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 7 V 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-Aug-2023 M Idrus 7 3 0 3 0 2 4 2 0 3 9 8 0 0 0 3 reski nuramalia 02-Sep-1998 jalan T A gani 1 1 1 0 8 1 0 0 1 0 0 0

2 01-Aug-2023 Arif risnandar 7 3 0 3 0 8 6 1 0 4 9 1 0 0 0 1 Musdalifah 21-Apr-1991 MorowA 1 1 1 0 8 1 0 0 1 0 0 0

3 01-Aug-2023 Henri jaya 7 3 0 2 0 7 4 9 0 9 9 9 0 0 0 4 Nurfadillah 09-Sep-1999 Balang beru 1 1 1 0 8 1 0 0 1 0 0 0

4 01-Aug-2023 Usman 7 3 0 3 0 2 4 7 0 8 8 3 0 0 0 2 Rosma 07-Aug-1983 Tino Toa Bissappu 1 0 1 0 4 1 0 0 1 0 0 0

5 01-Aug-2023 Sukramto 7 3 0 3 0 1 4 5 0 8 8 3 0 0 0 1 Ahrianti 05-Aug-1983 Panaikang 4 0 0 0 8 0 0 0 0 0 0 0

6 01-Aug-2023 Jusman 7 3 0 4 1 1 5 3 0 6 9 7 0 0 0 2 Anita 13-Jun-1997 Bungung Konci 1 1 1 0 8 1 0 0 1 0 0 0

7 02-Aug-2023 Hiswanto Nur 7 3 0 4 1 1 6 9 0 6 9 9 0 0 0 2 Widyawati 29-Jun-1999 Simpang 1 0 1 0 4 1 0 0 1 0 0 0

8 02-Aug-2023 Ical 7 3 0 3 0 2 6 7 0 5 9 4 0 0 0 4 Ita armita 27-May-1994 JL Bungung Barania 1 1 1 0 8 1 0 0 1 0 0 0

Muhammad alam
9 02-Aug-2023 7 3 0 4 1 1 6 6 0 3 9 8 0 0 0 2 Sri Rahayu 23-Mar-1998 Ujung Barat 1 0 1 0 4 1 0 0 1 0 0 0
sabirin

10 02-Aug-2023 Amri 7 3 0 3 0 2 4 9 0 4 9 6 0 0 0 1 Risma ratna sari 09-Apr-1996 Jalan sungai calendu 1 1 1 0 8 1 0 0 1 0 0 0

11 02-Aug-2023 Samir 7 3 0 4 0 5 4 2 0 5 0 0 0 0 0 2 Pratiwi 10-Nov-2000 Maccini baji 1 1 1 0 8 1 0 0 1 0 0 0

12 04-Aug-2023 Arfan 7 3 0 6 1 1 7 1 1 2 0 9 0 0 0 1 Yayu 31-Dec-2009 Barocia 1 1 1 0 8 1 0 0 1 0 0 0

13 05-Aug-2023 Arjun 7 3 0 4 1 0 7 1 1 2 9 3 0 2 0 6 Rosniati 29-Aug-1996 Jangang Jangang 1 0 1 0 4 1 0 0 1 0 0 0

14 05-Aug-2023 jefriadi 7 3 0 4 0 2 4 1 0 3 9 3 0 0 0 4 sanniati 01-Mar-1993 mattiro baji 1 1 1 0 11 1 0 0 0 0 0 0

15 05-Aug-2023 Satriman 7 3 0 2 0 7 4 2 1 0 9 1 0 0 0 1 Mutmainnah 02-Jun-1991 Bonto Lebang 1 0 1 0 4 1 0 0 1 0 0 0

16 06-Aug-2023 Hendra 7 3 0 4 0 8 4 1 1 2 9 3 0 0 0 1 Riskawati 01-Sep-1993 Balang Toa 1 0 1 0 4 1 0 0 1 0 0 0

17 07-Aug-2023 Eri 7 3 0 4 0 5 4 6 0 8 0 2 0 0 0 2 Nurul 06-Aug-1999 Bonto Rannu 1 0 1 0 2 1 0 0 1 0 0 0

18 07-Aug-2023 ruddin 7 3 0 4 1 0 4 5 0 4 9 5 0 0 0 1 Caya 05-Apr-1995 pa'baeng Rumbia 1 0 1 0 2 1 0 0 1 0 0 0

19 07-Aug-2023 Andi Binanta 7 3 0 4 0 5 6 4 0 4 9 8 0 0 0 1 Joharni 24-Apr-1998 petang 1 0 1 0 2 1 0 0 1 0 0 0

