Fom Baru Jamkesda 2017

FORMAT REKAP RAWAT INAP
PUSKESMAS SAPEKEN
BULAN DESEMBER 2017
TANGGAL JUMLAH
JENIS UMUR
NO NAMA PASIEN ALAMAT NO. KARTU/ SPM REGESTER HARI
KELAMIN (TH) MASUK KELUAR RAWAT
1 2 3 4 5 6 7 8 9 10
1 By. Nur inayah P 0 Hr Sapeken 1189 JIX.1700530 11/22/2017 11/28/2017 6
2 Nur Inayah P 23 Th Sapeken 1189 JIX.1700533 11/23/2017 11/28/2017 5
3 Mimbar L 55 Th Paliat 15 JXI.1700532 11/23/2017 11/27/2017 4
4 Hasanah p 58 Th Sapeken 196 JXI.1700548 11/27/2017 12/1/2017 4
5 Saifullah L 9 Th Sapeken 1200 JXII.1700549 11/29/2017 12/1/2017 2
6 Rahman L 59 Th Pag.Besar 167 JXII.1700578 12/6/2017 12/8/2017 2
7 Erwin L 16 Th Tajung Kiaok 53 JXII.1700579 12/9/2017 12/16/2017 6
8 Albani L 56 Th Sapeken 1271 JXII.1700586 10/21/2017 12/14/2017 4
9 Amir Mahmud L 74 Th Sapeken 1253 JXII.1700587 12/11/2017 12/13/2017 2
10 Amir Mahmud L 74 Th Sapeken 1253 JXII.1700589 12/13/2017 12/19/2017 6
11 Ahmad L 60 Th Tanjung Kiaok 54 JXII.1700592 12/15/2017 12/19/2017 4
12 Maria Hulfa P 29 Th Sapeken 12 JXII.1700299 12/17/2017 12/20/2017 3
13 Juhairia P 47 Th Sapeken 1288 JXII.1700599 12/18/2017 12/26/2017 6
14 Rustini P 25 Th Sabuntan 236 JXII.1700403 12/23/2017 12/26/2017 3
15 Barlian P 32 Th Sabuntan 2 JXII.1700529 12/24/2017 12/25/2017 1
16 Suhani P 60 Th Saur 119 JXII.1700607 12/26/2017 12/31/2017 5
17 Ayu Amalia P 19 Th Sapeken 1308 JXII.1700406 12/27/2017 12/28/2017 1
18 Hapsah P 56 Th Sepanjang 502 JXII.1700606 12/27/2017 12/31/2017 4
TOTAL 78
PUSKESMAS SAPEKEN
BULAN DESEMBER 2017
DIAGNOSA KODE (ICD X) TOTAL BIAYA KET
11 12 13
Asfisia Berat (Riwayat Ibu Post Date) Rp 275,000 S
Febris es. Bendungan Asi Rp 205,000 S
Susp. HNP+CKD Rp 199,000 S
Strok+HT Rp 199,000 S
Thypoid Rp 107,000 S
GE Rp 107,000 S
Hemaptoe Rp 291,000 S
Colic Abdomen Rp 199,000 S
DC+Asam Bronkial Rp 107,000 S
DC+Asam Bronkial Rp 291,000 S
Susp. TB Rp 199,000 S
Bendungan Asi Rp 150,000 S
DM Tipe II Dg Luka Ganggren Rp 291,000 S
Late HPP Rp 977,500 S
Susp. Kokliliasis+ISPA Rp 61,000 S
Gastritis Rp 235,000 S
Febris es. Bendungan Asi Rp 60,000 S
Ispa+Susp.HNP Rp 199,000 S
Rp 4,152,512
SUMENEP, 30 Desember 2017

Kepala UPT. Puskesmas Sapeken
SUHARTO,Amd.Gz. SKM.
NIP. 19690329 199203 1 007
FORMAT REKAP RAWAT IN
UPT. PUSKESMAS SAPEKE
BULAN NOVEMBER 201
JENIS UMUR
NO NAMA PASIEN ALAMAT NO. KARTU/ SPM
KELAMIN (TH)
1 2 3 4 5 6
1 Murida P 33 Th Saur 6
2 Amiruddin L 32 Th Pag. Besar 23
3 Malya P 54 Th Sapeken 1068
4 Semmi p 54 Th Tanjung Kiaok 48
5 Jumdawati P 30 Th Sadulang Kecil 257
6 Uratul Aini P 30 Th Sapeken 699
7 Sunatia P 35 Th Paliat 69
8 Albaini P 67 Th Sapeken 928
9 Buddin L 60 Th Sadulang Besar 1
10 Suhrawi L 60 Th Sapeken 73
11 Morhama P 70 Th Sapeken 137
12 SaiFul L 41 Th Pag. Kecil 1022
13 Bahriani P 42 Th Sadulang Besar 275
14 Jakina P 25 Th Tanjung Kiaok 21
15 Nur Kholis L 6 Th Sadulang Besar 11
16 Sitti Aisyah P 44 Th Sapeken 720
17 Kaina P 5 Th Sapeken 953
18 Khusairi L 29 Th Sapeken 451
19 Novianti Wulandari P 17 Th Sakala 129
20 Nizanul Hasan P 21 Th Sapeken 1170
21 Assadur Rahman L 16 Th Tanjung Kiaok 191
22 Nur Inayah P 24 Th Sapeken 1189
23 Nur Aini P 32 Th Sapeken 1168
24 Sahlan L 70 Th Paliat 25
25 Mujarapah P 26 Th Pag. Kecil 202
26
27
28
29
30
31
TOTAL
UPT. PUSKESMAS SAPEKEN
BULAN NOVEMBER 2017
TANGGAL JUMLAH
REGESTER HARI DIAGNOSA KODE (ICD X)
MASUK KELUAR RAWAT
7 8 9 10 11
JXI.1700473 10/23/2017 10/29/2017 6 ISK Hematuria( N 39 )
JXI.1700447 10/25/2017 10/29/2017 4 Sinusic Hepatic
JXI.1700479 10/27/2017 11/1/2017 5 Gastritis ( K29 )
JXI.1700509 10/29/2017 11/4/2017 6 Gastritis ( K29 )
JXI.1700493 11/1/2017 11/4/2017 3 Anemia Defisiensi Besi
JXI.1700489 11/1/2017 11/3/2017 2 Colic Abdomen
JXI.1700525 11/1/2017 11/5/2017 4 GEA
JXI.1700511 11/1/2017 11/5/2017 4 DM Tipe 1 + Hipoglikemia
JXI.1700531 11/2/2017 11/5/2017 3 CVA Hemorogic
JXI.1700508 11/3/2017 11/6/2017 3 Vertigo
JXI.1700494 11/7/2017 11/10/2017 3 Susp. TB + DC
JXI.1700497 11/8/2017 11/13/2017 5 Asma ( J 45 ) + gastritis
JXI.1700519 11/8/2017 11/9/2017 1 PEB
JXI.1700501 11/9/2017 11/11/2017 2 Gastritis ( K29 )
JXI.1700504 11/11/2017 11/17/2017 6 ansietas + Gastritis(K29)
JXI.1700512 11/14/2017 11/18/2017 4 Susp.Thipoid
JXI.1700535 11/16/2017 11/20/2017 4 Gastritis ( K29 )
JXI.1700514 11/16/2017 11/18/2017 2 Febris. Bendungan Asi
JXI.1700516 11/16/2017 11/20/2017 4 Gastritis ( K29 )
JXI.1700521 11/18/2017 11/22/2017 4 TB + Gastritis
JXI.1700520 11/20/2017 11/21/2017 1 Susp.Gastritis ( K29 )
JXI.1700529 11/22/2017 11/27/2017 5 Ulkus Diabetikum
JXI.1700534 11/23/2017 11/25/2017 2 Febris
88
SUMENEP, 30 November 2017

