1.

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

1 2 3 4 5 6
7 1 7 1 0 0 5 Bulan : 2022
NAMA FASKES/ RS.Hermina Manado 7 8 9 V 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

GABRIELLA DEBORA
1 01-Oct-2022 ANDHIKA 7 1 7 1 0 4 6 8 0 9 9 8 0 0 0 1 28-Sep-1998 WANEA 081243828400 1 1 1 0 9 1 0 0 1 0 0 0
SOLA GRACIA SAMADI

2 02-Oct-2022 JOFRAN 7 1 0 2 0 8 5 7 1 0 9 4 0 0 0 1 INDRIA PANGAU 17-Oct-1994 PERUM GPI JL GANDARIA 081917654485 1 1 1 0 9 1 0 0 1 0 0 0

3 05-Oct-2022 VICENTIUS 7 1 7 4 0 3 4 5 1 1 9 4 0 0 0 3 IRONE SUMAMPOUW 05-Nov-1994 MALALAYANG SATU (I) 081243184150 1 1 1 0 9 1 0 0 1 0 0 0

4 05-Oct-2022 SANDHY 7 1 7 1 1 1 1 9 0 1 8 9 0 0 0 1 HELEN SEKEON 08-Nov-1993 KALAWAT 082189242621 1 1 1 0 9 1 0 0 1 0 0 0

5 05-Oct-2022 7 1 0 2 1 3 5 2 0 4 9 0 0 0 0 1 KYRIE ELEISON REMBET 12-Apr-1990 RANOTANA WERU 082394756929 1 1 1 0 9 1 0 0 1 0 0 0

ALPRI HAKARTONO
6 06-Oct-2022 7 1 7 1 0 9 6 6 0 6 8 9 0 1 1 2 NIFIYANTI PONTOH 26-Jun-1989 PERKAMIL 082398182062 1 1 1 0 9 1 0 0 1 0 0 0
MANOPPO

7 06-Oct-2022 7 1 0 6 0 9 5 7 0 4 8 9 0 0 0 2 ENJEL KATUUK 17-Apr-1989 MAPANGET 082187343731 1 1 1 0 9 1 0 0 1 0 0 0

8 07-Oct-2022 7 1 0 7 0 1 6 6 0 2 9 9 0 0 0 2 MONICA BELLA ADAM 26-Feb-1999 WAWALI 085656895506 1 1 1 0 9 1 0 0 1 0 0 0

9 10-Oct-2022 HARRY 7 1 0 2 1 0 5 1 0 9 8 7 0 0 0 1 STERLY TRIVENA SERAN 14-Aug-1983 KOPIWANGKER 082191569874 1 1 1 0 9 1 0 0 1 0 0 0

10 10-Oct-2022 JOSHUA KAUNANG 7 1 0 5 0 1 4 7 0 4 9 4 0 0 0 1 AFRILYA NIKE SOLANG 07-Apr-1994 PANIKI BAWAH 082187944732 1 1 1 0 9 1 0 0 1 0 0 0

11 10-Oct-2022 7 1 7 1 0 5 5 8 1 2 7 8 0 0 0 1 IRAWATI SUNGE 18-Dec-1978 TIKALA KUMARAKA 081356100629 1 1 1 0 11 1 0 0 0 0 0 0

IMELDA ANGGEREINY
12 10-Oct-2022 7 1 7 1 0 9 5 4 0 8 8 3 0 0 0 1 14-Aug-1983 KLEAK 085256333332 1 1 1 0 9 1 0 0 1 0 0 0
DAJOH

13 10-Oct-2022 1 2 7 1 0 6 6 3 0 5 9 2 0 0 0 8 SUDIATI LUMBAN GAOL 23-May-1992 PERUM RIZKY PANIKI GRIYA 085358492285 1 1 1 0 9 1 0 0 1 0 0 0

ARLINA FEIBY OLANDA

14 11-Oct-2022 RAYFVALDO KANSIL 7 1 0 6 0 8 5 1 0 2 8 8 0 0 0 1 11-Feb-1988 KOLONGAN TETEMPANGAN 0822340243165 1 1 1 0 11 1 0 0 0 0 0 0
LEGI

