Register Poli Umum Agustus 2023

Hari/ Tanggal : Selasa, 01 Agustus 2023
Petugas : Imelda, Ety,Widya
No Register No BPJS NIK No Telpon
1 17.707 0001971296763 6310066027900001
2 10.851 Tdk ada 6310092012610001 081295836107
3 29.094 00016798972953 6310091907820005 082154659591
4 26.585 0002722640995 631009410770179 085391712650
5 29.095 Umum 6310094805810006 081349625247
6 29.096 Non aktif 6302181704880001 081348746890
7 28.710 0001847821533 6302180609930001 085754318106
8 29.097 0002722829062 6310065206110001 082152713560
9 16.790 0002722622962 6310090707610002 tdk ada
10 13.400 0001807008265 6310094502660005 085249931946
11 10.905 0002722598954 6310066604140004 085753173261

12 12.060 0001548032512 6471041002030004 082353575917
13 27.354 faskes lain 3578125201090001 085101600567
14 6189 0002520856506 6310094107650115 082149820021
15 28.105 TDK ada 6310094506680006 082155053833
16 13.554 0001928864654 6310095505630006 085751481095
17 22.576 0000206467108 6310091902830004 081348537247

18 26.059 0001922728871 6310095912680002 081348583311
19 18.616 0002722634109 6310093009650003 085246036996
20 18.616 0002722634133 6310094407040008 085246036996
21 16.292 0002722618405 6310090107760124 082353381531
22 16.292 0003068517745 3529106206750002 082353381531
23 6717 0001929869302 6310096010730004 082153054531
24 6717 0002722851189 6310064407180002 082153054531
25 6717 0001929869291 6310092507660005 082153054531
26 24.457 0002722686175 6310091212490004 081351442023

27 29.093 0002722547946 6310062104410001 082217812247
PO
ir
ah
Nama Dokter
ur
lL
m
U
Tg
Ny.Anawati 42th 07-02-1975 dr.rahma
Tn.Nurdin 62 th 20-12-1961 dr.Ferisa
Tn.Muttakin 41th 19-07-1982 dr.rahma
Ny.Isnaniah 49th 01-07-1973 dr.Ferisa
Ny. Partini 42th 08-05-1981 dr.rahma
Tn. Ahmad Yani 35th 17-04-1988 dr.rahma
Tn. Rusdiansyah 31th 06-09-1993 dr.Ferisa
Ny.Nor Halimah 12th 12-06-2011 dr.rahma

Tn. Surahmin 62th 07-07-1961 dr.Ferisa
Ny.Mimi astuti 56th 05-02-1966 dr.ferisa
An. Nuraqia Hidayati 9th 26-04-2014 dr.rahma

An. M. Rohen Ardian 20th 10-02-2003 dr.ferisa
An.rahman 13th 12-01-2007 dr.Rahma
Ny.Intang 58th 01-07-1965 dr.rahma
Ny. St.Muhani 55th 05-06-1968 dr.Ferisa
Ny.Lasinem 60th 15-05-1963 dr.ferisa
Tn.M.Zaki Yamani 40th 19-02-1983 dr.rahma

Ny.rahimah 54th 19-12-1968 dr.rahma
Tn.kaspul Anwar 57th 30-09-1965 dr.rahma

An. St.Kholisah 18th 09-07-2004 dr.rahma
Tn. Bahruddin 47th 01-07-1976 dr.Ferisa
Ny. Sa'Tiya 47th 22-06-1975 dr.Ferisa
Ny. Ningsih 50th 20-10-1973 dr.rahma
An. Nur Azmya Aira 5,1 th 04-07-2018 dr.rahma
Tn.Sunarto 57th 25-07-1966 dr.rahma
Tn.Johan 71th 12-12-1949 dr.rahma

Tn.Subakri 82th 21-04-1941 dr.rahma
POLI UMUM
Pembiayaan
Status
Alamat Pendidikan JK Status Penyakit
Kunjungan Umum BPJS
Perum.griya bumi raya SMA P L L ✓
Jl.Hidayah RT.07 SD L L L ✓
Jl. Padat karya RT.02 SMK L B B ✓
Jl.cendrawasih SD P L L ✓
Jl. Petiti gg.dahlia S1 P B B ✓
Jl.banyuwangi RT.03 SMA L B B ✓
TP SMA L B B ✓
gg Swarga SD P B B ✓
JlSimpang sari Rt.15 SD L L L ✓
Jl.gunung antasari Rt 02 SD P L L ✓
Jl.perjuangan Rt.17 SD P B B ✓
Jl.Snada RT.07 SMP P B B ✓
Jl Belibis RT.04 SMP L L B ✓
Jl.Anang kacil Rt.04 SD P L L ✓
Jl. Karang jawa RT.04 SD P L L ✓
JL Perjuangan RT.01 SD P P B ✓
Jl.Sabar subur RT.02 S2 L B B ✓

JL.Transmigrasi RT.02 SMP P B B ✓
Jl. Kebanjiran RT.02 SMP L B B ✓
Jl. Kebanjiran RT.02 SMK P B B ✓
Jl.Setia maju SD P B B ✓
Jl.Setia maju SD P B B ✓
Jl.banyuwangi RT.07 SMP P L L ✓
Jl.banyuwangi RT.07 P B B ✓
Jl.banyuwangi RT.07 SMP L B B ✓
bersujud RT.03 SMA L B B ✓

Jl.Mulawarman SD L B B ✓
Pembiayaan Wkt Playan
Diagnosis Terapi & Tindakan

SKTM D P
PCT, Amox, Ctm, Amroxol,

CC + Cepalgia vit.c 08.25 08.30
Amlodipin, ibu,
HT, Sydrm. Dispepsia 08.35 08.40
omeprazole, vit.BC
Pct,hyosine,omeprazole,kali
GEA tampa dehidrasi 08.30 08.35
um pectim, zinc,
Sindrome dispepsia,poswt cerebral omeprazole,antasida,vit.B1
infaction 2 08.45 08.50
HT + CC ibu, Pct, amlodipin, vit B12,

amox 08.50 08.55
PCT,CTM,Amroxol,
Commond cold 09.00 09.05
Vit.c,Antasida
Faringitis ibu, amox,BC,dompridone 09.10 09.15
Serumen o irigasi telinga, ibu, amox, vit

C 09.34 09.38
sterosis + HT Hiperlipdemia simvastatin, ruj. Rs 09.25 09.30
betahestin, amlodipin,
DM+HT+hiperlipidemia metformin, gliben, 09.30 09.35
simvastatin
otitis Ekterna PCT, Amox, Vit.C 09.50 09.55

Sus.ggn Refraksi (H53.9) Ruj.RS.Poli mata 09.55 10.00
Pct,amroxol,amox,
Asma broncial 10.15 10.20
Salbutamol ,vit.c
captopril, amlodipin,
HT gr.II ibuprofen, 10.20 10.25
omefrazole,kalk,vit bc
Amlodipin, captopril,
HT gr.II + Hiperlipidemia simvastatin, ibu, Vit BC 1025 10.30
betahestin, amox, ctm,

Vertigo+otitis ekterna chlorampenicol ear loop, vit 09.10 09.15
B12 c
Sinusitis maxilan Ruj.RS Poli THT 10.14 10.19
CKD ST.V Ruj.poli PD RSHAAN 10.43 10.48
otitis Ekterna Dextra+dispepsia pct,amox,omeprazole, BC 10.44 10.54
Commond cold ibu,amroxol,vit.c 10.42 10.47
hiperlipidemia ibu, simvastatin, antasida 10.15 10.25
omeprazole, antasida,
syndrom,dispepsia + hiperlipidemia 10.50 11.00
simvastatin, betahestine
ibuprofen,
displedemia+hiperurecemia+cepalgi
alluprinol,simvastatin, vit.c, 10.40 10.50
a
Vit B12
eksime pct,amox,nystatin 10.35 10.45
captopril, alluprinol
HT gr.II +hiperurecemia ibuprofen, omefrazole,,vit 10.46 11.06
bc
DM Tipe II + Neuropaty Ruj.RS 11.07 11.27
Katarak Matur Ruj RS poli mata 11.28 11.38
TTV
Pekerjaan KIE
TD RR Suhu Nadi TB BB Lab
IRT ✓ 116/77 24 36,5 82 167 67
wiraswasta ✓ 149/89 22 36,9 82 169 60
wiraswasta ✓ 122/95 24 36,7 78 162 50
IRT ✓ 144/100 22 36,5 85 Pakai kursi roda
guru ✓ 157/92 24 36,8 102 150 74
wiraswasta ✓ 119/87 22 36,5 87 163 79
wiraswasta ✓ 136/98 20 36,6 70 165 79
tdk bekerja ✓ 22 36,6 72 134 35
wiraswasta ✓ 172/102 22 36,6 69 174 68

Hb.12,8
chol: 288
IRT ✓ 155/92 24 36,4 89 149 40
GDP: 170
AU: low
Pelajar ✓ 24 36,7 131 22
tdk bekerja ✓ 122/77 24 36,6 87 160 45
Pelajar ✓ 24 36,7 156 50
IRT ✓ 170/93 28 36,9 85 147 55
irt ✓ 180/111 28 36,6 58 150 61
irt ✓ 132/75 28 36,6 77 145 61
PNS ✓ 130/92 28 36,6 113 157 85

IRT ✓ Paien tidak dibawa
wiraswasta ✓ 126 24 36,6 101 160 68
tdk bekerja ✓ 124/92 24 36,6 104 150 35
wiraswasta ✓ 104/78 24 36,6 97 170 64
IRT ✓ 140/82 24 36,7 83 156 59
GDS: 90
IRT ✓ 131/90 24 36,6 94 150 55 Kol: 254
AU: 9,4
✓ 24 36,7 14
GDS: 121
wiraswasta ✓ 157/109 24 36,7 66 156 60 Kols: 178
AU : 8,2
swasta ✓ 131/82 24 36,7 70 155 65
wiraswasta ✓ 1`42/132 24 36,6 88 157 30
Riwayat PTM
Riwayat
Riwayat Riwayat Riwayat Pemeriksa
Riwayat
Penyakit PTM ( Perdaraha an
Alergi
Keluarga ≥ 15 th ) n IVA/Sada
nis
Asma
HT HT,Stroke, makanan
HT
HT
HT HT
HT HT,Stroke
HT
Hari/ Tanggal : Rabu, 02 Agustus 2023
Petugas : Anton, Yassar,Melynda
1 484 0002722688278/s4 6310066801130002 083893590504
2 21.170 0001554360197/DA 6310096207710001 081319557355
3 4908 0002749229054/DA 6310090607870007 085251958547

4 3859 0002738307071/DA - 083142154997
5 28.230 0002773721474/DA 6310020904900004 081349330024
6 29.102 0002722838635/DA 6310094101630004 081358834166
7 18.128 0002220625517/S4 6310095012548003 085771878726
8 26.735 0003068388251/DA 6310091004720017 083193979506
9 27.724 0001930261837/DA 6310090110880006 082148062951
10 3612 0000894868058/DA 6310095204590002 -
11 23.152 Non Aktif 6310096006620001 -
12 10.633 0002722631591/DA 6310094909870004 085248337769
13 14.406 0002908463196/DA 6310095305930007 -
14 20.353 0001389731163/DA 6310096512880016 085251180812
15 22.682 0002264145085/DA 6303025808960003 -
16 3051 0003092731446/DA 3504055712590002 -

28.68
28.682 0002070705093/DA 6302090106730002 081361976636
2
18 28.851 0001922767121/DA 6310092001610001 081549124828

19 17.874 0003068548481/DA 6371054202800015 -
20 20.924 0002722803186/DA 6310060304950001 -
21 25.616 0002722842652/DA 6310064108130001 08115191374
22 21.373 0003057627249/DA 6310024212970002 -

23 25623 0002456637039/DA 6302115708450002 082152113250
24 29104 0002722676376/DA 6310094609690003 082155395503
25
26
27
PO
ir
ah
Nama Dokter
ur
lL
m
U
Tg
An.Nana aulia Rahman 10 th 28-1-2013 dr ferisa
Ny. Misnawati 52 th 23-07-1971 dr. Rahmah
Tn. Akhmad Mauludin Fauzi 35 th 06-07-1987 dr. Rahmah
An. M. Naufal Rizky 5 th 28-10-2019 dr. Ferisa
Tn. Masdar 32 th 09-04-1990 dr. Rahmah
Ny. Buhana 60 th 01-01-1963 dr. Ferisa
Ny. Nafsiah 69 th 10-12-1954 dr. Rahmah
Tn. Samani 50 th 10-04-1972 dr. Ferisa
Tn. Faulizan 35 th 01-10-1988 dr. Rahmah
Ny. Halidah 63 th 12-04-1959 dr. Rahmah
Ny. Rukmini 61 th Tidak ingat dr. Ferisa
Ny. Nur Thaibah 36 th 09-09-1987 dr. Rahmah
Ny. Mufliha 30 th 13-05-1993 dr. Rahmah
Ny. St. Maisyarah Taher 32 th 25-12-1988 dr. Ferisa

Ny. Riska Agustina 25 th 18-08-1998 dr. Ferisa
Ny. Mistini 62 th 17-12-1959 dr. Ferisa

Tn. Samsul Bahri 50 th 01-06-1973 dr. Ferisa
Tn. Sukarman 62 th 20-01-1961 dr. Rahmah

Ny. Iriani 40 th 02-02-1980 dr. Rahmah
Tn. Suryadi 24 th 03-04-1995 dr. Ferisa
An. Adinda Agustina 7 th 01-08-2013 dr. Rahmah
Ny. Gita Nur Hikmah 26 th 02-12-1997 dr. Rahmah

Ny. Nur Intan 78 th 17-08-1945 dr. Ferisa
Ny. Marsiti 54 th 06-09-1969 dr. Rahmah
POLI UMUM
Pembiayaan
Status
Alamat Pendidikan JK Status Penyakit
Kunjungan Umum BPJS
gg.Pelita 3 kampung baru SD P L Baru ✓
Jl. Transmigrasi KM 6 Ds. Kamp Baru SMP P L Lama ✓
Jl. Banyuwangi RT. 14 SMA L L Baru ✓

Jl. BB RT. 09 Ds. Bersujud - L L Lama ✓
Jl. Plajau Indah RT. 07 S1 L L Baru ✓
Jl. Pasar Ampera RT. 04 SD P B Baru ✓
Jl. Kuburan Muslimin RT. 12 SD P L Baru ✓
Jl. Pelabuhan BCM SD L L Lama ✓
Jl. Perjuangan RT. 14 SMA L L Baru ✓
Jl. Borneo RT. 12 SD P L Lama ✓
Jl. Mekar Sari RT. 15 SMP P L Lama ✓
Jl. Pasar Sabtu SMA P B Baru ✓
Jl. Transmigrasi Ds. Baroqah SMA P B Baru ✓
Jl. Pesantren RT. 09 SMA P L Lama ✓
Jl. BB RT. 09 Ds. Bersujud SMP P L Lama ✓
Jl. Banyuwangi RT. 07 SD P B Baru ✓

Jl. Plajau Indah RT. 01 D3 L L Baru ✓
Jl. BB RT. 09 Ds. Bersujud SD L L Baru ✓

Jl. Kodeco RT. 03 SMA P L Lama ✓
Tungkaran Pangeran RT. 18 SMP L L Baru ✓
Jl. Rahayu Gg. Kelapa Dua RT. 7 SD P L Baru ✓
Jl. Raya Serongga RT. 4 - P L Lama ✓

Jl. Batam RT. 1 SD P L Lama ✓
Jl. Rahayu RT. 6 SD P B Baru ✓
✓
✓
✓

SKTM D P
Synrom dyspepsia omeprazol,Antasid tab. 08.30 08.35

Captopril, amlodipin,
DM tipe 2 + Displipidemia metformin 08.35 08.40
Atralgia + Dermatitis Alergi Cetirizin, betametason 08.35 08.40
ISPA Ambroxol, Noza, Amox 08.45 08.50
Ibuprofen, Metronidazol,
Plebitis 08.50 08.55
Omeprazole
HT urgency + Hiperlipidemia + Otitis Amlodipine, Captopril,

Ekrsterna Betahistin, Simvastatin 08.55 09.00
Furosemid, Amlodipin, PCT,

CHF 09.00 09.05
Omeprazol, BH com
Unstable Angina Pectoris Rujuk ke Interna RSUD 09.05 09.10
Hemoroid gr III Antihemoroid supp, Asmef,

vit C, surat sakit 09.10 09.15
HT gr II + Katarak mature ODS + Captopril, Amlodipin, PCT,

Dermatitis Alergi Simvastatin 09.10 09.15
HT, synd dispepsia, Hiperlipidemia, Amlodipin, omeprazol,

stomatitis simvastatin, nystatin drop 09.15 09.20
Ibuprofen, omeprazol,
Tension type Headache 09.40 09.45
diazepam
ISPA PCT, Ambroxol, CTM, vit c 09.25 09.30
F20.3 (Skizofrenia tidak spesifik) Rujuk ke poli jiwa RSUD 09.20 09.25
F51.8 (Sleep Anxiety) Rujuk ke poli jiwa RSUD 09.30 09.35
Amlodipin, Betahistin,
HT, Hiperlipidemia, Hiperurisemia Omeprazol, Antasida, 09.20 09.25
Simvastatin, Allopurinol
NAC, Amlodipin,
ISPA, HT, Hiperlipidemia 09.45 0950
Simvastatin, Noza, Amox
Ibuprofen, captopril,
OA + HT gr II + susp ISK 09.50 09.55
amlodipin, ciprofloxacin
DM tipe 2 + Hiperglikemia Metformin 09.55 10.00
Ibuprofen, Kaolin pectin,

Diare akut tanpa dehidrasi 10.00 10.05
Zinc, Kotrimoxazol, Oralit
Amoxicillin, Ibuprofen,
ISPA 10.10 10.15
Ambroxol, Antasida, vit C
F20.3 (Skizofrenia) Rujuk ke poli jiwa RSUD 09.35 09.40

Post op katarak Rujuk ke poli mata RSUD 10.30 10.35
Cetirizin, PCT, Betametason 10.50
Dermatitis Alergi 10.55
salep
TTV
Pekerjaan KIE
pelajar ✓ 21 36,5 102 145 40 -
IRT ✓ 187/117 23 36,6 94 152 75 -
- ✓ 136/85 21 36,6 71 169 65 -

- ✓ 26 36,3 102 115 20 -
Wiraswasta ✓ 143/79 23 36,8 83 175 89 -
IRT ✓ 193/121 21 36,6 90 159 71 -
IRt ✓ 178/77 24 36,5 83 135 35 -
Wiraswasta ✓ 147/96 23 36,6 83 165 70 -
Swasta ✓ 139/116 22 36,7 109 164 58 -
IRT ✓ 172/132 22 36,7 103 138 48 -
Hb 11,2,
GDS 112,
✓ 133/72 22 36,9 82 139 30
Chol 254,
AU 4,6
GDS 99,
IRT ✓ 122/83 22 36,7 71 139 50 Chol 194,
AU 3,7
IRT ✓ 124/74 22 36,8 78 148 57 -
IRT ✓ 131/86 23 36,7 81 148 61 -
IRT ✓ 117/89 23 36,9 127 159 60 -

Hb 12,9,
GDS 117,
IRT ✓ 153/84 23 36,6 84 150 55
Chol 218,
AU 8,3
Wiraswasta ✓ 140/100 22 36,7 94 163 60 -
Tidak bekerja ✓ 170/102 22 36,7 96 151 55 GDS 97

