1.

Petugas Entri Data

REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

1 2 3 V 5 6
3 6 0 4 0 3 0 Bulan : 2022
NAMA FASKES/ PUSKESMAS ANYAR 7 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

STATUS PESERTA KB (Kode)

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
ISTRI

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN

KOMPLIKASI BERAT
PENCABUTAN DAN

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN

PENCABUTAN
NAMA SUAMI

KEGAGALAN
PEMBERIAN/
TANGGAL

OPERATIF/
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

LAINNYA

MANDIRI
LAHIR

TIDAK

APBN

APBD
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-Apr-2022 Hanari 3 6 7 2 0 4 5 8 0 8 9 7 0 0 0 1 Qurotul aini 18-Aug-1997 Kubar 3 0 0 0 3 0 0 1 1 0 0 0

2 01-Apr-2022 Bayu 3 6 0 4 3 0 5 6 0 7 9 8 0 0 0 2 Mully isnaini 16-Jul-1998 Tegal 3 0 0 0 3 0 0 1 1 0 0 0

3 01-Apr-2022 Rahmatullah 3 6 7 2 0 4 6 5 0 9 9 6 0 0 0 4 Ajah 25-Sep-1996 Pasir sereh baru 3 1 0 0 3 0 0 1 1 0 0 0

4 01-Apr-2022 Dede Priyadi 3 6 0 4 3 0 5 3 1 0 0 0 0 0 0 1 Hodijah 13-Oct-2020 Kubar 3 0 0 0 3 0 0 1 1 0 0 0

5 01-Apr-2022 MURTANI 3 6 9 4 3 0 5 3 0 1 0 0 0 0 0 2 SUKRIAH. N. A 03-Jan-2000 KADUDAGO 1 1 1 0 8 1 0 0 1 0 0 0

6 06-Apr-2022 SUKARNA 3 6 0 3 2 3 6 4 0 7 8 6 0 0 0 1 SISCA AMBARWATI 24-Jul-1986 KADUODENG 3 1 0 0 8 0 0 1 1 0 0 0

7 06-Apr-2022 PARNO 3 6 0 4 3 0 4 8 0 4 8 1 0 0 0 3 RUMIATI 08-Apr-1981 KP PEGADUNGAN 3 1 0 0 8 0 0 1 1 0 0 0

8 13-Apr-2022 KURDI 3 6 0 4 3 0 7 1 0 8 9 4 0 0 0 1 EKA NOVITA SARI 31-Aug-1994 KP.UMBUL SEPUR 1 1 1 0 9 1 0 0 1 0 0 0

9 13-Apr-2022 SAFAAT 3 6 0 4 3 0 6 0 0 8 7 4 0 0 0 1 SULIAH 10-Aug-1974 BOJONG 3 1 0 0 8 0 0 1 1 0 0 0

10 13-Apr-2022 WASPADA 3 6 0 4 3 0 5 1 0 3 7 8 0 0 0 0 SITI HAWA KAMILA 11-Mar-1978 KARANG JETAK 3 1 0 0 8 1 0 0 1 0 0 0

11 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Wulan safitri 18-Jul-1990 Anyar 1 1 0 1 8 1 0 0 1 0 0 0

12 15-Jun-2022 M. RIDWAN. Y 3 6 0 4 3 0 6 0 0 5 9 9 0 0 0 1 YULIYANA 20-May-1999 Kp. Warung 1 1 1 0 8 0 0 1 1 0 0 1

13 15-Jun-2022 JANURI 3 6 0 4 3 0 4 5 1 0 9 5 0 0 0 2 MASITI 05-Oct-1995 Kp. Garung 1 1 1 0 8 0 0 1 1 0 0 1

14 15-Jun-2022 nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Dewi 15-Nov-1995 Anyar 1 1 1 0 3 1 0 0 1 0 0 0

