DAFTAR 10 BESAR PENYAKIT JKN (RAWAT JALAN)

PUSKESMAS : KALIPUCANG
BULAN : MEI 2017

0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th 10 - 14 th 15 - 19 th 20 - 24 th 25 - 30 th 31 - 35 th 36 - 40 th 41 - 45 th 46 - 50 th 51 - 55 th 56 - 60 th 61 - 65 > 65 th
NO KODE ICD DIAGNOSA PENYAKIT JML
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P l P L P

1 J06.9 Acute upper respiratory infection, unspecified 3 2 3 2 4 5 3 3 3 2 3 2 3 2 4 2 2 48

2 K30 Dyspepsia 4 3 5 2 3 2 4 3 2 3 2 4 2 3 42
3 I10 Essential (primary) hypertension 5 3 4 3 1 3 5 3 1 4 2 3 37
6 M79.1 Myalgia 3 5 5 1 1 2 2 1 3 2 1 3 1 4 2 1 37
4 K29.1 Other acute gastritis 3 2 5 3 3 2 1 2 3 2 3 1 2 3 35
12 K04.1 Necrosis of pulp 3 3 1 3 5 5 5 2 2 1 2 1 1 34
11 J02.9 Acute pharyngitis, unspecified 2 2 3 5 1 5 1 1 3 2 1 2 1 3 1 33
Non-insulin-depend diabetes mellitus without
9 E11.9 5 3 1 5 3 4 1 2 2 2 1 2 31
complication

10 A15.1 Tuberculosis of lung, confirmed by culture only 2 2 5 1 3 2 3 1 2 2 1 3 1 28

5 J00 Acute nasopharyngitis [common cold] 2 1 3 2 2 2 1 2 3 2 2 2 2 2 28

8 M79.2 Neuralgia and neuritis, unspicified 7 3 1 2 2 2 3 3 2 2 27

13 K04.0 Pulpitis 2 2 1 2 5 5 3 2 1 2 1 26
7 Z51.9 Medical care, unspecified 2 1 1 3 2 2 1 2 2 3 2 3 1 25
20 I11.0 Hypertensive heart disease 3 5 5 1 2 2 1 1 3 23
14 M54.5 Low back pain 2 2 3 1 2 3 3 2 18
19 N390 Urinary tract infection, site not specified 2 3 2 5 2 1 1 1 17
15 L23.9 1 3 3 1 1 2 1 1 1 14
Allergic contact dermatitis, unspecified cause
16 A09 Diarrhoea and gastroenteritis 2 1 2 2 1 1 2 1 1 13
17 H25.9 Senile cataract, unspecified 3 1 2 2 1 2 11
Headache
18 R51 2 3 1 1 2 1 10
21 A75.9 Typhus fever, unspecified 2 2 1 2 1 1 9
22 I64 Stroke, not specified as haemorrhage 3 2 1 2 1 9
34 Z36.8 Other antenatal screening 1 2 3 3 9
23 H81.1 Benign paroxysmal vertigo 2 3 1 2 8

24 J45.9 Asthma 2 \ 1 2 1 1 7
25 Z30.9 Other Contraseptive Management 1 2 1 1 5
26 M15.4 Erosive (osteo)arthrosis 1 1 3 5

27 I50.0 Congestive Heart Failure 1 1 1 1 4

28 J34.0 Abscess, furuncle and carbuncle of nose 1 1 2 4
36 L04.2 Acute lymphadenitis of upper limb 1 1 1 1 4
29 B35.6 Tinea cruris 1 1 2 4
30 H66.9 Otitis media, unspecified 1 1 1 3

31 B35.4 Tinea corporis 1 1 1 3

32 J01.0 Acute maxillary sinusitis 2 1 3

33 G44.2 Tension-type headache 2 1 3

Unilateral or unspecified inguinal hernia,
35 K40.9 2 2
without obstruction or gangrene
 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th 10 - 14 th 15 - 19 th 20 - 24 th 25 - 30 th 31 - 35 th 36 - 40 th 41 - 45 th 46 - 50 th 51 - 55 th 56 - 60 th 61 - 65 > 65 th
NO KODE ICD DIAGNOSA PENYAKIT JML
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P l P L P
37 D53.1 Other megaloblastic anaemias 1 1 2

38 I25.1 Atherosclerotic heart disease 1 1

39 B35.3 Tinea pedis 1 1

40 G44.0 Cluster headache syndrome 1 1

JUMLAH 0 0 0 0 0 0 0 5 5 9 7 7 16 30 30 30 23 31 16 32 23 44 19 30 28 29 28 21 26 37 24 30 26 18 624 1248

7 8 10 4 9 9 18 20 12 24 21 18 34 11 28 22 255

624

Mengetahui, Kalipucang, 31 Mei 2017

Kepala UPTD Puskesmas Kalipucang Pengelola Program

H. Sugiharto, S.Kep.Ners H. Enday Hidayat, AM. Kep

NIP : 19680913 198902 1 001 NIP : 19660605 198901 1 002
 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th 10 - 14 th 15 - 19 th 20 - 24 th 25 - 30 th 31 - 35 th 36 - 40 th 41 - 45 th 46 - 50 th 51 - 55 th 56 - 60 th 61 - 65 > 65 th
NO KODE ICD DIAGNOSA PENYAKIT JML
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P l P L P

TGL 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 JML

PENYAKIT PASIEN 0

Rp 52,533,000

11674

11608

66

Rp 52,523,000
1 ISPA #REF!

3 HYPERTEN #REF!
SI
 1 ISPA #REF!

569
 REKAPITULASI PELAYANAN RAWAT JALAN
BPJS KESEHATAN

INSTANSI : PUSKESMAS KALIPUCANG

BULAN DAN TAHUN : 28 FEBRUARI 2017

JUMLAH KUNJUNGAN PASIEN

NO TANGGAL
ASKES BPJS JAMKESMAS TNI/POLRI JAMSOSTEK TOTAL
1 01/02/17 2 6 6 14
2 02/02/17 4 17 4 25
3 03/02/17 1 9 10 20
4 04/02/17 2 13 4 19
5 06/02/17 3 14 10 27
6 07/02/17 3 8 11
7 08/02/17 9 17 26
8 09/02/17 2 9 6 17
9 10/02/17 14 14 28
10 11/02/17 9 6 15
11 13/02/17 12 5 17
12 14/02/17 2 7 15 24
13 16/02/17 1 13 21 35
14 17/02/17 1 10 8 19
15 18/02/17 12 11 23
16 20/02/17 9 7 16
17 21/02/17 7 15 22
18 22/02/17 2 11 14 27
19 23/02/17 1 14 12 27
20 24/02/17 2 10 11 23
21 25/02/17 1 21 14 36
22 27/02/17 3 12 9 24
23 28/02/17 1 10 17 28
JUMLAH 28 251 244 0 0 523

Mengetahui, Kalipucang, 28 Februari 2017

Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

H. Sugiharto, S.Kep.Ners H. Enday Hidayat, AM. Kep

NIP : 19680913 198902 1 001 NIP : 19660605 198901 1 002
 Rp 56,048,017 Rp 42,036,013

ruari 2017
PJS

AM. Kep
8901 1 002
 DAFTAR 10 BESAR PENYAKIT JKN (RAWAT INAP)

PUSKESMAS : Puskesmas Kalipucang

BULAN : April 2015

KODE 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th 10 - 14 th 15 - 19 th 20 - 24 th 25 - 30 th 31 - 35 th 36 - 40 th 41 - 45 th 46 - 50 th 51 - 55 th 56 - 60 th 61 - 65 th > 65 th JUML

NO ICD DIAGNOSA PENYAKIT AH
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
1 K291 Other acute gastritis 0
Diarrhoea and gastroenteritis of
2 A090 presumed infectious origin 0

