1.

Petugas Entri
Data
REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

1 2 3 4 5 6
3 2 7 4 0 0 3 Bulan : 2023
NAMA FASKES/ PUSKESMAS KALI JAGA PERMAI V 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

PESERTA KB JENIS TINDAKAN Kasus PENGGUNAAN SUMBER ALOKON

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
STATUS PESERTA KB

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN
ISTRI

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN
PENCABUTAN

PENCABUTAN

KEGAGALAN
PEMBERIAN/

KOMPLIKASI
NAMA SUAMI

OPERATIF/

LAINNYA
TANGGAL

MANDIRI
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

BERAT
LAHIR

(Kode)

TIDAK

APBN

APBD
DAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1 01-Jul-2023 Zakaria 3 2 7 4 0 3 6 0 0 9 0 4 0 0 0 1 Siti Sunenti 20-Sep-2004 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

2 02-Jul-2023 Yudha 3 2 7 4 0 3 5 7 0 5 9 2 0 0 0 5 Ratu 17-May-1995 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

3 02-Jul-2023 Komarudin 3 2 7 3 0 3 4 5 0 9 9 5 0 0 1 0 Ida 05-Sep-1995 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

4 02-Jul-2023 Deni 3 2 7 4 0 3 6 5 1 2 9 1 0 0 0 8 Listiani 25-Dec-1991 Kalijaga 1 1 1 0 3 1 0 0 1 0 0 0

5 03-Jul-2023 Surahman 3 2 7 4 0 3 5 4 0 8 9 7 0 0 0 4 Siti Nuriah 14-Sep-1997 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

6 03-Jul-2023 Ali 3 2 7 4 0 3 5 6 0 4 8 7 0 0 1 1 Irma 16-Apr-1987 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

7 04-Jul-2023 Ago 3 2 7 4 0 3 6 0 0 9 9 3 0 0 0 8 Ernita 20-Sep-1993 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

8 04-Jul-2023 M.Ilham 3 2 7 4 0 5 5 5 0 6 9 4 0 0 1 3 Safitri 15-Jun-1994 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

9 05-Jul-2023 Suhendra 3 2 7 4 0 3 5 1 1 1 9 7 0 0 0 8 Novita 11-Nov-1997 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

10 05-Jul-2023 Jaya 3 2 7 4 0 3 5 2 1 1 9 7 0 0 0 5 Ade 12-Nov-1997 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

11 05-Jul-2023 Dede 3 2 7 4 0 3 6 9 0 6 8 3 0 0 0 9 Siti 29-Jun-1983 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

12 06-Jul-2023 Ahmad 3 2 7 4 0 3 6 6 0 2 9 6 0 0 0 9 Latifah 26-Feb-1996 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

13 10-Jul-2023 Boni 3 2 7 4 0 3 5 0 1 1 8 5 0 0 1 0 Siti Aisah 10-Nov-1985 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

14 10-Jul-2023 Kanafi 3 2 7 4 0 3 5 5 0 5 9 0 0 0 1 1 Herina 15-Mar-1990 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

15 10-Jul-2023 Mahfud 3 2 7 4 0 3 5 2 0 0 5 8 5 0 0 5 Irma 12-Jul-1987 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

16 10-Jul-2023 Fajar 3 2 7 4 0 3 5 2 0 3 9 2 0 0 1 8 Khoerunissa 12-Mar-1992 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

17 10-Jul-2023 Jaenal 3 2 7 4 0 3 4 5 0 8 9 3 0 0 1 1 Nur Suhastuti 06-May-1992 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

18 10-Jul-2023 Rian 3 2 7 4 0 3 6 0 0 9 9 8 0 0 0 1 Lusi 20-Sep-1998 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

19 11-Jul-2023 Biki 3 2 7 4 0 3 4 9 0 2 8 8 0 0 1 1 Siti Fatimah 09-Feb-1988 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

20 11-Jul-2023 Iman 3 2 7 4 0 3 6 4 0 9 0 0 0 0 0 6 Sekar Kelana 24-Sep-2000 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