15 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Umu muhajiroh 06-Jul-1992 Anyar 1 1 0 0 3 1 0 0 1 0 0 0

16 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Sugiyanti 15-Feb-1984 Anyar 1 1 1 0 3 1 0 0 1 0 0 0

17 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Fitriyani 15-Jan-1997 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

18 15-Jun-2022 HAERUDIN 3 6 0 4 3 0 5 5 0 6 8 2 0 0 0 2 SATYAH 15-Aug-1982 PALUPUY 1 0 1 0 8 0 0 1 1 0 0 1

19 15-Jun-2022 AWANG 3 6 0 4 3 0 5 3 0 2 8 4 0 0 0 1 ROHMAH 13-Feb-1984 Kp. Kadudago 2 1 0 0 8 0 0 1 1 0 0 1

KP KARANGGE DESA BANDULU

20 15-Jun-2022 UDI SUPRIYADI 3 6 0 4 3 0 5 9 0 3 8 0 0 0 0 1 SANI 19-Mar-1980 2 1 0 0 8 0 0 1 1 0 0 1
KECAMATAN ANYAR

21 15-Jun-2022 SOHRA 3 6 0 4 3 0 4 5 1 1 7 9 0 0 0 2 ARKASIH 05-Nov-1979 Kp. Garung 2 1 0 0 8 0 0 1 1 0 0 1

22 15-Jun-2022 nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Naimah 10-Jan-1980 Anyar 1 1 1 0 3 1 0 0 1 0 0 0

23 15-Jun-2022 SETIAWAN 3 6 0 4 3 0 4 6 0 8 8 8 0 0 0 2 KUSRINI 06-Aug-1988 Kp. Kubar 2 1 0 0 8 0 0 1 1 0 0 1

24 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Sisca ambrawati 13-Jan-1995 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

25 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Dini Amalia sari 12-Mar-1986 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

26 15-Jun-2022 JERI SAPUTRA 3 6 7 3 0 6 5 7 1 1 0 1 0 0 0 1 LALA LAILATUL. Q 17-Nov-2001 Kp. Pabuaran 1 1 1 0 8 0 0 1 1 0 0 1

27 15-Jun-2022 IBNU MULKAN 3 6 0 4 3 0 5 0 0 5 9 9 0 0 0 2 MULYATI 10-May-1999 Kp. Curug warnasari 2 1 0 0 8 0 0 1 1 0 0 1

28 15-Jun-2022 NURMANDA SUMARAU 3 6 0 4 3 0 4 9 0 4 7 8 0 0 0 1 YUYUN QUROTUN UYUN 09-Apr-1978 KP .WALURAN REL 2 1 0 0 8 0 0 1 1 0 0 1

29 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Rusmiyati 30-Jan-1985 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

30 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Lala lailatul 29-Nov-1997 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

31 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Diana 24-Jun-1993 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

32 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Masiti 12-Mar-1996 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

33 15-Jun-2022 DANIEL 3 6 0 4 3 0 6 4 0 7 0 1 0 0 0 4 DIANA 24-Jul-2001 KP KAMURANG DESA 1 1 1 0 8 0 0 1 1 0 0 1

KP. CURUG WARNASARI DESA TAMBANG

34 15-Jun-2022 RIAN SUHANDI 3 6 0 4 3 0 4 9 1 0 9 7 0 0 0 2 MURSINAH 16-Oct-1997 2 1 0 0 8 0 0 1 1 0 0 1
AYAM

KP KARANGGE DESA BANDULU

35 15-Jun-2022 JUHDI SE 3 6 0 4 3 0 5 9 0 6 8 2 0 0 0 2 MASUROH 19-Jun-1982 1 1 0 1 9 0 0 1 1 0 0 1
KECAMATAN ANYAR

36 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Nia habibah 19-Nov-1996 Anyar 1 0 1 0 6 1 0 0 1 0 0 0