SUHARTO,Amd.Gz. SKM.
NIP. 19690329 199203 1 007
TOTAL BIAYA KET
12 13
Rp 291,000 S
Rp 199,000 S
Rp 245,000 S
Rp 291,000 S
Rp 154,000 S
Rp 111,000 S
Rp 199,000 S
Rp 199,000 S
Rp 153,000 S
Rp 153,000 S
Rp 153,000 M
Rp 173,000 S
Rp 69,000 S
Rp 104,000 S
Rp 199,000 S
Rp 291,000 S
Rp 199,000 S
Rp 199,000 S
Rp 106,000 S
Rp 199,000 S
Rp 199,000 S
Rp 59,000 S
Rp 70,000 S
Rp 245,000 PP
Rp 103,000 S
Rp 4,363,000
FORMAT BIAYA RAWAT INAP
NOMOR REGESTER : JXII.1700592

NAMA PASIEN : Ahmad
UMUR : 60Th
ALAMAT : Tanjung Kiaok
NOMOR SPM : 54
HARI I HARI II HARI III HARI IV HARI V

NO TINDAKAN
TINDAKAN JML ( RP ) TINDAKAN JML ( RP ) TINDAKAN JML ( RP ) TINDAKAN JML ( RP ) TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
3 Pasang Infus 10.000 Rp - Rp - Rp - Rp -
4 Cabut infus 10.000 Rp - Rp - Rp - 1 Rp 10,000
5 Pasang Chaceter 42.500 Rp - Rp - Rp - Rp -
6 Cabut Chaceter 10.000 Rp - Rp - Rp - Rp -
7 Incubator Bayi 5.000 Rp - Rp - Rp - Rp -
8 Tes Kehamilan 5.000 Rp - Rp - Rp - Rp -
9 Rawat Luka 20.000 Rp - Rp - Rp - Rp -
10 Jasa Medik Dokter 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000
11 Jasa Keperawatan 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN Erwin
UMUR : 16Th
ALAMAT : Tanjung Kiawok
NOMOR SPM : 53

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000 1
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000 6
4 Cabut infus 10.000 Rp - Rp - 1 Rp - Rp -
10 Jasa Medik Dokter 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1
11 Jasa Keperawatan 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN : Barlian
UMUR : 32 Th
ALAMAT : Sabuntan
NOMOR SPM : 02

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
1 Rawat Inap 10.000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000
3 Pasang Infus 10.000 Rp -
4 Cabut infus 10.000 Rp -
5 Pasang Chaceter 42.500 Rp -
6 Cabut Chaceter 10.000 1 Rp 10,000
7 Incubator Bayi 5.000 Rp -
8 Tes Kehamilan 5.000 Rp -
9 Rawat Luka 20.000 Rp -
10 Jasa Medik Dokter 15.000 1 Rp 15,000
11 Jasa Keperawatan 15.000 1 Rp 15,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN :Amir Mahmud
UMUR :74 Th
ALAMAT : Sapeken
NOMOR SPM : 1253

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000
3 Pasang Infus 10.000 Rp - Rp -
4 Cabut infus 10.000 Rp - 1 Rp 10,000
5 Pasang Chaceter 42.500 Rp - Rp -
6 Cabut Chaceter 10.000 Rp - Rp -
7 Incubator Bayi 5.000 Rp - Rp -
8 Tes Kehamilan 5.000 Rp - Rp -
9 Rawat Luka 20.000 Rp - Rp -
10 Jasa Medik Dokter 15.000 1 Rp 15,000 1 Rp 15,000
11 Jasa Keperawatan 15.000 1 Rp 15,000 1 Rp 15,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
NOMOR REGESTER :JXII.17000589

NAMA PASIEN : Amir Mahmud
UMUR : 74 Th
ALAMAT : Sapeken
NOMOR SPM : 1253

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
4 Cabut infus 10.000 Rp - Rp - Rp - Rp -
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN : Juhairiyah
UMUR : 47 Th
ALAMAT : Sapeken
NOMOR SPM :1288

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN : saifullah
UMUR : 9 Th
ALAMAT :Sapeken
NOMOR SPM :1200

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000
4 Cabut infus 10.000 Rp - 1 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
NOMOR REGESTER :JXI.17000579

NAMA PASIEN : Hadijah
UMUR : 56 Th
ALAMAT : Sapeken
NOMOR SPM : 1247

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
1 Rawat Inap 10.000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000
4 Cabut infus 10.000 1 Rp 10,000
6 Cabut Chaceter 10.000 Rp -
12 Retribusi 5000 1 Rp 5,000
JUMLAH
NOMOR REGESTER : JXI.1700586