IRT ✓ 113/79 23 36,6 93 146 54 -
GDS 102,
Wiraswasta ✓ 127/80 23 36,7 90 169 61 Chol 194,
AU 5,7
Pelajar ✓ 23 36,8 101 140 30 -
IRT ✓ 80/55 21 36,7 80 155 44 -

IRT ✓ 140/90 22 36,4 98 155 56 -
IRT ✓ 128/76 24 36,5 66 147 60 -
✓ -
✓ -
✓ -
Riwayat PTM
Riwayat
Riwayat Riwayat Riwayat Pemeriksa
Riwayat
Penyakit PTM ( Perdaraha an
Alergi
Keluarga ≥ 15 th ) n IVA/Sada
nis
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
HT,
- - - -
Jantung
HT - - - -
HT - - - -
HT - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
HT - - - -
HT - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
Hari/ Tanggal : Kamis, 03 Agustus 2023
Petugas : Melinda,Jumariah,Yasar,Cterina,Suradi
No Register No BPJS NIK No Telpon Nama
ur
Um
1 16.790 0002722622973 6310094506650005 Ny.Yatmi
2 12.210 0002720685868 6310066203140001 An.Mariyani Syaputri
3 29.105 0002495465954 6310062102160003 An.Raffasya Alfarizky

Setiawan
An.Darius Gerardo
4 15.631 0001961367186 631009010610004
Sitomorang
5 28.249 0000893709977 6310091209930004 An.Ronald Syaputra
0003172599494
6 29.108 3 3211144410600008 Ny.Onih
7 17.731 0002044589793 6310091508620003 Tn.C Sondang

8 26.421 0002722542895 6507211307810002 Tn.Hermawan
9 26.902 0002908461982 6371025010610016 Ny.ida wati
10 18.869 6310092508600003 Tn.Sarman
11 18.640 6310092702760004 Tn.Misransyah
12 14.362 0001922792747 6310090506570001 085249816817 Tn.H.dadong
13 5323 6310067105140001 Ny.Jumiati
14 3681 0002722850379 6310068504140001 085218671829 An.Aprilia Nur Sifa
15 17.316 000089471911 63100911080400015 Ny.Sariyanti
16 21.431 0001618207389 6310095410050004 Nn.Rika Nur safitri

17 19.650 0002722693961 6310090806750004 085386978244 Tn.Muhsin
18 21.195 0001928866206 6310095110730009 Ny.Sarminah
19 12.658 0002824174168 6310095002550001 Ny.Siti Badriah
20 15.340 0002370548114 6310063008980002 Tn.Hestino Akbar
21 28.733 0002722689819 6310096204720002 0855251279899 Ny.Rosdiana

6
22 24.162 0002897752004 6310066808160001 082150301013 An.Agustina Az-zahra
23 28.442 0001922802434 6310090212830003 083150401642 Tn.Rustam ipansyah
24 29.094 0001679097295 6310091907820005 082154659591 Tn.Muttakin

3
25 4513 0002722709125 6310095807640004 Ny.Sumarmi
26 1917 0002722612318 6310090706660002 Tn.M.Idris
27 25.480 0001553914405 6310092608600001 081349668799 Tn.Supiyani
28 22.051 0001922736429 6310094409740002 Ny.khoiril
29 25.280 0002722838038 6310094904580003 081321646115 Ny.Djurnia
30 29.109 0002722837127 6310091702950002 082149416890 TN.M.Pasdanil

POLI UMUM
Pembiayaan
Status Status
r
hi
Dokter Alamat Pendidikan JK

ur
La
Kunjungan Penyakit
m
Umum
U
l
Tg
05/06/19 Jl.Simpang sari

58 th dr. Rahmah Rt.02 SD P L B
65
22/03/20 Jl.Pasar ampera

9 th dr. Ferisa Rt.09 SD P L B
14
7 th 21/02/20 Jl.Komp Griya SD L B B

16 dr. Rahmah Permai Rt.07
03/05/20 Jl.Banyuwangi
13 th dr. Ferisa Rt.07 SD L L B
10
12/09/19 Jl.Bina bersama

30 th dr. Ferisa rt.01 SMK L L L
93
04/10/19
62 th 60 dr. Rahmah Jl.Mawar Rt.15 SD P L L
15/08/19
61 th dr. Rahmah Jl.BB Rt.09 SMP L L B
62
13/05/19 Jl.Harapan
40 th dr. Ferisa Bersama Rt.09 SLTP L L L
83
10/10/19 Jl.Komplek
62 th dr. Rahmah Rt.06 Smk P L B
61
25/08/19 Gang Mawar

60 th dr. Ferisa Rt.04 SD L L B
60
27/02/19 Jl.Raya
44 th dr. Rahmah SD L L L
76 batulicin Rt.02
05/06/19 Jl.Gema Citra

67 th 57 dr. Rahmah Rt.07 SD L L L
13/12/19 Jl.Raya
40 th dr. Ferisa Serongga SD P L L ✓
83
25/04/20
9 th dr. Ferisa Jl.Kodeco Rt.01 SD P L B
14
11/08/20
19 th dr. Ferisa Jl.Lap 5 Okt SD L L B
04
Jl.Komp
14/10/20
15 th dr. Ferisa Bengkol Sei SMP P B B
05
Kecil Rt.09
08/06/19 Jl.Transmigrasi
44 th dr. Ferisa SD L L B
75 Rt.08
11/10/19
50 th dr. Ferisa Jl.Kodeco Rt.03 SD P L L
73
10/02/19 Jl.Sei Belanak

64 th dr. Ferisa SMP P B B
55 TP
25 th dr. Ferisa SD L L L
96 Rt.09
22/04/19 Jl.Kamp baru

51 th dr. Ferisa SD P B B
72 rt.03
7 th 28/08/20 Jl.pel speed SD P B B

16 dr. Ferisa rt.05
39 th dr. Ferisa SMA L B B
83 Rt.13
41 th 19/07/19 jl.padat raya SMK L L L ✓

82 dr. Ferisa rt.02
18/07/19 Jl.Sungai kecil
57 th dr.Rahman SD P L B
64 Rt.01
07/06/19 Jl.Perjuangan
55 th dr.Rahman SD L L B
66 Rt.17
26/08/19
61 th dr.Ferisa Jl.Al-amin Rt.13 SD L L B
60
Jl.Tranmigrasi
47 th 4/4/1974 dr.Ferisa rt 09 SD P L L
09/04/19
62 th 58 dr.ferisa JL.PnPM rt.18 SMP P L B
17/02/19
28 th dr.Rahman Jl.PNPM Rt.08 SMP L L L
95
UMUM
Terapi &
Diagnosis Pekerjaan
BPJS SKTM Tindakan D P
Catopril
12,5,Amlo
dipin,Pct,
✓ HT Gr II + Dm Tipe II Simvastati 08.25 08.30 IRT
n,Vit
B12,Diaze
pam
Amoxilin,
Pct,Demp
✓ Obs Vomil 08.35 08.40 Pelajar
eridone,Zi
nk
Ibuprofe
m,Asikoli
✓ Herpes zoster n,Vit 08.40 08.45 Pelajar
C,Asiklovi
r
Post Heting cc digiti I Dressing

✓ 08.45 08.50 Pelajar
Moramus
Rujuk kr
poli paru
B.20 + Tuberallose of Wiraswas
✓
interanus penikelum RSDHAAN 08.50 08.55 ta
B20 +
Alo.3
Ceterizine
✓ Scabies ,Pct,Salep 09.00 09.05 IRT
24
Rujuk Poli
Saraf Wiraswas
✓ Neurepati DM 09.10 09.15
RSUD ta
DHAAN
Multiple
nevus
78.1 Wiraswas
✓ Multiple Nevus 09.34 09.38
Ruju8k ta
kpoli kuli
RSDHAAN
Rujuk poli
penyakit
HT gr I + Ulkus
✓ dalam 09.25 09.30 IRT
Gaster
111.9 +
k25.2
Natrium
Wiraswas
✓ Sterosis diclofena 09.30 09.35 ta
k,Vit B12
Glibend,
Metyform
✓ -DM,-HT in,Amlodi 09.50 09.55 Wiraswas
pin,Vit ta
B12
Pasien
TCM,Amb
✓ -ISPA,-HT roxol,Cete 09.55 10.00 IRT
rizin,Amlo
dipin
Amlodipin
,Betahisti
HT,Vertigo,Dispepsia n,Urepran 10.15 10.20 IRT
,Vit
bcomp
Pct,Demp
✓ CTEA eridone,Zi 10.20 10.25 pelajar
nk
✓ Kontrol TD 1025 10.30 IRT
-NAC,-
Noza,Am
✓ ISPA 09.10 09.15 IRT
oxilin,Vit
c
Metformi
n,Glimefi
de,pct,O
DM Tipe II
✓ meprazol 10.14 10.19 IRT
Hiperglikemia
e,Vit
b12,Ceter
izine
Metformi
n,Amlodip
in,Ambro
✓ Dm,HT,ISPA 10.43 10.48 IRT
xol,pct,Ce
terizin,PC
T TCM
Amlodipin
,Metformi
HT,DM,Dispepsia,Cm n,Omepra
✓ 10.44 10.54 IRT
mold cold zole,NAC,
Ceterizin,
Vit bcomp
NAC,Cete
rizin,Amo
✓ ISPA,Dispepsia xillin,Vit 10.42 10.47 IRT
C,Antasid
a
Catopril,A
mlodipin,
✓ HT gr II +Dispepsia pct,Omep 10.15 10.25 IRT
razole,Vit
bcomp
Demperid
one,antas
✓ Dispepsia,Dermatitis ida,parac 10.50 11.00 IRT
etamol,ke
tokonazol
e
Rujuk poli
liken Simplex Wiraswas
✓ kulit 10.40 10.50
choronicus (28.19 RSDHAAN ta
✓ GEA Teruskan 10.35 10.45 tidak

Obat bekerja
Ruju7k
Post SNH + CPSP Poli Saraf
✓ 10.45 10.50 IRT
(169.3) RSUDHAA
N
Ambroxol Wiraswas
✓ ISPA 10.50 10.55
,PCT,Vit.C ta
Simvastati Wiraswas
✓ CHF + Hiperusemia n,Allopuri 10.50 10.55
ta
nol
Rujuk poli
penyakkit
DM Tipe 11 Terapi
✓ insulin dalam 10.55 1056 IRT
RSUDHAA
N
Amlodipin
e,Vit
✓ HT gr I + DM Tipe II B12,Simv 10.55 10.56 IRT
asatain
Amoxillin,
Asmet,De Wiraswas
✓ Susp ISK 10.58
xametaso ta
n,Vt C
11.00
TTV Riwayat PTM
Riwayat
KIE Riwayat
PTM
TD RR Suhu Nadi TB BB Lab Penyakit
( ≥ 15
Keluarga
th )
GDS=99,K
✓ 180/107 24 36,5 98 155 49 oleterol=
232
✓ 24 36,7 127 25
✓ 24 36,7 127 20
✓ 24 36,7 160 41
✓ 119/93 24 36,7 104 172 60
✓ 147/85 24 36,8 83 146 45
✓ 116/73 22 36,6 77 171 85

✓ 117/82' 24 36,6 78 168 76
✓ 142/94 24 36,7 159 74
73
✓ 132/87 24 36,6 77 141 42
✓ 131/80 24 36,8 101 163 51
✓ 159/111 24 36,7 79 163 59
✓ 132/95 24 36,7 87 160 70
✓ 24 37,7 118 19
✓ 190/124 24 36,6 77 154 75
✓ 110/86 24 38,2 126 155 40

✓ 118/89 24 36,7 114 154 45 Gds=254
✓ 148/80 24 36,8 106 157 56
✓ 184/98 24 36,7 83 155 59
✓ 117/87 24 36,7 91 167 69
✓ 158/104 24 36,5 79 146 61
✓ 36,7 119 21
✓ 127/114 24 37,1 106 159 56
✓ 123/90 24 37 78 162 50
✓ 159/89 24 36,7 121 148 49
✓ 151/102 24 37,1 96 161 75
GDS=115,
✓ 135/90 24 36,7 96 161 61
Kol=272
✓ 131/80 24 36,7 89 146 51
✓ 131/68 24 36,7 89 144 41
✓ 145/81 24 36,9 91 165 65

0
Riwayat PTM
Riwayat
Riwayat Pemeriksa
Riwayat
Perdaraha an
Alergi
n IVA/Sada
nis
73
Hari/ Tanggal : Jumat, 04 Agustus 2023
Petugas : Anton, Totok, Yassar, Erni
ur
Um
0002462920751
1 20.575 6310094101820013 An. Al Baday
/DA
0002612884882
2 24.781 6310090506650007 085393272333 Tn. Hairuddin
/DA
0002478617234
3 25.861 6310096709560001 081255392082 Ny. Hj. Nahrah
/DA
0002454012499 6306051508780001 082194379117 tn abdul kholiq

4 29116
/zam zam
0003059475129
5 28170 6310082508910003 081347298556 Tn joko dianto
/zamzam
0001452153262
6 22.344 /DA 6310092201770004 08125067762 Tn. Fahri Riza
7 20636 non aktif 6310096103820001 082254243309 Ny annisa
0001929856375
8 27881 6310096103710005 tdk di tulis ny mardiana
/DA
000214014407/ 1102130411770001 082153040620 tn walinton

9 12776
DA
0001928844551 6310094304030009
10 27651 081944234411 Ny kasmah
/pkm s4
0002658284537
11 28208 6310090202720005 081348737376 tn egi sugianto
/DA
0002737323011
12 20759 6310094811810001 082255813617 ny rahma wati
/DA
0002722841594
13 24431 6310094505920017 085787908404 Ny. Hariyati
/DA
14 990 0001922777763 6310091011750009 085332501877 Tn. Syahrudin
15 16889 0003036907091 352930708620003 085389687610 Tn. M. Jupri
16 29115 Umum 631009700756004 081348489300 Ny. Rukayah Halim
Tn. H. Mahrawi
17 18205 2720812498 6310090802630001 081250007875 Hasyim
18 25699 Umum 6310082607920001 082153279943 Tn. M. Arif Yulianto
19 10736 0001922802423 6310094101660010 081320425652 Ny. Sugianor
20 24138 0002922719859 6310095407640002 tdk di tulis Ny. Ermas
0002722593000 6310044605900004 085787770051 Ny. Jusnia

21 8943
3
22 28728 0001553916339 6310094703560002 tdk di tulis Ny. Norsiah

23 22682 0002462938773 6310061803180003 082153707323 An. M. Athaya Khairan
24
25
26
27
28
29
30
POLI UMUM
Pembiayaan
Status Status
r
hi

ur
La
Kunjungan Penyakit
m
Umum
U
l
Tg
10 th 04-08-2013 dr. Rahmah Jl. PNPM RT. 18 SD L L B
Jl. Sei Hanau

58 th 05-06-1965 dr. Ferisa RT. 17 SMP L L L
Jl. Pelabuhan
67 th 24-09-1956 dr. Ferisa Sepped RT 1 SD L L B
gg abtung rt 3
45 th 15-8-1978 dr rahma SMA L B B ✓
GA
jl senada rt 3
32 th 25-8-1991 dr rahma SMK L B B ✓
GA
jl insgub pelita
46 th 22-1-197 dr rahma rt 4 kamp baru D3 L L L
jl mangga rt 14
41 th 21-3-1982 dr rahma bersujud SMK P B B ✓
jl kodeco km 1
52 th 21 mar 1971 dr. Ferisa SD P L L
rt 3
jl kaca piring rt
46 th 4-11-1977 dr rahma SMK L L L
7 GA
jl perum
20 th 2-4-2003 dr. Ferisa arraudah rt 12 SMP P B B ✓
barokah
jl cendrawasih
51 th dr. Ferisa SMA L L L
rt 11
2/2/1972
jl pasar ampera
43 th 6 nov 1981 dr. Ferisa rt 4 TP SMK P L L
jl pasar ampera
31 th 5-5-1992 dr. Ferisa SD P B B
TP
48 th 10-11-1975 dr. Rahmah Jl. BB RT 14 SD L L L
Jl. Borneo RT
60 th 7-8-1963 dr. Rahmah 12 SD L B B
Jl. Bakau Perum

67 th 30-7-1956 dr. Ferisa Guru SD RT13 SD P B B ✓
Jl. Hidayah Gg.

57 th 8-2-1963 dr. Ferisa MA L L L
Family
Jl. Pesantren rt.

31 th 26-7-1992 dr. Rahmah 1 SMA L B B ✓
Jl.
57 th 1-1-1966 dr. Ferisa TransmigrasiRT SMP P L L
13
56 th 14-7-1964 dr. Rahmah Jl. HidayahRT. 7 - P B B
34 th 6-5-1989 dr. Ferisa Jl. Padaelo RT 5 SMP P B B
67 th 7-3-1956 dr. Ferisa Jl. Mawar RT.13 SD P L L

Jl. Batu Benawa
5,5 th 18-3-2018 dr. Rahmah - L L L
RT. 9
UMUM
Terapi &
Diagnosis Pekerjaan KIE
PCT,
Amoxicillin,
✓ Abdominal Pain CTM, 08.00 08.05 Pelajar ✓
Ambroxol,
Antasida
Nadic,
Wiraswas
✓ LBP Methylprednis 09.25 09.30 ✓
ta
olon, vit. B12
✓ Post SNH + HT Amlodipin 08.35 08.40 IRT ✓
furosemide,a
HT urugency mlodipin,aspil Wiraswas
08.50 08.55 ✓
+hemoroid grade 3 et,antihemoro ta
id
pct,
ISPA + GEA tanpa Wiraswas
ambroxol,omz 08.45 08.50 ✓
dehidrasi ta
,zinc,kaolin
Rencana
Wiraswas
✓ neuropati DM Rujuk poli 09.10 09.15 ta ✓
syaraf RSMP
pct,
obs febris ambroxol,anta 09.20 09.25 IRT ✓
side,vit c
hiperlipidemia,syndr omz,antasid,ib
om
✓ uprofen,svt,all 09.15 09.20 IRT ✓
dispepsia,hyperurice
upurinol
mia
close fraktur costae rujuk poli

Wiraswas
✓ 09.05 09.10 ✓
bedah rs aan ta
asam
Wiraswas
konstipasi mefenamat,zi 09.20 09.25 ✓
ta
nc
rujuk penyakit Wiraswas
✓ selulitis, HT, CAD 09.25 09.40 ✓
dalam rsmp ta
ibuprofen
✓ obs cepalgia 09.50 09.55 IRT ✓
vitb12
cardeomiopathy Rujuk Sp.PD

✓ 09.25 09.30 IRT ✓
Postpartum RSMP
Rujuk Sp.B Wiraswas
✓ Susp. BSK 09.42 09.45 ✓
RSUD ta
Rujuk Sp. THT Wiraswas
✓ Massa Nassal Cavity 09.45 09.50 ✓
RSUD ta
Amlodipin,
Ibuprofen,
HT, DM Tipe II Glimepirid, 08.40 08.45 IRT ✓
Metformin,
Vit B12
Rujuk Sp.B
RSUD,
Amlodipin,
HT Urgency, ISPA, Wiraswas
✓ Cptopril, 10.05 10.10 ✓
BPH Susp ta
Ambroxol,
Noza,
Amoxilin
Frozen Shoulder Rujuk Sp.PD