15 11-Oct-2022 GERALD 7 1 7 2 0 3 4 7 1 0 9 5 0 0 0 2 BELLA OMEGA SUPIT 07-Dec-1995 DANOWUDU 085211229068 1 1 1 0 9 1 0 0 1 0 0 0

16 13-Oct-2022 7 1 0 2 1 5 4 4 0 5 0 3 0 0 0 2 MEYVITA ANGELA LASUT 04-May-2003 LINGKUNGAN II MAPANGET 085757502904 1 1 1 0 9 1 0 0 1 0 0 0

TRIYANI WAHYU NINGSIH

17 13-Oct-2022 ADARTO SASONGKE 7 1 7 2 0 4 5 5 0 9 8 8 0 0 0 2 15-Sep-1988 MANEMBO NEMBO ATAS 082296000032 1 1 1 0 9 1 0 0 1 0 0 0
JANIS
DWIRANGGA
18 14-Oct-2022 7 1 7 1 0 3 4 6 0 8 9 2 0 0 0 1 ZURIATI ALI 06-Aug-1992 PERUM GPI JL RAMBUTAN F 085823000432 1 1 1 0 9 1 0 0 1 0 0 0
SAPUTRA
PAMELA PRASTICA
19 14-Oct-2022 BRYANDO PUIRIH 7 1 0 6 0 8 5 4 1 0 9 2 0 0 0 1 14-Oct-1992 WATUTUMOU I 089698289691 1 1 1 0 9 0 1 0 1 0 0 0
MONTUNG
FRISKA MARIA MEYLANI
20 14-Oct-2022 7 1 7 1 0 2 5 4 0 5 9 3 0 0 0 2 14-May-1993 SINDULANG SATU 085218145604 1 1 1 0 9 1 0 0 1 0 0 0
EKEL
AMEILIA VIOLETA
21 17-Oct-2022 3 5 1 5 1 2 5 0 0 5 9 1 0 0 0 1 10-May-1991 MANEMBO NEMBO ATAS 082112403399 1 1 1 0 9 1 0 0 1 0 0 0
YALESTYA

22 17-Oct-2022 7 5 0 1 0 4 6 4 0 2 0 0 0 0 0 1 DWI CAHYANI BAKARI 24-Feb-2000 KAIRAGI DUA 081244698723 1 1 1 0 9 1 0 0 1 0 0 0

23 18-Oct-2022 FRANGKY 9 2 0 2 0 4 6 9 0 8 9 2 0 0 0 1 DIEN CHRISTA RANDA 29-Aug-1992 JL. MERPATI 081382190700 1 1 1 0 9 1 0 0 1 0 0 0

24 18-Oct-2022 CLANCE 7 1 0 5 0 8 6 4 0 4 9 1 0 0 0 1 APRILIA PHILIA REGAR 24-Apr-1991 SEA MITRA SEA 082319612727 1 1 1 0 9 1 0 0 1 0 0 0

25 18-Oct-2022 7 1 0 4 0 6 5 7 0 5 9 7 0 0 0 1 JENIFFER MAJESTY TULE 17-Mar-1997 DAMAU BOWONE 082259742474 1 1 1 0 9 1 0 0 1 0 0 0

FITRIA RIANA
26 18-Oct-2022 KEVIN ROTTY 7 1 0 6 0 5 5 0 0 5 9 3 0 0 0 1 10-May-1993 PERUMAHAN GRIA BINTANG MAS 082150566722 1 1 1 0 9 1 0 0 1 0 0 0
TARIMAKASEH
DANIEL
27 19-Oct-2022 7 1 7 1 0 8 6 8 1 1 7 9 0 0 0 1 SPICE RIVKA TATORI 28-Nov-1979 KOMBOS BARAT 082191246573 1 1 1 0 11 1 0 0 0 0 0 0
PANANGGUNG
 WAODE NURZAMZAM
28 20-Oct-2022 7 4 7 1 0 1 5 3 0 3 9 0 0 0 0 2 13-Mar-1990 JL DELINA D NO 26 GPI 081354995848 1 1 1 0 9 1 0 0 1 0 0 0
AMIN

29 20-Oct-2022 PATRICK PANAWA 7 1 7 1 0 5 5 3 0 9 9 8 0 0 2 1 FAIZA IVANI LIATU 13-Sep-1998 JL MANGUNI LK IV 081241527145 1 1 1 0 9 1 0 0 1 0 0 0