NAMA PASIEN : Ansari
UMUR : 56 Th
ALAMAT : Sapeken
NOMOR SPM : 1271

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN : Hasanah
UMUR : 58 Th
ALAMAT : Sapeken
NOMOR SPM : 196

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN : Mimbar
UMUR : 55 Th
ALAMAT : Paliat
NOMOR SPM : 015

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
9 Rawat Luka 20.000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN :Rahman
UMUR : 59 Th
ALAMAT : Pag. Besar
NOMOR SPM :167

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000
4 Cabut infus 10.000 Rp - 1 Rp 10,000
9 Rawat Luka 20.000 Rp Rp
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN : Suhani
UMUR : 60 Th
ALAMAT :saur
NOMOR SPM :119

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN : Hapsah
UMUR : 56 Th
ALAMAT :Sepanjang
NOMOR SPM :502

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
12 Retribusi 5000 1 Rp 5,000
JUMLAH
NOMOR REGESTER :JVII.1700531

NAMA PASIEN : Buddin
UMUR : 60 Th
ALAMAT :Sadulang Besar
NOMOR SPM :01

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
3 Pasang Infus 10.000 Rp - Rp - Rp -
4 Cabut infus 10.000 Rp - Rp - Rp 10,000
5 Pasang Chaceter 42.500 Rp - Rp - Rp -
6 Cabut Chaceter 10.000 Rp - Rp - Rp -
7 Incubator Bayi 5.000 Rp - Rp - Rp -
8 Tes Kehamilan 5.000 Rp - Rp - Rp -
9 Rawat Luka 20.000 Rp - Rp - Rp -
10 Jasa Medik Dokter 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000
11 Jasa Keperawatan 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN : Nur Kholis
UMUR : 6 Th
ALAMAT :Sadulang Besar
NOMOR SPM :11

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
4 Cabut infus 10.000 Rp - Rp - Rp - Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN :Kaina
UMUR : 5 Th
ALAMAT : Sapeken
NOMOR SPM :953

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
9 Rawat Luka 20.000 Rp Rp Rp Rp
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN :Albaini
UMUR : 67 Th
ALAMAT : Sapeken
NOMOR SPM :928

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
12 Retribusi 5000 1 Rp 5,000
JUMLAH

NAMA PASIEN :
UMUR : Th
ALAMAT :
NOMOR SPM

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11
1 Rawat Inap 10.000
2 Injeksi 1.000
3 Pasang Infus 10.000
4 Cabut infus 10.000
5 Pasang Chaceter 42.500
6 Cabut Chaceter 10.000
7 Incubator Bayi 5.000
8 Tes Kehamilan 5.000
9 Rawat Luka 20.000
10 Jasa Medik Dokter 15.000
11 Jasa Keperawatan 15.000
12 Retribusi 5000
JUMLAH
DIAOGNOSA : Susp, TB Paru
TGL MASUK : 15-12-2017
TGL KELUAR : 19-12-2017
JUMLAH HARI RAWAT : 4 Hari
HARI V HARI VI
TOTAL
JML ( RP ) TINDAKAN JML ( RP )
12 13 14 15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000

Kepala Puskesmas Sapeken
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA :Hemaptoe
TGL MASUK : 09-12-2017
TGL KELUAR : 16-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 10,000 1 Rp 10,000 Rp 60,000
Rp 6,000 6 Rp 6,000 Rp 36,000
Rp - Rp - Rp -
Rp - 1 Rp 10,000 Rp 10,000
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp 15,000 1 Rp 15,000 Rp 90,000
Rp 15,000 1 Rp 15,000 Rp 90,000
Rp 5,000
Rp 291,000
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA :Susp. Kokliliasis+ISPA
TGL MASUK : 24-12-2017
TGL KELUAR : 25-12-2017
JUMLAH HARI RAWAT : 1Hari
HARI V HARI VI
TOTAL
12 13 14 15
Rp 10,000
Rp 6,000
Rp -
Rp -
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp 15,000
Rp 15,000
Rp 5,000
Rp 61,000
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA :DC+Asma Bronkial
TGL MASUK : 11-12-2017
TGL KELUAR : 13-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 20,000
Rp 12,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 30,000
Rp 30,000
Rp 5,000
Rp 107,000
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA :Asma Bronchialis+DC
TGL MASUK :13-12-2017
TGL KELUAR : 19-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 10,000 1 Rp 10,000 Rp 60,000
Rp 6,000 6 Rp 6,000 Rp 36,000
Rp - Rp - Rp -
Rp - 1 Rp 10,000 Rp 10,000
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp - Rp - Rp
Rp 15,000 1 Rp 15,000 Rp 90,000
Rp 15,000 1 Rp 15,000 Rp 90,000
Rp 5,000
Rp 291,000
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA :DM Tipe II dg Luka Ganggren
TGL MASUK : 18-12-2017
TGL KELUAR : 26-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 10,000 1 Rp 10,000 Rp 60,000
Rp 6,000 6 Rp 6,000 Rp 36,000
Rp - Rp - Rp -
Rp - 1 Rp 10,000 Rp 10,000
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp - Rp - Rp -
Rp 15,000 1 Rp 15,000 Rp 90,000
Rp 15,000 1 Rp 15,000 Rp 90,000
Rp 5,000
Rp 291,000

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA :Thypoid
TGL MASUK : 29-11-2017
TGL KELUAR : 01-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 20,000
Rp 12,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 30,000
Rp 30,000
Rp 5,000
Rp 107,000
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA :ISPA
TGL MASUK : 06-12-2017
TGL KELUAR : 07-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 10,000
Rp 6,000
Rp
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 15,000
Rp 15,000
Rp 5,000
Rp 61,000

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA :Colic Abdomen
TGL MASUK : 10 -12-2017
TGL KELUAR : 14-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA :HT+Strok
TGL MASUK : 27-11-2017
TGL KELUAR : 01-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA : Susp.HNP+CKD
TGL MASUK : 23 -11-2017
TGL KELUAR : 27 -11-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA : GE
TGL MASUK : 06-12-2017
TGL KELUAR : 08-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 20,000
Rp 12,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp
Rp 30,000
Rp 30,000
Rp 5,000
Rp 107,000
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA : Gastritis
TGL MASUK : 26-12-2017
TGL KELUAR : 31-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 10,000 Rp 50,000
Rp 6,000 Rp 30,000
Rp - Rp -
Rp - Rp -
Rp - Rp -
Rp - Rp -
Rp - Rp -
Rp - Rp -
Rp - Rp -
Rp 15,000 Rp 75,000
Rp 15,000 Rp 75,000
Rp 5,000
Rp 235,000
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA : Ispa + susp.HNP