3 I101 Hypertension, stage II 0

4 A010 Typhoid fever 0
5 I100 Hypertension, stage I 0
6 J4590 Bronchial Asthma in Exacerbation 0
7 R509 Fever, unspecified 0

8 E116 Non-insulin-depend diabetes mellitus 0

with other spec comp

9 R060 Dyspnoea 0
10 A060 Acute amoebic dysentery 0

11 E160 Drug-induced hypoglycaemia without 0

coma

12 J4599 Asthma 0
13 R100 Acute abdomen 0

Non-insulin-depend diabetes mellitus

14 E116 with other spec comp 0

Hypertensive heart and renal disease

15 I131 with renal failure 0

16 N390 Urinary tract infection, site not 0

specified

17 S018 Open wound of other parts of head 0

18 R220 Localized swelling, mass and lump, 0

head

JUMLAH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Mengetahui, Kalipucang, 30 April 2015

Kepala UPTD Puskesmas Kalipucang Pengelola Program

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
ADAH

ADAH
 DAFTAR 10 BESAR PENYAKIT JKN (RAWAT INAP)

PUSKESMAS : Puskesmas Kalipucang

BULAN : April 2015

KODE 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th 10 - 14 th 15 - 19 th 20 - 24 th 25 - 30 th 31 - 35 th 36 - 40 th 41 - 45 th 46 - 50 th 51 - 55 th 56 - 60 th 61 - 65 th > 65 th JUML

NO ICD DIAGNOSA PENYAKIT AH
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P RASTAM,
1 K291 Other acute gastritis 1 1 1 3 DEDE
NASIKIN, TRI
Diarrhoea and gastroenteritis of PUJI
ANDI
2 A090 presumed infectious origin 1 1 HIDAYAT
3 I101 Hypertension, stage II 1 1 RUHYAT
4 A010 Typhoid fever 0
5 I100 Hypertension, stage I 0
6 J4590 Bronchial Asthma in Exacerbation 0
7 R509 Fever, unspecified 1 1 RIDWAN

E119 Non-insulin-depend
8
diabetes 1 1 UJU
mellitus without complication
9 R060 Dyspnoea 0
10 A060 Acute amoebic dysentery 1 1 AISAH

11 J069 Acute upper respiratory infection, 1 1 TRI PUJI,

unspecified

12 N219 Calculus of lower urinary tract, 1 1 UJU

unspecified

13 D509 Iron deficiency anaemia, unspecified 1 1 UJU

14 J039 Acute tonsillitis, unspecified 1 1 RIDWAN

RUDIANA,
VRATIKA,
EDI,
15 A759 Typhus fever, unspecified 1 1 1 1 1 1 1 7 PARTINI,
SUHUD,
NOVIATUN,
16 N390 Urinary tract infection, site not 1 1 2 BUCU,
ENOK EMAH
specified RASTAM

17 S018 Open wound of other parts of head 0

18 R220 Localized swelling, mass and lump, 0

head
JUMLAH 0 0 0 0 0 0 0 0 2 0 0 1 1 1 0 2 0 0 1 1 2 0 0 0 3 1 1 0 0 0 1 0 0 4 21

Mengetahui, Kalipucang, 30 April 2015

Kepala UPTD Puskesmas Kalipucang Pengelola Program

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
 Suryati, SKM. MSi Eruk Rukiah, AM. Kep
NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
 REKAPITULASI PELAYANAN RITP
BPJS KESEHATAN
INSTANSI : PUSKESMAS
KALIPUCANG
BULAN DAN TAHUN : APRIL 2015 9

JUMLAH BESARAN JUMLAH

NOMOR UMUR DIAGNOSA TINDAKAN YANG TGL TGL JUMLAH SELURUH
NO NAMA PASIEN JENIS KARTU ALAMAT HARI RAWAT TARIF TAGIHAN PAKET
IDENTITAS (TH) PENYAKIT DIBERIKAN MASUK KELUAR TAGIHAN
(a) PAKET (b) RITP (axb)

Dusun Pamotan 003/003 Desa INFUS +

1 BUCU SUBANA 0001457465444 BPJS 64 Pamotan Kec. Pamotan ISK THERAPY ORAL 01-04-15 04-04-15 3 HARI 100,000 3 x 100,000 Rp. 300,000-

Dusun Kedung Palungpung 005/004 INFUS +

2 RUDIANA 0000437191356 JAMKESMAS 47 Desa Tunggilis Kec. Kalipucang TYPHOID FEVER THERAPY ORAL 02-04-15 06-04-15 4 HARI 100,000 4 x 100,000 Rp. 400,000-

Dusun Sidamukti 005/007 Desa INFUS +

3 AISAH 0001838084297 BPJS 70 Sidamukti Kec. Patimuan DISENTRI THERAPY ORAL 02-04-15 06-04-15 4 HARI 100,000 4 x 100,000 Rp. 400,000-

Dusun Girisetra 006/002 Desa INFUS +

4 VRATIKA FITRAH I. 0001475989536 BPJS 14 Kalipucang Kec. Kalipucang TYPHOID FEVER THERAPY ORAL 02-04-15 07-04-15 5 HARI 100,000 5 x 100,000 Rp. 500,000-

RASTAM Dusun Kalenanyar 001/013 Desa INFUS +

5 RACHMAT 0000519576996 JAMKESMAS 36 Rawaapu Kec. Patimuan GASTRITIS + ISK THERAPY ORAL 03-04-15 07-04-15 4 HARI 100,000 4 x 100,000 Rp. 400,000-

Dusun Cibuluh II 015/004 Desa INFUS +

6 DEDE NASIKIN 000140011029 JAMKESMAS 47 GASTRITIS 03-04-15 07-04-15 4 HARI 100,000 4 x 100,000 Rp. 400,000-
Cibuluh Kec. Kalipucang THERAPY ORAL

Dusun Empangsari 008/005 Desa INFUS +

7 TRI PUJIAWATI 0001476465221 BPJS 24 GASTRITIS + ISPA 04-04-15 08-04-15 4 HARI 100,000 4 x 100,000 Rp. 400,000-
Kalipucang Kec. Kalipucang THERAPY ORAL

Dusun Girisetra 005/001 Desa INFUS +

8 EDI LUKMAN 0001427737814 BPJS 51 TYPHOID FEVER 04-04-15 09-04-15 5 HARI 100,000 5 x 100,000 Rp. 500,000-
Kalipucang Kec. Kalipucang THERAPY ORAL

Dusun Sindangsari 004/007 Desa INFUS +

9 RUHYAT 0001288764426 BPJS 46 HYPERTENSI GR II 05-04-15 09-04-15 4 HARI 100,000 4 x 100,000 Rp. 400,000-
Banjarharja Kec. Kalipucang THERAPY ORAL
DM II +
Dusun Pamotan 003/003 Desa INFUS +
10 UJU JUARIAH 0001841166461 BPJS 86 VESIKOLITIASIS + 06-04-15 07-04-15 1 HARI 100,000 1 x 100,000 Rp. 100,000-
Pamotan Kec. Pamotan THERAPY ORAL
ANEMIA
Dusun Ciawitali 005/003 Desa INFUS +
11 PARTINI 0000438384756 JAMKESMAS 34 TYPHOID FEVER 07-04-15 11-04-15 4 HARI 100,000 4 x 100,000 Rp. 400,000-
Pamotan Kec. Kalipucang THERAPY ORAL
Dusun Ciawitali 001/005 Desa INFUS +
12 ANDI HIDAYAT 0000438421871 JAMKESMAS 32 GEA 07-04-15 11-04-15 4 HARI 100,000 4 x 100,000 Rp. 400,000-
Pamotan Kec. Kalipucang THERAPY ORAL
Dusun Pamotan 005/001 Desa INFUS +
13 SUHUD PAMBUDI 0001379407274 BPJS 18 Pamotan Kec. Pamotan TYPHOID FEVER THERAPY ORAL 10-04-15 14-04-15 4 HARI 100,000 4 x 100,000 Rp. 400,000-