(M75.5) RSMP 08.25 08.30 Swasta ✓
Rujuk Sp. PD
DM Post Terapi RSUD, Asmef,
Insulin, HT, Simvastatin,
✓ 09.30 09.35 IRT ✓
Hiperlipidemia, Post Ciprofloxacin,
Conbustion Amlodipin,
Neocenta
Rujuk Sp.PD
✓ HD 09.10 09.15 IRT ✓
RSUD
Cetirizine,
✓ Scabies, ht Amlodipin, 09.55 10.00 IRT ✓
Scabimide zalf
Omeprazole,
✓ Syndr. Dispepsia, OA Antasida, 09.00 09.05 IRT ✓
Ibuprofen, Vit
B12
PCT, Amoxilin,
✓ Ektima Cetirizine, 10.00 10.05 - ✓
Betametasone
✓ ✓
✓ ✓
✓ ✓
✓ ✓
✓ ✓
✓ ✓
✓ ✓
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga
th )
26 38,1 125 25
Hipertens
143/89 23 36,8 95 174 56
i
181/110 21 36,6 94 148 65 HT
190/100 26 36,7 87 178 74 HT
117/84 26 36,7 97 163 60
124/88 21 36,7 84 164 76 DM
129/91 24 36,8 115 145 67
khol=265,
131/87 21 36,4 121 146 60 au=6.8,gd
s=76
125/83 21 36,6 160 60

83
21 36,6 163 90
150/131 26 36,5 55 165 110 HT
141/108 26 36,7 94 14 60
200/110 21 36,7 87 154 58
143/92 21 36,7 82 165 71
141/88 22 37,1 109 152 60
AU : 4,3,
Chol :
164/104 23 36,2 67 143 60 HT,DM
172,
GDP : 233
208 23 36,7 98 154 51
128/88 21 36,6 56 167 55
133/91 22 36,6 93 152 46`
85/58 22 36,6 88 146 36
142/86 22 36,9 86 152 59
127/79 26 36,6 64 147 40

- 26 36,7 102 107 15
0
Riwayat PTM
Riwayat
Riwayat Pemeriksa
Perdaraha an
n IVA/Sada
nis
73
Hari/ Tanggal : Sabtu, 05 Agustus 2023
Petugas : Totok, Yassar
ur
Um
0001929869021
1 4038 6310096303740001 081256340256 Ny. Tatik
/ DA
0000398051346
2 28.889
/ Kalapanunggal 3202185602910007 082298006654 Ny. Wulan Febriani
0002746528648
3 458 6310096505480001 081250586589 Ny. Hj. Tawa
/ DA
4 26.320 0002722804525 6310094603890007 Ny. Selviana

/ DA
000549203027 /
5 16.620 3308061505700004 Tn. Sahuri
DA
0002229873849 An. Ahmad Relvito

6 25.752 6310010403170002 082154404599 Abqary
/ DA
0002738044787
7 456 6310091510580004 081349743950 Tn. Bahrudin H. N.
/ DA
0002485908948
8 1261 6310092101600002 085248127532 Tn. Andi Rani Hasan
/ DA
9 28.287 - 3515122205550002 - Tn. Subantu
0001548081933 6310095809670002
10 16.008 Ny. Dahlia
/ DA
11 28.939 0001098735478 6310094409090006 085247774226 An. Zulfa Nur Fitri

/ DA
12 28.939 0002311641641 6310065902110002 085247774226 An. Yasmin Medina

/ DA Aulia
0000895465473
13 11.392 6310097112580008 Ny. Icot
/ DA
0000895329707
14 22.319 6310095704600004 082349699289 Ny. Katerina Katiyem
/ DA
0001928865622
15 4610
/ DA (Non Aktif) 6310095008760002 081254495949 Ny. Emik Listiyowati
0002722838411
16 26.022 6310090503040002 082153906862 Tn. M. Saleh
/ DA
0001553911165
17 4173 6310091705860009 Tn. Fahrul Razi
/ DA
0002722518235
18 29.120 / Teluk 630205420518235 Ny. Hj. Jarminah
Kepayang
0002722811027
19 11.579 6310066911170002 082255186938 An. Sugih Kirana Al Rei
/ DA
20 27.058 0002738318038 6310094201810004 081349316442 Ny. Nor Asisah

/ DA
0000894712702
21 5131 6310094902010005 083152142553 Nn. Megawati
/ DA
0000894712601
22 5131 083152142553 Ny. Mastura
/ DA
23 16.542 0002722820747 6310064103180001 085348087108 An. Tasya Azzahra

/ DA
24 29.122 0002299765151 6310094702720003 081257437277 Ny. Ruhani

/ Zam-zam
0003258960355
25 29.125 6310060912160001 083125373312 An. A. Yazid Busthomi
/ DA
0002659955771
26 16.661 6310096812670004 Ny. Syahribulan
/ DA
27 796 Umum 6310095001020005 087818206099 Nn. Juwita

0002722925248
28 28.099 6310092506770002 Tn. Rosmani
/ DA
POLI UMUM
Pembiayaan
Status Status
r
hi

ur
La
Kunjungan Penyakit
m
Umum
U
l
Tg
Jl. Banyuwangi
49 thN 23-03-1974 dr. Rahmah RT 8 SD P L L
Perum Alif
32 thn 16-02-1991 dr. Ferisa Azhar SMA P L B ✓
Jl. Perjuangan
75 thn 25-05-1948 dr. Rahmah SD P L L
RT. 15
34 thn 06-03-2989 dr. Rahmah Jl. Hidayah RT. D3 P L B

13
Gg. Mangga RT.

53 thn 15-05-1970 dr. Ferisa 14 SMP L B B
Perum Gunung
6 thn 04-03-2017 dr. Ferisa SD L L L
Tinggi RT. 6
65 thn 15-10-1958 dr. Rahmah Jl. BB RT. 09 SD L L L

Jl. Singo Sari
63 thn 21-01-1960 dr. Rahmah SD L L B
RT. 17
68 thn 22-05-1955 dr. Ferisa Jl. BB RT. 15 SMP L L L ✓
Jl. Poros Lap 5

52 thn 18-09-1967 dr. Ferisa Oktober RT. 14 SD P L L
14 thn dr. Rahmah Komp. Brimob SD L B B
9/4/2009
8 thn 19-02-2015 dr. Rahmah Komp. Brimob SD P B B
Jl. Usaha
64 thn 31-12-1958 dr. Ferisa Bersama Rt. 5 SD P L L
Jl. Bina
63 thn 17-04-1960 dr. Ferisa Bersama RT. 1 SD P L L
47 thn 10-08-1976 dr. Ferisa Jl. Kodeco RT. 2 SMP P L L ✓
Jl. Singosari RT.

19 thn 05-04-2004 dr. Ferisa 15 SMK L L L
Jl. Transmigrasi
37 thn 17-05-1986 dr. Rahmah Gg. Jamrud RT. SMA L L L
12
Jl. Bangun
58 thn 02-08-1965 dr. Rahmah SMP P L B
Banua
5 thn 6 Gg. Kebanjiran

29-11-2017 dr. Ferisa TK P L L
bln RT 2
42 thn 02-10-1981 dr. Rahmah SD P L L
Jl. Lap 5
21 thn 09-02-2021 dr. Rahmah SMA P L B
Oktober
Jl. Lap 5
54 thn 01-12-1969 dr. Rahmah SD P l L
Oktober
5 thn 5 01-03-2018 dr. Rahmah Jl. Banyuwangi SD P L B

bln RT. 2
51 thn 07-02-1972 Jl. Raya SD P B B ✓

dr. Ferisa Batulicin RT. 10
Jl. Pasar
7 thn 09-12-2016 dr. Rahmah `SD L B B
Ampera
Jl. Bangun
56 thn 28-12-1967 dr. Rahmah Benua RT. 11 SMA P L L
Jl. Al Amin RT.

21 thn 10-01-2002 dr. Rahmah SMA P L B
4
Jl. Bersama RT
46 thn 25-06-1977 dr. Rahmah SD L L B
3
UMUM
Terapi &
Metformin
500 mg,
✓ DM tipe 2 + HT Glemipirid, 08.30 08.35 IRT ✓
Captopril, vit.
B
Konsul ke dr.
Alopecia 08. 49 08.54 IRT ✓
Sp. KK
Captopril,
Ibuprofen,
Antasida,
✓ HT gr II 09.03 09.08 IRT ✓
Kalk,
Simvastatin,
vit B compleks
PCT,
Omeprzol,
✓ Dispepsia syndrome 09.09 09.16 IRT ✓
Betahistin,
Hemafort
Ambroxol,
Wiraswas
✓ ISPA, Atralgia Noza, Nadic, 09.15 09.20 ✓
ta
vit. B complex
Ambroxol,
Noza,
ISPA + Otitis
✓ Amoxicillin. 09.06 09.11 - ✓
Eksterna
Chlorampenic
ol drop
PCT,
Amoxicillin,
✓ ISPA 09.33 09.38 Swasta ✓
Ambroxol, vit.
C
Furosemid,
Captopril,
Wiraswas
✓ HT gr II, Myalgia Ibuprofen, 09.27 09.32 ✓
ta
Antasida, vit.
B complex
Nifedipin,
Ambroxol,
HT, Susup.
Cetirizin, 09.51 09.56 - ✓
Bronchitis, Myalgia
Ciprofloxacin,
Nadic, vit. B12
Simvastattin,
✓ Hiperlipidemia, LBP Nadic, Vit B. 09.44 09.49 IRT ✓
complex
PCT, Cetirizin,
Amoxicillin,
✓ Anemia, Pyoderma Vit C, Tablet 09.52 09.57 - ✓
FE,
Betametason,
Surat Sakit
PCT,
Amoxicillin,
✓ ISPA 09.57 10.08 - ✓
Ambroxol, Vit.
C
Nadic,
Sciatica pain, Omeprazol,
✓ 09.59 10.04 IRT ✓
syndrome dispepsia Antasida, Vit.
B12
Ambroxol,
Noza,
Amoxicillin,
✓ HT Urgency, ISPA vit. B 10.06 10.11 IRT ✓
complex,
Nifedipin,
Furosemid
Noza,
Ambroxol,
ISPA, Dispepsia Amoxicillin, 10.20 10.25 IRT ✓
Domperidon,
Antasida
Rujuk poli
ortopedi Wiraswas
✓ Malunion Fracture RSUD 10.04 10.09 ✓
ta
Kotabaru
PCT, N-Asetil,
✓ ISPA 10.12 10.17 Swasta ✓
CTM, Vit C
Captopril,
Furosemid,
✓ HT Urgency, ISPA Aspilet, PCT, 09.18 09.23 IRT ✓
Antasida, Vit B
complex
✓ ISPA Novatusin 10.40 10.45 Pelajar ✓
Captopril,
✓ HT gr II Betahistin, Vit. 10.45 10.50 IRT ✓
B complex`
Ibuprofen,
Wiraswas
✓ Parotitis Antasida, Vit. 10.23 10.28 ✓
ta
C
Furosemid,
Apilet,
✓ CHF, OA 10.27 10.34 IRT ✓
Abuprofen,
Antasida, Kalk
✓ Serumen Prop Fenol gliserol 10.57 11.05 ✓

tetes telinga
Omeprazol,
Susp. Dispepsia, LBP Antasida, 10.33 10.38 IRT ✓
Ibuprofen, vit
B complex
Fenol gliserol
✓ Serumen Prop 10.40 10.45 Pelajar ✓
tetes telinga
Captopril,
Ibuprofen,
✓ HT gr I + Chest Pain Omeprazol, 10.54 11.02 IRT ✓
Kalk, Vit. B
complex
Omeprazol,
PCT, Kaolin
✓ GEA Pectin, 11.01 11.6 Pelajar ✓
Domperidon,
Zinc
Ciprofloxacyn,
Asam
Wiraswas
✓ Otitis Eksterna Mefenamat, 11.07 11.13 ✓
ta
Dexametason,
Vit. C
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga
th )
Riwayat
151/95 23 36,7 99 146 79 GDP 280 DM + HT
128/87 26 36,8 88 69
GDS 123,
Hipertens
155/101 22 36,5 109 161 60 Chol 204,
i
AU 4,4
140/98 22 36,7 78 160 58
119/87 20 35,8 89 162 49
22 36,7 62 112 19
124/68 22 36,8 77 166 45

180/111 22 36,8, 90 161 62 GDS. 133
157/95 22 36,6 151 70 Asma
79
HB 11,7,
131/85 23 36,6 73 153 66 Chol 289,
AU 5,7
22 36,8 68 152 35 Hb 9,4
21 36,8 62 131 20
211/118 22 36,6 77 150 40
214/133 22 36,5 85 153 74 HT
148/108 23 36,7 90 151 47
112/71 24 36,8 72 48
146/89 22 36,1 66 150 71
200/125 24 36,9 90 139 59 HT
23 36,1 109 30
166/88 22 36,6 83 159 80
103/79 21 36,7 86 147 45
166/95 22 36,6 94 145 55
20 36,6 71 108 15
11/73 24 36,7 101
22 36,8 114 18
144/82 24 36,7 77 148 44
118/98 23 36,2 99 154 84

168/95 22 36,6 73 95
0
Riwayat PTM
Riwayat
Riwayat Pemeriksa
Perdaraha an
n IVA/Sada
nis
73
Hari/ Tanggal : Kamis, 27 Juli 2023
Petugas : Catherin, suradi
ur
Um
1 17033 000192897703 6310095809090005 0823 3408 7718 wafa aisyah
2 6365 0001922748254 6310095002720008 0852 4848 5095 ny. St fatimah
3 24084 0002722623423 6310064605160004 0852 5100 0235 An. Hana Hamidah
4 25842 0002722635279 6310090806590005 0823 4205 0016 Tn. Masran
5 13352 0002520536242 6310090101910020 0853 8670 6516 Tn. M Syahlan

6 12658 0002824174168 6310095002550001 0852 5704 8421 Ny Siti Bahriah
7 26309 0002722578941 6310066601150009 0821 5205 1011 An. Nur aqila
8 25365 0001618207378 6310094803000012 0821 5509 1389 Nn Paridah Riyani
9 24631 0002254858571 6372045510960004 0813 2159 8712 Ny Tina wati
10 27354 0002164670425 3578121807830003 0851 0160 0567 Tn syahdan
11 16661 0002659955771 6310096812670004 0812 3696 2377 Tn sahribulan
12 26175 0002424302313 6310095708770002 0813 4808 6548 Ny normawati
13 24565 0002220634293 6310094102490001 0822 56686873 ny majuang

;000192268984
14 22772 6310065408130002 0812 5017 747 An. Nayra
4
15 24702 0002414353307 3578054712670001 0813 4799 9873 Ny marpuah
0858 44587
16 29083 0001929859694 6310104107730046 Ny jamirah
3381
17 23773 0001928002678 7308135211910001 0822 5184 6988 ny nurhayati
18 21514 0002722677693 6310094406640003 0853 4806 9345 ny ramaiyah
19 5921 0002069869048 6310092206110003 0813 5106 2555 An.Mrizky
20 6562 0002722704851 6310094107850210 0831 2355 7006 Ny Siti maisaroh
21 29.085 0002722582214 6302065409730007 082351525289 Ny Noorhasanah
22 29.086 0002885215274 6310094608680004 Ny Masniah
23 28.984 0002722590055 6310066310060001 081250160950 Tn Mamang
24 13.757 0002849409461 631006290517000 085787990478 An Fajar Fadillah

25
26
27
0002750417673 6310095008830004 082155658145 Ny.Gustina Wati
29 28,947
POLI UMUM
Pembiayaa
Status Status
r
hi

ur
La
Kunjungan Penyakit
m
Umum
U
l
Tg
jl kodeco km
14 th 18-09-2009 dr. Rahmah 2.5 SMP P L B
51 th 10-2-1972 dr. Ferisa jl nusa indah SD P L L
7 th 6-5-2016 dr. Rahmah jl Mulawarman - P B B
64 th 8-6-1959 dr. Ferisa lap 5 oktober SD L L L
32 th 1-1-1991 dr. Ferisa jl raya serongga SD L L L

68 th 10-2-1955 dr. Rahmah Jl sei belanak SMP P L L
jl kampung
8 th 26-1-2015 dr. Rahmah SD P L B
baru
23 th 8-3-2000 dr. Ferisa sungai hanau SD P L L
27 th 12-9-1996 dr. Rahmah Jl BB SMA P L B
40 th 18-7-1983 dr. Ferisa jl belibis S1 L L B
56 th 28-12-1967 dr. Rahmah jl BB SMA L L L
46 th 17-8-1977 dr. Rahmah jl TP SMP P L L
74 th 1-2-1949 dr. Ferisa jl pasar ampera SD P L L

10 th 14-2-2013 dr. Ferisa jl transmigrasi SD P L B
56 th 7-12-1967 dr. Ferisa jl kemakmuran semea P L B
50 th 1-7-1973 dr. Ferisa jl sarigadung - P B B
31 th 12-11-1991 dr. Ferisa sei dua rt 4 SD P L B
59 4-6-1964 dr. Ferisa jl kodeco SD P L L
12 th 22-6-2011 dr. Ferisa jl bb SMP L B B
38 th 1-7-1985 Jl usaha SD P L L
dr. Ferisa bersama
49 th 14-09-1973 dr. Ferisa Jl H Antung Rt 8 SMP P B B
Jl lapangan 5
oktober rt 6
Jl Cendana Rt
19 th 26-08-2004 dr. Ferisa SMA P B B
08
Jl Transmigrasi belum
6 th 29-05-2017 dr. Ferisa L L L ✓
Rt 11 sekolah
40 th dr.Rahmah RT.7 TP P L L ✓
8/10/1983
UMUM
Terapi &
Diagnosis Pekerjaan
PCt,
✓ CC ambroxol, 08.25 08.30 pelajar
vit c, ctm
Glibenkla
mid,
Metformi
n,
Paraceta
DM, Hiperlipidemia, mol,
✓ neuropati, dyspepsia omeptazo 08.35 08.40 IRT
le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
✓ Sup. Epilepsi minta 08.40 08.45 -
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
✓ HT meprazol 08.45 08.50 swasta
o,allopuri
nol
clozapine,
✓ Skizofrenia HLP,Trihe 08.50 08.55 -
xipenidil
Metformi
n,ibuprof
en,amlodi
DM, HT, Abses Wiraswas
✓ pinambro 09.00 09.05
mamae ta
xol,antasi
d,Vit B12,
furosemid
pct,amox,
domperid
✓ GEA 09.10 09.15 Pelajar
on,zink,or
alit
Rujuk Poli
Jiwa,
Gangguan cemas Ambroxol
✓ 09.34 09.38 -
(F41.9) Ispa ,
flutrop,a
mox,Vit c
ibuprofen
✓ faringitis 09.25 09.30 IRT
,Vit C
PCT,
lanzopraz
ol,antasid
Wiraswas
✓ Gastritis, Hemoroid , anti 09.30 09.35
hemoroid ta
,domperi
don
amlodipin
,
ibuprofen
✓ HT ,omepraz 09.50 09.55 swasta
ol,Kalk,
Vit B
Comp
CPT,amlo
dipin,ibuy
✓ HT, Konjungtivitis 09.55 10.00 IRT
profen,Vit
B12
allopurino
l,
HT,DyspepsiaHeperu
✓ amlodipin 10.15 10.20 IRT
risemia
,antasid,V
it B12
antacid,p
ct,dompe
✓ Dyspepsia, Tonsilitis 10.20 10.25 pelajar
ridon,am
ox
pct,amox,
vit c,
✓ Gastritis, OMA 1025 10.30 IRT
cloram
tetes
ambroxol,
noza,amo
✓ ispa.ht 09.10 09.15 IRT
x,amlodip
in
ibuprofen
,ciproflox
✓ Cephalgia acin,ome 10.14 10.19 IRT
prazol,he
mafort
furosemid
,amlodipi
✓ Ht, CC n,pctamb 10.43 10.48 IRT
roxol,ctm,
vit c
Rujuk Poli
✓ ppok anak 10.44 10.54 IRT
✓ HT, dyspepsia amlodipin 10.42 10.47 IRT