37 15-Jun-2022 HOIRUL ANWAR 3 6 0 4 3 0 7 0 1 2 9 9 0 0 0 4 LIA NUR SAFITRI 30-Dec-1999 KP. CIGONDANG 1 1 1 0 8 0 0 1 1 0 0 1

38 15-Jun-2022 A. RIDLA. A 3 6 7 2 0 4 4 8 0 1 0 1 0 0 0 1 WULAN SAFITRI 08-Jan-2001 Kp. Waluran 1 1 1 0 8 0 0 1 1 0 0 1

39 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Anita 27-Nov-1984 Anyar 1 1 1 0 3 1 0 0 1 0 0 0

40 15-Jun-2022 TB. SAHRIL 3 6 7 3 0 1 6 2 0 6 8 9 0 0 0 3 FITRIYANI 22-Jun-1989 Kp. Rahayu 1 1 1 0 8 0 0 1 1 0 0 1

41 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Lia nur Safitri 22-Mar-1995 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

42 15-Jun-2022 ENDANG. S 3 2 0 1 2 0 4 5 1 2 8 4 0 0 0 4 DINI AMALIANA. S 05-Dec-1984 Kp. Kadu odeng 1 1 1 0 8 0 0 1 1 0 0 1

KP KARANGGE DESA BANDULU

43 15-Jun-2022 SUROHMAN 3 6 0 4 3 0 4 9 0 6 8 4 0 0 0 5 SARWIYAH 09-Jun-1984 2 1 0 0 8 0 0 1 1 0 0 1
KECAMATAN ANYAR

44 15-Jun-2022 HAGI SUGARA 3 6 0 4 3 0 4 1 1 1 9 8 0 0 0 1 DIANA NOVITA. L 01-Nov-1998 Kp. Sukajadi 1 1 1 0 8 0 0 1 1 0 0 1

45 15-Jun-2022 HASAN BASRI 3 6 0 4 3 0 5 0 0 3 8 8 0 0 0 5 YESI SUSIYANTI 10-Mar-1988 KP SIMPANG TIGA 2 1 0 0 8 0 0 1 1 0 0 1

46 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Uun uniah 15-Feb-1994 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

47 15-Jun-2022 NASRUDIN 3 6 0 4 3 0 4 3 1 1 0 3 0 0 0 5 NOVIATUL KHOTIMAH 03-Nov-2003 KP CIJERUK 1 1 1 0 8 0 0 1 1 0 0 1

48 15-Jun-2022 PARNO 3 6 0 4 3 0 4 8 0 4 8 1 0 0 0 3 RUMIATI 08-Apr-1981 KP PEGADUNGAN 2 1 0 0 8 0 0 1 1 0 0 1

49 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Satiah 08-Dec-1988 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

50 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Dewi kuniasari 19-Mar-1992 Anyar 1 1 1 0 3 1 0 0 1 0 0 0

51 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Linda 19-Jan-1994 Anyar 1 1 1 0 3 1 0 0 1 0 0 0

52 15-Jun-2022 JAENUDIN 3 6 0 4 3 0 6 8 0 7 8 1 0 0 0 1 KHUSNUL KHOTIMAH 28-Jul-1981 KP.GINTUNG 2 1 0 0 8 0 0 1 1 0 0 1

53 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Maryunani 21-Mar-1991 Anyar 1 1 0 1 3 1 0 0 1 0 0 0

54 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Yayah 19-Dec-1984 Anyar 1 1 1 0 3 1 0 0 1 0 0 0

55 15-Jun-2022 KASMIN 3 6 0 4 3 0 6 3 0 3 8 0 0 0 0 1 MASRENI 23-Mar-1980 Kp. Kadudago 2 1 0 0 8 0 0 1 1 0 0 1

56 15-Jun-2022 ROMAY .I.T 3 6 0 4 3 0 6 7 0 4 9 2 0 0 0 4 YURIKA 27-Apr-1992 Kp. Samboja 2 1 0 0 8 0 0 1 1 0 0 1