TGL MASUK : 27-12-2017
TGL KELUAR : 31-12-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA : CVA Hemorogic
TGL MASUK : 02-11-2017
TGL KELUAR : 05-11-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000
SUMENEP, 25,November 2017

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA : Colik Abdonen

TGL MASUK : 11-11-2017
TGL KELUAR : 15-11-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA : Susp. Thipoid
TGL MASUK : 14-11-2017
TGL KELUAR : 18-11-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA : DM tipe 1 + Hipoglikemia

TGL MASUK : 01-11-2017
TGL KELUAR : 05-11-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
DIAOGNOSA :
TGL MASUK : 16-11-2017
TGL KELUAR : 20-11-2017
HARI V HARI VI
TOTAL
12 13 14 15
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp
Rp -
Rp -
Rp -
Rp -

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Suhrawi DIAOGNOSA
UMUR : 60Th TGL MASUK
ALAMAT : Sapeken TGL KELUAR
NOMOR SPM : JUMLAH HARI RAWAT
HARI I HARI II HARI III HARI IV HARI V HARI VI

NO TINDAKAN
TINDAKAN JML ( RP ) TINDAKAN JML ( RP ) TINDAKAN JML ( RP ) TINDAKAN JML ( RP ) TINDAKAN JML ( RP ) TINDAKAN JML ( RP )
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
4 Cabut infus 10.000 Rp - Rp - 1 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Morhama DIAOGNOSA
NOMOR SPM : 137 JUMLAH HARI RAWAT

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
9 Rawat Luka 20.000 1 Rp 20,000 1 Rp 20,000 Rp -
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Sahlan DIAOGNOSA
UMUR : 70 Th TGL MASUK
ALAMAT : Paliat TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
4 Cabut infus 10.000 Rp - Rp - Rp -
6 Cabut Chaceter 10.000 Rp - Rp - Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN Sitti Aisyah DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
3 Pasang Infus 10.000 Rp - Rp - Rp - Rp - Rp - Rp -
4 Cabut infus 10.000 Rp - Rp - Rp - Rp - Rp - 1 Rp 10,000
5 Pasang Chaceter 42.500 Rp - Rp - Rp - Rp - Rp - Rp -
6 Cabut Chaceter 10.000 Rp - Rp - Rp - Rp - Rp - Rp -
7 Incubator Bayi 5.000 Rp - Rp - Rp - Rp - Rp - Rp -
8 Tes Kehamilan 5.000 Rp - Rp - Rp - Rp - Rp - Rp -
9 Rawat Luka 20.000 Rp - Rp - Rp - Rp - Rp - Rp -
10 Jasa Medik Dokter 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000
11 Jasa Keperawatan 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Murida DIAOGNOSA
ALAMAT : Saur TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 25 Novenber 2017

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Asadur Rahman DIAOGNOSA
ALAMAT : Tanjung Kiaok TGL KELUAR
NOMOR SPM :1 JUMLAH HARI RAWAT

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Nizanul Hasan DIAOGNOSA
ALAMAT :Sapeken TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Amiruddin DIAOGNOSA
ALAMAT : Pagerungan Besar TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Hijratul Husna DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Malya DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
3 Pasang Infus 10.000 Rp - Rp - Rp - Rp - Rp -
4 Cabut infus 10.000 Rp - Rp - Rp - Rp - 1 Rp 10,000
5 Pasang Chaceter 42.500 Rp - Rp - Rp - Rp - Rp -
6 Cabut Chaceter 10.000 Rp - Rp - Rp - Rp - Rp -
7 Incubator Bayi 5.000 Rp - Rp - Rp - Rp - Rp -
8 Tes Kehamilan 5.000 Rp - Rp - Rp - Rp - Rp -
9 Rawat Luka 20.000 Rp - Rp - Rp - Rp - Rp -
10 Jasa Medik Dokter 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000
11 Jasa Keperawatan 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Saiful DIAOGNOSA
ALAMAT : Pag. Kecil TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
9 Rawat Luka 20.000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN :Khusairi DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Semmi DIAOGNOSA
ALAMAT :Tanjung Kiaok TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Sunatia DIAOGNOSA
ALAMAT :Paliat TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Buddin DIAOGNOSA
ALAMAT :Sadulang Besar TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Nur Kholis DIAOGNOSA
ALAMAT :Sadulang Besar TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN :Kaina DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN :Albaini DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : DIAOGNOSA
UMUR : Th TGL MASUK
ALAMAT : TGL KELUAR
NOMOR SPM JUMLAH HARI RAWAT

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000
2 Injeksi 1.000
9 Rawat Luka 20.000
12 Retribusi 5000
JUMLAH

SUHARTO,Amd.Gz.SKM
NIP. 19690329 199203 1 007
: Vertigo
: 03-11-2017
: 06-11-2017
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000
ENEP, 25 November 2017

a Puskesmas Sapeken
9690329 199203 1 007
:Susp. TB+DC
: 07-11-2017
: 10-11-2017
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000

a Puskesmas Sapeken
9690329 199203 1 007

:Ulkus Diabetikum
: 22-11-2017
: 25-11-2017
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp -
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000

a Puskesmas Sapeken
9690329 199203 1 007

:Ansietas + Gastritis
: 11-11-2017
: 17-11-2017
: 6 Hari
TOTAL
15
Rp 60,000
Rp 36,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 90,000
Rp 90,000
Rp 5,000
Rp 291,000

a Puskesmas Sapeken
9690329 199203 1 007

:ISK Hematuria
: 23-10-2017
: 29-10-2017
: 6 Hari
TOTAL
15
Rp 60,000
Rp 36,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp
Rp 90,000
Rp 90,000
Rp 5,000
Rp 291,000
ENEP, 25 Novenber 2017

a Puskesmas Sapeken
9690329 199203 1 007

:TB + Gastritis
: 18-11-2017
: 22-11-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
a Puskesmas Sapeken
9690329 199203 1 007