NOFIATUN Dusun Cikadim 003/001 Desa INFUS +

14 HASANAH 0001015158925 JAMKESMAS 17 Rawaapu Kec. Patimuan TYPHOID FEVER THERAPY ORAL 10-04-15 15-04-15 5 HARI 100,000 5 x 100,000 Rp. 500,000-
 JUMLAH BESARAN JUMLAH
NOMOR JENIS KARTU UMUR DIAGNOSA TINDAKAN YANG TGL TGL JUMLAH SELURUH
NO NAMA PASIEN ALAMAT HARI RAWAT TARIF TAGIHAN PAKET
IDENTITAS (TH) PENYAKIT DIBERIKAN MASUK KELUAR TAGIHAN
(a) PAKET (b) RITP (axb)

ENOK EMAH Dusun Sindangmangu 002/004 Desa INFUS +

15 RAHMAWATI 0000070886068 ASKES 48 Bagolo Kec. Kalipucang TYPHOID FEVER THERAPY ORAL 10-04-15 15-04-15 5 HARI 100,000 5 x 100,000 Rp. 500,000-

Dusun Ciawitali 006/005 Desa INFUS +

16 RIDWAN 0000438423816 JAMKESMAS 9 TONSILITIS + FEBRIS 11-04-15 15-04-15 4 HARI 100,000 4 x 100,000 Rp. 400,000-
Pamotan Kec. Kalipucang THERAPY ORAL

INFUS +
17 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
18 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
19 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
20 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
21 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
22 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL
INFUS +
23 THERAPY ORAL 0 HARI 100,000 0 x 100,000 Rp. 0-

INFUS +
24 THERAPY ORAL 0 HARI 100,000 0 x 100,000 Rp. 0-

INFUS +
25 THERAPY ORAL 0 HARI 100,000 0 x 100,000 Rp. 0-

INFUS +
26 THERAPY ORAL 0 HARI 100,000 0 x 100,000 Rp. 0-

INFUS +
27 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
28 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
29 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

30 INFUS + 0 HARI 100,000 0 x 100,000 Rp. 0-

THERAPY ORAL

INFUS +
31 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL
 JUMLAH BESARAN JUMLAH
NOMOR JENIS KARTU UMUR DIAGNOSA TINDAKAN YANG TGL TGL JUMLAH SELURUH
NO NAMA PASIEN ALAMAT HARI RAWAT TARIF TAGIHAN PAKET
IDENTITAS (TH) PENYAKIT DIBERIKAN MASUK KELUAR TAGIHAN
(a) PAKET (b) RITP (axb)

INFUS +
32 THERAPY ORAL 0 HARI 100,000 0 x 100,000 Rp. 0-

INFUS +
33 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
34 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
35 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
36 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
37 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
38 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
39 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL
INFUS +
40 THERAPY ORAL 0 HARI 100,000 0 x 100,000 Rp. 0-

INFUS +
41 THERAPY ORAL 0 HARI 100,000 0 x 100,000 Rp. 0-

INFUS +
42 THERAPY ORAL 0 HARI 100,000 0 x 100,000 Rp. 0-

INFUS +
43 THERAPY ORAL 0 HARI 100,000 0 x 100,000 Rp. 0-

INFUS +
44 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
45 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

INFUS +
46 0 HARI 100,000 0 x 100,000 Rp. 0-
THERAPY ORAL

JUMLAH 64 HARI 6,400,000 Rp. 6,400,000-

Mengetahui, 124 Kalipucang, 30 April 2015

Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
 JUMLAH BESARAN JUMLAH
NOMOR JENIS KARTU UMUR DIAGNOSA TINDAKAN YANG TGL TGL JUMLAH SELURUH
NO NAMA PASIEN ALAMAT HARI RAWAT TARIF TAGIHAN PAKET
IDENTITAS (TH) PENYAKIT DIBERIKAN MASUK KELUAR TAGIHAN
(a) PAKET (b) 2015RITP (axb)
Mengetahui, Kalipucang, 30 April
Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
100,000
 FORMULIR PENGAJUAN KLAIM (FPK)
BIAYA PELAYANAN KESEHATAN

TANGGAL MASUK : .................... TGL. TERIMA YANKES : ................ TGL. TERIMA KEU : .................
NO. REG. MASUK : .................... NO. REG. KLAIM YANKES: ................ NO. REG. KLAIM KEU : .................

JENIS PENAGIHAN : KOLEKTIF

JENIS PELAYANAN : RAWAT INAP
NAMA PENGAJU/PPK : PUSKESMAS KALIPUCANG
NO. KARTU PESERTA :
BULAN/THN PELAYANAN: APRIL 2015
ALAMAT : JL. RAYA KALIPUCANG NO. 427
TELEPON :

DIAJUKAN (DIISI PENGAJU KLAIM) DISETUJUI (DIISI PETUGAS)

JUMLAH KODE JUMLAH
NO URAIAN BIAYA
KASUS TINDAKAN BIAYA Rp. AKUN KASUS TINDAKAN BIAYA Rp.
HR/R/LB HR/R/LB
1 Rawat Inap 46 64 HARI Rp. 6,400,000

JUMLAH 46 64 HARI Rp. 6,400,000 JUMLAH

Mengetahui, Cijulang, .............................. 2015

Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

Suryati, SKM. MSi _______________________

NIP : 19690923 199102 2 002 ..............................................
 REKAPITULASI PELAYANAN PERSALINAN
BPJS KESEHATAN
INSTANSI : PUSKESMAS KALIPUCANG
BULAN DAN TAHUN : APRIL 2015 22

GPA JENIS PERSALINAN

NOMOR TANGGAL (GRAVIDA, (DENGAN BESARAN JUMLAH SELURUH
NO NAMA PASIEN UMUR JENIS KARTU ALAMAT NO. TELP
IDENTITAS PELAYANAN PARTUS, PENYULIT / TANPA TARIF TAGIHAN
ABORTUS) PENYULIT)

1 05-03-2015 G4P3A0 Tanpa Penyulit 600,000 Rp. 600,000-

2 05-03-2015 G2P0A1 Observasi Rujukan 125,000 Rp. 125,000-

3 06-03-2015 G1P0A0 Pasca salin 175,000 Rp. 175,000-

4 09-03-2015 Rp. 0-

5 11-03-2015 Rp. 0-

6 12-03-2015 Rp. 0-

7 21-03-2015 Rp. 0-

8 31-03-2015 Rp. 0-

9 31-03-2015 Rp. 0-

10 31-03-2015 Rp. 0-

11 31-03-2015 Rp. 0-

JUMLAH Rp. 900,000-

Mengetahui, Kalipucang, 30 April 2015

Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
 RINCIAN BIAYA PERSALINAN PUSKESMAS KALIPUCANG
BULAN MARET 2015

Jumlah Biaya Jasa Obat BHP

No Nama Pasien Tnp Dg Obs Tnp Obs Tnp Obs Tnp Obs Tnp Obs
Dg PNYLT Rujukan Dg PNYLT Rujukan Dg PNYLT Rujukan Dg PNYLT Rujukan
PNYLT PNYLT Rujukan PNYLT PNYLT PNYLT PNYLT
1 RAMINI 1 750,000 0 562,500 0 0 93,750 0 0 93,750 0
2 EVA HELPIANA 1 750,000 0 562,500 0 0 93,750 0 0 93,750 0
3 DESI ARIYANTI 1 750,000 0 562,500 0 0 93,750 0 0 93,750 0
4 SUHARTI 1 600,000 450,000 0 0 75,000 0 0 75,000 0 0
5 1 600,000 450,000 0 0 75,000 0 0 75,000 0 0
6 1 600,000 450,000 0 0 75,000 0 0 75,000 0 0
7 HARTI WIDURIYATI 1 125,000 0 0 125,000 0 0 0 0 0 0
8 NIA 1 125,000 0 0 125,000 0 0 0 0 0 0
9 DESY RATNASARI 1 125,000 0 0 125,000 0 0 0 0 0 0
9 1 125,000 0 0 125,000 0 0 0 0 0 0
10 1 125,000 0 0 125,000 0 0 0 0 0 0
Jumlah 3 3 5 1,800,000 2,250,000 625,000 1,350,000 1,687,500 625,000 225,000 281,250 0 225,000 281,250 0