,antacid,
Rujuk Ke
poli
bedah
RSUD
Obs Hematuria susp DHAAN,H
✓ 10.15 10.25 IRT
BSK
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
✓ Dermatofilosis 10.50 11.00 IRT
konazole
Omepera
✓ Syndrome Dispepsia zole,Anta 10.40 10.50 SMA
sida
ambroxol,
noza,Amo tidak
✓ ISPA,Scabies 10.35 10.45
xillin,scabi bekerja
ceb zalf
PCT, Captopril,
Ht gr II, Kolik Amlodipine,
10.35 10.40 IRT ✓
abdomen Hyocine,
Omeprasole, B12
TTV Riwayat PTM
Riwayat
KIE Riwayat
PTM
( ≥ 15
Keluarga
th )
✓ 23 36,5 82 165 56
GDS: 280
✓ 113/83 24 36,6 88 156 54 Chol : 220
AU : 4
✓ 25 36,8 104 13
GDS : 119
✓ 171/109 25 36,5 93 157 57
AU : 7.5
✓ 128/94 24 36,7 117 154 57

✓ 181/89 23 36,7 90 155 60
✓ 26 36,9 118 27
✓ 108/77 24 93 160 53
✓ 122/85 22 37 87 154 54
✓ 134/80 24 36,5 72 167 59
GDS : 117
✓ 132/90 22 36,7 84 148 43 AU : 5,8
✓ 221/130 24 36,5 100 151 90 GDS : 118
HB : 13.1
✓ 154/111 24 36,7 92 142 48
AU : 6.3
✓ 24 36,6 133 25
✓ 145/82 24 36,6 75 151 51
✓ 178/80 21 36,7 81 154 65
✓ 146/104 24 35,8 122 164 70
✓ 167/108 24 36,7 90 157 55
✓ 22 36,7 150 47
✓ 196/111 22 36,7 77 156 53 GDS : 100

AU : 6,2
✓ 115/97 24 36,6 82 141 41
✓ 155/88 24 36,7 73 153 67
✓ 126/83 24 36,7 82 150 55
✓ 26 38,3 107 17
148/119 - - - -
24 36.5 101 159 70

Riwayat PTM
Riwayat
Riwayat Pemeriksa
Riwayat
Perdaraha an
Alergi
n IVA/Sada
nis
- - -
1 17033 000192897703 6310095809090005 0823 3408 7718 wafa aisyah
2 6365 0001922748254 6310095002720008 0852 4848 5095 ny. St fatimah
3 24084 0002722623423 6310064605160004 0852 5100 0235 An. Hana Hamidah
4 25842 0002722635279 6310090806590005 0823 4205 0016 Tn. Masran
5 13352 0002520536242 6310090101910020 0853 8670 6516 Tn. M Syahlan

6 12658 0002824174168 6310095002550001 0852 5704 8421 Ny Siti Bahriah
7 26309 0002722578941 6310066601150009 0821 5205 1011 An. Nur aqila
9 24631 0002254858571 6372045510960004 0813 2159 8712 Ny Tina wati
10 27354 0002164670425 3578121807830003 0851 0160 0567 Tn syahdan
11 16661 0002659955771 6310096812670004 0812 3696 2377 Tn sahribulan
12 26175 0002424302313 6310095708770002 0813 4808 6548 Ny normawati
13 24565 0002220634293 6310094102490001 0822 56686873 ny majuang

14 22772 ;0001922689844 6310065408130002 0812 5017 747 An. Nayra
15 24702 0002414353307 3578054712670001 0813 4799 9873 Ny marpuah
16 29083 0001929859694 6310104107730046 0858 44587 3381 Ny jamirah
17 23773 0001928002678 7308135211910001 0822 5184 6988 ny nurhayati
18 21514 0002722677693 6310094406640003 0853 4806 9345 ny ramaiyah
19 5921 0002069869048 6310092206110003 0813 5106 2555 An.Mrizky
20 6562 0002722704851 6310094107850210 0831 2355 7006 Ny Siti maisaroh
21 29.085 0002722582214 6302065409730007 082351525289 Ny Noorhasanah
22 29.086 0002885215274 6310094608680004 Ny Masniah
23 28.984 0002722590055 6310066310060001 081250160950 Tn Mamang

25
26
27
27436 000895355379 6310095702030006 082153705455 Nn. Rahmania

29
26731 0003068344181 6310095711720001 083141071871 ny jumah

30
20544 0001902977515 6302064309050003 082256393502 Nn berlian
31
15887 0002274667064 6310064712140001 082358935029 an vania asyfa
32
27946 0002390405196 7208012212960001 082150667446 Tn roy sambora
33
28905 0003080533072 6401061806160001 085245074465 an m ariqin halim

34
25260 000275098981 6310092909790007 082351718169 tn m jarni
35
13537 0002228118041 6310094309620001 085388706001 ny sananiah

36
22682 0002264145085 6303025808960003 082153707323 ny riska agustina
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
POLI UMUM
Pembiayaan
Status
Pendidik Status
r
hi
Dokter Alamat JK Kunjung

ur
La
an Penyakit Umum
m
an BPJS
U
l
Tg
14 th 18-09-2009 dr. jl kodeco km 2.5 SMP P L B ✓

Rahmah
51 th 10-2-1972 dr. Ferisa jl nusa indah SD P L L ✓
7 th 6-5-2016 dr. jl Mulawarman - P B B ✓

Rahmah
64 th 8-6-1959 dr. Ferisa lap 5 oktober SD L L L ✓
32 th 1-1-1991 dr. Ferisa jl raya serongga SD L L L ✓

68 th 10-2-1955 dr. Jl sei belanak SMP P L L ✓
Rahmah
8 th 26-1-2015 dr. jl kampung baru SD P L B ✓

Rahmah
23 th 8-3-2000 dr. Ferisa sungai hanau SD P L L ✓
27 th 12-9-1996 dr. Jl BB SMA P L B ✓

Rahmah
40 th 18-7-1983 dr. Ferisa jl belibis S1 L L B ✓
56 th 28-12-1967 dr. L L L ✓
jl BB SMA
Rahmah
46 th 17-8-1977 dr. jl TP SMP P L L ✓

Rahmah
74 th 1-2-1949 dr. Ferisa jl pasar ampera SD P L L ✓

10 th 14-2-2013 dr. Ferisa jl transmigrasi SD P L B ✓
56 th 7-12-1967 dr. Ferisa jl kemakmuran semea P L B ✓
50 th 1-7-1973 dr. Ferisa jl sarigadung - P B B ✓
31 th 12-11-1991 dr. Ferisa sei dua rt 4 SD P L B ✓
59 4-6-1964 dr. Ferisa jl kodeco SD P L L ✓
12 th 22-6-2011 dr. Ferisa jl bb SMP L B B ✓
38 th 1-7-1985 dr. Ferisa Jl usaha bersama SD P L L ✓
49 th 14-09-1973 dr. Ferisa Jl H Antung Rt 8 SMP P B B ✓
55 th 06-08-1968 dr. Ferisa Jl lapangan 5 oktober SD P B B ✓

rt 6
19 th 26-08-2004 dr. Ferisa Jl Cendana Rt 08 SMA P B B ✓
belum
6 th 29-05-2017 dr. Ferisa Jl Transmigrasi Rt 11 sekolah L L L ✓ ✓
19 th 17-2-2003 dr. jl raya serongga GB P B B ✓
Rahmah
dr. jl samping kodeco rt

51 th 17 nov 1972 P B B ✓
Rahmah 2
18 th 3-9-2005 dr. Ferisa jl banyuwangi rt 1 GA P B B ✓
9 th 7 des 2014 dr. jl raya komp baru P L B ✓

Rahmah
dr. jl banyuwangi rt 14
25 th 22-12-1996 L B B ✓
Rahmah GA
dr. jl lap 5 oktober

7 th 18-06-2006 L B B ✓
Rahmah bersujud
42 th 29-9-1979 dr. jl raya serongga GB L L L ✓

Rahmah
58 th 16 mar 1965 dr. jl pasar minggu rt 2 P L L ✓

Rahmah
29 th 18 agust jl batubenawa rt 9 P L L ✓
1998 dr. Ferisa
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
MUM
Terapi &
SKTM Tindakan D P
PCt,
CC ambroxol, 08.25 08.30 pelajar ✓
vit c, ctm
Glibenkla
mid,
Metformi
n,
Paraceta
neuropati, dyspepsia omeptazo 08.35 08.40 IRT ✓
le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
Sup. Epilepsi minta 08.40 08.45 - ✓
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
HT meprazol 08.45 08.50 swasta ✓
o,allopuri
nol
clozapine,
Skizofrenia HLP,Trihe 08.50 08.55 - ✓
xipenidil
Metformi
n,ibuprof
en,amlodi
Wiraswas
DM, HT, Abses mamae pinambro 09.00 09.05 ✓
ta
xol,antasi
d,Vit B12,
furosemid
pct,amox,
domperid
GEA 09.10 09.15 Pelajar ✓
on,zink,or
alit
Rujuk Poli
Jiwa,
09.34 09.38 - ✓
(F41.9) Ispa ,
flutrop,a
mox,Vit c
ibuprofen
faringitis 09.25 09.30 IRT ✓
,Vit C
PCT,
lanzopraz
ol,antasid
Wiraswas
Gastritis, Hemoroid , anti 09.30 09.35 ✓
hemoroid ta
,domperi
don
amlodipin
,
ibuprofen
HT ,omepraz 09.50 09.55 swasta ✓
ol,Kalk,
Vit B
Comp
CPT,amlo
dipin,ibuy
HT, Konjungtivitis 09.55 10.00 IRT ✓
profen,Vit
B12
allopurino
l,
HT,DyspepsiaHeperuri
amlodipin 10.15 10.20 IRT ✓
semia
,antasid,V
it B12
antacid,p
ct,dompe
Dyspepsia, Tonsilitis 10.20 10.25 pelajar ✓
ridon,am
ox
pct,amox,
vit c,
Gastritis, OMA 1025 10.30 IRT ✓
cloram
tetes
ambroxol,
noza,amo
ispa.ht 09.10 09.15 IRT ✓
x,amlodip
in
ibuprofen
,ciproflox
Cephalgia acin,ome 10.14 10.19 IRT ✓
prazol,he
mafort
furosemid
,amlodipi
Ht, CC n,pctamb 10.43 10.48 IRT ✓
roxol,ctm,
vit c
Rujuk Poli
ppok anak 10.44 10.54 IRT ✓
HT, dyspepsia amlodipin 10.42 10.47 IRT ✓

,antacid,
Rujuk Ke
poli
bedah
RSUD
Obs Hematuria susp
DHAAN,H 10.15 10.25 IRT ✓
BSK
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
Dermatofilosis 10.50 11.00 IRT ✓
konazole
Omepera
Syndrome Dispepsia zole,Anta 10.40 10.50 SMA ✓
sida
ambroxol,
noza,Amo tidak
ISPA,Scabies 10.35 10.45 ✓
ceb zalf
rujuk penyakit dalam
hipertiroid 10.35 10.40 pelajar ✓ 111/85
rsaan
furosemide,amlodipin,
ht grade 1 +CC pct,ambroxol,amoxicili 08.25 08.30 IRT ✓
n 160/96
ranitidin, antasid
dyspepsia syndrome+
kaolin pectin,zinc, 08.20 08.25 ✓
diare akut
oralit kotrimoxazole
pelajar 112/78
ISPA ambroxol,pct vit 08.41 08.46 ✓
pelajar
Comond cold noza, ibuprofen vit c 08.30 08.35 ✓
IRT 124/77
pct
Comond cold amoxicilin,ctm,ambro 08.50 08.55 ✓
xol,vit c pelajar
dm type 2 insulin rujuk poli penyakit ✓

dalam rs aan 08.47 08.52
wiraswasta 138/87
amlodipin,nadik,ambr
ht grade 1+ispa LBP oxol,ceterizine,kalek, 08.13 08.15 ✓
vit b comp IRT 147/87
malaise vit b comp ctm 08.54 08.59 ✓
IRT 119/79
09.07 09.14 ✓
09.03 09.09 ✓
09.12 09.18 ✓
09.16 09.21 ✓
09.32 09.38 ✓
09.25 09.30 ✓
09.46 09.52 ✓
09.25 09.30 ✓
09.37 09.42 ✓
09.42 09.48 ✓
09.55 10.05 ✓
09.58 10.08 ✓
08.57 09.05 ✓
10.04 10.09 ✓
10.07 10.12 ✓
10.16 10.24 ✓
10.10 10.15 ✓
✓
✓
✓
✓
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga
th )
23 36,5 82 165 56
GDS: 280
113/83 24 36,6 88 156 54 Chol : 220
AU : 4
25 36,8 104 13
GDS : 119
171/109 25 36,5 93 157 57
AU : 7.5
128/94 24 36,7 117 154 57

181/89 23 36,7 90 155 60
26 36,9 118 27
108/77 24 93 160 53
122/85 22 37 87 154 54
134/80 24 36,5 72 167 59
GDS : 117
132/90 22 36,7 84 148 43 AU : 5,8
221/130 24 36,5 100 151 90 GDS : 118
HB : 13.1
154/111 24 36,7 92 142 48
AU : 6.3
24 36,6 133 25
145/82 24 36,6 75 151 51
178/80 21 36,7 81 154 65
146/104 24 35,8 122 164 70
167/108 24 36,7 90 157 55
22 36,7 150 47
196/111 22 36,7 77 156 53 GDS : 100

AU : 6,2
115/97 24 36,6 82 141 41
155/88 24 36,7 73 153 67
126/83 24 36,7 82 150 55
26 38,3 107 17
26 36.6 151 153 39
26 36.7 84 148 48
26 36.7 89 155 51
26 36.7 102 122 24
26 36.8 76 183 59
26 36.5 107 124 25
gds
220,khol
216,au
26 36.6 77 168 80 8,3
26 36.7 74 155 72
hb 14.5
26 36.6 103 159 60 gds 121
Riwayat PTM
Riwayat
Riwayat Pemeriksa
Perdaraha an
n IVA/Sada
nis
1 17033 000192897703 6310095809090005 0823 3408 7718 wafa aisyah
2 6365 0001922748254 6310095002720008 0852 4848 5095 ny. St fatimah
3 24084 0002722623423 6310064605160004 0852 5100 0235 An. Hana Hamidah
4 25842 0002722635279 6310090806590005 0823 4205 0016 Tn. Masran
5 13352 0002520536242 6310090101910020 0853 8670 6516 Tn. M Syahlan

6 12658 0002824174168 6310095002550001 0852 5704 8421 Ny Siti Bahriah
7 26309 0002722578941 6310066601150009 0821 5205 1011 An. Nur aqila
9 24631 0002254858571 6372045510960004 0813 2159 8712 Ny Tina wati
10 27354 0002164670425 3578121807830003 0851 0160 0567 Tn syahdan
11 16661 0002659955771 6310096812670004 0812 3696 2377 Tn sahribulan
12 26175 0002424302313 6310095708770002 0813 4808 6548 Ny normawati
13 24565 0002220634293 6310094102490001 0822 56686873 ny majuang

14 22772 ;0001922689844 6310065408130002 0812 5017 747 An. Nayra
15 24702 0002414353307 3578054712670001 0813 4799 9873 Ny marpuah
16 29083 0001929859694 6310104107730046 0858 44587 3381 Ny jamirah
17 23773 0001928002678 7308135211910001 0822 5184 6988 ny nurhayati
18 21514 0002722677693 6310094406640003 0853 4806 9345 ny ramaiyah
19 5921 0002069869048 6310092206110003 0813 5106 2555 An.Mrizky
20 6562 0002722704851 6310094107850210 0831 2355 7006 Ny Siti maisaroh
21 29.085 0002722582214 6302065409730007 082351525289 Ny Noorhasanah
22 29.086 0002885215274 6310094608680004 Ny Masniah
23 28.984 0002722590055 6310066310060001 081250160950 Tn Mamang

25
26
27
29 16790 0002722622962 6310090707610002 Tidak Ada Tn. Surahmin
30 18640 BPJS DA 6310092702760004 081399603807 Tn. Misran
31 26382 0002722557824 6310090407850002 082150748757 Tn. Syamsir Rahman
32 27272 Umum 6310021805980001 085161561805 Tn. Syamsir
An. Cinta Nafeesa

33 4086 0002060743217 6310015802160001 081253941108
Adeeva
34 25021 Umum 6302170405620001 0852251524711 Tn. Aminullah
35 26175 0002427302313 6310095708770002 081348046548 Ny. Normawati
36 4526 0002824177792 6310096410770003 085350468507 Ny. Ernawati
An. Farkah Ziyan

37 27.083 0002496479679 6302081907170001 085346504447
Dzulkarnain
38 19.532 Umum 6310015911160001 082255157796 An. Nur Alika

POLI UMUM
Pembiay
Status
Pendidik Status
r
hi
Dokter Alamat JK Kunjung

ur
La
an Penyakit Umum
m
an
U
l
Tg
14 th 18-09-2009 dr. Rahmah jl kodeco km 2.5 SMP P L B

8 th 26-1-2015 dr. Rahmah jl kampung baru SD P L B

38 th 1-7-1985 dr. Ferisa Jl usaha bersama SD P L L
Jl lapangan 5 oktober
rt 6
19 th 26-08-2004 dr. Ferisa Jl Cendana Rt 08 SMA P B B
belum
6 th 29-05-2017 dr. Ferisa Jl Transmigrasi Rt 11 sekolah L L L ✓
Jl. Simpang Sari 2 RT
62 th 7-7-1961 dr. Rahmah L L L ✓
15
47 th 7-2-1976 dr. Rahmah Jl. Raya Batulicin L L L ✓
35 th 4-7-1985 dr. Rahmah Jl. Pasar Sbtu RT 3 L L L ✓
25 th 18-5-1998 dr. Rahmah Jl. Perjuangan RT 7 L L L ✓
7 th 18-2-2016 dr. Rahmah Jl. Kersik Putih RT 11 P B B ✓
61 th 4-5-1962 dr. Ferisa Jl. TP RT 20 L L L ✓
46 th 17-8-1977 dr. Ferisa Jl. TP RT 11 P L L ✓
46 th 24-10-1977 Jl. Pelabuhanan P L L ✓

dr. Ferisa speed Rt.03
Jl. Tungkaran
6 th 19-07-2007 dr. Ferisa P K L ✓
Pangeran RT 5
7 th 19-11-2016 dr. Ferisa Jl. Pesantren Rt.08 P K L ✓