57 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Ana gurita husna 24-Dec-1997 Anyar 1 1 1 0 3 1 0 0 1 0 0 0

58 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Diana Novita lestari 09-Jan-1993 Anyar 1 1 0 1 8 1 0 0 1 0 0 0

59 15-Jun-2022 PETTER. B 3 6 0 4 3 0 5 3 0 5 8 3 0 0 0 3 REZA UTAMI. P 13-May-1983 Kp. Kisepuh 2 1 0 0 8 0 0 1 1 0 0 1

60 15-Jun-2022 HADIYAN 3 6 7 2 0 4 4 7 0 9 7 6 0 0 0 2 RUSMIYATI 07-Sep-1976 Kp. Pabuaran 1 1 1 0 8 0 0 1 1 0 0 1

61 15-Jun-2022 TIBI SAHRULLAH 3 6 0 4 3 0 5 3 0 8 8 8 0 0 0 2 YENI FAUZIAH 13-Aug-1988 Kp. Simpangtiga 2 1 0 0 8 0 0 1 1 0 0 1

62 15-Jun-2022 DEDI MUKHTAR 3 6 0 1 2 7 4 5 0 5 0 1 0 0 0 1 UUN UNIAH 02-Mar-2001 KP.SIRIH LOR 1 1 1 0 8 0 0 1 1 0 0 1

63 15-Jun-2022 HARYADIMAN 3 6 0 4 3 0 5 6 0 8 8 5 0 0 0 2 IKA WATI 16-Aug-1985 Kp. Pegadungan 2 1 0 0 8 0 0 1 1 0 0 1

64 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Noviatul khotimah 24-Nov-2000 Anyar 1 1 1 0 8 1 0 0 1 0 0 0

65 15-Jun-2022 Nn 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Masuroh 16-Mar-1978 Anyar 1 1 1 0 9 1 0 0 1 0 0 0

 66 22-Jun-2022 AHMAD JAMALUDIN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 OKOY 20-May-1976 Kp. Sirih lor 3 1 0 0 8 0 0 1 1 0 0 1

67 22-Jun-2022 FEBRIA ANDIKA 1 3 0 8 1 9 5 3 1 1 9 8 0 0 0 2 SITI NURANISAH 13-Nov-1998 KP. RAHAYU 1 1 1 0 8 0 0 1 1 0 0 1

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 Data Lamp.R/I/KB/20
LAMPIRAN R/I/KB/20 Lembar 3

1 2 3 4 5 V
3 6 0 4 0 3 0 Bulan : 2022
NAMA FASKES/ PUSKESMAS ANYAR 7 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 INFORMED PB DAN KESERTAAN JKN PEMBERIAN INFORMED

NO. METODE KONTRASEPSI CONSENT CONSENT (Untuk
(Untuk PB) PB PASCA PB PASCA Peserta KB Ulangan)
GANTI CARA PELAYANAN ULANG PENCABUTAN KOMPLIKASI BERAT 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 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
2 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
3 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
4 IMPLAN 0 0 0 0 0 0 1 0 1 0 0
5 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
6 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
7 IMPLAN 1 0 0 0 1 0 0 0 0 0 0
8 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
9 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
10 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
11 IMPLAN 0 0 0 0 0 0 1 0 1 0 0
12 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
13 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
14 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
15 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
16 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
17 IMPLAN 0 0 0 0 0 0 1 0 1 0 0
18 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
19 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
20 IMPLAN 0 0 0 0 0 0 1 1 0 0 0
21 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0
22 IMPLAN 0 0 0 0 1 0 0 0 0 0 0

JUMLAH 40 27 0 27 37 0 22 16 9 0 0 0

Serang , 16-November-2022
Pimpinan Faskes KB/Jaringan/Jejaring*

197408222002122003
NIP/NRP
* Coret yang tidak perlu