Mengetahui 4,675,000 biaya jasa obat+bhp Kalipucang, 31 Maret 2015

Kepala UPTD Puskesmas Kalipucang 1,800,000 1,350,000 450,000 Bendahara BPJS Puskesmas Kalipucang
2,250,000 1,687,500 562,500
625,000 625,000 0
4,675,000 3,662,500 1,012,500
Suryati, SKM. MSi 4,675,000 Eruk Rukiah, AM. Kep
NIP. 19690923 199102 2 002 900000 NIP. 19680513 198901 2 001
3,775,000
 FORMULIR PENGAJUAN KLAIM (FPK)
BIAYA PELAYANAN KESEHATAN

TANGGAL MASUK : .................... TGL. TERIMA YANKES : .................... TGL. TERIMA KEU : .................
NO. REG. MASUK : .................... NO. REG. KLAIM YANKES : .................... NO. REG. KLAIM KEU : .................

JENIS PENAGIHAN : KOLEKTIF

JENIS PELAYANAN : PERSALINAN
NAMA PENGAJU/PPK : PUSKESMAS KALIPUCANG
NO. KARTU PESERTA :
BULAN/THN PELAYANAN: APRIL 2015
ALAMAT : JL. RAYA KALIPUCANG NO. 427
TELEPON :

DIAJUKAN (DIISI PENGAJU KLAIM) DISETUJUI (DIISI PETUGAS)

JUMLAH JUMLAH
NO URAIAN BIAYA KODE AKUN
KASUS TINDAKAN BIAYA Rp. KASUS TINDAKAN BIAYA Rp.
HR/R/LB HR/R/LB
1 Dengan Penyulit 0 Rp. 750,000 Rp. 0
2 Tanpa Penyulit 0 Rp. 600,000 Rp. 0
3 Observasi Rujukan 0 Rp. 125,000 Rp. 0
4 Pasca Salin 0 Rp. 175,000 Rp. 0

JUMLAH 0 Rp. 0 JUMLAH

Mengetahui, Cijulang, .............................. 2015

Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

Suryati, SKM. MSi _______________________

NIP : 19690923 199102 2 002 ..............................................
 REKAPITULASI PELAYANAN PERSALINAN
BPJS KESEHATAN
INSTANSI : PUSKESMAS KALIPUCANG
BULAN DAN TAHUN : APRIL 2015 22

GPA JENIS PERSALINAN

NOMOR TANGGAL (GRAVIDA, (DENGAN BESARAN JUMLAH SELURUH
NO NAMA PASIEN UMUR IDENTITAS JENIS KARTU ALAMAT NO. TELP PELAYANAN PARTUS, PENYULIT / TANPA TARIF TAGIHAN
ABORTUS) PENYULIT)

1 Rp. 0-

2 Rp. 0-

3 Rp. 0-

4 Rp. 0-

5 Rp. 0-

6 Rp. 0-

7 Rp. 0-

8 Rp. 0-

9 Rp. 0-

JUMLAH Rp. 0-

Mengetahui, Kalipucang, 30 April 2015

Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
 REKAPITULASI PELAYANAN JAMINAN KESEHATAN NASIONAL (JKN)

PUSKESMAS : Kalipucang
BULAN : April 2015

RAWAT JALAN RAWAT INAP RUJUKAN PERSALINAN

NO PUSKESMAS
PBI NON PBI PBI NON PBI PBI NON PBI PBI NON PBI
1 Kalipucang
Jumlah

Kalipucang, 30 April 2015

Pengelola Program

Eruk Rukiah, AM. Kep

NIP : 19680513 198901 2 001
 DAFTAR 10 BESAR PENYAKIT JKN (RUJUKAN)

PUSKESMAS : Puskesmas Kalipucang

BULAN : April 2015

N KODE 0 - 7 hr 8 - 28 hr 29 hr - 1 1 - 4 th 5 - 9 th 10 - 14 15 - 19 20 - 24 25 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65 > 65 th JUML

DIAGNOSA PENYAKIT th th th th th th th th th th th th
O ICD L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P AH

Oth/unsp sympt & signs involv

1 R418 1 1
cognitive funct & awareness

2 J46 Status asthmaticus 1 1

3 I509 Heart failure, unspecified 1 1

Fracture of other and

4 S6280 unspecified parts of wrist and 0
hand, closed
5 R060 Dyspnoea 0

Non-insulin-depend diabetes
6 E116 mellitus with other spec comp 0

Hypertensive heart and renal

7 I131 disease with renal failure 0

8 K291 Other acute gastritis 0

Non-insulin-depend diabetes
9 E119 mellitus without complication 1 1

10 I101 Hypertension, stage II 0

Haemorrhagic condition,
11 D699 unspecified 0

12 S010 Open wound of scalp 0

Stroke, not specified as
13 I64 haemorrhage or infarction 0
 Iron deficiency anaemia
14 D500 secondary to blood loss 1 1
(chronic)

Delayed and secondary

15 O722 0
postpartum haemorrhage

16 K295 Chronic gastritis, unspecified 0

17 R100 Acute abdomen 0

18 R509 Fever, unspecified 0
JUMLAH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 2 0 0 5

Mengetahui, Kalipucang, 30 April 2015

Kepala UPTD Puskesmas Kalipucang Pengelola Program

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
NURYANI

NURYANI

IDA
WIDIYAWA
TI

SAHWI
SAHWI
 REKAPITULASI KLAIM PELAYANAN AMBULAN
BPJS KESEHATAN

INSTANSI : PUSKESMAS KALIPUCANG

BULAN DAN TAHUN : MARET 2015
DIAGNOSA NANYA
DULU DOKTER 61
MEDIA
PELAYANAN
NO. KARTU JARAK
NO NAMA PASIEN JENIS KARTU UMUR DIAGNOSA FASKES TUJUAN (RS) JAM
IDENTITAS KODE HARI TANGGAL BERANGKAT JAM TIBA TEMPUH
(KM)
1 SAHWI 0000438443932 JAMKESMAS 61 E119 + D500 DM II + ANEMIA GRAVIS
ASMA BRONCHIALEU
RSUD CIAMIS KAMIS 02-04-2015 12.25 13.25 73
SERANGAN BERAT +
2 NURYANI 0001476029463 BPJS 49 R418 + J46 PENURUNAN RSUD BANJAR MINGGU 05-04-2015 16.00 17.00 48
KESADARAN
3 IDA WIDIYAWATI 0000519120303 JAMKESMAS 50 I509 SUSP. CHF RSUD BANJAR JUMAT 10-04-2015 19.05 20.05 48
4 RSUD BANJAR 48
5 RSUD BANJAR 48
6 RS BANJAR PATROMAN SENIN 09-03-2015 15.05 16.05 48
7 RSUD BANJAR 48
8 RSUD BANJAR 48
9 RS SIAGA MEDIKA SENIN 23-03-2015 13.00 15.30 120
10 RSUD BANJAR 48
11 RSUD BANJAR 48
12 RSUD BANJAR 48
JUMLAH

Mengetahui, Kalipucang, 31 Maret 2015

Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
 Mengetahui, Kalipucang, 31 Maret 2015
Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
 JUMLAH BIAYA
TAGIHAN