MUM
Terapi &
PCt,
✓ CC ambroxol, 08.25 08.30 pelajar ✓
vit c, ctm
Glibenkla
mid,
Metformi
n,
Paraceta
✓ neuropati, dyspepsia omeptazo 08.35 08.40 IRT ✓
le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
✓ Sup. Epilepsi minta 08.40 08.45 - ✓
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
✓ HT meprazol 08.45 08.50 swasta ✓
o,allopuri
nol
clozapine,
✓ Skizofrenia HLP,Trihe 08.50 08.55 - ✓
xipenidil
Metformi
n,ibuprof
en,amlodi
Wiraswas
✓ DM, HT, Abses mamae pinambro 09.00 09.05 ✓
ta
xol,antasi
d,Vit B12,
furosemid
pct,amox,
domperid
✓ GEA 09.10 09.15 Pelajar ✓
on,zink,or
alit
Rujuk Poli
Jiwa,
✓ 09.34 09.38 - ✓
(F41.9) Ispa ,
flutrop,a
mox,Vit c
ibuprofen
✓ faringitis 09.25 09.30 IRT ✓
,Vit C
PCT,
lanzopraz
ol,antasid
Wiraswas
✓ Gastritis, Hemoroid , anti 09.30 09.35 ✓
hemoroid ta
,domperi
don
amlodipin
,
ibuprofen
✓ HT ,omepraz 09.50 09.55 swasta ✓
ol,Kalk,
Vit B
Comp
CPT,amlo
dipin,ibuy
✓ HT, Konjungtivitis 09.55 10.00 IRT ✓
profen,Vit
B12
allopurino
l,
HT,DyspepsiaHeperuri
✓ amlodipin 10.15 10.20 IRT ✓
semia
,antasid,V
it B12
antacid,p
ct,dompe
✓ Dyspepsia, Tonsilitis 10.20 10.25 pelajar ✓
ridon,am
ox
pct,amox,
vit c,
✓ Gastritis, OMA 1025 10.30 IRT ✓
cloram
tetes
ambroxol,
noza,amo
✓ ispa.ht 09.10 09.15 IRT ✓
x,amlodip
in
ibuprofen
,ciproflox
✓ Cephalgia acin,ome 10.14 10.19 IRT ✓
prazol,he
mafort
furosemid
,amlodipi
✓ Ht, CC n,pctamb 10.43 10.48 IRT ✓
roxol,ctm,
vit c
Rujuk Poli
✓ ppok anak 10.44 10.54 IRT ✓
✓ HT, dyspepsia amlodipin 10.42 10.47 IRT ✓

,antacid,
Rujuk Ke
poli
bedah
RSUD
Obs Hematuria susp
✓ DHAAN,H 10.15 10.25 IRT ✓
BSK
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
✓ Dermatofilosis 10.50 11.00 IRT ✓
konazole
Omepera
✓ Syndrome Dispepsia zole,Anta 10.40 10.50 SMA ✓
sida
ambroxol,
noza,Amo tidak
✓ ISPA,Scabies 10.35 10.45 ✓
ceb zalf
Wiraswas
LBP, HT gr II Rujuk SP.PD RSMP 10.35 10.40 ✓ 149/87
ta`
Amlodipine,
HT, DM Tipe II Glimepiride, 08.25 08.30 Swasta ✓ 141/85
Metformin,Vit B12
PCT, Cipro, CTM, Wiraswas

CC, Susp Ulkus Gaster 08.20 08.25 ✓ 102/74
Omeprazole ta`
PCT, Amoxilin, N-
CC Acetil, CTM, Vit C, 08.41 08.46 Swasta ✓ 114/84
Surat Sakit
Faringitis Ibuprofen, Vit C 08.30 08.35 Pelajar ✓ -
Hyoscine, Ranitidine, Wiraswas

Syndrom Dispepsia 08.50 08.55 ✓ 137/81
Antasida ta`
Amlodipin, Ibuprofen,
HT Urgency,
Vit B12, Captopril, 08.47 08.52 IRT ✓ 211/112
Hiperuresemia
Allopurinol,
Hiperlipedia Nadiks,Simvastatin,Vit IRT ✓ 128/84

.B 08.13 08.15
Cetrizine,Nystatin,Vit.
Flu Singapure (HFMD) 11.30 11.40 Pelajar ✓
V
Urtikaria, Infeksi CTM, Amoxcilin,
11.00 11.10 Pelajar ✓
Sekunder Scabimet
✓
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga
th )
23 36,5 82 165 56
GDS: 280
113/83 24 36,6 88 156 54 Chol : 220
AU : 4
25 36,8 104 13
GDS : 119
171/109 25 36,5 93 157 57
AU : 7.5
128/94 24 36,7 117 154 57

181/89 23 36,7 90 155 60
26 36,9 118 27
108/77 24 93 160 53
122/85 22 37 87 154 54
134/80 24 36,5 72 167 59
GDS : 117
132/90 22 36,7 84 148 43 AU : 5,8
221/130 24 36,5 100 151 90 GDS : 118
HB : 13.1
154/111 24 36,7 92 142 48
AU : 6.3
24 36,6 133 25
145/82 24 36,6 75 151 51
178/80 21 36,7 81 154 65
146/104 24 35,8 122 164 70
167/108 24 36,7 90 157 55
22 36,7 150 47
196/111 22 36,7 77 156 53 GDS : 100

AU : 6,2
115/97 24 36,6 82 141 41
155/88 24 36,7 73 153 67
126/83 24 36,7 82 150 55
26 38,3 107 17
24 36.7 58 174 65 - - - HT- -
GDP: 210,
22 36.6 88 163 53 Chol: 178, - - HT,DM -
AU : 5,4
24 36.6 115 149 30 - - - - -
22 36.7 94 166 70 - - - - -
28 37.2 89 118 20 - - - - -
23 36.7 72 164 70 - - - - -
22 36.7 102 151 90 AU: 6,3 - - HT -
24 36.7 86 150 58 Chol : 232

AU : 5,1
26 36.8 116 21
25 36.7 112 18
Riwayat PTM
Riwayat
Riwayat Pemeriksa
Perdaraha an
n IVA/Sada
nis
- -
- -
- -
-
- -
- -
- -
- -
ir
ah
No Register No BPJS NIK No Telpon Nama Dokter Alamat
ur
lL
Um
Tg
0823
00019289 63100958 wafa 18-09- dr. jl kodeco km
1 17033 7703 09090005 3408 aisyah 14 th 2009
7718 Rahmah 2.5
0852
00019227 63100950 ny. St
2 6365 4848 51 th 10-2-1972 dr. Ferisa jl nusa indah
48254 02720008 fatimah
5095
0852
00027226 63100646 An. Hana dr. jl
3 24084 5100 7 th 6-5-2016
23423 05160004 Hamidah Rahmah Mulawarman
0235
0823
4 25842 00027226 63100908 4205 Tn. Masran 64 th 8-6-1959 dr. Ferisa lap 5 oktober
35279 06590005
0016
0853
00025205 63100901 Tn. M jl raya
5 13352 8670 32 th 1-1-1991 dr. Ferisa
36242 01910020 6516 Syahlan serongga
0852
00028241 63100950 Ny Siti dr.
6 12658 5704 68 th 10-2-1955 Jl sei belanak
74168 02550001 Bahriah Rahmah
8421
0821
00027225 63100666 An. Nur dr. jl kampung
7 26309 5205 8 th 26-1-2015
78941 01150009 aqila Rahmah baru
1011
0821
00016182 63100948 Nn Paridah
8 25365 5509 23 th 8-3-2000 dr. Ferisa sungai hanau
07378 03000012 Riyani
1389
0813
00022548 63720455 Ny Tina dr.
9 24631 2159 27 th 12-9-1996 Jl BB
58571 10960004 wati Rahmah
8712
0851
00021646 35781218
10 27354 0160 Tn syahdan 40 th 18-7-1983 dr. Ferisa jl belibis
70425 07830003
0567
0812
00026599 63100968 Tn 28-12- dr.
11 16661 3696 56 th jl BB
55771 12670004 sahribulan 1967 Rahmah
2377
0813
00024243 63100957 Ny dr.
12 26175 4808 46 th 17-8-1977 jl TP
02313 08770002 normawati Rahmah
6548
00022206 63100941 0822 ny jl pasar

13 24565 74 th 1-2-1949 dr. Ferisa ampera
34293 02490001 56686873 majuang
;0001922 63100654 0812

14 22772
689844 08130002 5017 747 An. Nayra
10 th 14-2-2013 dr. Ferisa jl transmigrasi
00024143 35780547 0813 Ny jl

15 24702 4799 56 th 7-12-1967 dr. Ferisa kemakmuran
53307 12670001 marpuah
9873
0858
00019298 63101041
16 29083 44587 Ny jamirah 50 th 1-7-1973 dr. Ferisa jl sarigadung
59694 07730046 3381
0822
00019280 73081352 ny 12-11-
17 23773 5184 31 th dr. Ferisa sei dua rt 4
02678 11910001 nurhayati 1991
6988
0853
18 21514 00027226 63100944 4806 ny 59 4-6-1964 dr. Ferisa jl kodeco
77693 06640003 ramaiyah
9345
0813
00020698 63100922
19 5921 5106 An.Mrizky 12 th 22-6-2011 dr. Ferisa jl bb
69048 06110003
2555
0831
00027227 63100941 Ny Siti Jl usaha
20 6562 2355 38 th 1-7-1985 dr. Ferisa
04851 07850210 7006 maisaroh bersama
Ny
00027225 63020654 08235152 14-09- Jl H Antung Rt
21 29.085 Noorhasan 49 th dr. Ferisa
82214 09730007 5289 1973 8
ah
00028852 63100946 Ny 06-08- Jl lapangan 5

22 29.086 55 th dr. Ferisa oktober rt 6
15274 08680004 Masniah 1968
00027225 63100663 08125016 Tn 26-08- Jl Cendana Rt

23 28.984 19 th dr. Ferisa
90055 10060001 0950 Mamang 2004 08
Jl
00028494 63100629 08578799 An Fajar 29-05-
24 13.757 6 th dr. Ferisa Transmigrasi
09461 0517000 0478 Fadillah 2017
Rt 11
25
26
27
POLI UMUM
Status Status Terapi &

Pendidikan JK Diagnosis
Kunjungan Penyakit Umum BPJS SKTM Tindakan D
PCt,
ambroxo
SMP P L B ✓ CC l, vit c, 08.25
ctm
Glibenkl
amid,
Metform
in,
DM, Paraceta
Hiperlipidemia, mol,
SD P L L ✓ 08.35
neuropati, omeptaz
dyspepsia ole,
antacid,
Vit B 12,
simvasta
tin
Rujuk
Poli
anak(ibu
pasien
- P B B ✓ Sup. Epilepsi minta 08.40
tunda)
PCT,
Diazepa
m
Amlodipi
n,Nadic,
SD L L L ✓ HT Omepraz 08.45
olo,allop
urinol
clozapin
e,
SD L L L ✓ Skizofrenia HLP,Trih 08.50
exipenidi
l
Metform
in,ibupro
fen,amlo
DM, HT, Abses dipinam
SMP P L L ✓ broxol,a 09.00
mamae
ntasid,Vi
t B12,
furosemi
d
pct,amo
x,dompe
SD P L B ✓ GEA 09.10
ridon,zin
k,oralit
Rujuk
Poli Jiwa,
Gangguan Ambroxo
SD P L L ✓ cemas (F41.9) l, 09.34
Ispa flutrop,a
mox,Vit
c
ibuprofe
SMA P L B ✓ faringitis 09.25
n,Vit C
PCT,
lanzopra
zol,antas
Gastritis,
S1 L L B ✓ id, anti 09.30
Hemoroid
hemoroi
d,dompe
ridon
amlodipi
n,
ibuprofe
SMA L L L ✓ HT n,omepr 09.50
azol,Kalk
, Vit B
Comp
CPT,aml
HT, odipin,ib
SMP P L L ✓ 09.55
Konjungtivitis uyprofen
,VitB12
allopurin
HT,DyspepsiaH ol,
SD P L L ✓
eperurisemia amlodipi 10.15
n,antasid
,Vit B12
antacid,
Dyspepsia, pct,dom
SD P L B ✓ 10.20
Tonsilitis peridon,
amox
pct,amo
x,vit c,
semea P L B ✓ Gastritis, OMA cloram 1025
tetes
ambroxo
l,noza,a
- P B B ✓ ispa.ht 09.10
mox,aml
odipin
ibuprofe
n,ciprofl
oxacin,o
SD P L B ✓ Cephalgia 10.14
meprazo
l,hemafo
rt
furosemi
d,amlodi
SD P L L ✓ Ht, CC pin,pcta 10.43
mbroxol,
ctm,vit c
Rujuk
SMP L B B ✓ ppok 10.44
Poli anak
amlodipi
SD P L L ✓ HT, dyspepsia n,antaci 10.42
d,
Rujuk Ke
poli
bedah
RSUD
Obs Hematuria
SMP P B B ✓ DHAAN, 10.15
susp BSK
Hyoscire,
omepera
zole,Ant
asida
CTM,Ket
SD P B B ✓ Dermatofilosis okonazol 10.50
e
Omeper
Syndrome
SMA P B B ✓ azole,An 10.40
Dispepsia
tasida
ambroxo
l,noza,A
belum
L L L ✓ ✓ ISPA,Scabies moxillin, 10.35
sekolah
scabiceb
zalf
Wkt Playan TTV
Pekerjaan KIE
P TD RR Suhu Nadi TB BB Lab
08.30 pelajar ✓ 23 36,5 82 165 56
GDS: 280
08.40 IRT ✓ 113/83 24 36,6 88 156 54 Chol : 220
AU : 4
08.45 - ✓ 25 36,8 104 13

swasta ✓ 171/109 25 36,5 93 157 57 GDS : 119
08.50 AU : 7.5
08.55 - ✓ 128/94 24 36,7 117 154 57
Wiraswas
09.05 ✓ 181/89 23 36,7 90 155 60
ta
09.15 Pelajar ✓ 26 36,9 118 27
09.38 - ✓ 108/77 24 93 160 53
09.30 IRT ✓ 122/85 22 37 87 154 54

Wiraswas
09.35 ✓ 134/80 24 36,5 72 167 59
ta
GDS : 117
09.55 swasta ✓ 132/90 22 36,7 84 148 43
AU : 5,8
10.00 IRT ✓ 221/130 24 36,5 100 151 90 GDS : 118
HB : 13.1
10.20 IRT ✓ 154/111 24 36,7 92 142 48
AU : 6.3
10.25 pelajar ✓ 24 36,6 133 25
10.30 IRT ✓ 145/82 24 36,6 75 151 51
09.15 IRT ✓ 178/80 21 36,7 81 154 65

10.19 IRT ✓ 146/104 24 35,8 122 164 70
10.48 IRT ✓ 167/108 24 36,7 90 157 55
10.54 IRT ✓ 22 36,7 150 47
GDS : 100
10.47 IRT ✓ 196/111 22 36,7 77 156 53
AU : 6,2
10.25 IRT ✓ 115/97 24 36,6 82 141 41
11.00 IRT ✓ 155/88 24 36,7 73 153 67
10.50 SMA ✓ 126/83 24 36,7 82 150 55
tidak
10.45 ✓ 26 38,3 107 17
bekerja
Riwayat PTM
Riwayat
Riwayat
Riwayat Riwayat Pemeriksa
PTM Riwayat
Penyakit Perdaraha an
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
ir
ah
No Register No BPJS NIK No Telpon Nama Dokter
ur
lL
Um
Tg
0823
0001928977 63100958 wafa 18-09- dr.
1 17033 03 09090005 3408 aisyah 14 th 2009
7718 Rahmah
0852
0001922748 63100950 ny. St
2 6365 4848 51 th 10-2-1972 dr. Ferisa
254 02720008 fatimah
5095
0852
0002722623 63100646 An. Hana dr.
3 24084 5100 7 th 6-5-2016
423 05160004 Hamidah Rahmah
0235
0823
4 25842 0002722635 63100908 4205 Tn. Masran 64 th 8-6-1959 dr. Ferisa
279 06590005
0016
0853
0002520536 63100901 Tn. M
5 13352 8670 32 th 1-1-1991 dr. Ferisa
242 01910020 Syahlan
6516
0852
0002824174 63100950 Ny Siti dr.
6 12658 5704 68 th 10-2-1955
8421
0821
0002722578 63100666 An. Nur dr.
7 26309 5205 8 th 26-1-2015
941 01150009 aqila Rahmah
1011
0821
0001618207 63100948 Nn Paridah
8 25365 378 03000012 5509 Riyani 23 th 8-3-2000 dr. Ferisa
1389
0813
0002254858 63720455 Ny Tina dr.
9 24631 2159 27 th 12-9-1996
571 10960004 wati Rahmah
8712
0851
0002164670 35781218
10 27354 0160 Tn syahdan 40 th 18-7-1983 dr. Ferisa
425 07830003
0567
0812
11 16661 0002659955 63100968 3696 Tn 56 th 28-12- dr.
771 12670004 sahribulan 1967 Rahmah
2377
0813
0002424302 63100957 Ny dr.
12 26175 4808 46 th 17-8-1977
6548
0002220634 63100941 0822 ny

13 24565 74 th 1-2-1949 dr. Ferisa
293 02490001 56686873 majuang
;0001922689 63100654 0812

14 22772 An. Nayra 10 th 14-2-2013 dr. Ferisa
844 08130002 5017 747
0813
0002414353 35780547 Ny
15 24702 4799 56 th 7-12-1967 dr. Ferisa
307 12670001 marpuah
9873
0858
0001929859 63101041
16 29083 44587 Ny jamirah 50 th 1-7-1973 dr. Ferisa
694 07730046
3381
0822
0001928002 73081352 ny 12-11-
17 23773 5184 31 th dr. Ferisa
678 11910001 nurhayati 1991
6988
0853
0002722677 63100944 ny
18 21514 4806 59 4-6-1964 dr. Ferisa
693 06640003 ramaiyah
9345
0813
0002069869 63100922
19 5921 5106 An.Mrizky 12 th 22-6-2011 dr. Ferisa
048 06110003 2555
0831
0002722704 63100941 Ny Siti
20 6562 2355 38 th 1-7-1985 dr. Ferisa
851 07850210 7006 maisaroh
Ny
0002722582 63020654 08235152 14-09-
21 29.085 Noorhasan 49 th dr. Ferisa
214 09730007 5289 1973
ah
0002885215 63100946 Ny 06-08-

22 29.086 55 th dr. Ferisa
274 08680004 Masniah 1968
0002722590 63100663 08125016 Tn 26-08-

23 28.984 19 th dr. Ferisa
055 10060001 0950 Mamang 2004
0002849409 63100629 08578799 An Fajar 29-05-

24 13.757 6 th dr. Ferisa
461 0517000 0478 Fadillah 2017
25
26
27
POLI UMUM
Pembiayaan
Status Status
Alamat Pendidikan JK Diagnosis
Kunjungan Penyakit Umum BPJS SKTM
jl kodeco km
2.5 SMP P L B ✓ CC
DM,
Hiperlipidemia,
jl nusa indah SD P L L ✓
neuropati,
dyspepsia
jl
- P B B ✓ Sup. Epilepsi
Mulawarman
lap 5 oktober SD L L L ✓ HT
jl raya
SD L L L ✓ Skizofrenia
serongga
DM, HT, Abses

