 79 21 45 86 124 210

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 2 1 1 0 3 1 4
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 2 16 1 8 3 24 27
0 0 0 0 0 0 0 0 0 1 3 0 0 1 3 4
0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 2
0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 16 0 6 0 22 22
0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0 0 3 0 2 0 5 0 5
0 0 0 0 0 0 0 0 0 3 4 1 3 4 7 11

0 0 0 0 0 0 0 0 0 6 21 2 9 8 30 38
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 1 2 0 0 1 2 3
0 0 0 0 0 0 0 0 0 2 16 2 8 4 24 28
0 0 0 0 0 0 0 0 0 2 3 0 1 2 4 6
0 0 0 0 0 0 0 0 0 1 0 1 0 2 0 2
OENONI 1 OENONI 2 APREN Total TOTAL
L B L B L B L
L P L+P
P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 13 0 5 0 18 18

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 1 0 1 0 2 0 2
0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 4 8 2 4 6 12 18

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

OEKABITI, 30 SEPTEMBER 2022

PELAPOR

ADY IMANUEL ISMAU,Amd.Kes

 LAPORAN BULANAN
REKAPITULASI POLI GIGI BULAN OKTOBER TAHUN 2022 DI PUSKESMAS
KABUPATEN KUPANG PUSKESMAS OEKABITI

NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2

No Elemen Data B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini 7 20 1 5 0 1 2 0 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Kumulatif s.d. Bulan lalu 42 70 5 16 8 6 11 20 3 9 0 3 3 2 3 4 4 6 1 0 8 6 2 7

II Kelompok Umur :
≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1
5 – 9 tahun 1 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2
10 – 14 tahun 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3
15 – 19 tahun 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4
20 – 44 tahun 3 11 0 2 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5
45 – 54 tahun 1 1 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6
55 – 59 tahun 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7
60 – 69 tahun 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8
> 70 tahun 0 1 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9

III Kelompok Sasaran :

1 Bumil 0 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 6 10 0 5 0 1 2 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0

IV Asal Pasien :
1 Datang sendiri 7 20 1 5 0 1 2 0 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa :
1 Karies 1 1 0 0 0 1 2 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 1 7 0 1 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 2 2 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 3 10 1 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2
No Elemen Data B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P

VI Tindakan :
Konsultasi Dokter Gigi/perawat 0 11 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
701 gigi
Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Jam Dinas
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 1 3 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
710 Premidikasi/Lain2 4 5 0 1 0 1 2 0 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0
VII Rujukan :
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.

Mengetahui
KEPALA PUSKESMAS OEKABITI
ORAN BULANAN
BER TAHUN 2022 DI PUSKESMAS DAN JEJARINGNYA
ANG PUSKESMAS OEKABITI

OENONI 1 OENONI 2 APREN Total TOTAL

B L B L B L B L
L P L+P
L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 9 23 3 5 12 28 40
4 3 2 0 1 0 0 0 0 0 0 0 73 102 24 50 97 152 249

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 1 2 1 0 2 2 4
0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 2
0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 3 3
0 0 0 0 0 0 0 0 0 0 0 0 3 11 1 2 4 13 17
0 0 0 0 0 0 0 0 0 0 0 0 1 2 1 1 2 3 5
0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 2 3
0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 2
0 0 0 0 0 0 0 0 0 0 0 0 1 2 0 1 1 3 4

0 0 0 0 0 0 0 0 0 0 0 0 0 8 0 0 0 8 8
0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0 0 0 0 0 2 1 1 0 3 1 4
0 0 0 0 0 0 0 0 0 0 0 0 7 13 2 5 9 18 27

0 0 0 0 0 0 0 0 0 0 0 0 9 23 3 5 12 28 40
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 0 4 2 6
0 0 0 0 0 0 0 0 0 0 0 0 1 9 0 1 1 10 11
0 0 0 0 0 0 0 0 0 0 0 0 3 2 0 0 3 2 5
0 0 0 0 0 0 0 0 0 0 0 0 3 10 1 4 4 14 18
OENONI 1 OENONI 2 APREN Total TOTAL
B L B L B L B L
L P L+P
L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 11 0 2 0 13 13

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0 0 0 0 1 3 0 2 1 5 6
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 6 8 2 1 8 9 17

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 2 1 0 0 2 1 3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

OEKABITI, 31 OKTOBER 2022

PELAPOR
 LAPORAN BULANAN
REKAPITULASI POLI GIGI BULAN NOVEMBER TAHUN 2021 DI PUSKESMAS DAN JE
KABUPATEN KUPANG PUSKESMAS OEKABITI

NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1

No Elemen Data B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L
I Total Kunjungan Poli Gigi :
1 Bulan ini 4 11 0 1 1 3 3 1 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Kumulatif s.d. Bulan lalu 49 90 6 21 8 7 13 20 5 11 0 3 3 2 3 4 4 6 1 0 8 6 2 7 4 3 2

II Kelompok Umur :
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 2 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 6 0 1 1 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 45 – 54 tahun 2 2 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 1 0 0 0 0 0 0 1 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 > 70 tahun 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran :

1 Bumil 0 3 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 4 7 0 0 1 3 3 1 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

IV Asal Pasien :
1 Datang sendiri 4 11 0 1 1 3 3 1 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa :
1 Karies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 2 4 0 0 1 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 1 5 0 0 0 3 3 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 1 2 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1
No Elemen Data B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L
VI Tindakan :
Konsultasi Dokter Gigi/perawat 4 11 0 1 1 3 3 1 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
701 gigi
Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Jam Dinas
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 708 Pencabutan gigi permanen 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
710 premidikasi/Lain2 1 3 0 0 1 3 3 1 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

VII Rujukan :
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.

