1.

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

1 2 3 4 5 6
7 3 0 3 0 0 5 Bulan : 2023
NAMA FASKES/ RSUD Prof Dr H. ANWAR MAKKATUTU 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 Dandi 7 3 0 6 0 3 5 8 0 4 9 9 0 0 0 3 Salmiati 18-Apr-1999 Tanggalla 1 1 1 0 8 1 0 0 1 0 0 0

2 01-Jul-2023 Nasir 7 3 0 3 0 2 5 7 1 5 8 6 0 0 0 1 Syukmawati 17-May-1988 jln dr ratulangi 3 1 0 0 2 1 0 0 1 0 0 0

3 01-Jul-2023 Abd hamid 7 3 0 3 0 3 5 2 0 4 8 0 0 0 0 3 Sahari 12-Apr-1980 Bangkeng buki 1 1 1 0 8 1 0 0 1 0 0 0

4 01-Jul-2023 Firman 7 3 0 6 0 3 4 1 0 7 9 2 0 0 9 8 Anha 01-Jul-1992 Pattinrokang 1 1 1 0 8 1 0 0 1 0 0 0

5 02-Jul-2023 Kamri 7 3 0 4 0 3 4 3 0 4 9 0 0 0 0 1 Saringai 03-Apr-1990 Sapanang Jenepont 1 1 1 0 8 1 0 0 1 0 0 0

6 02-Jul-2023 Mudo Firman 7 3 0 4 1 1 4 1 0 7 8 8 0 0 0 5 Nurjannah 01-Jul-1988 Ga'dea Tarowang 1 1 1 0 8 1 0 0 1 0 0 0

7 02-Jul-2023 Rusdi 7 3 0 4 0 8 4 3 0 4 9 8 0 0 0 1 Wiwik 03-Apr-1990 Tompo balang 1 1 1 0 8 1 0 0 1 0 0 0

8 02-Jul-2023 Nurul Ihzan 7 3 0 4 1 0 4 1 1 0 9 8 0 0 0 3 Irmawati syam 01-Oct-1998 Togo togo 1 1 1 0 8 1 0 0 1 0 0 0

9 02-Jul-2023 H M Gazali 7 3 0 3 0 4 5 9 0 2 8 2 0 0 0 1 HJ Suryani 19-Feb-1982 paradayya 1 1 1 0 11 1 0 0 0 0 0 0

10 02-Jul-2023 Hanaping 7 3 0 3 0 3 6 8 1 1 8 9 0 0 0 3 Anita reski 28-Nov-1989 Kp bonto sapiri 1 1 1 0 8 1 0 0 1 0 0 0

11 02-Jul-2023 Syamsul 7 3 0 3 0 2 6 0 7 8 7 0 0 0 0 7 Idayanti 27-Jul-1987 paradayya 1 1 1 0 11 1 0 0 0 0 0 0

12 05-Jul-2023 Syamsir 7 3 0 3 0 2 6 1 1 1 9 7 0 0 0 2 Irmayanti 11-Dec-1987 Jalan sungai calendu 1 1 1 0 2 1 0 0 1 0 0 0

13 05-Jul-2023 - 7 3 0 3 0 2 4 4 0 8 9 5 0 0 0 6 ANNISA NURFADILLAH 08-Apr-1995 Jl.Andi manappiang 1 0 1 0 4 1 0 0 1 0 0 0

14 05-Jul-2023 Agus 7 3 0 4 0 4 5 5 0 5 8 4 0 0 0 7 Rosnia 29-Nov-1989 Bonto burungeng 1 1 1 0 11 1 0 0 0 0 0 0

15 05-Jul-2023 SYARIF ALQADRI 7 3 0 3 0 5 6 7 0 6 9 1 0 0 0 2 MUTMAINNA 27-Jul-1991 mattoanging 1 0 1 0 6 1 0 0 1 0 0 0

16 06-Jul-2023 supriadi 7 3 0 3 0 1 1 7 1 1 2 9 7 0 0 1 Saripa 31-Dec-1997 Bangkeng bonto 1 1 1 0 8 1 0 0 1 0 0 0

17 06-Jul-2023 Muh Nur Qalbi 7 3 0 3 0 7 7 0 0 8 9 9 0 0 0 4 Mita wahyuni 30-Aug-1999 Gangang baku 1 1 1 0 8 1 0 0 1 0 0 0