Jl sei belanak SMP P L L ✓
mamae
jl kampung
SD P L B ✓ GEA
baru
Gangguan
sungai hanau SD P L L ✓ cemas (F41.9)
Ispa
Jl BB SMA P L B ✓ faringitis
Gastritis,
jl belibis S1 L L B ✓
Hemoroid
jl BB SMA L L L ✓ HT
HT,
jl TP SMP P L L ✓
Konjungtivitis
jl pasar HT,DyspepsiaH
SD P L L ✓
ampera eperurisemia
Dyspepsia,
jl transmigrasi SD P L B ✓
Tonsilitis
jl
semea P L B ✓ Gastritis, OMA
kemakmuran
jl sarigadung - P B B ✓ ispa.ht
sei dua rt 4 SD P L B ✓ Cephalgia
jl kodeco SD P L L ✓ Ht, CC
jl bb SMP L B B ✓ ppok
Jl usaha
SD P L L ✓ HT, dyspepsia
bersama
Jl H Antung Rt Obs Hematuria
SMP P B B ✓
8 susp BSK
Jl lapangan 5
SD P B B ✓ Dermatofilosis
oktober rt 6
Jl Cendana Rt Syndrome
SMA P B B ✓
08 Dispepsia
Jl
belum
Transmigrasi L L L ✓ ✓ ISPA,Scabies
sekolah
Rt 11
Wkt Playan TTV
Terapi &
Pekerjaan KIE
Tindakan D P TD RR Suhu Nadi TB
PCt,
ambroxo
l, vit c, 08.25 08.30 pelajar ✓ 23 36,5 82 165
ctm
Glibenkl
amid,
Metform
in,
Paraceta
mol,
08.35 08.40 IRT ✓ 113/83 24 36,6 88 156
omeptaz
ole,
antacid,
Vit B 12,
simvasta
tin
Rujuk
Poli
anak(ibu
pasien
minta 08.40 08.45 - ✓ 25 36,8 104
tunda)
PCT,
Diazepa
m
Amlodipi
n,Nadic,
Omepraz 08.45 08.50 swasta ✓ 171/109 25 36,5 93 157
olo,allop
urinol
clozapin
e,
HLP,Trih 08.50 08.55 - ✓ 128/94 24 36,7 117 154
exipenidi
l
Metform
in,ibupro
fen,amlo
dipinam
Wiraswas
broxol,a 09.00 09.05 ✓ 181/89 23 36,7 90 155
ta
ntasid,Vi
t B12,
furosemi
d
pct,amo
x,dompe
09.10 09.15 Pelajar ✓ 26 36,9 118
ridon,zin
k,oralit
Rujuk
Poli Jiwa,
Ambroxo
l, 09.34 09.38 - ✓ 108/77 24 93 160
flutrop,a
mox,Vit
c
ibuprofe
09.25 09.30 IRT ✓ 122/85 22 37 87 154
n,Vit C
PCT,
lanzopra
zol,antas
Wiraswas
id, anti 09.30 09.35 ✓ 134/80 24 36,5 72 167
ta
hemoroi
d,dompe
ridon
amlodipi
n,
ibuprofe
n,omepr 09.50 09.55 swasta ✓ 132/90 22 36,7 84 148
azol,Kalk
, Vit B
Comp
CPT,aml
odipin,ib
09.55 10.00 IRT ✓ 221/130 24 36,5 100 151
uyprofen
,VitB12
allopurin
ol,
amlodipi 10.15 10.20 IRT ✓ 154/111 24 36,7 92 142
n,antasid
,Vit B12
antacid,
pct,dom
10.20 10.25 pelajar ✓ 24 36,6 133
peridon,
amox
pct,amo
x,vit c,
1025 10.30 IRT ✓ 145/82 24 36,6 75 151
cloram
tetes
ambroxo
l,noza,a
09.10 09.15 IRT ✓ 178/80 21 36,7 81 154
mox,aml
odipin
ibuprofe
n,ciprofl
oxacin,o
10.14 10.19 IRT ✓ 146/104 24 35,8 122 164
meprazo
l,hemafo
rt
furosemi
d,amlodi
pin,pcta 10.43 10.48 IRT ✓ 167/108 24 36,7 90 157
mbroxol,
ctm,vit c
Rujuk
10.44 10.54 IRT ✓ 22 36,7 150
Poli anak
amlodipi
n,antaci 10.42 10.47 IRT ✓ 196/111 22 36,7 77 156
d,
Rujuk Ke
poli
bedah
RSUD
DHAAN, 10.15 10.25 IRT ✓ 115/97 24 36,6 82 141
Hyoscire,
omepera
zole,Ant
asida
CTM,Ket
okonazol 10.50 11.00 IRT ✓ 155/88 24 36,7 73 153
e
Omeper
azole,An 10.40 10.50 SMA ✓ 126/83 24 36,7 82 150
tasida
ambroxo
l,noza,A
tidak
moxillin, 10.35 10.45 ✓ 26 38,3 107
bekerja
scabiceb
zalf
Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
BB Lab Penyakit Perdaraha an
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
56
GDS: 280
54 Chol : 220
AU : 4
13
57 GDS : 119
AU : 7.5
57
60
27
53
54
59
43 GDS : 117
AU : 5,8
90 GDS : 118
HB : 13.1
48
AU : 6.3
25
51
65
70
55
47
GDS : 100
53
AU : 6,2
41
67
55
17
ur
Um
1 17033 000192897703 6310095809090005 0823 3408 7718 wafa aisyah
2 6365 0001922748254 6310095002720008 0852 4848 5095 ny. St fatimah
3 24084 0002722623423 6310064605160004 0852 5100 0235 An. Hana Hamidah
4 25842 0002722635279 6310090806590005 0823 4205 0016 Tn. Masran

5 13352 0002520536242 6310090101910020 0853 8670 6516 Tn. M Syahlan
6 12658 0002824174168 6310095002550001 0852 5704 8421 Ny Siti Bahriah
7 26309 0002722578941 6310066601150009 0821 5205 1011 An. Nur aqila
9 24631 0002254858571 6372045510960004 0813 2159 8712 Ny Tina wati
10 27354 0002164670425 3578121807830003 0851 0160 0567 Tn syahdan
11 16661 0002659955771 6310096812670004 0812 3696 2377 Tn sahribulan

12 26175 0002424302313 6310095708770002 0813 4808 6548 Ny normawati
13 24565 0002220634293 6310094102490001 0822 56686873 ny majuang
14 22772 ;0001922689844 6310065408130002 0812 5017 747 An. Nayra
15 24702 0002414353307 3578054712670001 0813 4799 9873 Ny marpuah
16 29083 0001929859694 6310104107730046 0858 44587 3381 Ny jamirah
17 23773 0001928002678 7308135211910001 0822 5184 6988 ny nurhayati
18 21514 0002722677693 6310094406640003 0853 4806 9345 ny ramaiyah
19 5921 0002069869048 6310092206110003 0813 5106 2555 An.Mrizky
20 6562 0002722704851 6310094107850210 0831 2355 7006 Ny Siti maisaroh

21 29.085 0002722582214 6302065409730007 082351525289 Ny Noorhasanah
22 29.086 0002885215274 6310094608680004 Ny Masniah
23 28.984 0002722590055 6310066310060001 081250160950 Tn Mamang
25
26
27
30 26.328 tidak aktif 6310096411740002 085350081208 N y.Rina Noviati
31 19.148 0002722709002 631009407830012 083159113683 Ny.Harpiani
32 5192 0000895205799 6310095406590002 085349541936 Ny.Khairunnisa
33 28.999 tidak aktif 6310094207100003 087816982215 An. Nurul Afifah
34 20.352 0001929854946 6310092405930001 089641808089 Tn.M.Yusuf
35 24.353 0003054576914 630206480400003 085787459350 Ny. Pika Nor Audina
36 28.998 tidak aktif 6310095608750003 082158135546 Ny.Murniasih

POLI UMUM
Pendid Status Status

ir
ah
Dokter Alamat JK
ur
ikan Kunjungan Penyakit

lL
m
U
Tg
14 th 18-09-2009 dr. Rahmah jl kodeco km 2.5 SMP P L B

8 th 26-1-2015 dr. Rahmah jl kampung baru SD P L B

seme
56 th 7-12-1967 dr. Ferisa jl kemakmuran a P L B

Jl lapangan 5 oktober rt
6
19 th 26-08-2004 dr. Ferisa Jl Cendana Rt 08 SMA P B B
belum
6 th 29-05-2017 dr. Ferisa Jl Transmigrasi Rt 11 sekola L L L
h
47th 24-11-1974 dr.Rizky Jl.Raya Serongga Rt.02 P K L ✓
38th 07-07-1983 dr.Rizky Jl.Gunung Besar Rt.05 P K L
62th 14-07-1959 dr.Rizky Jl.Kenangan Rt.06 P K L
Jl.Lap 5 Okt Rt.06 Desa

13th 7/2/2010 dr.Rahma P B B ✓
Bersujud
30th 25-05-1993 dr.Rahma Jl.PNPM Kel.TP Rt.18 L K L
24 Th 08-04-2000 dr.Rizky Jl.Banyuwangi Desa GA P K L
Jl.Tranmigrasi Rt.12
48th 16-08-1975 dr.Rahma P B B ✓
Kampung Baru
LI UMUM
Terapi &
Diagnosis
Umum BPJS SKTM Tindakan D
PCt,
✓ CC ambroxol, 08.25
vit c, ctm
Glibenkla
mid,
Metformi
n,
Paraceta
✓ 08.35
neuropati, dyspepsia omeptazo
le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
✓ Sup. Epilepsi minta 08.40
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
✓ HT meprazol 08.45
o,allopuri
nol
clozapine,
✓ Skizofrenia HLP,Trihe 08.50
xipenidil
Metformi
n,ibuprof
en,amlodi
✓ DM, HT, Abses mamae pinambro 09.00
xol,antasi
d,Vit B12,
furosemid
pct,amox,
domperid
✓ GEA 09.10
on,zink,or
alit
Rujuk Poli
Jiwa,
Ambroxol
✓ Gangguan cemas (F41.9) Ispa 09.34
,
flutrop,a
mox,Vit c
ibuprofen
✓ faringitis ,Vit C 09.25
PCT,
lanzopraz
ol,antasid
✓ Gastritis, Hemoroid , anti 09.30
hemoroid
,domperi
don
amlodipin
,
ibuprofen
✓ HT ,omepraz 09.50
ol,Kalk,
Vit B
Comp
CPT,amlo
✓ HT, Konjungtivitis dipin,ibuy
profen,Vit 09.55
B12
allopurino
l,
✓ HT,DyspepsiaHeperurisemia amlodipin 10.15
,antasid,V
it B12
antacid,p
ct,dompe
✓ Dyspepsia, Tonsilitis 10.20
ridon,am
ox
pct,amox,
vit c,
✓ Gastritis, OMA cloram 1025
tetes
ambroxol,
noza,amo
✓ ispa.ht 09.10
x,amlodip
in
ibuprofen
,ciproflox
✓ Cephalgia acin,ome 10.14
prazol,he
mafort
furosemid
,amlodipi
✓ Ht, CC n,pctamb 10.43
roxol,ctm,
vit c
Rujuk Poli
✓ ppok 10.44
anak
amlodipin
✓ HT, dyspepsia 10.42
,antacid,
Rujuk Ke
poli
bedah
RSUD
✓ Obs Hematuria susp BSK DHAAN,H 10.15
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
✓ Dermatofilosis 10.50
konazole
Omepera
✓ Syndrome Dispepsia zole,Anta 10.40
sida
ambroxol,
noza,Amo
✓ ✓ ISPA,Scabies 10.35
xillin,scabi
ceb zalf
Susp CTS Vit.B.Com,Nadiks 11.04 11.19
DM tipe II,HT grade Metformin,Gliniprimd,Nystati

✓ II,Flour Albus n,Amlodifin,Nadiks 10.55 11.04
Rujuk Poli Penyakit dalam

✓ HT grade II,DM tipe RSMP
II,Hiperkolestrol Metformin,Simvastatin,Amlod 10.35 10.40
ifin,Captropil 12,5
Paracetamol,Ranitidine,Choro
Dispesia,OMA 10.50 11.04
mphenicole tetes,Vit.C
✓ Epilepsi Rujuk Poli Saraf RSMP 10.20 10.30

✓ Susp Tumor Jinak Rujuk Poli Bedah RSMP 10.45 10.50
Captropil
HT Grade II, CE TTH 25,Amlodifin,Ibuprofen,Antasi 10.45 10.50
d,Pehavral
Wkt Playan TTV
Pekerjaan KIE
P TD RR Suhu Nadi TB BB
08.30 pelajar ✓ 23 36,5 82 165 56
08.40 IRT ✓ 113/83 24 36,6 88 156 54
08.45 - ✓ 25 36,8 104 13
08.50 swasta ✓ 171/109 25 36,5 93 157 57

08.55 - ✓ 128/94 24 36,7 117 154 57
Wiraswas
09.05 ✓ 181/89 23 36,7 90 155 60
ta
09.15 Pelajar ✓ 26 36,9 118 27
09.38 - ✓ 108/77 24 93 160 53
09.30 IRT ✓ 122/85 22 37 87 154 54
Wiraswas
09.35 ✓ 134/80 24 36,5 72 167 59
ta
09.55 swasta ✓ 132/90 22 36,7 84 148 43

10.00 IRT ✓ 221/130 24 36,5 100 151 90
10.20 IRT ✓ 154/111 24 36,7 92 142 48
10.25 pelajar ✓ 24 36,6 133 25
10.30 IRT ✓ 145/82 24 36,6 75 151 51
09.15 IRT ✓ 178/80 21 36,7 81 154 65
10.19 IRT ✓ 146/104 24 35,8 122 164 70
10.48 IRT ✓ 167/108 24 36,7 90 157 55
10.54 IRT ✓ 22 36,7 150 47
10.47 IRT ✓ 196/111 22 36,7 77 156 53

10.25 IRT ✓ 115/97 24 36,6 82 141 41
11.00 IRT ✓ 155/88 24 36,7 73 153 67
10.50 SMA ✓ 126/83 24 36,7 82 150 55
tidak
10.45 ✓ 26 38,3 107 17
bekerja
Pelajar ✓ 26 35,8 101 136 28
IRT ✓ 158/88 26 36,6 116 155 69
GDP : 194
IRT ✓ 193/102 24 36,7 120 156 54 Chol : 237
AU : 5,8
Pelajar ✓ 26 36,7 102 151 36
Wiraswasta ✓ 154/99 24 36,6 80 159 71
IRT ✓ 97/74 26 36,7 113 164 56
IRT ✓ 176/126 24 36,7 86 152 61

Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
Lab Penyakit Perdaraha an
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
GDS: 280
Chol : 220
AU : 4
GDS : 119
AU : 7.5
GDS : 117
AU : 5,8
GDS : 118
HB : 13.1
AU : 6.3
GDS : 100
AU : 6,2
ur
m
U
1 17033 000192897703 6310095809090005 0823 3408 7718 wafa aisyah
2 6365 0001922748254 6310095002720008 0852 4848 5095 ny. St fatimah
3 24084 0002722623423 6310064605160004 0852 5100 0235 An. Hana Hamidah
4 25842 0002722635279 6310090806590005 0823 4205 0016 Tn. Masran
5 13352 0002520536242 6310090101910020 0853 8670 6516 Tn. M Syahlan

6 12658 0002824174168 6310095002550001 0852 5704 8421 Ny Siti Bahriah
7 26309 0002722578941 6310066601150009 0821 5205 1011 An. Nur aqila
9 24631 0002254858571 6372045510960004 0813 2159 8712 Ny Tina wati
10 27354 0002164670425 3578121807830003 0851 0160 0567 Tn syahdan
11 16661 0002659955771 6310096812670004 0812 3696 2377 Tn sahribulan
12 26175 0002424302313 6310095708770002 0813 4808 6548 Ny normawati
13 24565 0002220634293 6310094102490001 0822 56686873 ny majuang

14 22772 ;0001922689844 6310065408130002 0812 5017 747 An. Nayra
15 24702 0002414353307 3578054712670001 0813 4799 9873 Ny marpuah
16 29083 0001929859694 6310104107730046 0858 44587 3381 Ny jamirah
17 23773 0001928002678 7308135211910001 0822 5184 6988 ny nurhayati
18 21514 0002722677693 6310094406640003 0853 4806 9345 ny ramaiyah
19 5921 0002069869048 6310092206110003 0813 5106 2555 An.Mrizky
20 6562 0002722704851 6310094107850210 0831 2355 7006 Ny Siti maisaroh
21 29.085 0002722582214 6302065409730007 082351525289 Ny Noorhasanah
22 29.086 0002885215274 6310094608680004 Ny Masniah
23 28.984 0002722590055 6310066310060001 081250160950 Tn Mamang

25
26
27
29 27.887 Tidak ada BPJS 6310090509630002 Tidak ada Tn. Nawir

POLI UMUM
Pembiayaan
Status Status
Pendidi
ir
ah
Dokter Alamat JK Kunjun Penyak

ur
kan
lL
Um
gan it Umum BPJS

Tg
14 th 18-09-2009 dr. Rahmah jl kodeco km 2.5 SMP P L B ✓
7 th 6-5-2016 dr. Rahmah jl Mulawarman - P B B ✓

68 th 10-2-1955 dr. Rahmah Jl sei belanak SMP P L L ✓
8 th 26-1-2015 dr. Rahmah jl kampung baru SD P L B ✓
27 th 12-9-1996 dr. Rahmah Jl BB SMA P L B ✓
56 th 28-12-1967 dr. Rahmah jl BB SMA L L L ✓
46 th 17-8-1977 dr. Rahmah jl TP SMP P L L ✓

Jl lapangan 5
55 th 06-08-1968 dr. Ferisa SD P B B ✓
oktober rt 6

belum
Jl Transmigrasi
6 th 29-05-2017 dr. Ferisa sekola L L L ✓ ✓
Rt 11
h
05 Jl.Tranmigrasi
59 Th September dr. Rahmah Rt.13 Desa L K L ✓
1963 bersujud
UM
Pembiayaan Wkt Playan TTV
Terapi &
SKTM Tindakan D P TD RR
PCt,
CC ambroxol, 08.25 08.30 pelajar ✓ 23
vit c, ctm
Glibenkla
mid,
Metformi
DM, n,
Hiperlipid Paraceta
emia, mol,
neuropati omeptazo 08.35 08.40 IRT ✓ 113/83 24
, le,
dyspepsia antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
Sup.
Epilepsi minta 08.40 08.45 - ✓ 25
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
HT meprazol 08.45 08.50 swasta ✓ 171/109 25
o,allopuri
nol
Skizofreni clozapine,
HLP,Trihe 08.50 08.55 - ✓ 128/94 24
a xipenidil
Metformi
n,ibuprof
DM, HT, en,amlodi
Wiraswas
Abses pinambro 09.00 09.05 ✓ 181/89 23
ta
mamae xol,antasi
d,Vit B12,
furosemid
pct,amox,
domperid
GEA 09.10 09.15 Pelajar ✓ 26
on,zink,or
alit
Rujuk Poli
Gangguan Jiwa,
cemas Ambroxol
09.34 09.38 - ✓ 108/77 24
(F41.9) ,
Ispa flutrop,a
mox,Vit c
ibuprofen
faringitis 09.25 09.30 IRT ✓ 122/85 22
,Vit C
PCT,
lanzopraz
Gastritis, ol,antasid Wiraswas
, anti 09.30 09.35 ✓ 134/80 24
Hemoroid hemoroid ta
,domperi
don
amlodipin
,
ibuprofen
HT ,omepraz 09.50 09.55 swasta ✓ 132/90 22
ol,Kalk,
Vit B
Comp
CPT,amlo
HT,
dipin,ibuy
Konjungti profen,Vit 09.55 10.00 IRT ✓ 221/130 24
vitis
B12
allopurino
HT,Dyspe l,
psiaHeper amlodipin 10.15 10.20 IRT ✓ 154/111 24
urisemia ,antasid,V
it B12
antacid,p
Dyspepsia ct,dompe
10.20 10.25 pelajar ✓ 24
, Tonsilitis ridon,am
ox
pct,amox,
Gastritis, vit c,
1025 10.30 IRT ✓ 145/82 24
OMA cloram
tetes
ambroxol,
noza,amo
ispa.ht 09.10 09.15 IRT ✓ 178/80 21
x,amlodip
in
ibuprofen
,ciproflox
Cephalgia acin,ome 10.14 10.19 IRT ✓ 146/104 24
prazol,he
mafort
furosemid
,amlodipi
Ht, CC n,pctamb 10.43 10.48 IRT ✓ 167/108 24
roxol,ctm,
vit c
Rujuk Poli
ppok anak 10.44 10.54 IRT ✓ 22
HT, amlodipin 10.42 10.47 IRT ✓ 196/111 22

dyspepsia ,antacid,
Rujuk Ke
poli
bedah
Obs
RSUD
Hematuri DHAAN,H
10.15 10.25 IRT ✓ 115/97 24
a susp
yoscire,o
BSK
meperazo
le,Antasid
a
Dermatofi CTM,Keto
10.50 11.00 IRT ✓ 155/88 24
losis konazole
Omepera
Syndrome zole,Anta
10.40 10.50 SMA ✓ 126/83 24
Dispepsia
sida
ambroxol,
ISPA,Scabi noza,Amo tidak
10.35 10.45 ✓ 26
es xillin,scabi bekerja
ceb zalf
Metformi
n,Glimepr
HT grade I, inide,Aml
DM tipe II, odifin,Sim Wiraswas
11.13 11.18 ✓ 133/90 24 36,6
Hiperlipedem vastatin,I ta
ia buprofen,
Vit.B12,Ka
lk
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
Suhu Nadi TB BB Lab Penyakit Perdaraha an
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
36,5 82 165 56
GDS: 280
36,6 88 156 54 Chol : 220
AU : 4
36,8 104 13
GDS : 119
36,5 93 157 57
AU : 7.5
36,7 117 154 57