20 07-Aug-2023 abd azis 7 3 0 4 0 5 5 2 0 1 9 2 0 0 0 4 Nurlina 12-Jan-1992 Sunggu mana 1 0 1 0 2 1 0 0 1 0 0 0

21 07-Aug-2023 Rudi 7 3 0 4 0 2 5 6 0 2 8 3 0 0 0 2 Risnawati 16-Feb-1983 Sangingloe 1 1 1 0 11 1 0 0 0 0 0 0

22 08-Aug-2023 Supriadi 7 3 0 4 0 5 4 2 0 2 9 5 0 0 0 2 Kaspina 02-Apr-1995 padekokang 1 1 1 0 8 1 0 0 1 0 0 0

23 08-Aug-2023 A M Ikhwan 7 3 0 2 0 2 5 8 0 6 0 9 0 0 0 1 dahlia amalia 18-Jun-2003 Pao 1 1 1 0 8 1 0 0 1 0 0 0

24 10-Aug-2023 Kasmir 7 3 0 4 0 5 5 0 5 8 6 6 0 0 0 4 Asseng 10-May-1986 Sunggu manai 1 1 1 0 11 1 0 0 0 0 0 0

25 10-Aug-2023 Riswandi Wais 7 3 0 3 0 4 5 9 1 2 9 6 0 0 0 1 Erna 10-Aug-1996 Bulo Bulo 1 0 1 0 4 1 0 0 1 0 0 0

26 10-Aug-2023 Irfan 7 3 0 4 0 8 5 6 0 7 9 2 0 0 0 2 Kasmila 16-Jul-1992 Mattoanging 1 0 1 0 4 1 0 0 1 0 0 0

27 10-Aug-2023 Muh Faisal Irsan 7 3 0 4 0 4 4 6 1 0 0 4 0 0 0 3 Kasmiati 10-Jun-2004 Kaluku 1 0 1 0 4 1 0 0 1 0 0 0

28 10-Aug-2023 Arman Maulana 7 3 0 4 0 3 7 1 0 7 9 8 0 0 0 4 Nur Mita 31-Jul-1998 Empoang Selatan 1 0 1 0 4 1 0 0 1 0 0 0

29 11-Aug-2023 - 7 3 0 3 0 2 6 4 0 9 9 6 0 0 0 2 Irnawati 04-Feb-1996 Jl Pemuda 1 1 0 1 8 1 0 0 1 0 0 0

30 11-Aug-2023 Rahman 7 3 0 2 0 5 5 6 1 2 9 7 0 0 0 2 LILI Hardianti 12-Dec-1997 kayu loe 1 1 1 0 8 1 0 0 1 0 0 0

31 11-Aug-2023 andi parawanda 7 3 0 2 0 2 5 2 1 2 9 9 0 0 0 4 Tasya amanda 12-Dec-1999 Lingk.Doajang 1 1 1 0 9 1 0 0 1 0 0 0

32 11-Aug-2023 A Jamaluddin 7 3 0 2 1 0 6 3 0 5 8 3 0 0 0 2 Nurhayati 23-May-1983 Bonto bangung 1 1 1 0 11 1 0 0 0 0 0 0

33 11-Aug-2023 Kasman 7 3 0 4 1 1 5 9 0 9 8 8 0 0 0 1 Sukaeni 19-Sep-1988 Kampung beru 1 1 1 0 11 1 0 0 0 0 0 0

34 12-Aug-2023 Rangga aprianto 7 3 0 3 0 2 6 7 0 1 9 7 0 0 0 4 Resky arini syahrir 17-Jul-1997 BTN Arakeke 1 1 1 0 9 1 0 0 1 0 0 0

35 12-Aug-2023 H Syukur 7 3 0 4 1 1 6 5 0 5 9 6 0 0 0 1 hastuti 09-Nov-1991 BT Baru 1 1 1 0 11 1 0 0 0 0 0 0

36 12-Aug-2023 Alam 7 3 7 1 1 3 4 8 1 2 8 0 0 0 1 1 samasinar 08-Dec-1980 Biring kassi 1 1 1 0 11 1 0 0 0 0 0 0

37 13-Aug-2023 Syahrul 7 3 0 3 0 1 6 6 0 5 8 2 0 0 0 1 Murniati 26-May-1982 cabodo 1 1 1 0 11 1 0 0 0 0 0 0

38 14-Aug-2023 Ardi 7 3 0 4 0 5 5 7 0 8 8 9 0 0 0 2 Erni 17-Aug-1989 Bungung Papara 1 0 1 0 2 1 0 0 1 0 0 0

39 15-Aug-2023 Asman 7 3 0 3 0 2 6 3 0 3 8 7 0 0 0 4 Isnawati 23-Mar-1987 Jalan sungai calendu 1 1 1 0 11 1 0 0 0 0 0 0