18 06-Jul-2023 Riswandi 6 2 0 3 0 4 6 7 1 0 0 4 0 0 0 1 Ummi ratnasari 27-Oct-2004 sunggu manai 1 1 1 0 8 1 0 0 1 0 0 0

19 07-Jul-2023 A TRI APRIL WANDI 7 3 0 3 0 5 4 3 0 1 9 7 0 0 0 1 A NUR HAJAR HAMZAH 03-Jan-1997 dampang 1 1 1 0 2 1 0 0 1 0 0 1

20 07-Jul-2023 KARMAN 7 3 0 3 0 5 4 6 0 4 0 3 0 0 0 6 MILANDA 06-Apr-2003 BORONG KALUKUA 1 1 1 0 2 1 0 0 1 0 0 0

21 07-Jul-2023 Carlito soares 7 3 0 6 1 1 5 7 0 8 8 9 0 0 0 3 Yanti 17-Aug-1988 Gowa 1 1 0 1 8 1 0 0 1 0 0 0

22 07-Jul-2023 - 7 3 0 3 0 3 5 0 0 7 9 7 0 0 0 2 RISMA 10-Jul-1997 Kampung arakeke 1 1 1 0 2 1 0 0 1 0 0 0

23 08-Jul-2023 Feri irawan 7 3 0 3 0 1 4 2 0 0 8 9 8 0 0 0 Husni auliyah 02-Aug-1998 Beloparang 1 1 1 0 8 1 0 0 1 0 0 0

24 08-Jul-2023 Ahmad 7 3 0 3 0 7 6 2 0 4 8 7 0 0 0 1 Rusdini 22-Apr-1987 Lele lompo 1 1 1 0 8 1 0 0 1 0 0 0

25 08-Jul-2023 Andrik chaspani 7 3 0 3 0 2 5 3 0 1 9 1 0 0 0 2 Ulfa angrani 13-Jan-1991 Biring ere 1 1 1 0 8 1 0 0 1 0 0 0

26 09-Jul-2023 Sahrir 7 3 0 4 0 9 6 7 0 3 8 7 0 0 0 1 Rosnia 27-Mar-1987 Taman roya 1 1 1 0 11 1 0 0 0 0 0 0

27 09-Jul-2023 Iwan 7 3 0 4 0 7 6 0 0 3 9 7 0 0 0 2 Rosdiana 20-Mar-1987 kelara 1 1 1 0 11 1 0 0 0 0 0 0

28 10-Jul-2023 Najamuddin 7 3 0 3 0 1 6 5 0 8 1 0 0 0 0 3 Nuraeni 25-Aug-2010 jln ta gani 1 1 1 0 8 1 0 0 1 0 0 0

29 10-Jul-2023 Abd malik 7 3 0 3 0 4 5 2 0 1 8 1 0 0 0 3 Erniati 01-Dec-1981 Batu massong 1 1 1 0 8 1 0 0 1 0 0 0

30 10-Jul-2023 Jumarlin 7 3 0 3 0 7 4 1 0 7 3 6 0 0 2 3 Syamsi 07-Jan-1996 sapa sapa 1 1 1 0 8 1 0 0 1 0 0 0

31 11-Jul-2023 ZAENAL ABIDIN 7 3 0 3 0 1 5 2 1 0 7 6 0 0 0 4 NURLINA Y 12-Oct-1976 SALLUANG 3 0 0 0 4 1 0 0 1 0 0 0

32 12-Jul-2023 Suhendra SE 7 3 0 3 0 1 4 6 0 6 9 0 0 0 0 2 St. Hardiyanti 06-Jun-1990 Jl Gunung Latimojong 1 1 1 0 8 1 0 0 1 0 0 0

33 12-Jul-2023 Aswandi 7 3 0 3 0 4 6 6 0 6 9 1 0 0 0 2 Sitti rahma 26-Jun-1991 Taruttu 1 1 1 0 8 1 0 0 1 0 0 0

34 13-Jul-2023 Muh Hajar 7 6 0 2 0 1 4 9 0 3 9 2 0 0 0 3 Anita purnamasari 09-Mar-1997 ganrang batu 1 1 1 0 2 1 0 0 1 0 0 0

35 14-Jul-2023 Riswan 7 3 0 4 0 2 4 2 0 8 9 0 0 0 0 1 Nurislamiah 02-May-1990 Bungung lompoa 1 1 1 0 8 1 0 0 1 0 0 0