36,7 90 155 60
36,9 118 27
93 160 53
37 87 154 54
36,5 72 167 59
GDS : 117
36,7 84 148 43 AU : 5,8
36,5 100 151 90 GDS : 118
HB : 13.1
36,7 92 142 48
AU : 6.3
36,6 133 25
36,6 75 151 51
36,7 81 154 65
35,8 122 164 70
36,7 90 157 55
36,7 150 47
36,7 77 156 53 GDS : 100

AU : 6,2
36,6 82 141 41
36,7 73 153 67
36,7 82 150 55
38,3 107 17
94 155 79
ur
m
U
1 17033 000192897703 6310095809090005 0823 3408 7718 wafa aisyah
2 6365 0001922748254 6310095002720008 0852 4848 5095 ny. St fatimah
3 24084 0002722623423 6310064605160004 0852 5100 0235 An. Hana Hamidah
4 25842 0002722635279 6310090806590005 0823 4205 0016 Tn. Masran
5 13352 0002520536242 6310090101910020 0853 8670 6516 Tn. M Syahlan

6 12658 0002824174168 6310095002550001 0852 5704 8421 Ny Siti Bahriah
7 26309 0002722578941 6310066601150009 0821 5205 1011 An. Nur aqila
9 24631 0002254858571 6372045510960004 0813 2159 8712 Ny Tina wati
10 27354 0002164670425 3578121807830003 0851 0160 0567 Tn syahdan
11 16661 0002659955771 6310096812670004 0812 3696 2377 Tn sahribulan
12 26175 0002424302313 6310095708770002 0813 4808 6548 Ny normawati
13 24565 0002220634293 6310094102490001 0822 56686873 ny majuang

14 22772 ;0001922689844 6310065408130002 0812 5017 747 An. Nayra
15 24702 0002414353307 3578054712670001 0813 4799 9873 Ny marpuah
16 29083 0001929859694 6310104107730046 0858 44587 3381 Ny jamirah
17 23773 0001928002678 7308135211910001 0822 5184 6988 ny nurhayati
18 21514 0002722677693 6310094406640003 0853 4806 9345 ny ramaiyah
19 5921 0002069869048 6310092206110003 0813 5106 2555 An.Mrizky
20 6562 0002722704851 6310094107850210 0831 2355 7006 Ny Siti maisaroh
21 29.085 0002722582214 6302065409730007 082351525289 Ny Noorhasanah
22 29.086 0002885215274 6310094608680004 Ny Masniah
23 28.984 0002722590055 6310066310060001 081250160950 Tn Mamang

25
26
27
29
POLI UMUM
Pembiayaan
Status Status
Pendidi
ir
ah

ur
kan
lL
Um
gan it Umum BPJS

Tg


Jl lapangan 5
oktober rt 6

belum
Jl Transmigrasi
Rt 11
h
UM
Pembiayaan Wkt Playan TTV
Terapi &
SKTM Tindakan D P TD RR
PCt,
CC ambroxol, 08.25 08.30 pelajar ✓ 23
vit c, ctm
Glibenkla
mid,
Metformi
DM, n,
Hiperlipid Paraceta
emia, mol,
neuropati omeptazo 08.35 08.40 IRT ✓ 113/83 24
, le,
dyspepsia antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
Sup.
Epilepsi minta 08.40 08.45 - ✓ 25
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
HT meprazol 08.45 08.50 swasta ✓ 171/109 25
o,allopuri
nol
Skizofreni clozapine,
HLP,Trihe 08.50 08.55 - ✓ 128/94 24
a xipenidil
Metformi
n,ibuprof
DM, HT, en,amlodi
Wiraswas
Abses pinambro 09.00 09.05 ✓ 181/89 23
ta
mamae xol,antasi
d,Vit B12,
furosemid
pct,amox,
domperid
GEA 09.10 09.15 Pelajar ✓ 26
on,zink,or
alit
Rujuk Poli
Gangguan Jiwa,
cemas Ambroxol
09.34 09.38 - ✓ 108/77 24
(F41.9) ,
Ispa flutrop,a
mox,Vit c
ibuprofen
faringitis 09.25 09.30 IRT ✓ 122/85 22
,Vit C
PCT,
lanzopraz
, anti 09.30 09.35 ✓ 134/80 24
Hemoroid hemoroid ta
,domperi
don
amlodipin
,
ibuprofen
HT ,omepraz 09.50 09.55 swasta ✓ 132/90 22
ol,Kalk,
Vit B
Comp
CPT,amlo
HT,
dipin,ibuy
Konjungti profen,Vit 09.55 10.00 IRT ✓ 221/130 24
vitis
B12
allopurino
HT,Dyspe l,
psiaHeper amlodipin 10.15 10.20 IRT ✓ 154/111 24
urisemia ,antasid,V
it B12
antacid,p
Dyspepsia ct,dompe
10.20 10.25 pelajar ✓ 24
ox
pct,amox,
Gastritis, vit c,
1025 10.30 IRT ✓ 145/82 24
OMA cloram
tetes
ambroxol,
noza,amo
ispa.ht 09.10 09.15 IRT ✓ 178/80 21
x,amlodip
in
ibuprofen
,ciproflox
Cephalgia acin,ome 10.14 10.19 IRT ✓ 146/104 24
prazol,he
mafort
furosemid
,amlodipi
Ht, CC n,pctamb 10.43 10.48 IRT ✓ 167/108 24
roxol,ctm,
vit c
Rujuk Poli
ppok anak 10.44 10.54 IRT ✓ 22
HT, amlodipin 10.42 10.47 IRT ✓ 196/111 22

dyspepsia ,antacid,
Rujuk Ke
poli
bedah
Obs
RSUD
Hematuri DHAAN,H
10.15 10.25 IRT ✓ 115/97 24
a susp
yoscire,o
BSK
meperazo
le,Antasid
a
Dermatofi CTM,Keto
10.50 11.00 IRT ✓ 155/88 24
losis konazole
Omepera
Syndrome zole,Anta
10.40 10.50 SMA ✓ 126/83 24
Dispepsia
sida
ambroxol,
ISPA,Scabi noza,Amo tidak
10.35 10.45 ✓ 26
es xillin,scabi bekerja
ceb zalf
✓
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
Suhu Nadi TB BB Lab Penyakit Perdaraha an
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
36,5 82 165 56
GDS: 280
36,6 88 156 54 Chol : 220
AU : 4
36,8 104 13
GDS : 119
36,5 93 157 57
AU : 7.5
36,7 117 154 57

36,7 90 155 60
36,9 118 27
93 160 53
37 87 154 54
36,5 72 167 59
GDS : 117
36,7 84 148 43 AU : 5,8
36,5 100 151 90 GDS : 118
HB : 13.1
36,7 92 142 48
AU : 6.3
36,6 133 25
36,6 75 151 51
36,7 81 154 65
35,8 122 164 70
36,7 90 157 55
36,7 150 47
36,7 77 156 53 GDS : 100

AU : 6,2
36,6 82 141 41
36,7 73 153 67
36,7 82 150 55
38,3 107 17
- - - - - - -
ur
Um
1 17033 000192897703 6310095809090005 0823 3408 7718 wafa aisyah
2 6365 0001922748254 6310095002720008 0852 4848 5095 ny. St fatimah
3 24084 0002722623423 6310064605160004 0852 5100 0235 An. Hana Hamidah
4 25842 0002722635279 6310090806590005 0823 4205 0016 Tn. Masran
5 13352 0002520536242 6310090101910020 0853 8670 6516 Tn. M Syahlan

6 12658 0002824174168 6310095002550001 0852 5704 8421 Ny Siti Bahriah
7 26309 0002722578941 6310066601150009 0821 5205 1011 An. Nur aqila
9 24631 0002254858571 6372045510960004 0813 2159 8712 Ny Tina wati
10 27354 0002164670425 3578121807830003 0851 0160 0567 Tn syahdan
11 16661 0002659955771 6310096812670004 0812 3696 2377 Tn sahribulan
12 26175 0002424302313 6310095708770002 0813 4808 6548 Ny normawati
13 24565 0002220634293 6310094102490001 0822 56686873 ny majuang

14 22772 ;0001922689844 6310065408130002 0812 5017 747 An. Nayra
15 24702 0002414353307 3578054712670001 0813 4799 9873 Ny marpuah
16 29083 0001929859694 6310104107730046 0858 44587 3381 Ny jamirah
17 23773 0001928002678 7308135211910001 0822 5184 6988 ny nurhayati
18 21514 0002722677693 6310094406640003 0853 4806 9345 ny ramaiyah
19 5921 0002069869048 6310092206110003 0813 5106 2555 An.Mrizky
20 6562 0002722704851 6310094107850210 0831 2355 7006 Ny Siti maisaroh
21 29.085 0002722582214 6302065409730007 082351525289 Ny Noorhasanah
22 29.086 0002885215274 6310094608680004 Ny Masniah
23 28.984 0002722590055 6310066310060001 081250160950 Tn Mamang

25
26
27
POLI UMUM
Pembiayaan
Status Status
Pendidi
ir
ah

ur
kan
lL
Um
gan it Umum BPJS

Tg


Jl lapangan 5
oktober rt 6
Jl Transmigrasi belum
Rt 11
h
UMUM
Terapi &
SKTM Tindakan D P
PCt,
CC ambroxol, 08.25 08.30 pelajar ✓
vit c, ctm
Glibenkla
mid,
Metformi
n,
Paraceta
DM, Hiperlipidemia, neuropati, mol,
dyspepsia omeptazo 08.35 08.40 IRT ✓
le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
Sup. Epilepsi minta 08.40 08.45 - ✓
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
HT meprazol 08.45 08.50 swasta ✓
o,allopuri
nol
clozapine,
Skizofrenia HLP,Trihe 08.50 08.55 - ✓
xipenidil
Metformi
n,ibuprof
en,amlodi
Wiraswas
DM, HT, Abses mamae pinambro 09.00 09.05 ✓
ta
xol,antasi
d,Vit B12,
furosemid
pct,amox,
domperid
GEA 09.10 09.15 Pelajar ✓
on,zink,or
alit
Rujuk Poli
Jiwa,
Ambroxol
Gangguan cemas (F41.9) Ispa 09.34 09.38 - ✓
,
flutrop,a
mox,Vit c
ibuprofen
faringitis 09.25 09.30 IRT ✓
,Vit C
PCT,
lanzopraz
ol,antasid
Wiraswas
Gastritis, Hemoroid , anti 09.30 09.35 ✓
hemoroid ta
,domperi
don
amlodipin
,
ibuprofen
HT ,omepraz 09.50 09.55 swasta ✓
ol,Kalk,
Vit B
Comp
CPT,amlo
dipin,ibuy
HT, Konjungtivitis 09.55 10.00 IRT ✓
profen,Vit
B12
allopurino
l,
HT,DyspepsiaHeperurisemia amlodipin 10.15 10.20 IRT ✓
,antasid,V
it B12
antacid,p
ct,dompe
Dyspepsia, Tonsilitis 10.20 10.25 pelajar ✓
ridon,am
ox
pct,amox,
vit c,
Gastritis, OMA 1025 10.30 IRT ✓
cloram
tetes
ambroxol,
noza,amo
ispa.ht 09.10 09.15 IRT ✓
x,amlodip
in
ibuprofen
,ciproflox
Cephalgia acin,ome 10.14 10.19 IRT ✓
prazol,he
mafort
furosemid
,amlodipi
Ht, CC n,pctamb 10.43 10.48 IRT ✓
roxol,ctm,
vit c
Rujuk Poli
ppok anak 10.44 10.54 IRT ✓
HT, dyspepsia amlodipin 10.42 10.47 IRT ✓

,antacid,
Rujuk Ke
poli
bedah
RSUD
Obs Hematuria susp BSK DHAAN,H 10.15 10.25 IRT ✓
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
Dermatofilosis 10.50 11.00 IRT ✓
konazole
Omepera
Syndrome Dispepsia zole,Anta 10.40 10.50 SMA ✓
sida
ambroxol,
noza,Amo tidak
ISPA,Scabies 10.35 10.45 ✓
ceb zalf
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga
th )
23 36,5 82 165 56
GDS: 280
113/83 24 36,6 88 156 54 Chol : 220
AU : 4
25 36,8 104 13
GDS : 119
171/109 25 36,5 93 157 57
AU : 7.5
128/94 24 36,7 117 154 57

181/89 23 36,7 90 155 60
26 36,9 118 27
108/77 24 93 160 53
122/85 22 37 87 154 54
134/80 24 36,5 72 167 59
GDS : 117
132/90 22 36,7 84 148 43 AU : 5,8
221/130 24 36,5 100 151 90 GDS : 118
HB : 13.1
154/111 24 36,7 92 142 48
AU : 6.3
24 36,6 133 25
145/82 24 36,6 75 151 51
178/80 21 36,7 81 154 65
146/104 24 35,8 122 164 70
167/108 24 36,7 90 157 55
22 36,7 150 47
196/111 22 36,7 77 156 53 GDS : 100

AU : 6,2
115/97 24 36,6 82 141 41
155/88 24 36,7 73 153 67
126/83 24 36,7 82 150 55
26 38,3 107 17
Riwayat PTM
Riwayat
Riwayat Pemeriksa
Perdaraha an
n IVA/Sada
nis
ir
ah
ur
lL
m
U
Tg
0001928977 63100958 0823 3408 wafa 18-09- dr.
1 17033 03 09090005 7718 aisyah 14 th 2009 Rahmah
0001922748 63100950 0852 4848 ny. St

2 6365 254 02720008 5095 fatimah 51 th 10-2-1972 dr. Ferisa
0002722623 63100646 0852 5100 An. Hana dr.

3 24084 423 05160004 0235 Hamidah 7 th 6-5-2016
Rahmah
0002722635 63100908 0823 4205 Tn.

4 25842 64 th 8-6-1959 dr. Ferisa
279 06590005 0016 Masran
0002520536 63100901 0853 8670 Tn. M

5 13352 32 th 1-1-1991 dr. Ferisa
242 01910020 6516 Syahlan
0002824174 63100950 0852 5704 Ny Siti dr.
6 12658 68 th 10-2-1955
168 02550001 8421 Bahriah Rahmah
0002722578 63100666 0821 5205 An. Nur dr.

7 26309 8 th 26-1-2015
941 01150009 1011 aqila Rahmah
0001618207 63100948 0821 5509 Nn

8 25365 Paridah 23 th 8-3-2000 dr. Ferisa
378 03000012 1389
Riyani
0002254858 63720455 0813 2159 Ny Tina dr.

9 24631 27 th 12-9-1996
571 10960004 8712 wati Rahmah
0002164670 35781218 0851 0160 Tn

10 27354 40 th 18-7-1983 dr. Ferisa
425 07830003 0567 syahdan
0002659955 63100968 0812 3696 Tn 28-12- dr.

11 16661 771 12670004 2377 sahribula 56 th 1967
n Rahmah
0002424302 63100957 0813 4808 Ny dr.

