INSTRUMEN

MONEV RUJUKAN NON SPESIALISTIK DARI FKTP KE FKTRL

TINGKAT KABUPATEN

NAMA KABUPATEN :

PENANGGUNG JAWAB OPROGRAM

- NAMA :

- NO HP :

PERIODE : Tahun 2023

JUMLAH
KASUS JUMLAH PERSENTASE
DIAGNOSIS NON SPESIALISTIK
NAMA RUJUKA KASUS RUJUKAN
NO YANG SERING DIRUJUK
PUSKESMAS N NON DIRUJUK NON
SPESIALI KE FKRTL SPESIALISTIK
STIK
d = b/c x diagnosis Jumlah Rujukan
100% TACC
a b C d e f g
1 UPTD 1 1693 0,06% Disorders of 20 20
PUSKESMAS refraction and
KAWAL accommodation
Dyspepsia 3 3
Essential 7 7
(primary)
hypertension
Pneumonia, 3 3
unspecified
asthma 30 30
Myopia 25 25
Respiratory 30 30
tuberculosis,
bacteriologically
and histologically
confirmed
Non-insulin- 43 43
dependent
diabetes mellitus
Otitis externa, 3 3
unspecified
Cutaneous 4 4
abscess, furuncle
and carbuncle of
trunk
Other 3 3
conjunctivitis
 Disorders of 5 5
initiating and
maintaining sleep
[insomnias]
Acute tonsillitis 4 4
Convulsions, not 5 5
elsewhere
classified
Haemorrhoids 4 4
Hypermetropia 13 13
Conjunctival 3 3
haemorrhage
Presbyopia 7 7
11 11
Other gastritis

Acute bronchitis, 5 5
unspecified
Vertigo of central 4 4
origin
Bronchitis, not 5 5
specified as
acute or chronic

10 DAFTAR DIAGNOSIS NON SPESIALISTIK YANG PALING SERING DIRUJUK

1.
2.
3.
4.
5.
6.

MASALAH DAN KENDALA

1.
 INSTRUMEN

MONEV PROGRAM PASIEN RUJUK BALIK (PRB)

TINGAKT KABUPATEN / KOTA …..

NAMA KABUPATEN/KOTA :

PENANGGUNG JAWAB OPROGRAM

- NAMA :

- NO HP :

PERIODE : Tahun …

JUMLAH PERSENTASE DIAGNOSIS KASUS PRB

KASUS PRB PROGRAM PRB
NAMA JUMLAH
NO KONTROL d = b/c x 100% diagnosis Jumlah Kontrol ke
PUSKESMAS KASUS PRB
KE Pusesmas
PUSKESMAS
a b C d e f g
1 UPTD 5 5 100% 1. HT 5 5
PUSKESMAS 2. DM
KAWAL

MASALAH DAN KENDALA

 INSTRUMEN

MONEV RUJUKAN NON SPESIALISTIK DARI FKTP KE FKTRL

DI PUSKESMAS KAWAL

NAMA PUSKESMAS : UPTD PUSKESMAS KAWAL

PENANGGUNG JAWAB

- NAMA : SESWITA, AMG

- NO HP : 081372365087

PERIODE : Tahun 2023

JUMLAH
KODE KASUS PRB
KASUS YANG JUMLAH PERSENTASE
NO DIAG YANG KETERANGAN
DIRUJUK KASUS PRB PROGRAM PRB
NOSIS KONTROL KE
PUSKESMAS
a b C d e = c/d x 100% g
1 Disorders of H52 5 5 100 %
refraction
and
accommodati
on
Dyspepsia K30
Essential I10
(primary)
hypertension
Impacted H61.2
cerumen
Pneumonia, J18
unspecified
Mixed J45.8
asthma
Myopia H52.1
Astigmatism H52.2
Respiratory A16
tuberculosis,
bacteriologic
ally and
histologically
confirmed
Dermatophyt B35.9
osis
Non-insulin- E11
dependent
diabetes
mellitus
Asthma J45
Otitis H60.9
externa,
unspecified
Cutaneous L02.2
abscess,
furuncle and
carbuncle of
trunk
Other H10.8
conjunctivitis
Disorders of G47.0
initiating and
maintaining
sleep
[insomnias]
Inflammatory N61
disorders of
breast
Tinea pedis B35.3
Acute J03
tonsillitis
Convulsions, R56
not
elsewhere
classified
Unspecified O06.9
abortion,
complete or
unspecified,
without
complication
Scabies B86
Haemorrhoid I84
s
Hypermetropi H52.0
a
Conjunctival H11.3
haemorrhage
Presbyopia H52.4
Other N39
disorders of
urinary
system
 K29.6
Other
gastritis

Acute J20.9
bronchitis,
unspecified
Ulcer of L97
lower limb,
not
elsewhere
classified
Varicella B01
[chickenpox]
Folliculitis L66.4
ulerythemato
sa reticulata
Vertigo of H81.4
central origin
Hordeolum H00
and
chalazion
Urinary tract N39.0
infection,
site not
specified
Viral warts B07
Bronchitis, J40
not specified
as acute or
chronic
Chronic J31
rhinitis,
nasopharyngi
tis and
pharyngitis
Benign D17
lipomatous
neoplasm
Plasmodium B51.9
vivax malaria
without
complication

MASALAH DAN KENDALA DI PUSKESMAS