40 16-Aug-2023 Sahrul 7 3 0 3 0 4 4 1 0 7 7 8 0 2 5 2 Fatmawati 07-Aug-19977 Dusun Ganting 4 1 0 0 9 0 0 0 0 0 0 0

41 16-Aug-2023 Saparuddin 7 3 0 3 0 8 6 2 0 6 0 4 0 0 0 1 Anita 22-Jun-2004 Borong Ganjeng 1 0 1 0 4 1 0 0 1 0 0 0

42 16-Aug-2023 Ansyar 7 3 0 3 0 1 6 5 1 0 9 6 0 0 0 3 Sunarti 25-Oct-1996 Dodoki 1 0 1 0 4 1 0 0 1 0 0 0

43 16-Aug-2023 Yusran Safutra 7 3 0 4 0 5 5 3 0 8 9 8 0 0 0 1 Eka Asmira M 13-Aug-1998 Bungung Carammeng 1 0 1 0 4 1 0 0 1 0 0 0

44 17-Aug-2023 Romang 7 3 0 3 0 6 5 7 1 2 9 7 3 0 0 1 Mardiana 17-Dec-1997 Bungung Barua 1 0 1 0 2 1 0 0 1 0 0 0

45 18-Aug-2023 Hamrin 7 3 0 3 0 7 4 2 0 4 8 8 0 0 0 1 Kamelia 05-Jan-1987 Saukang 1 0 1 0 2 1 0 0 1 0 0 0

46 18-Aug-2023 Alamsyah 7 3 0 3 0 1 4 2 0 5 9 1 0 0 0 2 Elfiana 02-May-1991 Kareng Maja 1 0 1 0 2 1 0 0 1 0 0 0

47 19-Aug-2023 Abd rahman 7 3 0 4 1 1 4 7 1 1 8 9 0 0 0 1 Herlina 07-Nov-1989 Gaddea 1 1 1 0 11 1 0 0 0 0 0 0

48 20-Aug-2023 Muh Basir 7 3 0 3 0 1 4 5 0 3 8 2 0 0 0 3 Hawali 05-Mar-1962 Tino Toa 1 0 1 0 4 1 0 0 1 0 0 0

49 20-Aug-2023 Syamsul alam 7 3 0 3 0 4 4 1 1 1 9 7 0 0 0 1 Marwati 01-Nov-1997 Bonto2a 1 1 1 0 11 1 0 0 0 0 0 0

50 20-Aug-2023 Hambali 7 3 0 3 0 1 4 4 0 3 7 9 0 0 0 1 Ardiani 04-Mar-1979 Tino Toa 1 0 1 0 4 1 0 0 1 0 0 0

51 20-Aug-2023 Syafriadi 7 3 0 7 0 7 4 7 1 2 8 4 0 0 0 3 Sri wahyuni 07-Dec-1984 Jalan merpati baru 1 1 1 0 11 1 0 0 0 0 0 0

52 20-Aug-2023 Pawe 7 3 0 3 0 6 6 0 0 6 8 5 0 0 0 1 Fitriani 20-Jun-1985 Bangkeng bonto 1 1 1 0 11 1 0 0 0 0 0 0

53 20-Aug-2023 Amrullah 7 3 0 3 0 4 5 7 0 8 9 7 0 0 0 5 Eka FITRIANI 17-Aug-1997 Papua Barat 1 0 0 0 4 1 0 0 1 0 0 0

54 20-Aug-2023 Zulkipli 7 3 0 3 0 2 4 7 0 1 9 5 0 0 0 1 Niar Ika Rahmadani 07-Jan-1995 Tanetea 1 0 1 0 4 1 0 0 1 0 0 0

55 20-Aug-2023 Asriadi 7 3 1 1 0 4 4 9 0 2 9 0 0 0 0 1 Sutriana jabir 09-Feb-1990 lacaulu 1 1 1 0 9 1 0 0 1 0 0 0

56 21-Aug-2023 Musmalyadi 7 3 0 4 0 4 6 2 0 6 6 6 0 0 0 1 Sukmawati 26-Jun-1986 Ulu Galung 1 0 1 0 2 1 0 0 1 0 0 0

57 21-Aug-2023 Nur Hamzah Haidar 7 3 0 3 0 2 4 3 0 6 0 1 0 0 0 1 Aninda maharani 03-Jun-2001 Jl Dr Ratulangi 1 0 1 0 2 1 0 0 1 0 0 0

58 23-Aug-2023 Muh Risal 7 3 0 4 0 7 6 7 0 8 8 4 0 0 0 1 Nurhidayah Hakim 27-Aug-1984 lingrung loe 1 1 1 0 8 1 0 0 1 0 0 0