21 11-Jul-2023 M.Jalahir 3 2 0 9 1 2 6 6 0 3 8 2 0 0 0 7 Lilis 26-Mar-1982 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

22 12-Jul-2023 Nurdayat 3 2 7 4 0 3 5 8 0 7 0 8 0 0 0 3 Evlyn 18-Jul-1980 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

23 12-Jul-2023 Nurdayat 3 2 7 4 0 3 5 8 0 7 0 8 0 0 0 3 Evelyn 18-Jul-1980 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

24 13-Jul-2023 M.Arifin 3 2 1 5 2 3 5 9 0 9 9 7 0 0 0 4 Ida 19-Sep-1997 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

25 15-Jul-2023 Arbian 3 2 7 4 0 3 5 1 0 4 0 4 0 0 0 3 Aimar 11-Apr-2001 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

26 15-Jul-2023 Kasan 3 2 7 4 0 3 4 9 0 3 8 0 0 0 0 7 Sri Rochaeni 04-Mar-1980 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

27 17-Jul-2023 Rio 3 1 7 4 0 3 6 8 0 8 8 4 0 0 0 4 Yuliana 18-Aug-1998 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

 28 20-Jul-2023 Nopan 3 2 7 4 2 3 5 5 0 7 8 1 0 0 1 1 Nurasia 15-Jul-2003 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

29 20-Jul-2023 Ari Apiah 3 2 7 4 0 5 5 7 0 7 9 9 0 0 0 6 Nina 17-Jul-1990 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

30 20-Jul-2023 Deni 3 2 7 4 0 3 6 7 1 1 9 7 0 0 1 1 Ismi 27-Nov-1997 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

31 20-Jul-2023 Iwan 3 2 7 4 0 3 5 5 0 6 9 7 0 0 1 6 Murni 15-Jun-1997 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

32 21-Jul-2023 Anan 3 2 7 4 0 3 6 8 0 9 0 1 0 0 0 3 Siti Aenah 28-Sep-2001 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

33 25-Jul-2023 Wasis 3 2 7 4 0 3 5 1 0 5 9 7 0 0 1 7 Siti Rona Dewi 11-May-1997 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

34 25-Jul-2023 Johari 3 2 7 4 0 3 6 5 0 4 9 1 0 0 0 8 Saumi 25-Apr-1991 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

35 26-Jul-2023 Sarif 3 2 7 4 0 1 5 7 0 5 9 8 0 0 0 5 Yuli Safitri 17-Mar-1998 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

36 26-Jul-2023 Amay 3 2 7 4 0 3 5 4 0 8 4 9 0 0 0 8 Icih Fauziah 14-Aug-1979 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

37 26-Jul-2023 Muarip 3 2 7 4 0 3 6 4 0 3 8 1 0 0 0 2 Maeni 24-Mar-1981 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

38 27-Jul-2023 Dicky 3 2 7 4 0 5 7 1 1 2 0 1 0 0 1 2 Putri Sari 31-Dec-2001 Kalijaga 1 1 0 0 3 1 0 0 1 0 0 0

39 29-Jul-2023 Dedi 3 2 7 4 0 3 4 1 0 4 8 4 0 0 1 3 Firma 01-Apr-1984 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

40 29-Jul-2023 Haerudin 3 2 7 4 0 3 6 3 0 1 8 4 0 0 0 6 Iriyanti 23-Jan-1984 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

41 29-Jul-2023 Agus 3 2 7 4 0 3 5 1 0 9 3 0 0 0 0 4 Nurul Ulfa 11-Sep-1993 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

42 29-Jul-2023 Tedi 3 2 7 4 0 3 6 2 0 1 8 9 0 0 0 2 Diana 22-Jan-1989 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

43 29-Jul-2023 Jajuli 3 2 7 4 0 3 5 0 0 4 9 9 0 0 0 8 Janatul 10-Apr-1999 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