:Gastritis
: 16-11-2017
: 20-11-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
a Puskesmas Sapeken
9690329 199203 1 007

:Sinusic Hepatic
: 25-10-2017
: 29-10-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
a Puskesmas Sapeken
9690329 199203 1 007

:Gastritis
: 20 -11-2017
: 24-11-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000

a Puskesmas Sapeken
9690329 199203 1 007

:Gastritis
: 27-10-2017
: 01-11-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 75,000
Rp 75,000
Rp 5,000
Rp 245,000

a Puskesmas Sapeken
9690329 199203 1 007

: Asma Bronchial+Gastritis
: 08 -11-2017
: 13 -11-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp 75,000
Rp 75,000
Rp 5,000
Rp 245,000

a Puskesmas Sapeken
9690329 199203 1 007

: Gastritis
: 16-11-2017
: 20-11-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000

a Puskesmas Sapeken
9690329 199203 1 007

: Gastritis
: 29-10-2017
: 04-11-2017
: 6 Hari
TOTAL
15
Rp 60,000
Rp 36,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 90,000
Rp 90,000
Rp 5,000
Rp 291,000
25,November 2017
a Puskesmas Sapeken
9690329 199203 1 007
: GEA
: 01-11-2017
: 05-11-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
25,November 2017
a Puskesmas Sapeken
9690329 199203 1 007

: CVA Hemorogic
: 02-11-2017
: 05-11-2017
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000
25,November 2017
a Puskesmas Sapeken
9690329 199203 1 007
: Colik Abdonen
: 11-11-2017
: 15-11-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
25,November 2017
a Puskesmas Sapeken
9690329 199203 1 007
: Susp. Thipoid
: 14-11-2017
: 18-11-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000

a Puskesmas Sapeken
9690329 199203 1 007

: DM tipe 1 + Hipoglikemia
: 01-11-2017
: 05-11-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000

a Puskesmas Sapeken
9690329 199203 1 007
:
: 16-11-2017
: 20-11-2017
: 4 Hari
TOTAL
15
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp
Rp -
Rp -
Rp -
Rp -

a Puskesmas Sapeken
9690329 199203 1 007

NOMOR REGESTER : JIX.1700455

NAMA PASIEN Ridho DIAOGNOSA
UMUR : 8,5Th TGL MASUK
ALAMAT : Saseel TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 30 oktober 2017

SUHARTO CAKOE, SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Kazali DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
3 Pasang Infus 10.000 Rp - 1 Rp 10,000 Rp - Rp - Rp - Rp -
4 Cabut infus 10.000 Rp - Rp - Rp - Rp - Rp - Rp 10,000
9 Rawat Luka 20.000 1 Rp 20,000 1 Rp 20,000 Rp - 1 Rp 20,000 1 Rp 20,000 1 Rp 20,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 30 Oktober 2017

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007
NOMOR REGESTER : JX.1700446

NAMA PASIEN : Nadzif Qolby DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000
4 Cabut infus 10.000 1 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Iwan DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007
NOMOR REGESTER :JX.17000442

NAMA PASIEN : Hairullah DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Mahnan DIAOGNOSA
ALAMAT : Paliat TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Nurleli DIAOGNOSA
ALAMAT :Sapeken TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000 1 Rp 10,000 7 8 9 10
3 Pasang Infus 10.000 Rp - Rp - Rp - Rp - 6 Rp 6,000 6 Rp 6,000
4 Cabut infus 10.000 Rp - Rp - 1 Rp - Rp - Rp 10,000
10 Jasa Medik Dokter 15.000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 1 Rp 15,000 Rp - Rp -
12 Retribusi 5000 1 Rp 5,000 1 Rp 15,000 1 Rp 15,000
JUMLAH
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Saiful DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Maria DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
3 Pasang Infus 10.000 Rp - Rp - Rp - 1 Rp 10,000 Rp -
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007
NOMOR REGESTER : JVII.17000404

NAMA PASIEN Rasiani DIAOGNOSA
ALAMAT Sakala TGL KELUAR
NOMOR SPM 126 JUMLAH HARI RAWAT

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000
4 Cabut infus 10.000 Rp - Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 30 Agustus 2017

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN Bachtiar DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000
9 Rawat Luka 20.000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN Mura DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000
4 Cabut infus 10.000 Rp 10,000
9 Rawat Luka 20.000 Rp
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007
NOMOR REGESTER JVII.17000407

NAMA PASIEN : Rista Ifra Agustina DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000
4 Cabut infus 10.000 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 30,Agustus
3 2017
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007
: Susp. Thypoid
: 24-09-2017
: 29-09-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 75,000
Rp 75,000
Rp 5,000
Rp 245,000
ENEP, 30 oktober 2017

a Puskesmas Sapeken
9690329 199203 1 007
:Susp. Hepatitis B
: 26-09-2017
: 01-10-2017
: 6 Hari
TOTAL
15
Rp 60,000
Rp 36,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 90,000
Rp 90,000
Rp 5,000
Rp 291,000
ENEP, 30 Oktober 2017

a Puskesmas Sapeken
9690329 199203 1 007

Colic Abdomen
: 04-10-2017
: 05-10-2017
: 1 Hari
TOTAL
15
Rp 10,000
Rp 6,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 15,000
Rp 15,000
Rp 5,000
Rp 61,000

a Puskesmas Sapeken
9690329 199203 1 007

:Mialgia+Hipokemia
: 04-10-2017
: 07-10-2017
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000

a Puskesmas Sapeken
9690329 199203 1 007

Gastritis
: 02-10-2017
: 07-10-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp
Rp 75,000
Rp 75,000
Rp 5,000
Rp 245,000

a Puskesmas Sapeken
9690329 199203 1 007

Susp. Hepatitis
: 09-10-2017
: 14-10-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 75,000
Rp 75,000
Rp 5,000
Rp 245,000
a Puskesmas Sapeken
9690329 199203 1 007

Susp, KP +Gastritis
: 10-10-2017
: 16-10-2017
: 6 Hari
TOTAL
15
Rp 40,018
Rp 44,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 90,000
Rp 5,000
Rp 249,018
a Puskesmas Sapeken
9690329 199203 1 007

