Petugas Entri
Data
REGISTER PELAYANAN KB R/I/KB/20
Lembar 1
V 2 3 4 5 6
7 2 0 8 0 0 1 Bulan : 2023
NAMA FASKES/ RSUD Anuntaloko 7 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota
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
SYAFRUDIN R.
67 03-Mar-2023 7 2 0 8 0 1 6 6 1 2 8 5 0 0 0 1 EKA SANTI MAHIR 26-Dec-1985 TOMOLI 0000000000000 2 1 0 0 8 1 0 0 1 0 0 0
MAPODJI
Hamka, SKM., M.
69 04-Mar-2023 7 2 0 8 0 1 4 7 0 8 8 4 0 0 0 1 isryani, S.Si 07-Aug-1984 Kampal 0000000000000 2 1 0 0 3 1 0 0 1 0 0 0
Kes
INYOMAN RAY
70 05-Mar-2023 7 2 0 8 1 5 7 0 1 0 8 8 0 0 0 2 NI NYOMAN YUNITA 30-Oct-1988 MERTSARI 082292095466 2 1 0 0 8 1 0 0 1 0 0 1
MARTEN
I PUTU RUDI
71 05-Mar-2023 7 2 0 8 0 9 5 5 0 4 9 2 0 0 0 1 EKA ETI SUSANTI 05-Apr-1992 TOLAI TIMUR 0000000000000 1 1 1 0 8 1 0 0 1 0 0 0
SASTRAWAN
77 08-Mar-2023 Moh. juman 7 2 0 8 0 7 4 1 0 1 8 4 0 0 0 5 Sodiah indah luspita sari 01-Jan-1984 Bolano barat 082213071628 1 1 1 0 11 1 0 0 0 0 0 0
81 11-Mar-2023 I kadek ardianto 7 2 0 2 1 8 5 7 0 9 9 0 0 0 0 2 Ni gusti ayu made rijaya 17-Nov-1990 Baliara 082377762024 1 1 1 0 8 1 0 0 1 0 0 0
Syarifuddin h.
91 17-Mar-2023 7 2 0 8 1 1 5 7 0 8 8 3 0 0 0 1 Fatmawati 17-Aug-1983 Tindaki 0000000000000 1 1 1 0 11 1 0 0 0 0 0 0
djulunau
106 27-Mar-2023 Rully pon thema 7 2 0 8 1 1 6 3 0 1 8 6 0 0 0 1 yenny kristina 23-Jan-1986 Tindaki 0000000000000 2 1 0 0 8 1 0 0 1 0 0 0
I made eka
107 28-Mar-2023 7 2 0 8 0 1 5 8 0 2 7 7 0 0 0 1 putu erna setiawati 16-Feb-1977 Maesa 0000000000000 2 1 0 0 8 1 0 0 1 0 0 0
darmawan
109 28-Mar-2023 Lerry dison 7 3 7 3 0 1 4 5 0 2 8 8 0 0 0 1 Febrianti tandi pasang 05-Feb-1988 Masigi 0000000000000 2 1 0 0 8 1 0 0 1 0 0 0
117 30-Mar-2023 hery rapianto 7 2 0 8 1 1 6 6 0 7 9 6 0 0 0 2 claudia gerarda budiman 26-Jul-1996 Sumbersari 0000000000000 2 1 0 0 8 1 0 0 1 0 0 0
125 10-Apr-2023 EDY SASTRAWAN 7 2 0 8 0 9 6 4 0 7 9 1 0 0 0 1 NI MADE CITRA PUSPITA 24-Jul-1991 TANALANTO 000000000000 1 1 1 0 11 1 0 0 0 0 0 0
ARYA VERRY
136 26-Apr-2023 7 2 0 8 1 2 5 4 1 0 9 4 0 0 0 1 MARLINA 14-Oct-1994 MENSUNG 085394610333 1 1 1 0 11 1 0 0 0 0 0 0
IRAWAN. K
MAWARDI H.
137 27-Apr-2023 7 2 0 8 1 2 4 1 0 1 7 0 0 0 0 6 YANTI 01-Jan-1970 BUGIS 085314424080 1 1 1 0 11 1 0 0 0 0 0 0
HARUNA
178 15-May-2023 I NENGAH KARTIKA 7 2 0 8 1 1 5 8 1 0 8 7 0 0 0 3 NI GUSRI AYU RINAWATI 18-Oct-1987 TINDAKI 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0
179 16-May-2023 IGEDE NAMO DWIPA 7 2 0 8 1 2 4 1 0 7 9 4 0 0 1 7 INENGAH ERNIASIH 01-Jul-1994 TOLAI BARAT 0000000000000 1 1 1 0 11 1 0 0 0 0 0 0
180 16-May-2023 ramludin 7 2 0 8 0 4 6 8 1 0 7 6 0 0 0 1 fauziah 28-Oct-1976 jono kalora 0000000000000 1 1 1 0 3 1 0 0 1 0 0 0
181 16-May-2023 MOH. SOLIKIN 7 2 0 8 1 2 5 3 1 2 8 5 0 0 0 1 NUR HIDAYATI 13-Dec-1985 KOTA RAYA 082194969027 1 1 1 0 11 1 0 0 0 0 0 0
JONATAN
187 24-May-2023 7 2 0 2 2 7 4 1 0 3 8 8 0 0 0 1 MARLENI KORE 01-Mar-1988 MAESA 085299608473 1 1 1 0 11 1 0 0 0 0 0 0
ENGLIRAMLIJ
RISMAN IKHSAN