44 29-Jul-2023 Ali 3 2 1 2 0 9 4 6 0 4 9 0 0 0 0 7 Tasirih 06-Apr-1994 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

45 29-Jul-2023 Heru 3 2 7 4 0 3 5 5 0 7 8 8 0 0 1 3 Yuliana 15-Jul-1980 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

46 29-Jul-2023 Endang 3 2 7 4 0 3 4 3 1 1 7 9 0 0 1 5 Saniah 03-Nov-1979 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

47 29-Jul-2023 Masud 3 2 0 8 2 2 5 0 0 8 9 9 0 0 0 2 Mega 10-Aug-1999 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

48 29-Jul-2023 Ahmad 3 2 7 4 0 3 5 0 0 8 9 4 0 0 1 2 Artin 10-Aug-1994 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

49 29-Jul-2023 Indra 3 2 7 4 0 3 6 7 0 0 1 0 0 0 5 8 Nurjanah 20-May-1987 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

50 31-Jul-2023 Suhidi 3 2 7 4 0 3 5 6 1 2 7 5 0 0 0 7 Runika 16-Dec-1975 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

51 31-Jul-2023 Tardianto 3 2 7 4 0 6 9 0 2 8 8 0 0 0 0 6 Siti Hamidah 29-Feb-1988 Kalijaga 3 1 0 0 3 1 0 0 1 0 0 0

1) Keterangan Kode

STATUS PESERTA KB KODE JENIS ALOKON (Diisi Pada Jenis Tindakan dan Kasus)
1 : Peserta KB Baru 3 : Peserta KB Ulangan 1 : Suntikan 1 Bulanan 3 : Suntikan 3 Bulanan 5 : Pil Progestin 7 : Implan 1 Batang 9 : IUD 11 : Tubektomi
2 : Peserta KB Ganti 4 : Komplikasi 2 : Suntikan 3 Bulanan 4 : Pil Kombinasi 6 : Kondom 8 : Implan 2 Batang 10 : Vasektomi

2) SELAIN STATUS PESERTA KB, JENIS TINDAKAN DAN KASUS DIISI TANDA CENTANG (V)
1. Petugas Entri Lamp.R/I/KB/20
Data LAMPIRAN R/I/KB/20 Lembar 3

1 2 3 4 5 6
3 2 7 4 0 0 3 Bulan : 2023
NAMA FASKES/ PUSKESMAS KALI JAGA PERMAI V 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

RINGKASAN HASIL PELAYANAN KB

PESERTA KB BARU (PB) PESERTA KB ULANGAN PELAYANAN KASUS

PEMBERIAN
PEMBERIAN INFORMED PB DAN KESERTAAN JKN INFORMED CONSENT
METODE
NO. CONSENT (Untuk Peserta KB
KONTRASEPSI
(Untuk PB) PB PASCA PB PASCA Ulangan) PELAYANAN ULANG KOMPLIKASI BERAT
GANTI CARA PENCABUTAN KEGAGALAN
PERSALINAN KEGUGURAN
PB JKN PB NON JKN TOTAL PB

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
2 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
3 SUNTIKAN 1 1 0 1 0 0 0 0 0 0 0
4 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
5 SUNTIKAN 1 1 0 1 0 0 0 0 0 0 0
6 SUNTIKAN 1 1 0 1 0 0 0 0 0 0 0
7 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
8 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
9 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
10 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
11 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
12 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
13 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
14 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
15 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
16 SUNTIKAN 1 1 0 1 0 0 0 0 0 0 0
17 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
18 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
19 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
20 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
21 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
22 SUNTIKAN 1 1 0 1 0 0 0 0 0 0 0

JUMLAH 13 13 0 13 1 0 38 0 38 0 0 0

Kota Cirebon , 31-July-2023

Pimpinan Faskes KB/Jaringan/Jejaring*

dr. Yati Hayati Azizah

( .................................................................................................)
197606212006042004

NIP/NRP
* Coret yang tidak perlu