Asma Broncialis
: 12-10-2017
: 18-10-2017
: 6 Hari
TOTAL
15
Rp 60,000
Rp 36,000
Rp
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 90,000
Rp 90,000
Rp 5,000
Rp 291,000
a Puskesmas Sapeken
9690329 199203 1 007

AF ( Atrial Fibrialis)
: 16-10-2017
: 21-10-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp 10,000
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 75,000
Rp 75,000
Rp 5,000
Rp 255,000

a Puskesmas Sapeken
9690329 199203 1 007

GEA
: 04-08-2017
: 06-08-2017
: 2 Hari
TOTAL
15
Rp 20,000
Rp 12,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 30,000
Rp 30,000
Rp 5,000
Rp 107,000
ENEP, 30 Agustus 2017

a Puskesmas Sapeken
9690329 199203 1 007

GEA
: 07-08-2017
: 09-08-2017
: 2 Hari
TOTAL
15
Rp 20,000
Rp 12,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp 30,000
Rp 30,000
Rp 5,000
Rp 107,000

a Puskesmas Sapeken
9690329 199203 1 007

Colik Abdomen
: 07-08-2017
: 08-08-2017
: 1 Hari
TOTAL
15
Rp 10,000
Rp 6,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp
Rp 15,000
Rp 15,000
Rp 5,000
Rp 61,000

a Puskesmas Sapeken
9690329 199203 1 007

: GEA
: 10-08-2017
: 11-08-2017
: 1 Hari
TOTAL
15
Rp 10,000
Rp 6,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 15,000
Rp 15,000
Rp 5,000
Rp 61,000
30,Agustus 2017
a Puskesmas Sapeken
9690329 199203 1 007

NOMOR REGESTER : JVIII.1700404

NAMA PASIEN Jumain DIAOGNOSA
UMUR :58Th TGL MASUK
ALAMAT saseel TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
4 Cabut infus 10.000 Rp - 1 Rp - Rp - 1 Rp - 1 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 30 September 2017

SUHARTO CAKOE, SKM
NIP. 19690329 199203 1 007

NAMA PASIEN Juraida DIAOGNOSA
ALAMAT Sepanjang TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
3 Pasang Infus 10.000 1 Rp - Rp - 1 Rp - 1 Rp 10,000
4 Cabut infus 10.000 Rp - 1 Rp 10,000 Rp - Rp -
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 30 september 2017

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007
NOMOR REGESTER : JVI.1700410

NAMA PASIEN Kartini DIAOGNOSA
ALAMAT Sadulang Besar TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
4 Cabut infus 10.000 Rp - Rp - 1 Rp 10,000 Rp - 1 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN Hermansyah DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
3 Pasang Infus 10.000 Rp - Rp - 1 Rp 10,000 Rp - Rp - Rp -
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007
NOMOR REGESTER JIX.17000417

NAMA PASIEN Alwi DIAOGNOSA
ALAMAT Tanjung Kiaok TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN Meysha DIAOGNOSA
ALAMAT Sapeken TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 30 september 2017
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN Masuni DIAOGNOSA
ALAMAT Saredeng Besar TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007
NOMOR REGESTER :JIX.17000419

NAMA PASIEN Hermansyah DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN Syahrudin DIAOGNOSA
ALAMAT Pagerungan Kecil TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN ACH. Samil DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
4 Cabut infus 10.000 Rp - Rp - Rp - Rp - Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Mahya DIAOGNOSA
ALAMAT : Pag.Besar TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN Mariyama DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
9 Rawat Luka 20.000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN Sahlan DIAOGNOSA
ALAMAT Paliat TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007
NOMOR REGESTER : JIX1700445

NAMA PASIEN : Suaiba DIAOGNOSA
UMUR :50 Th TGL MASUK
ALAMAT :Tanjung Kiaok TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
4 Cabut infus 10.000 Rp - 1 Rp 10,000 Rp - Rp - Rp - 1 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 30 Juli 2017

SUHARTO CAKOE, SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Nur Aida DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 30 Juli 2017
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Suwandi DIAOGNOSA
ALAMAT : Tanjung Kiaok TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 30 Juni 2017

SUHARTO CAKOE, SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Bustamin DIAOGNOSA
ALAMAT : Pagerungan Besar TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Izul fikri DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000
4 Cabut infus 10.000 1 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM
NIP. 19690329 199203 1 007

NAMA PASIEN : Rahmi DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000
4 Cabut infus 10.000 1 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Suraiba DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000
4 Cabut infus 10.000 1 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Niko DIAOGNOSA
ALAMAT : Sabuntan TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Sunaliya DIAOGNOSA
ALAMAT :Sabuntan TGL KELUAR

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Sukdari DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000 1 Rp 10,000
2 Injeksi 1.000 6 Rp 6,000
4 Cabut infus 10.000 1 Rp 10,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Baim al azm Pratama DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007
NOMOR REGESTER : JIII.16000201

NAMA PASIEN : Asmin Qoida DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
12 Retribusi 5000 1 Rp 5,000
JUMLAH
SUMENEP, 31 Maret 2016
SUHARTO CAKOE, SKM

NIP. 19690329 199203 1 007

NAMA PASIEN : Wida Wati DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2 Injeksi 1.000 6 Rp 6,000 6 Rp 6,000 6 Rp 6,000
12 Retribusi 5000 1 Rp 5,000
JUMLAH

IMAM MUDHARI, SKM. M. Mkes

NIP. 19710915 199803 1 012

NAMA PASIEN : Wida Wati DIAOGNOSA

NO TINDAKAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 Rawat Inap 10.000
2 Injeksi 1.000
9 Rawat Luka 20.000
12 Retribusi 5000
JUMLAH