36 15-Jul-2023 JUDDING 7 3 0 3 0 2 4 8 0 5 6 5 0 0 0 1 NURSYAM 08-May-1965 JLN.SUNGAI CALENDU 3 0 0 0 4 1 0 0 1 0 0 0

37 16-Jul-2023 Ramli 7 3 0 3 0 1 2 0 1 0 0 9 0 0 0 3 NurAisyah 17-May-2003 Baruga 1 1 1 0 8 1 0 0 1 0 0 0

38 16-Jul-2023 Nurafdan 7 3 0 3 0 7 5 6 0 5 8 9 0 0 0 1 Mutmainna 16-May-1989 jl. bungung barania 4 1 0 0 8 0 0 0 0 0 0 0

39 17-Jul-2023 Akbar 7 3 0 3 0 8 4 8 0 6 0 4 0 0 0 1 Alfiranda putri 28-Jun-2004 Parasangang beru 1 1 1 0 8 1 0 0 1 0 0 0

40 17-Jul-2023 Firman 7 3 0 4 1 0 6 7 0 8 9 2 0 0 0 3 Suri 27-Aug-1992 Bt loe 1 1 1 0 8 1 0 0 1 0 0 0

41 18-Jul-2023 Rahman 7 3 0 3 0 2 4 5 0 5 0 9 0 0 0 2 Darmawati 06-May-2009 gamacayya 1 1 1 0 8 1 0 0 1 0 0 0

42 20-Jul-2023 Anci 7 3 0 2 0 8 4 7 0 8 9 0 0 0 0 1 Sulhati 07-Aug-1990 Tabuakang 1 1 0 0 8 1 0 0 1 0 0 0

43 20-Jul-2023 Ismail 7 3 0 4 0 4 5 8 1 2 0 0 0 0 0 1 Ernawati 18-Dec-2000 Bonto laya 1 1 1 0 8 1 0 0 1 0 0 0

44 20-Jul-2023 Jamaluddin 7 3 0 3 0 2 6 6 0 9 9 5 0 0 0 2 Ratna dewi sari 25-Sep-1995 Jalan andi mannappiang 1 1 1 0 8 1 0 0 1 0 0 0

45 20-Jul-2023 IMMAWAN WAHYUDI 7 3 0 2 0 2 5 1 0 6 8 9 0 0 0 3 ANDI ULFIANI 25-Jun-1989 Caile 1 1 1 0 9 1 0 0 1 0 0 0

46 20-Jul-2023 Saeful 7 3 0 4 0 5 5 1 0 4 9 9 0 0 0 1 Ardiyabti rahman 11-Apr-1999 Balambongan 1 1 1 0 8 1 0 0 1 0 0 0

47 20-Jul-2023 DAHLAN 6 4 0 3 0 5 5 0 0 4 9 4 0 0 0 1 ANDI FILIK 30-Apr-1994 Jl. kusuma bangsa 1 1 1 0 9 1 0 0 1 0 0 0

48 20-Jul-2023 RISWAN 7 3 0 3 0 2 7 1 0 7 8 8 0 0 0 1 DARMAWATI 11-Jul-1988 kampung beru 3 0 0 0 4 1 0 0 1 0 0 0

A M Ikhwan Al
49 21-Jul-2023 7 3 0 2 0 2 5 8 0 6 0 3 0 0 0 1 Dahlia amalia harun 18-Jun-2003 Kampung bendi 1 0 1 0 6 1 0 0 1 0 0 0
ghifati

50 21-Jul-2023 Sahauddin 7 3 7 1 0 3 6 1 0 4 8 9 0 0 1 0 Indayani 21-Apr-1989 Paradayya 1 1 1 0 11 1 0 0 0 0 0 0

51 21-Jul-2023 Jamaris 7 3 0 3 0 2 6 6 0 6 8 9 0 0 0 3 ERvina ernawati 25-Jun-1989 Jalan sungai bialo 1 1 1 0 11 1 0 0 0 0 0 0

52 26-Jul-2023 Ahmad arsyad 7 3 0 6 0 3 5 4 1 1 0 4 0 0 0 2 Novia sulfitri 01-Jul-1962 mampua 1 1 1 0 11 1 0 0 0 0 0 0

53 26-Jul-2023 Sahaba 7 3 0 3 0 4 4 1 0 7 8 6 0 1 9 3 Hasni 01-Jul-1986 B.ingru 1 1 1 0 9 1 0 0 1 0 0 0