PRATIWI MARGARETH
30 22-Oct-2022 MARCEL 7 1 7 1 0 7 5 2 0 9 8 9 0 0 0 1 12-Sep-0989 RANOTANA WERU 082190000314 1 1 1 0 9 1 0 0 1 0 0 0
LOLOWANG
HENDRA ALPINIA SHINTA
31 22-Oct-2022 7 1 7 1 0 5 4 2 1 1 9 2 0 0 2 1 02-Nov-1992 BANJER 08997594292 1 1 1 0 9 1 0 0 1 0 0 0
HERLAMBANG PONDAGITAN
MARIA VIRGINI CLAUDYA
32 24-Oct-2022 7 1 7 3 0 2 4 3 0 8 8 8 0 0 0 1 03-Aug-1988 JL. D.I. PANJAITAN 081342793403 3 0 0 0 9 1 0 0 1 0 0 0
TUERAH

33 25-Oct-2022 7 1 0 5 1 6 5 6 0 4 9 4 0 0 0 1 LAURA KUMONTOY 16-Apr-1993 WATUTUMOU I 085281356903 1 1 1 0 9 1 0 0 1 0 0 0

MELISA MEGAWATI
34 25-Oct-2022 7 1 7 1 0 7 6 3 0 5 9 2 0 0 0 3 23-May-1992 TANJUNG BATU 082189313737 1 1 1 0 9 0 1 0 1 0 0 0
WALUKOW

35 25-Oct-2022 BOBBY TENDEAN 7 1 7 1 0 5 7 1 0 5 9 1 0 0 0 1 NADHIRA THEREZA 31-May-1991 MALALAYANG SATU (I) 081218890008 1 1 1 0 9 1 0 0 1 0 0 0

36 27-Oct-2022 JOFAN DALENDING 7 1 0 4 0 1 6 7 0 9 8 8 0 0 0 2 STEFI TINGGINEHE 27-Sep-1988 KISIHANG 081212875194 1 1 1 0 9 1 0 0 1 0 0 0

DESYANI PRANATALIA
37 31-Oct-2022 7 1 7 1 0 9 4 7 1 2 9 5 0 0 0 1 07-Dec-1995 WINANGUN DUA 089624792315 1 1 1 0 9 1 0 0 1 0 0 0
PANEKENAN

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 1 7 1 0 0 5 Bulan : 2022
NAMA FASKES/ RS.Hermina Manado 7 8 9 V 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 IUD 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 IUD 1 1 0 1 1 0 0 0 0 0 0
5 IUD 1 1 0 1 1 0 0 0 0 0 0
6 IUD 1 1 0 1 1 0 0 0 0 0 0
7 IUD 1 1 0 1 1 0 0 0 0 0 0
8 IUD 1 1 0 1 1 0 0 0 0 0 0
9 IUD 1 1 0 1 1 0 0 0 0 0 0
10 IUD 1 1 0 1 1 0 0 0 0 0 0
11 IUD 1 1 0 1 1 0 0 0 0 0 0
12 IUD 1 1 0 1 1 0 0 0 0 0 0
13 MOW 1 1 0 1 1 0 0 0 0 0 0
14 IUD 1 0 1 1 1 0 0 0 0 0 0
15 IUD 1 1 0 1 1 0 0 0 0 0 0
16 IUD 1 1 0 1 1 0 0 0 0 0 0
17 IUD 1 1 0 1 1 0 0 0 0 0 0
18 IUD 1 1 0 1 1 0 0 0 0 0 0
19 IUD 1 1 0 1 1 0 0 0 0 0 0
20 IUD 1 1 0 1 1 0 0 0 0 0 0
21 IUD 1 1 0 1 1 0 0 0 0 0 0
22 MOW 1 1 0 1 1 0 0 0 0 0 0

JUMLAH 36 34 2 36 36 0 0 0 1 0 0 0

71 - KOTA MANADO , 31-October-2022

Pimpinan Faskes KB/Jaringan/Jejaring*

Dr.Alexandra Ch.S.Engel.SpOG(K)
( .................................................................................................)
7171085811590001

NIP/NRP
* Coret yang tidak perlu