Rp. 292,000-
Rp. 192,000-
Rp. 192,000-
Rp. 0-
Rp. 0-
Rp. 0-
Rp. 0-
Rp. 0-
Rp. 0-
Rp. 0-
Rp. 0-
Rp. 0-
Rp. 676,000-

ang, 31 Maret 2015

engelola BPJS

Rukiah, AM. Kep

680513 198901 2 001
ang, 31 Maret 2015
engelola BPJS

Rukiah, AM. Kep

680513 198901 2 001
 REKAPITULASI RUJUKAN
BPJS KESEHATAN

INSTANSI : PUSKESMAS KALIPUCANG

BULAN DAN TAHUN : APRIL 2015

RINCIAN
NO. KARTU
NO NAMA PASIEN JENIS KARTU FASKES TUJUAN JUMLAH TOTAL
BAHAN BAKAR PEMELIHARAAN
IDENTITAS JASA
JASA SUPIR
AMBULAN PENDAMPING
1 IDA WIDIYAWATI 0000519120303 JAMKESMAS RSUD BANJAR Rp. 192,000- 62,400 25,920 51,840 51,840
2 0 0 0 RSUD BANJAR Rp. 0- 62,400 -12,480 -24,960 -24,960
3 0 0 0 RSUD BANJAR Rp. 0- 62,400 -12,480 -24,960 -24,960
4 0 0 0 RS BANJAR PATROMAN Rp. 0- 62,400 -12,480 -24,960 -24,960
5 0 0 0 RSUD BANJAR Rp. 0- 62,400 -12,480 -24,960 -24,960
6 0 0 0 RSUD BANJAR Rp. 0- 62,400 -12,480 -24,960 -24,960
7 0 0 0 RS SIAGA MEDIKA Rp. 0- 156,000 -31,200 -62,400 -62,400
8 0 0 0 RSUD BANJAR Rp. 0- 62,400 -12,480 -24,960 -24,960
9 0 0 0 RSUD BANJAR Rp. 0- 62,400 -12,480 -24,960 -24,960
10 0 0 0 RSUD BANJAR Rp. 0- 62,400 -12,480 -24,960 -24,960
JUMLAH Rp. 192,000 717,600 -105,120 -210,240 -210,240

192,000
Mengetahui, 192,000 Kalipucang, 30 April 2015 192,000
Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
 FORMULIR PENGAJUAN KLAIM (FPK)
BIAYA PELAYANAN KESEHATAN

TANGGAL MASUK : .................... TGL. TERIMA YANKES : .................. TGL. TERIMA KEU : .................
NO. REG. MASUK : .................... NO. REG. KLAIM YANKE : .................. NO. REG. KLAIM KEU : .................

JENIS PENAGIHAN : KOLEKTIF

JENIS PELAYANAN : RUJUKAN
NAMA PENGAJU/PPK : PUSKESMAS KALIPUCANG
NO. KARTU PESERTA :
BULAN/THN PELAYANAN: APRIL 2015
ALAMAT : JL. RAYA KALIPUCANG NO. 427
TELEPON :

DIAJUKAN (DIISI PENGAJU KLAIM) DISETUJUI (DIISI PETUGAS)

JUMLAH KODE JUMLAH
NO URAIAN BIAYA
KASUS TINDAKAN BIAYA Rp. AKUN KASUS TINDAKAN BIAYA Rp.
HR/R/LB HR/R/LB
1 Rujukan ke RSUD Banjar 0 Rp. 192,000 Rp. 0
2 Rujukan ke RS Banjar Patroman 0 Rp. 192,000 Rp. 0
3 Rujukan ke RS Siaga Medika 0 Rp. 480,000 Rp. 0

JUMLAH 0 Rp. 0 JUMLAH

Mengetahui, Cijulang, .............................. 2015

Kepala UPTD Puskesmas Kalipucang Pengelola BPJS

Suryati, SKM. MSi _______________________

NIP : 19690923 199102 2 002 ..............................................
 DAFTAR 10 BESAR PENYAKIT JKN (RAWAT JALAN)

PUSKESMAS : Kalipucang 264 tgl 1-24

BULAN : Januari 2015

0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th 10 - 14 15 - 19 20 - 24 25 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65 > 65 th JUML
KODE th th th th th th th th th th th
NO ICD DIAGNOSA PENYAKIT AH
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
Influenza with other manifestations,
1 J118 virus not identified 0

2 K291 Other acute gastritis 0

3 E162 Hypoglycaemia, unspecified 0

4 H110 Pterygium 0

5 H539 Visual disturbance, unspecified 0

Other specified diseases of anus and
6 K628 rectum 0
7 C119 Malignant neoplasm, nasopharynx, 0
unspecified
8 A499 Bacterial infection, unspecified 0

9 K009 Disorder of tooth development, 0

unspecified

10 J039 Acute tonsillitis, unspecified 0

11 S098 Other specified injuries of head 0

12 S822 Fracture of shaft of tibia 0
13 J304 Allergic rhinitis, unspecified 0

14 Z518 Other specified medical care 0

15 R599 Enlarged lymph nodes, unspecified 0

16 H919 Hearing loss, unspecified 0

17 I209 Angina pectoris, unspecified 0

18 A664 Gummata and ulcers of yaws 0

19 K808 Other cholelithiasis 0

20 N832 Other and unspecified ovarian cysts 0

21 H010 Blepharitis 0
22 J209 Acute bronchitis, unspecified 0
22 H700 Acute mastoiditis 0
Neuralgia and neuritis, unspecified,
22 M7923 forearm 0

23 N832 Other and unspecified ovarian cysts 0

 10 - 14 15 - 19 20 - 24 25 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65
KODE 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th > 65 th JUML
NO DIAGNOSA PENYAKIT th th th th th th th th th th th
ICD L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P AH

23 0

23 K295 Chronic gastritis, unspecified 0

24 T620 Toxic effect, ingested mushrooms 0

Allergic contact dermatitis,
25 L239 unspecified cause 0
Pleural effusion, not elsewhere
26 J90 0
classified
27 H269 Cataract, unspecified 0
28 M545 Low back pain 0

29 H612 Impacted cerumen 0

30 A309 Leprosy, unspecified 0

31 H261 Traumatic cataract 0

32 Z518 Other specified medical care 0
33 Z030 Observation for suspected 0
tuberculosis
Tuberculosis of lung, confirmed by
34 A151 culture only 0
35 E078 Other specified disorders of thyroid 0
Fracture of lower end of both ulna
36 S5260 and radius, closed 0
37 R229 Localized swelling, mass and lump, 0
unspecified
38 K028 Other dental caries 0
39 H608 Other otitis externa 0
40 I101 Hypertension, stage II 0
41 I100 Hypertension, stage I 0

42 J340 Abscess, furuncle and carbuncle of 0

nose
43 R509 Fever, unspecified 0
44 R060 Dyspnoea 0
45 I500 Congestive heart failure 0
46 K041 Necrosis of pulp 0
47 N200 Calculus of kidney 0
48 K083 Retained dental root 0
49 M792 Neuralgia and neuritis, unspecified 0
50 O800 Spontaneous vertex delivery 0
51 O219 Vomiting of pregnancy, unspecified 0
52 L545 Low back pain 0
53 Z470 Follow-up care invol remov fract plate 0
oth int fixation dev
 10 - 14 15 - 19 20 - 24 25 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65
KODE 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th > 65 th JUML
NO DIAGNOSA PENYAKIT th th th th th th th th th th th
ICD L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P AH