NIP. 19710915 199803 1 012
gastritis
: 31-08-2017
: 05-09-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 75,000
Rp 75,000
Rp 5,000
Rp 245,000
ENEP, 30 September 2017

a Puskesmas Sapeken
9690329 199203 1 007
GEA
: 02-09-2017
: 06-09-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp 10,000
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 209,000
ENEP, 30 september 2017

a Puskesmas Sapeken
9690329 199203 1 007

Gastritis
: 03-09-2017
: 08-09-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp -
Rp 20,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 75,000
Rp 75,000
Rp 5,000
Rp 255,000

a Puskesmas Sapeken
9690329 199203 1 007

TB Paru
: 04-09-2017
: 10-09-2017
: 6 Hari
TOTAL
15
Rp 60,000
Rp 36,000
Rp 10,000
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 90,000
Rp 90,000
Rp 5,000
Rp 301,000

a Puskesmas Sapeken
9690329 199203 1 007

Agina Pectoris + Susp. Hepatitis
: 07-09-2017
: 12-09-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 75,000
Rp 75,000
Rp 5,000
Rp 245,000

a Puskesmas Sapeken
9690329 199203 1 007

:Bronkitis
: 08-09-2017
: 12-09-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
ENEP, 30 september 2017
a Puskesmas Sapeken
9690329 199203 1 007

Gout+Gastritis
: 10-09-2017
: 14-09-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
a Puskesmas Sapeken
9690329 199203 1 007

TB Paru (A15)
: 11-09-2017
: 13-09-2017
: 2 Hari
TOTAL
15
Rp 20,000
Rp 12,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 30,000
Rp 30,000
Rp 5,000
Rp 107,000
a Puskesmas Sapeken
9690329 199203 1 007

: Colic Abdomen
: 13-09-2017
: 16-09-2017
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000

a Puskesmas Sapeken
9690329 199203 1 007

Abses Geno (D)
: 14-09-2017
: 19-09-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 75,000
Rp 75,000
Rp 5,000
Rp 245,000

a Puskesmas Sapeken
9690329 199203 1 007

:Hemaptu-el Susp. TB Paru
: 14-09-2017
: 17-09-2017
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000

a Puskesmas Sapeken
9690329 199203 1 007

:Gastritis+Konstipasi
: 18-09-2017
: 23-09-2017
: 5 Hari
TOTAL
15
Rp 50,000
Rp 30,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp 75,000
Rp 75,000
Rp 5,000
Rp 245,000

a Puskesmas Sapeken
9690329 199203 1 007

Anemia+HM
: 19-09-2017
: 20-09-2017
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000
a Puskesmas Sapeken
9690329 199203 1 007

Ssp.Mioma Uteri
: 01-09-2017
: 07-09-2017
: 6 Hari
TOTAL
15
Rp 60,000
Rp 36,000
Rp -
Rp 20,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 90,000
Rp 90,000
Rp 5,000
Rp 301,000
a Puskesmas Sapeken
9690329 199203 1 007
: Gastritis
: 23-07-2017
: 26-07-2017
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000
a Puskesmas Sapeken
9690329 199203 1 007

: CVA
: 12-06-2017
: 19-06-2017
: 6 Hari
TOTAL
15
Rp 60,000
Rp 36,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 90,000
Rp 90,000
Rp 5,000
Rp 291,000
a Puskesmas Sapeken
9690329 199203 1 007
: Hematomesis Melena
: 15-06-2017
: 19-06-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
a Puskesmas Sapeken
9690329 199203 1 007
: Gastritis
: 18-06-2017
: 19-06-2017
: 1 Hari
TOTAL
15
Rp 10,000
Rp 6,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 15,000
Rp 15,000
Rp 5,000
Rp 61,000
ENEP, 30 Juni 2017

a Puskesmas Sapeken
9690329 199203 1 007
: Trauma Kepala
: 19-06-2017
: 20-06-2017
: 1 Hari
TOTAL
15
Rp 10,000
Rp 6,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 15,000
Rp 15,000
Rp 5,000
Rp 61,000
ENEP, 30 Juni 2017

a Puskesmas Sapeken
9690329 199203 1 007

: Colik Abdomen
: 21-07-2017
: 22-06-2017
: 1 Hari
TOTAL
15
Rp 10,000
Rp 6,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 15,000
Rp 15,000
Rp 5,000
Rp 61,000
ENEP, 30 Juni 2017

a Puskesmas Sapeken
9690329 199203 1 007

: Myom Uteri + Retensio urin
: 23-06-2017
: 27-06-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
ENEP, 30 Juni 2017
a Puskesmas Sapeken
9690329 199203 1 007

: Gastritis
: 23-06-2017
: 27-06-2017
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
ENEP, 30 Juni 2017
a Puskesmas Sapeken
9690329 199203 1 007

: Gastritis
: 25-06-2017
: 26-06-2017
: 1 Hari
TOTAL
15
Rp 10,000
Rp 6,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 15,000
Rp 15,000
Rp 5,000
Rp 61,000
ENEP, 30 Juni 2017
a Puskesmas Sapeken
9690329 199203 1 007

: ISPA
: 25-06-2017
: 28-06-2017
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000
ENEP, 30 Juni 2017
a Puskesmas Sapeken
9690329 199203 1 007

: Plag mount
: 27-03-2016
: 31-03-2016
: 4 Hari
TOTAL
15
Rp 40,000
Rp 24,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 60,000
Rp 60,000
Rp 5,000
Rp 199,000
ENEP, 31 Maret 2016
a UPT. Puskesmas Sapeken
9690329 199203 1 007
: Demam yg tidak diketahui sebabnya

: 28-03-2016
: 31-03-2016
: 3 Hari
TOTAL
15
Rp 30,000
Rp 18,000
Rp -
Rp 10,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 45,000
Rp 45,000
Rp 5,000
Rp 153,000
ENEP, 31 Maret 2016

MUDHARI, SKM. M. Mkes

9710915 199803 1 012
: Demam yg tidak diketahui sebabnya
: 28-03-2016
: 31-03-2016
: 3 Hari
TOTAL
15
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
Rp -
ENEP, 31 Maret 2016