188 24-May-2023 7 2 0 8 1 0 4 5 0 8 9 1 0 0 0 2 RISNAWATI 06-Aug-1991 POLY 0000000000000 1 1 1 0 11 1 0 0 0 0 0 0
TAKIR
I KADEK DEDY
211 05-Jun-2023 7 2 0 4 0 7 4 6 0 1 8 3 0 0 0 3 DEWI YANTI ZENNY 06-Jan-1983 SUMBERSARI 0000000000000 1 1 1 0 11 1 0 0 0 0 0 0
WIRAWAN
219 11-Jun-2023 MOH. AFAN 7 2 0 8 0 4 4 2 0 6 0 0 0 0 0 2 MARIA ALFA SALAM 02-Jun-2000 MOUTONG 0000000000000 1 0 1 0 5 1 0 0 1 0 0 0
I WAYAN
232 16-Jun-2023 7 2 0 8 0 6 6 0 4 8 5 0 0 0 0 1 NI PUTU NURHAYATI 20-Jun-1985 KAMPAL 0000000000000 1 0 1 0 5 1 0 0 1 0 0 0
SUKARDIAN
I GUSTI
279 15-Jul-2023 7 2 0 8 0 7 0 5 0 7 8 1 0 0 0 2 ARLUH BUDIASRI 10-Apr-1991 WANAMUKTI BARAT 0000000000000 1 0 1 0 5 1 0 0 1 0 0 0
MOYUDRARTA
AGUSTINUS
291 02-Aug-2023 7 2 0 8 1 3 4 5 0 6 8 4 0 0 0 1 Niluh Sumartini 05-Jun-1984 Masigi 0000000000000 1 0 1 0 5 1 0 0 1 0 0 0
KRISTIAN
343 28-Aug-2023 Obet. R 3 5 0 6 0 6 7 0 0 6 8 5 0 0 0 4 Tri setyo wahyuni 30-Jun-1985 Lobu mandiri 0000000000000 3 1 0 0 3 1 0 0 1 0 0 0
NI KADEK NOVI
348 04-Sep-2023 WAYAN SUGIANTO 7 2 0 8 1 2 4 8 0 8 9 3 0 0 0 1 08-Aug-1993 ogotion 0000000000000 1 1 1 0 11 1 0 0 0 0 0 0
BUDIARTI
371 29-Sep-2023 Yahmun 7 2 0 8 0 7 5 1 1 2 8 7 0 0 0 3 Siti nurhayati 11-Dec-1987 Kota raya barat 0000000000000 1 1 1 0 11 1 0 0 0 0 0 0
don alan
377 02-Oct-2023 7 2 0 4 1 5 5 1 0 2 9 2 0 0 0 1 fitria unas 11-Feb-1992 sipayon 0000000000000 1 1 1 0 11 1 0 0 0 0 0 0
imanuelbawiling
MUHAMMAD
411 30-Oct-2023 7 2 0 8 0 6 6 5 0 7 0 5 0 0 0 1 HASNI 25-Jul-2005 SAUSU TAMBU 0000000000000 1 0 1 0 5 1 0 0 1 0 0 0
FAHRUL
415 21-Nov-2023 I wayan karisiawan 7 2 0 8 0 6 4 8 0 1 9 6 0 0 0 1 Ni wayan elvi susanti 08-Jan-1996 Sausu trans 0 1 1 1 0 11 1 0 0 0 0 0 0
468 27-Nov-2023 I PUTU SUKRADANA 7 2 0 8 0 8 5 8 0 8 9 4 0 0 0 4 NI KETUT AYU RISKAYANI 18-Aug-1994 TINDAKI 0000000000000 1 1 1 0 9 1 0 0 1 0 0 0
494 05-Dec-2023 DEWA PUTU SRAMA 7 2 0 8 0 6 5 4 0 3 8 2 0 0 0 1 DESAK MADE RAI 14-Mar-1982 PETAPA 0 1 0 1 0 5 1 0 0 1 0 0 0
IWAYAN
498 07-Dec-2023 7 2 0 8 1 5 0 7 0 5 1 9 0 0 0 1 NYOMAN ARSINI 20-Feb-1982 TINOMBO 0 1 0 1 0 5 1 0 0 1 0 0 0
BUADIAWAN
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 16
1 2 3 4 5 6
7 2 0 8 0 0 1 Bulan : 2023
NAMA FASKES/ RSUD Anuntaloko 7 8 9 10 11 V
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota
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 PIL 0 1 0 1 1 0 0 0 0 0 0
2 PIL 0 1 0 1 1 0 0 0 0 0 0
3 PIL 0 1 0 1 1 0 0 0 0 0 0
4 PIL 0 1 0 1 1 0 0 0 0 0 0
5 PIL 0 1 0 1 1 0 0 0 0 0 0
6 SUNTIKAN 1 1 0 1 1 0 0 0 0 0 0
7 PIL 0 1 0 1 1 0 0 0 0 0 0
8 PIL 0 1 0 1 1 0 0 0 0 0 0
9 PIL 0 1 0 1 1 0 0 0 0 0 0
10 PIL 0 1 0 1 1 0 0 0 0 0 0
11 MOW 1 1 0 1 1 0 0 0 0 0 0
12 PIL 0 1 0 1 1 0 0 0 0 0 0
13 PIL 0 1 0 1 1 0 0 0 0 0 0
14 PIL 0 1 0 1 1 0 0 0 0 0 0
15 SUNTIKAN 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 PIL 0 1 0 1 1 0 0 0 0 0 0
18 PIL 0 1 0 1 1 0 0 0 0 0 0
19 PIL 0 1 0 1 1 0 0 0 0 0 0
20 PIL 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
NIP/NRP
* Coret yang tidak perlu