Seronegative rheumatoid arthritis,

54 M0609 unspecified site 0

Non-insulin-depend diabetes mellitus

55 E116 with other spec comp 0

56 L240 Irritant contact dermatitis due to 0

detergents

57 I849 Unspecified haemorrhoids without 0

complication

Maternal care for viable fetus in

58 O367 abdominal pregnancy 0

Neuralgia and neuritis, unspecified,

59 M7920 multiple sites 0

Severe depressive episode with

60 F323 psychotic symptoms 0

61 Z518 Other specified medical care 0

62 K011 Impacted teeth 0
63 H26099 Cataract (patient's age < 50) 0

64 M0590 Seropositive rheumatoid arthritis, 0

unspecified, multiple sites

Seronegative rheumatoid arthritis,

65 M0609 unspecified site 0

Irritant contact dermatitis due to

66 L240 detergents 0

67 K008 Other disorders of tooth development 0

68 D509 Iron deficiency anaemia, unspecified 0

69 M0607 Seronegative rheumatoid arthritis, 0

ankle/foot

Multiple open wounds of ankle and

70 S917 foot 0

71 H110 Pterygium 0

72 J209 Acute bronchitis, unspecified 0

73 J00 Acute nasopharyngitis [common cold] 0

 10 - 14 15 - 19 20 - 24 25 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65
KODE 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th > 65 th JUML
NO DIAGNOSA PENYAKIT th th th th th th th th th th th
ICD L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P AH

74 K083 Retained dental root 0

75 H110 Pterygium 0

76 R33 Retention of urine 0

77 C119 Malignant neoplasm, nasopharynx, 0

unspecified

78 E079 Disorder of thyroid, unspecified 0

11 L272 Dermatitis due to ingested food 0

1 R060 Dyspnoea 0
Traumatic cerebral oedema, without
2 S0610 open wound 0

3 K291 Other acute gastritis 0

Other specified diabetes mellitus
6 E139 0
without complications

Non-insulin-depend diabetes mellitus

4 E116 with other spec comp 0

9 E162 Hypoglycaemia, unspecified 0

11 E162 Hypoglycaemia, unspecified 0

13 E139 Other specified diabetes mellitus without 0

complications

79 K040 Pulpitis 0
80 R05 Cough 0
81 A010 Typhoid fever 0
82 L208 Other atopic dermatitis 0
Observation for other suspected
83 Z038 diseases and conditions 0

84 Z368 Other antenatal screening 0

85 H669 Otitis media, unspecified 0
86 Z308 Other contraceptive management 0
Diarrhoea and gastroenteritis of
87 A090 presumed infectious origin 0

88 H102 Other acute conjunctivitis 0

89 J4590 Bronchial Asthma in Exacerbation 0
90 H2599 Cataract (patient's age = 50) 0
 10 - 14 15 - 19 20 - 24 25 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65
KODE 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th > 65 th JUML
NO DIAGNOSA PENYAKIT th th th th th th th th th th th
ICD L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P AH

Non-insulin-depend diabetes mellitus

91 E119 without complication 0

Allergic contact dermatitis due to

92 L238 other agents 0

93 G439 Migraine, unspecified 0

94 M791 Myalgia 0
95 M792 Neuralgia and neuritis, unspecified 0

96 Z041 Examination and observation 0

following transport accident
97 J039 Acute tonsillitis, unspecified 0
Other and unspecified abnormalities
98 R008 of heart beat 0

Non-insulin-dependent diabetes
99 E118 mellitus with unspec comps 0

Bronchitis, not specified as acute or

100 J40 chronic 0

Other specified orthopaedic follow-up

101 Z478 care 0

102 H814 Vertigo of central origin 0

103 D259 Leiomyoma of uterus, unspecified 0

Urinary tract infection, site not

104 N390 specified 0

105 Z518 Other specified medical care 0

106 B009 Herpes-viral infection, unspecified 0

107 K040 Pulpitis 0

108 K052 Acute periodontitis 0

109 M0609 Seronegative rheumatoid arthritis, 0

unspecified site
Other spec abdom hernia without
110 K458 obstruction or gangrene 0

111 K121 Other forms of stomatitis 0

 10 - 14 15 - 19 20 - 24 25 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65
KODE 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th > 65 th JUML
NO DIAGNOSA PENYAKIT th th th th th th th th th th th
ICD L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P AH

112 G442 Tension-type headache 0

113 J00 Acute nasopharyngitis [common cold] 0

114 M0600 Seronegative rheumatoid arthritis, 0

multiple sites

115 J340 Abscess, furuncle and carbuncle of 0

nose

116 K295 Chronic gastritis, unspecified 0

117 J029 Acute pharyngitis, unspecified 0

118 H669 Otitis media, unspecified 0

119 H408 Other glaucoma 0

120 I519 Heart disease, unspecified 0

121 N894 Leukoplakia of vagina 0

122 I517 Cardiomegaly 0

123 I861 Scrotal varices 0

124 K299 Gastroduodenitis, unspecified 0

125 J039 Acute tonsillitis, unspecified 0

Men & behav dis due use

126 F162 hallucinogens: dependence syndrome 0

127 Z488 Other specified surgical follow-up care 0

128 K047 Periapical abscess without sinus 0

129 S7280 Fractures of other parts of femur, 0

closed

130 K053 Chronic periodontitis 0

 10 - 14 15 - 19 20 - 24 25 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65
KODE 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th > 65 th JUML
NO DIAGNOSA PENYAKIT th th th th th th th th th th th
ICD L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P AH

Examination and observation

131 Z042 following work accident 0

Other specified diseases of biliary

132 K838 tract 0

133 M100 Gout idiopatik 0

134 J018 Other acute sinusitis 0

135 Z043 Examination and observation 0

following other accident

136 I64 Stroke, not specified as haemorrhage 0

or infarction

137 O288 Other abnormal findings on antenatal 0

screening of mother
Seronegative rheumatoid arthritis,
138 M0607 0
ankle/foot

139 K006 Disturbances in tooth eruption 0

140 K032 Erosion of teeth 0

141 H609 Otitis externa, unspecified 0

142 N40 Hyperplasia of prostate 0

143 H669 Otitis media, unspecified 0

Excessive and frequent menstruation

144 N921 with irregular cycle 0

Adjustment and management of

145 Z458 other implanted devices 0

146 R104 Other and unspecified abdominal pain 0

147 M7911 Myalgia, shoulder region 0

148 R609 Oedema, unspecified 0

149 H813 Other peripheral vertigo 0

 10 - 14 15 - 19 20 - 24 25 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65
KODE 0 - 7 hr 8 - 28 hr 29 hr - 1 th 1 - 4 th 5 - 9 th > 65 th JUML
NO DIAGNOSA PENYAKIT th th th th th th th th th th th
ICD L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P AH

150 J339 Nasal polyp, unspecified 0

151 M7918 Myalgia, other site 0

152 G439 Migraine, unspecified 0

153 F162 Men & behav dis due use 0

hallucinogens: dependence syndrome

154 R51 Headache 0

155 Z488 Other specified surgical follow-up care 0

156 Z030 Observation for suspected 0

tuberculosis

157 I101 Hypertension, stage II 0

5 I101 Hypertension, stage II 0

Observation for other suspected diseases
6 Z038 and conditions 0

7 E116 Non-insulin-depend diabetes mellitus with 0

other spec comp

158 A060 Acute amoebic dysentery 0

159 L088 Other spec local infections of skin and 0

subcutaneous tissue

JUMLAH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Mengetahui, Kalipucang, 31 Januari 2015 213 -213

Kepala UPTD Puskesmas Kalipucang Pengelola Program

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
 REKAPITULASI RUJUKAN
BPJS KESEHATAN
INSTANSI : PUSKESMAS KALIPUCANG
BULAN DAN TAHUN : DESEMBER 2014

RINCIAN
NO. KARTU IDENTITAS
BAHAN BAKAR PEMELIHARAAN
NO NAMA PASIEN FASKES TUJUAN JUMLAH TOTAL JASA
JASA SUPIR
AMBULAN PENDAMPING
BPJS JAMKESMAS 33% 12% 27.5% 27.5% 100%
1 RSUD BANJAR Rp. 192,000- 63,360 23,040 52,800 52,800
2 RSUD BANJAR Rp. 0- 0 0 0 0
3 RSUD BANJAR Rp. 0- 0 0 0 0
4 RS BANJAR PATROMAN Rp. 0- 0 0 0 0
5 RSUD BANJAR Rp. 0- 0 0 0 0
6 RSUD BANJAR Rp. 0- 0 0 0 0
7 RS SIAGA MEDIKA Rp. 0- 0 0 0 0
8 #REF! #REF! #REF! #REF! #REF! #REF!
JUMLAH #REF! #REF! #REF! #REF! #REF!