Mengetahui
KEPALA PUSKESMAS OEKABITI

ADRIANA TAROTJI BETY,S.Tr.Keb

NIP. 19730420 199212 2 001
RAN BULANAN
ER TAHUN 2021 DI PUSKESMAS DAN JEJARINGNYA
NG PUSKESMAS OEKABITI

OENONI 1 OENONI 2 APREN Total TOTAL

L B L B L B L
L P L+P
P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 5 18 3 2 8 20 28
0 1 0 0 0 0 0 0 0 82 125 27 55 109 180 289

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 3 0 0 0 3 3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0 0 1 7 2 1 3 8 11
0 0 0 0 0 0 0 0 0 2 4 1 0 3 4 7
0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0 0 1 2 0 1 1 3 4
0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1

0 0 0 0 0 0 0 0 0 0 3 0 1 0 4 4
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 2 0 0 0 2 2
0 0 0 0 0 0 0 0 0 5 13 3 1 8 14 22

0 0 0 0 0 0 0 0 0 5 18 3 2 8 20 28
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 3 7 0 0 3 7 10
0 0 0 0 0 0 0 0 0 1 8 3 1 4 9 13
0 0 0 0 0 0 0 0 0 1 3 0 1 1 4 5
OENONI 1 OENONI 2 APREN Total TOTAL
L B L B L B L
L P L+P
P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 5 18 3 2 8 20 28

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 2 10 3 1 5 11 16

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

OEKABITI, 30 NOVEMBER 2022

PELAPOR

ADY IMANUEL ISMAU,A.Md.Kes

 NONBES OESENA KOTABES PONAIN TESBATAN 1 TESBATAN 2 OENONI 1 OENONI 2 APREN Total TOTAL
No Elemen Data B L B L B L B L B L B L B L B L B L B L
L P L+P
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan :

3 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 10 0 0 3 10 13
701 Konsultasi Dokter Gigi/perawat gigi
Konsultasi Dokter Gigi Diluar Jam 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Dinas
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 2
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Uperculektomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

VII Rujukan :
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cat : Kolom jumlah Puskesmas bisa ditambahkan atau dikurangi sesuai kondisi di Kab.

Mengetahui OEKABITI, 29 Desember 2022

KEPALA PUSKESMAS OEKABITI PELAPOR

ADY IMANUEL ISMAU, A.Md.Kes

ADRIANA TAROTJI BETY,A.Md.Keb
NIP. 19730420 199212 2 001
 LAPORAN BULANAN
REKAPITULASI POLI GIGI DI PUSTU/POSKESDES …...........................
BULAN …............................. TAHUN 2021

DESA TOTAL
No Elemen Data B L
L P L+P
L P L p
I Total Kunjungan Poli Gigi :
1 Bulan ini
2 Kumulatif s.d. Bulan lalu
II Kelompok Umur :
1 ≤ 5 tahun
2 5 – 9 tahun
3 10 – 14 tahun
4 15 – 19 tahun
5 20 – 44 tahun
6 45 – 54 tahun
7 55 – 59 tahun
8 60 – 69 tahun
9 > 70 tahun
III Kelompok Sasaran :
1 Bumil
2 Balita
3 Anak SD/MI
4 Lain-lain
IV Asal Pasien :
1 Datang sendiri
2 Rujukan
3 Kiriman kader
V Diagnosa :
1 Karies
2 Penyakit Gusi
3 Penyakit Pulpa
4 Lain - lain
VI Tindakan :
1 Konsultasi Dokter Gigi
Konsultasi Dokter Gigi Diluar Jam
2 Dinas
3 Tumpatan sementara
4 Tumpatan tetap
5 Pembersihan karang gigi
6 Insisi abses
7 Pencabutan gigi sulung
8 Pencabutan gigi permanen
9 Uperculektomy
VII Rujukan :
1 Puskesmas
2 Rumah sakit
3 Faskes lainnya
…...........
Pelapor,

…...............................
 NONBES OESENA KOTABES PONAIN TESBATAN TESBATAN 2 OENONI 1 OENONI 2 APREN PUSK/D
No Elemen Data
B L B L B L B L B L B L B L B L B L B
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L
I Total Kunjungan Poli Gigi :
1 Bulan ini
2 Kumulatif s.d. Bulan lalu
II Kelompok Umur :
1 ≤ 5 tahun
2 5 – 9 tahun
3 10 – 14 tahun
4 15 – 19 tahun
5 20 – 44 tahun
6 45 – 54 tahun
7 55 – 59 tahun
8 60 – 69 tahun
9 > 70 tahun

III Kelompok Sasaran :

1 Bumil
2 Balita
3 Anak SD/MI
4 Lain-lain
IV Asal Pasien :
1 Datang sendiri
2 Rujukan
3 Kiriman kader
V Diagnosa :
1 Karies
2 Penyakit Gusi
3 Penyakit Pulpa
4 Lain - lain
VI Tindakan :
701 Konsultasi Dokter Gigi/perawat gigi
702 Konsultasi Dokter Gigi Diluar Jam Dinas
703 Tumpatan sementara
704 Tumpatan tetap
705 Pembersihan karang gigi
706 Insisi abses
707 Pencabutan gigi sulung
708 Pencabutan gigi permanen
709 Uperculektomy
VII Rujukan :
1 Puskesmas
2 Rumah sakit
3 Faskes lainnya
 LAPORAN BULANAN
REKAPITULASI POLI GIGI DI PUSKESMAS DAN JEJARINGNYA
KAB/PUSK……………….

PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA……..
B L B L B L B L B L B L B L B L B L B L B L B L
P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L
BULANAN
SKESMAS DAN JEJARINGNYA
……………….

PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA…….. PUSK/DESA……..

L B L B L B L B L B L B L B L B L
P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L