MUDHARI, SKM. M. Mkes
9710915 199803 1 012
FORMAT REKAP RAWAT IN
UPT. PUSKESMAS SAPEKE
BULAN OKTOBER 2017
JENIS UMUR
NO NAMA PASIEN ALAMAT NO. KARTU/ SPM
KELAMIN (TH)
1 2 3 4 5 6
1 P 22 Th Sapeken 261
2 By.Salmawati P 0 Hr Sapeken 261
3 P 26 Th Sapeken 1649
4 By. Farti L 0 Hr Sapeken 1649
5 Elly Humairah P 30 Th Sasiil 1353
6 By. Elly Humairah P 0 Hr Sasiil 1353
7 Harmia P 35 Th Sapeken 2615
8 Mulhida P 30 Th Sapeken 808
9 By. Harmia L 0 Hr Sapeken 2615
10 By. Mulhida L 0 Hr Sapeken 808
11 Maina P 56 Th Sabuntan 109
12 Sarifah Laila P 21 Th Tanjung Kiaok 1643
13 Burahima L 64 Th Sadulang Besar 1692
14 Devi Indriasich P 24 Th Sapeken 1745
15 By. Devi Indriasich P 0 Hr Sapeken 1745
16 Lilik Istiana P 27 Th Sapeken 984
17 By. Lilik Istiana L 0 Hr Sapeken 984
18 Maryam P 31 Th Sapeken 2120
19 Yoyong P 58 Th Sabuntan 1779
20 Abdul Azim L 53 Th Pag. Kecil 1820
21 Gauzi L 60 Th Sapeken 1822
22 Aisyah P 61 Th Sapeken 1837
23 Mumtahanah P 26 Th Sapeken 1527
24 By. Mumtahanah L 0 Hr Sapeken 1527
25 Endang. S P 28 Th Sapeken 1849
26 By. Endang. S P 0 Hr Sapeken 1849
27 Ahmad Risqi L 12 Th Sapeken 1002
28 Adnan L 72 Th Sepanjang 1858
29 Nur Farika P 12 Th Paliat 1890
30 Nalia P 30 Th Sapeken 1898
31 By. Nalia P 0 Hr Sapeken 1898
TOTAL
UPT. PUSKESMAS SAPEKEN
BULAN OKTOBER 2017
TANGGAL JUMLAH
REGESTER HARI DIAGNOSA KODE (ICD X)
MASUK KELUAR RAWAT
7 8 9 10 11
JIV16000243 4/23/2016 4/24/2016 1 Anemia Post Haemorrhagic Akut ( D 62 )
JIV16000244 4/23/2016 4/24/2016 1 BBL 0 hr dg Asfiksia Berat ( P 210 )
JIV16000264 4/27/2016 5/2/2016 5 Stroke ( I 64 )
JIV16000261 4/29/2016 5/2/2016 3 Epilepsi ( G 40 )
JIV16000260 4/29/2016 5/3/2016 4 Gagal Jantung ( I 50 )
JV16000266 5/6/2016 5/7/2016 1 Anemia Post Haemorrhagic Akut ( D 62 )
JV16000267 5/7/2016 5/7/2016 1 BBL 0 hr dg Asfiksia Berat ( P 210 )
JV16000271 5/9/2016 5/12/2016 3 Asma ( J 45 )
JV16000276 5/14/2016 5/16/2016 2 ISK ( N 39 )
JV16000275 5/15/2016 5/18/2016 3 Hipertensi ( I 10 )
JV16000283 5/16/2016 5/19/2016 3 Gastritis ( K29 )
JV16000282 5/19/2016 5/23/2016 4 Demam yg tidak diketahui sebabnya (R50)
JV16000281 5/19/2016 5/23/2016 4 Luka Terbuka ( T 01 )
JV16000284 5/22/2016 5/24/2016 2 Asma ( J 45 )
64
SUMENEP, 30 Mei 2016


NIP. 19710915 199803 1 012
TOTAL BIAYA KET
12 13
Rp 58,000 S
Rp 37,750 S
Rp 101,000 S
Rp 60,000 S
Rp 111,000 S
Rp 59,000 S
Rp 58,000 S
Rp 101,000 S
Rp 30,750 S
Rp 30,750 S
Rp 295,000 S
Rp 173,000 R
Rp 249,000 R
Rp 58,000 S
Rp 30,750 S
Rp 58,000 S
Rp 30,750 S
Rp 910,500 S
Rp 173,000 S
Rp 127,000 R
Rp 173,000 S
Rp 173,000 S
Rp 111,000 S
Rp 30,750 S
Rp 58,000 S
Rp 30,750 S
Rp 219,000 S
Rp 299,000 S
Rp 127,000 S
Rp 154,000 S
Rp 87,250 S
Rp 4,215,000

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FORMAT REKAP RAWAT INAP

DIAGNOSA KODE (ICD X) TOTAL BIAYA KET

SUMENEP, 30 Desember 2017

SUMENEP, 30 November 2017

NOMOR REGESTER : JXII.1700592

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER : JXII.1700579

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER : JXII.1700529

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER : JXII.1700587

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER :JXII.17000589

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER : JXII.1700599

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER :JXII.17000549

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER :JXI.17000579

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER : JXI.1700586

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER : JXI.17000548

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER : JXI.1700532

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER : JXII.1700578

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER :JXII.1700607

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER :JXII.1700606

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER :JVII.1700531

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER :JVII.1700524

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER : JXI.1700512

HARI I HARI II HARI III HARI IV HARI V

NOMOR REGESTER : JXI.1700511

HARI I HARI II HARI III HARI IV HARI V

FORMAT BIAYA RAWAT INAP

HARI I HARI II HARI III HARI IV HARI V

SUMENEP, 30 Desember 2017

SUMENEP, 30 Desember 2017

SUMENEP, 30 Desember 2017

DIAOGNOSA : Ispa + susp.HNP

SUMENEP, 30 Desember 2017

SUMENEP, 25,November 2017

DIAOGNOSA : Colik Abdonen

SUMENEP, 25,November 2017

SUMENEP, 25 November 2017

DIAOGNOSA : DM tipe 1 + Hipoglikemia

SUMENEP, 25 November 2017

SUMENEP, 30 November 2017

NOMOR REGESTER : JXI.1700508

HARI I HARI II HARI III HARI IV HARI V HARI VI

SUMENEP, 25 November 2017

NOMOR REGESTER : JXI.1700494

HARI I HARI II HARI III HARI IV HARI V HARI VI

SUMENEP, 25 November 2017

NOMOR REGESTER : JXI.1700529

HARI I HARI II HARI III HARI IV HARI V HARI VI

SUMENEP, 25 November 2017