Mengetahui, Kalipucang, 24 Desember 2014 #REF!

Kepala UPTD Puskesmas Kalipucang Pengelola BPJS #REF!

Suryati, SKM. MSi Eruk Rukiah, AM. Kep

NIP : 19690923 199102 2 002 NIP : 19680513 198901 2 001
 DAFTAR JARAK PUSKESMAS KE RUMAH SAKIT RUJUKAN DI WILAYAH KERJA KAB. PAN
BERDASARKAN (PKS) PERJANJIAN KERJA SAMA BPJS DAN DINKES PANGANDA

NAMA RUJUKAN JARAK PENGURANGAN

NO PUSKESMAS (KM) 10 KM
PPK I PPK II PPK III
1 PKM Kalipucang RSUD Banjar 48 38
RSUD Ciamis 73 63
RSUD Cilacap 100 90
RSUD Banyumas 120 110
RS Siaga Medika 120 110
RS Hasan Sadikin 205 195
RS Margono 120 110
DI WILAYAH KERJA KAB. PANGANDARAN
PJS DAN DINKES PANGANDARAN

HARGA 10 KM HARGA 1 KM JUMLAH KETERANGAN

PERTAMA SELANJUTNYA TOTAL

40,000 4,000 192,000 Jawa Barat

40,000 4,000 292,000 Jawa Barat
40,000 4,000 400,000 Jawa Tengah
40,000 4,000 480,000 Jawa Tengah
40,000 4,000 480,000 Jawa Tengah
40,000 4,000 820,000 Jawa Barat
40,000 4,000 480,000 Jawa Tengah
 TARIF RUJUKAN DARI PUSKESMAS DI KABUPATEN PANGANDARAN KE RUMAH SAKIT
UNTUK PASIEN PESERTA JAMINAN KESEHATAN NASIONAL (JKN)

TAHUN 2014

I. TUJUAN RUJUKAN KE RUMAH SAKIT DI WILAYAH CIAMIS

BAHAN BAKAR
1 Lt/5 KM (1 Lt
Rp.6.500,-)
JARAK JUMLAH Sisa dikurangi
NO. NAMA PUSKESMAS RUJUKAN (KM) TOTAL (Rp) BBM

1 Puskesmas Padaherang 60 240,000 78,000 162,000

2 Puskesmas Mangunjaya 55 220,000 71,500 148,500
3 Puskesmas Sindangwangi 65 260,000 84,500 175,500
4 Puskesmas Kalipucang 73 292,000 94,900 197,100
5 Puskesmas Pangandaran 90 360,000 117,000 243,000
6 Puskesmas Cikembulan 90 360,000 117,000 243,000
7 Puskesmas Sidamulih 90 360,000 117,000 243,000
8 Puskesmas Selasari 108 472,000 140,400 331,600
9 Puskesmas Parigi 108 432,000 140,400 291,600
10 Puskesmas Cigugur 110 480,000 143,000 337,000
11 Puskesmas Langkaplancar 80 320,000 104,000 216,000
12 Puskesmas Jadikarya 80 320,000 104,000 216,000
13 Puskesmas Cimerak 140 560,000 182,000 378,000
14 Puskesmas Legokjawa 140 560,000 182,000 378,000
15 Puskesmas Cijulang 127 508,000 165,100 342,900

II. TUJUAN RUJUKAN KE RUMAH SAKIT DI WILAYAH KOTA BANJAR

BAHAN BAKAR 1
JARAK JUMLAH Lt/5 KM (1 Lt Sisa dikurangi
NO. NAMA PUSKESMAS RUJUKAN (KM) TOTAL (Rp) Rp.6.500,-) BBM

1 Puskesmas Padaherang 34 136,000 44,200 91,800

2 Puskesmas Mangunjaya 37 148,000 48,100 99,900
3 Puskesmas Sindangwangi 45 180,000 58,500 121,500
4 Puskesmas Kalipucang 48 192,000 62,400 129,600
5 Puskesmas Pangandaran 64 256,000 83,200 172,800
6 Puskesmas Cikembulan 75 300,000 97,500 202,500
7 Puskesmas Sidamulih 80 320,000 104,000 216,000
8 Puskesmas Selasari 88 352,000 114,400 237,600
9 Puskesmas Parigi 88 352,000 114,400 237,600
10 Puskesmas Cigugur 100 400,000 130,000 270,000
11 Puskesmas Langkaplancar 60 240,000 78,000 162,000
 12 Puskesmas Jadikarya 60 240,000 78,000 162,000
13 Puskesmas Cimerak 120 480,000 156,000 324,000
14 Puskesmas Legokjawa 120 480,000 156,000 324,000
15 Puskesmas Cijulang 102 408,000 132,600 275,400

II.TUJUAN RUJUKAN KE RUMAH SAKIT DI WILAYAH TASIKMALAYA

BAHAN BAKAR 1
JARAK JUMLAH Lt/5 KM (1 Lt Sisa dikurangi
NO. NAMA PUSKESMAS RUJUKAN (KM) TOTAL (Rp) Rp.6.500,-) BBM

1 Puskesmas Padaherang 75 300,000 97,500 202,500

2 Puskesmas Mangunjaya 70 280,000 91,000 189,000
3 Puskesmas Sindangwangi 80 320,000 104,000 216,000
4 Puskesmas Kalipucang 88 352,000 114,400 237,600
5 Puskesmas Pangandaran 105 420,000 136,500 283,500
6 Puskesmas Cikembulan 108 432,000 140,400 291,600
7 Puskesmas Sidamulih 110 440,000 143,000 297,000
8 Puskesmas Selasari 123 492,000 159,900 332,100
9 Puskesmas Parigi 123 492,000 159,900 332,100
10 Puskesmas Cigugur 125 580,000 162,500 417,500
11 Puskesmas Langkaplancar 95 380,000 123,500 256,500
12 Puskesmas Jadikarya 95 380,000 123,500 256,500
13 Puskesmas Cimerak 155 620,000 201,500 418,500
14 Puskesmas Legokjawa 155 620,000 201,500 418,500
15 Puskesmas Cijulang 142 568,000 184,600 383,400

III. TUJUAN RUJUKAN KE RUMAH SAKIT DI WILAYAH BANYUMAS/PURWOKERTO

BAHAN BAKAR 1
JARAK JUMLAH Lt/5 KM (1 Lt Sisa dikurangi
NO. NAMA PUSKESMAS RUJUKAN (KM) TOTAL (Rp) Rp.6.500,-) BBM

1 Puskesmas Padaherang 125 500,000 162,500 337,500

2 Puskesmas Mangunjaya 125 500,000 162,500 337,500
3 Puskesmas Sindangwangi 125 500,000 162,500 337,500
4 Puskesmas Kalipucang 120 480,000 156,000 324,000
5 Puskesmas Pangandaran 125 500,000 162,500 337,500
6 Puskesmas Cikembulan 130 520,000 169,000 351,000
 7 Puskesmas Sidamulih 130 520,000 169,000 351,000
8 Puskesmas Selasari 135 540,000 175,500 364,500
9 Puskesmas Parigi 156 624,000 202,800 421,200
10 Puskesmas Cigugur 150 600,000 195,000 405,000
11 Puskesmas Langkaplancar 160 640,000 208,000 432,000
12 Puskesmas Jadikarya 170 680,000 221,000 459,000
13 Puskesmas Cimerak 150 600,000 195,000 405,000
14 Puskesmas Legokjawa 165 660,000 214,500 445,500
15 Puskesmas Cijulang 160 640,000 208,000 432,000