54 26-Jul-2023 Supriadi 7 3 0 3 0 7 6 8 1 0 8 6 0 0 0 2 LILI SURYANI 08-Feb-1986 BTN.Grand Valley 3 1 0 0 8 1 0 0 1 0 0 0

55 27-Jul-2023 MALIK 7 3 0 3 0 3 4 8 1 2 9 1 0 0 0 3 ST MARWATI 12-Jun-1991 JANNAYYA 1 1 1 0 8 1 0 0 1 0 0 0

56 27-Jul-2023 RIDWAN 7 3 0 3 0 3 4 2 0 1 9 2 0 0 0 2 SURYANI 01-Feb-1992 Bonto Sapiri 1 1 1 0 8 1 0 0 1 0 0 0

57 27-Jul-2023 AMBANG 7 3 0 3 0 1 1 7 1 1 2 9 0 0 0 3 SARI 12-Mar-1990 Kayu Lompoa 1 1 1 0 8 1 0 0 1 0 0 0

58 27-Jul-2023 Nurdin 7 3 0 4 0 5 6 7 0 8 8 7 0 0 0 1 Gaida teapon 29-Jun-1988 Jombe selatan 1 1 1 0 9 1 0 0 1 0 0 0

59 27-Jul-2023 Arifin 7 3 0 3 0 5 4 7 1 0 8 4 0 0 0 2 Nurmiah 27-Oct-1984 Ujung katinting 1 1 1 0 11 1 0 0 0 0 0 0

60 27-Jul-2023 KHABIB LASINRANG 7 3 0 3 0 2 5 2 1 0 9 8 0 0 0 3 ELSA DWI NURUL 10-Dec-1998 JL PEMUDA 1 1 1 0 8 1 0 0 1 0 0 0

61 28-Jul-2023 Ilham firmansa 7 3 0 3 0 2 5 9 0 2 9 7 0 0 0 1 Sri rahmi 19-Feb-1979 jalan pemuda 1 1 1 0 11 1 0 0 0 0 0 0

62 28-Jul-2023 Haidir 7 3 0 3 0 2 4 6 0 4 9 7 0 0 0 1 Regita Nurul Aprilia 04-Jun-1997 Jln.Dr Ratulangi 1 1 1 0 8 1 0 0 1 0 0 0

63 28-Jul-2023 MUHTAR 7 3 0 3 0 2 6 2 1 2 8 7 0 0 0 1 ANDI DESI RATNASARI 22-Dec-1987 JLN MAWAR 1 1 1 0 2 1 0 0 1 0 0 0

64 30-Jul-2023 Asdar 7 3 7 1 1 4 6 9 1 2 8 4 0 0 0 8 Rosmiati 12-Sep-1984 Beloparang 1 1 1 0 11 1 0 0 0 0 0 0

65 31-Jul-2023 Syamsul alam 7 3 0 3 0 5 4 1 1 0 8 9 0 0 0 1 Wina oktaviana 01-Oct-1989 Rappoa 1 1 1 0 9 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
7 3 0 3 0 0 5 Bulan : 2023
NAMA FASKES/ RSUD Prof Dr H. ANWAR MAKKATUTU 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 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
2 IUD 1 1 0 1 1 0 0 0 0 0 0
3 IUD 1 1 0 1 1 0 0 0 0 0 0
4 KONDOM 0 1 0 1 1 0 0 0 0 0 0
5 IMPLAN 1 1 0 1 0 0 0 0 0 0 0
6 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
7 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
8 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
9 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
10 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
11 PIL 0 0 0 0 0 0 0 0 1 0 0
12 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
13 PIL 0 1 0 1 1 0 0 0 0 0 0
14 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
15 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
16 PIL 0 0 0 0 0 0 0 0 1 0 0
17 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
18 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
19 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0
20 MOW 1 1 0 1 1 0 0 0 0 0 0
21 MOW 1 1 0 1 1 0 0 0 0 0 0
22 SUNTIKAN 1 1 0 1 1 0 0 0 0 0 0

JUMLAH 56 59 0 59 57 0 2 0 5 1 0 0

Bantaeng , 09-September-2023
Pimpinan Faskes KB/Jaringan/Jejaring*

NURRATNA, S.ST.
( .................................................................................................)
197307011993022002

NIP/NRP
* Coret yang tidak perlu