59 24-Aug-2023 Irham 7 3 0 4 0 7 6 7 0 8 8 4 0 0 0 1 Nurhidayah Hakim 27-Aug-1984 Tino Toa 1 1 1 0 8 1 0 0 1 0 0 0

60 25-Aug-2023 Hasdianto 7 3 0 4 1 0 5 7 0 8 9 9 0 0 0 2 Jusni 17-Aug-1995 Borong Loe Pallantikang 1 1 1 0 8 1 0 0 1 0 0 0

61 25-Aug-2023 Ambo 7 3 0 3 0 1 5 6 0 8 8 5 0 0 0 2 Sriyanti 16-Aug-1985 Tino toa 1 1 1 0 11 1 0 0 0 0 0 0

62 25-Aug-2023 Dial 7 3 0 3 0 5 6 6 0 5 9 8 0 0 0 2 kasmawati 26-May-1998 papan loe 1 1 1 0 11 1 0 0 0 0 0 0

63 26-Aug-2023 Saparuddin 7 3 0 6 0 3 4 9 0 9 8 2 0 0 0 2 Misdayanti 09-Sep-1982 Datara tompobulu Gowa 1 1 1 0 8 1 0 0 1 0 0 0

64 26-Aug-2023 Edi jaya 7 3 0 3 0 1 7 1 1 2 8 7 0 0 1 9 Eni 31-Dec-1987 Kampung beru 1 1 1 0 11 1 0 0 0 0 0 0

65 27-Aug-2023 Lukman Nur 7 3 0 3 0 2 6 9 0 9 0 1 0 0 0 4 Giska Riannisa 29-Sep-2001 Lannying 3 1 1 1 0 8 1 0 0 1 0 0 0

 66 28-Aug-2023 Harianto 1 6 7 4 0 2 6 7 0 3 8 7 0 0 0 4 Merry Selviani 27-Jun-1982 Dusun Tamoa 1 0 1 0 2 1 0 0 1 0 0 0

67 28-Aug-2023 Hasbianto 7 3 0 4 0 8 4 1 1 2 8 4 0 0 0 6 Ramlah 05-May-1990 Kalonrang 1 0 1 0 2 1 0 0 1 0 0 0

68 28-Aug-2023 Mukrim 7 3 0 3 0 1 6 3 0 4 8 9 0 0 0 2 Husniah 23-Apr-1989 Lasepang 1 1 1 0 11 1 0 0 0 0 0 0

69 29-Aug-2023 Alamsyah 7 3 0 3 0 1 4 2 0 5 9 1 0 0 0 2 Elfiana 02-Jun-1991 Kampung Maja 1 1 1 0 8 1 0 0 1 0 0 0

70 29-Aug-2023 Eko Aprianto 7 3 0 2 0 1 5 1 0 2 8 8 0 0 0 3 Nurwahida 10-Feb-1988 Jl Daeng Tata Makassar 1 1 1 0 8 1 0 0 1 0 0 0

71 29-Aug-2023 Adil 7 3 0 3 0 5 4 2 0 6 9 1 0 0 0 1 Cia 02-Jun-1991 papan loe 1 1 1 0 11 1 0 0 0 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 4

1 2 3 4 5 6
7 3 0 3 0 0 5 Bulan : 2023
NAMA FASKES/ RSUD Prof Dr H. ANWAR MAKKATUTU 7 V 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 1 0 1 1 0 0 0 0 0 0
2 IMPLAN 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 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
5 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
6 PIL 0 1 0 1 1 0 0 0 0 0 0
7 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
8 MOW 1 1 0 1 1 0 0 0 0 0 0
9 SUNTIKAN 0 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 1 0 1 1 0 0 0 0 0 0
12 PIL 0 1 0 1 1 0 0 0 0 0 0
13 IMPLAN 0 0 0 0 0 0 0 0 0 0 1
14 MOW 1 1 0 1 1 0 0 0 0 0 0
15 MOW 1 1 0 1 1 0 0 0 0 0 0
16 PIL 0 1 0 1 1 0 0 0 0 0 0
17 MOW 1 1 0 1 1 0 0 0 0 0 0
18 MOW 1 1 0 1 1 0 0 0 0 0 0
19 IMPLAN 1 1 0 1 1 0 0 0 0 0 0
20 SUNTIKAN 0 1 0 1 1 0 0 0 0 0 0
21 PIL 0 1 0 1 1 0 0 0 0 0 0
22 PIL 0 1 0 1 1 0 0 0 0 0 0

JUMLAH 40 69 0 69 67 0 0 0 0 1 1 0

,
Pimpinan Faskes KB/Jaringan/Jejaring*

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

NIP/NRP
* Coret yang tidak perlu