V. TUJUAN RUJUKAN KE RUMAH SAKIT DI WILAYAH CILACAP

BAHAN BAKAR 1
JARAK JUMLAH Lt/5 KM (1 Lt Sisa dikurangi
NO. NAMA PUSKESMAS RUJUKAN (KM) TOTAL (Rp) Rp.6.500,-) BBM

1 Puskesmas Padaherang 98 392,000 127,400 264,600

2 Puskesmas Mangunjaya 90 360,000 117,000 243,000
3 Puskesmas Sindangwangi 90 360,000 117,000 243,000
4 Puskesmas Kalipucang 100 400,000 130,000 270,000
5 Puskesmas Pangandaran 115 460,000 149,500 310,500
6 Puskesmas Cikembulan 120 480,000 156,000 324,000
7 Puskesmas Sidamulih 120 480,000 156,000 324,000
8 Puskesmas Selasari 130 520,000 169,000 351,000
9 Puskesmas Parigi 125 500,000 162,500 337,500
10 Puskesmas Cigugur 135 540,000 175,500 364,500
11 Puskesmas Langkaplancar 130 520,000 169,000 351,000
12 Puskesmas Jadikarya 130 520,000 169,000 351,000
13 Puskesmas Cimerak 140 560,000 182,000 378,000
14 Puskesmas Legokjawa 140 560,000 182,000 378,000
15 Puskesmas Cijulang 125 500,000 162,500 337,500
RAN KE RUMAH SAKIT
IONAL (JKN)

Pembagian Jasa

Uang Harian
Kontribusi Ke Uang Harian Sopir Pendamping
Puskesmas (20%) (40%) (40%)

32,400 64,800 64,800

29,700 59,400 59,400
35,100 70,200 70,200
39,420 78,840 78,840
48,600 97,200 97,200
48,600 97,200 97,200
48,600 97,200 97,200
66,320 132,640 132,640
58,320 116,640 116,640
67,400 134,800 134,800
43,200 86,400 86,400
43,200 86,400 86,400
75,600 151,200 151,200
75,600 151,200 151,200
68,580 137,160 137,160

Pembagian Jasa

Uang Harian
Kontribusi Ke Uang Harian Sopir Pendamping
Puskesmas (20%) (40%) (40%)

18,360 36,720 36,720

19,980 39,960 39,960
24,300 48,600 48,600
25,920 51,840 51,840
34,560 69,120 69,120
40,500 81,000 81,000
43,200 86,400 86,400
47,520 95,040 95,040
47,520 95,040 95,040
54,000 108,000 108,000
32,400 64,800 64,800
 32,400 64,800 64,800
64,800 129,600 129,600
64,800 129,600 129,600
55,080 110,160 110,160

Pembagian Jasa

Uang Harian
Kontribusi Ke Uang Harian Sopir Pendamping
Puskesmas (20%) (40%) (40%)

40,500 81,000 81,000

37,800 75,600 75,600
43,200 86,400 86,400
47,520 95,040 95,040
56,700 113,400 113,400
58,320 116,640 116,640
59,400 118,800 118,800
66,420 132,840 132,840
66,420 132,840 132,840
83,500 167,000 167,000
51,300 102,600 102,600
51,300 102,600 102,600
83,700 167,400 167,400
83,700 167,400 167,400
76,680 153,360 153,360

Pembagian Jasa

Uang Harian
Kontribusi Ke Uang Harian Sopir Pendamping
Puskesmas (20%) (40%) (40%)

67,500 135,000 135,000

67,500 135,000 135,000
67,500 135,000 135,000
64,800 129,600 129,600
67,500 135,000 135,000
70,200 140,400 140,400
 70,200 140,400 140,400
72,900 145,800 145,800
84,240 168,480 168,480
81,000 162,000 162,000
86,400 172,800 172,800
91,800 183,600 183,600
81,000 162,000 162,000
89,100 178,200 178,200
86,400 172,800 172,800

Pembagian Jasa

Uang Harian
Kontribusi Ke Uang Harian Sopir Pendamping
Puskesmas (20%) (40%) (40%)

52,920 105,840 105,840

48,600 97,200 97,200
48,600 97,200 97,200
54,000 108,000 108,000
62,100 124,200 124,200
64,800 129,600 129,600
64,800 129,600 129,600
70,200 140,400 140,400
67,500 135,000 135,000
72,900 145,800 145,800
70,200 140,400 140,400
70,200 140,400 140,400
75,600 151,200 151,200
75,600 151,200 151,200
67,500 135,000 135,000
 JUMLAH KUNJUNGAN PASIEN BPJS (NON KAPITASI) FEBRUARI 2015
PUSKESMAS KALIPUCANG

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0 0 0 0 0
RAWAT INAP RUJUKAN PERSALINAN TOTAL
 JUMLAH KUNJUNGAN RAWAT JALAN PASIEN BPJS (KAPITASI) FEBRUARI 2015 PUSKESMAS KALIPUCANG

16
15

14

12

10

6
5
4
4
3
2
2
1

0
ASKES JAMKESMAS BPJS TNI/POLRI JAMSOSTEK TOTAL
 1

0
ASKES JAMKESMAS BPJS TNI/POLRI JAMSOSTEK TOTAL

DAFTAR 10 BESAR PENYAKIT PENGUNJUNG PESERTA BPJS

DI PUSKESMAS KALIPUCANG
BULAN JANUARI 2015

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0
PA0 TIS
0 0
SI R U0 R E0
RA
0
TIS
0
RI
S0
TIS
0
I D0 IN
0
A L0
IS I N A PI I O A T
STR RTE PA DI L FE
B AT P H -L TO
TB PU N
G A PE RM TY L AI
HY D E
0
PA0 TIS
0 0
SI R U0 R E0
RA
0
TIS
0
R I S0
TIS
0
I D0 IN
0
A L0
IS I EN A PI I O A T
TR RT PA DI L FE
B AT PH - L TO
AS PE TB PU RM TY IN
G LA
HY D E

JUMLAH KUNJUNGAN RAWAT JALAN PASIEN BPJS (KAPITASI) TRIWULAN III 2014
PUSKESMAS KALIPUCANG
JUMLAH KUNJUNGAN PASIEN BPJS (NON KAPITASI) TRIWULAN III 2014
PUSKESMAS KALIPUCANG
RAWAT INAP RUJUKAN PERSALINAN TOTAL
0 0 0 0
 TNI/POLR JAMSOST
BULAN ASKES JAMKESMAS BPJS TOTAL
I EK
JUMLAH KUNJU 1 2 3 4 5 15
 ISPA GASTRITIS HYPERTENSI TB PARU DIARE RA PULPITIS FEBRIS DERMATITIS TYPHOID LAIN-LAIN TOTAL
DAFTAR 10 0 0 0 0 0 0 0 0 0 0 0 0
 JAMKESM TNI/POLR JAMSOST
BULAN ASKES BPJS TOTAL
AS I EK
JULI 0 0 0 0 0 0
AGUSTUS 0 0 0 0 0 0
SEPTEMBE 0 0 0 0 0 0
JML 0 0 0 0 0 0
 RAWAT INAP RUJUKAN PERSALINAN TOTAL
JULI 0 0 0 0
AGUSTUS 0 0 0 0
SEPTEMBER 0 0 0 0
 JAMKESDA PUSKESMAS KALIPUCANG

KARTU DATANG
NO DESA
1 2 3 JML
1 KALIPUCANG 123 69 26 218
2 CIBULUH 236 236
3 BANJARHARJA 227 18 245
4 BAGOLO 1 1
5 PUTRAPINGGAN 206 18 224
JUMLAH 924