12 26175 normawa 46 th 17-8-1977
313 08770002 6548 Rahmah
ti
0002220634 63100941 0822 ny

13 24565 74 th 1-2-1949 dr. Ferisa
293 02490001 56686873 majuang
;0001922689 63100654 0812 5017
844 08130002 747
0002414353 35780547 0813 4799 Ny

15 24702 56 th 7-12-1967 dr. Ferisa
307 12670001 9873 marpuah
0001929859 63101041 0858 44587 Ny

16 29083 50 th 1-7-1973 dr. Ferisa
694 07730046 3381 jamirah
0001928002 73081352 0822 5184 ny 12-11-

17 23773 678 11910001 6988 nurhayati 31 th 1991 dr. Ferisa
0002722677 63100944 0853 4806 ny

18 21514 59 4-6-1964 dr. Ferisa
693 06640003 9345 ramaiyah
0002069869 63100922 0813 5106

19 5921 048 06110003 2555 An.Mrizky 12 th 22-6-2011 dr. Ferisa
20 6562 0002722704 63100941 0831 2355 Ny Siti 38 th 1-7-1985 dr. Ferisa

851 07850210 7006 maisaroh
Ny
0002722582 63020654 08235152528 Noorhasa 14-09-
21 29.085 49 th dr. Ferisa
214 09730007 9 1973
nah
0002885215 63100946 Ny 06-08-

22 29.086 55 th dr. Ferisa
274 08680004 Masniah 1968
0002722590 63100663 08125016095 Tn 26-08-

23 28.984 19 th dr. Ferisa
055 10060001 0 Mamang 2004
0002849409 63100629 08578799047 An Fajar 29-05-
461 0517000 8 Fadillah 2017
25
26
27
29
POLI UMUM
Pembiayaan
Status Status Terapi &

Kunjungan Penyakit Umum BPJS SKTM Tindakan
PCt,
jl kodeco
km 2.5 SMP P L B ✓ CC ambroxol,
vit c, ctm
Glibenkla
mid,
Metformi
DM, n,
Hiperlipid Paraceta
jl nusa emia, mol,
indah SD P L L ✓ neuropati omeptazo
, le,
dyspepsia antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
jl pasien
Sup.
Mulawar - P B B ✓ Epilepsi minta
man tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
lap 5
SD L L L ✓ HT meprazol
oktober
o,allopuri
nol
jl raya Skizofreni clozapine,

SD L L L ✓ HLP,Trihe
serongga a xipenidil
Metformi
n,ibuprof
DM, HT, en,amlodi
Jl sei
SMP P L L ✓ Abses pinambro
belanak
mamae xol,antasi
d,Vit B12,
furosemid
pct,amox,
jl
domperid
kampung SD P L B ✓ GEA
on,zink,or
baru
alit
Rujuk Poli
Gangguan Jiwa,
sungai cemas Ambroxol
SD P L L ✓
hanau (F41.9) ,
Ispa flutrop,a
mox,Vit c
ibuprofen
,Vit C
PCT,
lanzopraz
Gastritis, ol,antasid
jl belibis S1 L L B ✓ , anti
Hemoroid hemoroid
,domperi
don
amlodipin
,
ibuprofen
jl BB SMA L L L ✓ HT ,omepraz
ol,Kalk,
Vit B
Comp
CPT,amlo
HT,
dipin,ibuy
jl TP SMP P L L ✓ Konjungti profen,Vit
vitis
B12
allopurino
HT,Dyspe l,
jl pasar
SD P L L ✓ psiaHeper amlodipin
ampera
urisemia ,antasid,V
it B12
antacid,p
jl
Dyspepsia ct,dompe
transmigr SD P L B ✓
asi
ox
pct,amox,
jl
Gastritis, vit c,
kemakmu semea P L B ✓
OMA cloram
ran
tetes
ambroxol,
jl
noza,amo
sarigadun - P B B ✓ ispa.ht
x,amlodip
g
in
ibuprofen
,ciproflox
sei dua rt
4 SD P L B ✓ Cephalgia acin,ome
prazol,he
mafort
furosemid
,amlodipi
jl kodeco SD P L L ✓ Ht, CC n,pctamb
roxol,ctm,
vit c
Rujuk Poli
jl bb SMP L B B ✓ ppok anak
Jl usaha SD P L L ✓ HT, amlodipin

bersama dyspepsia ,antacid,
Rujuk Ke
poli
bedah
Obs
Jl H RSUD
Hematuri DHAAN,H
Antung Rt SMP P B B ✓
a susp
8 yoscire,o
BSK
meperazo
le,Antasid
a
Jl
lapangan Dermatofi CTM,Keto
SD P B B ✓
5 oktober losis konazole
rt 6
Jl Omepera
Syndrome
Cendana SMA P B B ✓ zole,Anta
Dispepsia
Rt 08 sida
ambroxol,
Jl
belum ISPA,Scabi noza,Amo
Transmigr L L L ✓ ✓
sekolah es xillin,scabi
asi Rt 11
ceb zalf
✓
Wkt Playan TTV
Pekerjaan KIE
D P TD RR Suhu Nadi TB BB
08.25 08.30 pelajar ✓ 23 36,5 82 165 56
08.35 08.40 IRT ✓ 113/83 24 36,6 88 156 54
08.40 08.45 - ✓ 25 36,8 104 13
08.45 08.50 swasta ✓ 171/109 25 36,5 93 157 57
08.50 08.55 - ✓ 128/94 24 36,7 117 154 57

Wiraswas
09.00 09.05 ✓ 181/89 23 36,7 90 155 60
ta
09.10 09.15 Pelajar ✓ 26 36,9 118 27
09.34 09.38 - ✓ 108/77 24 93 160 53
09.25 09.30 IRT ✓ 122/85 22 37 87 154 54
Wiraswas
09.30 09.35 ✓ 134/80 24 36,5 72 167 59
ta
09.50 09.55 swasta ✓ 132/90 22 36,7 84 148 43
09.55 10.00 IRT ✓ 221/130 24 36,5 100 151 90
10.15 10.20 IRT ✓ 154/111 24 36,7 92 142 48

10.20 10.25 pelajar ✓ 24 36,6 133 25
1025 10.30 IRT ✓ 145/82 24 36,6 75 151 51
09.10 09.15 IRT ✓ 178/80 21 36,7 81 154 65
10.14 10.19 IRT ✓ 146/104 24 35,8 122 164 70
10.43 10.48 IRT ✓ 167/108 24 36,7 90 157 55
10.44 10.54 IRT ✓ 22 36,7 150 47
10.42 10.47 IRT ✓ 196/111 22 36,7 77 156 53
10.15 10.25 IRT ✓ 115/97 24 36,6 82 141 41
10.50 11.00 IRT ✓ 155/88 24 36,7 73 153 67
10.40 10.50 SMA ✓ 126/83 24 36,7 82 150 55

tidak
10.35 10.45 ✓ 26 38,3 107 17
bekerja
✓ -
Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
GDS: 280
Chol : 220
AU : 4
GDS : 119
AU : 7.5
GDS : 117
AU : 5,8
GDS : 118
HB : 13.1
AU : 6.3
GDS : 100
AU : 6,2
- - - - - -
ir
ah
ur
lL
m
U
Tg
0001928977 63100958 0823 3408 wafa
1 17033 03 09090005 7718 aisyah 14 th 18-09-2009 dr. Rahmah
0001922748 63100950 0852 4848 ny. St

2 6365 254 02720008 5095 fatimah 51 th 10-2-1972 dr. Ferisa
0002722623 63100646 0852 5100 An. Hana

3 24084 423 05160004 0235 Hamidah 7 th 6-5-2016 dr. Rahmah
0002722635 63100908 0823 4205 Tn.

4 25842 64 th 8-6-1959 dr. Ferisa
279 06590005 0016 Masran
0002520536 63100901 0853 8670 Tn. M

5 13352 32 th 1-1-1991 dr. Ferisa
242 01910020 6516 Syahlan
0002824174 63100950 0852 5704 Ny Siti
6 12658 68 th 10-2-1955 dr. Rahmah
168 02550001 8421 Bahriah
0002722578 63100666 0821 5205 An. Nur

7 26309 8 th 26-1-2015 dr. Rahmah
941 01150009 1011 aqila
0001618207 63100948 0821 5509 Nn

8 25365 Paridah 23 th 8-3-2000 dr. Ferisa
378 03000012 1389
Riyani
0002254858 63720455 0813 2159 Ny Tina

9 24631 27 th 12-9-1996 dr. Rahmah
571 10960004 8712 wati
0002164670 35781218 0851 0160 Tn

10 27354 40 th 18-7-1983 dr. Ferisa
425 07830003 0567 syahdan
0002659955 63100968 0812 3696 Tn

11 16661 771 12670004 2377 sahribula 56 th 28-12-1967 dr. Rahmah
n
0002424302 63100957 0813 4808 Ny

12 26175 normawa 46 th 17-8-1977 dr. Rahmah
313 08770002 6548
ti
0002220634 63100941 0822 ny

13 24565 74 th 1-2-1949 dr. Ferisa
293 02490001 56686873 majuang
;0001922689 63100654 0812 5017
844 08130002 747
0002414353 35780547 0813 4799 Ny

15 24702 56 th 7-12-1967 dr. Ferisa
307 12670001 9873 marpuah
0001929859 63101041 0858 44587 Ny

16 29083 50 th 1-7-1973 dr. Ferisa
694 07730046 3381 jamirah
0001928002 73081352 0822 5184 ny

17 23773 678 11910001 6988 nurhayati 31 th 12-11-1991 dr. Ferisa
0002722677 63100944 0853 4806 ny

18 21514 59 4-6-1964 dr. Ferisa
693 06640003 9345 ramaiyah
0002069869 63100922 0813 5106

20 6562 0002722704 63100941 0831 2355 Ny Siti 38 th 1-7-1985

851 07850210 7006 maisaroh dr. Ferisa
Ny
0002722582 63020654 08235152528 Noorhasa
21 29.085 49 th 14-09-1973 dr. Ferisa
214 09730007 9
nah
0002885215 63100946 Ny
22 29.086 55 th 06-08-1968 dr. Ferisa
274 08680004 Masniah
0002722590 63100663 08125016095 Tn

23 28.984 19 th 26-08-2004 dr. Ferisa
055 10060001 0 Mamang
0002849409 63100629 08578799047 An Fajar
24 13.757 6 th 29-05-2017 dr. Ferisa
461 0517000 8 Fadillah
25
26
27
0001241013 63100930 08534546626 Tn.Toto

29 3.035 58 th 30-3-1965 dr.Rahmah
71 03610002 9 Indrawan
0000122569 63100913 08134813557 Tn.Syafru

30 11.641 72 th 13-10-1951 dr.Rahmah
942 10510002 9 din M
31 29.027 0001448263 63100913 08384770367 Tn.Aditya 34 th 13-12-1989

517 12890006 5 Nugraha dr.Rizky
0002745592 63100945 Ny.Tinaw

32 13.201 - 34 th 5-4-1989 dr.Rizky
773 04890005 ati
POLI UMUM
Pembiayaan
Status Status
jl kodeco
km 2.5 SMP P L B ✓ CC
DM,
jl nusa Hiperlipidemia,
indah SD P L L ✓ neuropati,
dyspepsia
jl
Mulawar - P B B ✓ Sup. Epilepsi
man
lap 5
SD L L L ✓ HT
oktober
jl raya
serongga
Jl sei DM, HT, Abses
SMP P L L ✓
belanak mamae
jl
baru
sungai Gangguan cemas

SD P L L ✓
hanau (F41.9) Ispa
Gastritis,
Hemoroid
jl TP SMP P L L ✓ HT, Konjungtivitis
jl pasar HT,DyspepsiaHep
SD P L L ✓
ampera erurisemia
jl
Dyspepsia,
Tonsilitis
asi
jl
kemakmu semea P L B ✓ Gastritis, OMA
ran
jl
g
sei dua rt
4 SD P L B ✓ Cephalgia
Jl usaha SD P L L ✓ HT, dyspepsia

bersama
Jl H
Obs Hematuria
susp BSK
8
Jl
lapangan
5 oktober
rt 6
Jl Syndrome
Cendana SMA P B B ✓
Dispepsia
Rt 08
Jl
belum
Transmigr L L L ✓ ✓ ISPA,Scabies
sekolah
asi Rt 11
PCT, Betahistine,
Jl.Insgub Dispepsia Omeprasole,
L L B ✓
RT.11 sindrom Domperidone,
Bcomp
Ciprofloxacin,
Vulnus Asmef, VitC,
Jl.BB RT.9 L B B ✓
Punctum Injeksi ATS (I.M),
Cross insisi
Vulnus
RT.5 GB L B B ✓ Lacetaru Asmef
m
Ranitidine,
RT.1 TP P L B ✓ Dispepsia
Bcomp
Wkt Playan TTV
Terapi &
Pekerjaan KIE
PCt,
ambroxol, 08.25 08.30 pelajar ✓ 23 36,5 82 165
vit c, ctm
Glibenkla
mid,
Metformi
n,
Paraceta
mol,
omeptazo 08.35 08.40 IRT ✓ 113/83 24 36,6 88 156
le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
minta 08.40 08.45 - ✓ 25 36,8 104
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
meprazol 08.45 08.50 swasta ✓ 171/109 25 36,5 93 157
o,allopuri
nol
clozapine,
HLP,Trihe 08.50 08.55 - ✓ 128/94 24 36,7 117 154
xipenidil
Metformi
n,ibuprof
en,amlodi
Wiraswas
pinambro 09.00 09.05 ✓ 181/89 23 36,7 90 155
ta
xol,antasi
d,Vit B12,
furosemid
pct,amox,
domperid
09.10 09.15 Pelajar ✓ 26 36,9 118
on,zink,or
alit
Rujuk Poli
Jiwa,
Ambroxol
09.34 09.38 - ✓ 108/77 24 93 160
,
flutrop,a
mox,Vit c
ibuprofen
09.25 09.30 IRT ✓ 122/85 22 37 87 154
,Vit C
PCT,
lanzopraz
ol,antasid
Wiraswas
, anti 09.30 09.35 ✓ 134/80 24 36,5 72 167
hemoroid ta
,domperi
don
amlodipin
,
ibuprofen
,omepraz 09.50 09.55 swasta ✓ 132/90 22 36,7 84 148
ol,Kalk,
Vit B
Comp
CPT,amlo
dipin,ibuy
09.55 10.00 IRT ✓ 221/130 24 36,5 100 151
profen,Vit
B12
allopurino
l,
amlodipin 10.15 10.20 IRT ✓ 154/111 24 36,7 92 142
,antasid,V
it B12
antacid,p
ct,dompe
10.20 10.25 pelajar ✓ 24 36,6 133
ridon,am
ox
pct,amox,
vit c,
1025 10.30 IRT ✓ 145/82 24 36,6 75 151
cloram
tetes
ambroxol,
noza,amo
09.10 09.15 IRT ✓ 178/80 21 36,7 81 154
x,amlodip
in
ibuprofen
,ciproflox
acin,ome 10.14 10.19 IRT ✓ 146/104 24 35,8 122 164
prazol,he
mafort
furosemid
,amlodipi
n,pctamb 10.43 10.48 IRT ✓ 167/108 24 36,7 90 157
roxol,ctm,
vit c
Rujuk Poli
anak 10.44 10.54 IRT ✓ 22 36,7 150
amlodipin 10.42 10.47 IRT ✓ 196/111 22 36,7 77 156

,antacid,
Rujuk Ke
poli
bedah
RSUD
DHAAN,H 10.15 10.25 IRT ✓ 115/97 24 36,6 82 141
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
10.50 11.00 IRT ✓ 155/88 24 36,7 73 153
konazole
Omepera
zole,Anta 10.40 10.50 SMA ✓ 126/83 24 36,7 82 150
sida
ambroxol,
noza,Amo tidak
10.35 10.45 ✓ 26 38,3 107
ceb zalf
10.48 10.55 ✓ 136/91 22 36,8 - 165 71
10.05 10.10 ✓ 152/92 - 36,5 - 156 63
10.53 10.59 ✓ 157/91 22 36,7 85 163 67
10.50 10.56 ✓ 152/85 22 36,7 108 153 50

Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
56
GDS: 280
54 Chol : 220
AU : 4
13
GDS : 119
57
AU : 7.5
57
60
27
53
54
59
GDS : 117
43 AU : 5,8
90 GDS : 118
HB : 13.1
48
AU : 6.3
25
51
65
70
55
47
53 GDS : 100
AU : 6,2
41
67
55
17
- - - - - - -
- - - - - - -
- - - - - - -
GDP:98 ;
- - - - - -
AU:3,9
ir
ah
ur
lL
m
U
Tg
0001928977 63100958 0823 3408 wafa
1 17033 03 09090005 7718 aisyah 14 th 18-09-2009
0001922748 63100950 0852 4848 ny. St

2 6365 254 02720008 5095 fatimah 51 th 10-2-1972
0002722623 63100646 0852 5100 An. Hana

3 24084 423 05160004 0235 Hamidah 7 th 6-5-2016
0002722635 63100908 0823 4205 Tn.

4 25842 64 th 8-6-1959
279 06590005 0016 Masran
0002520536 63100901 0853 8670 Tn. M

5 13352 32 th 1-1-1991
242 01910020 6516 Syahlan
0002824174 63100950 0852 5704 Ny Siti
6 12658 68 th 10-2-1955
168 02550001 8421 Bahriah
0002722578 63100666 0821 5205 An. Nur

7 26309 8 th 26-1-2015
941 01150009 1011 aqila
0001618207 63100948 0821 5509 Nn

8 25365 Paridah 23 th 8-3-2000
378 03000012 1389
Riyani
0002254858 63720455 0813 2159 Ny Tina

9 24631 27 th 12-9-1996
571 10960004 8712 wati
0002164670 35781218 0851 0160 Tn

10 27354 40 th 18-7-1983
425 07830003 0567 syahdan
0002659955 63100968 0812 3696 Tn

11 16661 771 12670004 2377 sahribula 56 th 28-12-1967
n
0002424302 63100957 0813 4808 Ny

12 26175 normawa 46 th 17-8-1977
313 08770002 6548
ti
0002220634 63100941 0822 ny

13 24565 74 th 1-2-1949
293 02490001 56686873 majuang
;0001922689 63100654 0812 5017
14 22772 An. Nayra 10 th 14-2-2013
844 08130002 747
0002414353 35780547 0813 4799 Ny

15 24702 56 th 7-12-1967
307 12670001 9873 marpuah
0001929859 63101041 0858 44587 Ny

16 29083 50 th 1-7-1973
694 07730046 3381 jamirah
0001928002 73081352 0822 5184 ny

17 23773 678 11910001 6988 nurhayati 31 th 12-11-1991
0002722677 63100944 0853 4806 ny

18 21514 59 4-6-1964
693 06640003 9345 ramaiyah
0002069869 63100922 0813 5106

19 5921 048 06110003 2555 An.Mrizky 12 th 22-6-2011
20 6562 0002722704 63100941 0831 2355 Ny Siti 38 th 1-7-1985

851 07850210 7006 maisaroh
Ny
0002722582 63020654 08235152528 Noorhasa
21 29.085 49 th 14-09-1973
214 09730007 9
nah
0002885215 63100946 Ny
22 29.086 55 th 06-08-1968
274 08680004 Masniah
0002722590 63100663 08125016095 Tn

23 28.984 19 th 26-08-2004
055 10060001 0 Mamang
0002849409 63100629 08578799047 An Fajar
24 13.757 6 th 29-05-2017
461 0517000 8 Fadillah
25
26
27
0001922769 63100959 08524842324

29 27455 Ny. Yani 35 th 19-09-1988
371 09880005 4
Ny.
0002722633 63100950 tidak ada
30 27871 661 06800014 distatus Normaya 43 th 10-06-1980
nti
63020642 08215777548 Ny.

31 19858 42 th 21-03-1981
03810008 2 Norlina
0001922802 63100941 08132042565 Ny.

32 10736 57 th 01-01-1966
423 01660010 2 Sugianor
An. Adera
33 15631 0002074271 63100664 08224398813 Situmora 6 th 24-02-2016
207 02160001 5
ng
63021257 08222342423 Ny. Desy
34 29037 32 th 17-12-1991
12910003 0 Erni Ristia
0002722708 63100970 08953736977 Ny.

35 26871 23 th 30-04-2000
653 04000008 19 Rusmiyati
POLI UMUM
Pembiayaan
Status Status
r
hi
Dokter Alamat Pendidikan JK Diagnosis

La
jl kodeco
dr. Rahmah km 2.5 SMP P L B ✓ CC
DM,
Hiperlipid
jl nusa emia,
dr. Ferisa indah SD P L L ✓ neuropati
,
dyspepsia
jl
Sup.
dr. Rahmah Mulawar - P B B ✓ Epilepsi
man
lap 5
dr. Ferisa oktober SD L L L ✓ HT
jl raya Skizofreni
dr. Ferisa serongga SD L L L ✓
a
DM, HT,
Jl sei
dr. Rahmah belanak SMP P L L ✓ Abses
mamae
jl
dr. Rahmah kampung SD P L B ✓ GEA
baru
Gangguan
sungai cemas
dr. Ferisa hanau SD P L L ✓
(F41.9)
Ispa
dr. Rahmah Jl BB SMA P L B ✓ faringitis
Gastritis,
dr. Ferisa jl belibis S1 L L B ✓
Hemoroid
dr. Rahmah jl BB SMA L L L ✓ HT
HT,
dr. Rahmah jl TP SMP P L L ✓ Konjungti
vitis
HT,Dyspe
jl pasar
dr. Ferisa ampera SD P L L ✓ psiaHeper
urisemia
jl
Dyspepsia
dr. Ferisa transmigr SD P L B ✓
, Tonsilitis
asi
jl
Gastritis,
dr. Ferisa kemakmu semea P L B ✓
OMA
ran
jl
dr. Ferisa sarigadun - P B B ✓ ispa.ht
g
sei dua rt
dr. Ferisa 4 SD P L B ✓ Cephalgia
dr. Ferisa jl kodeco SD P L L ✓ Ht, CC
dr. Ferisa jl bb SMP L B B ✓ ppok
Jl usaha SD P L L ✓ HT,
dr. Ferisa bersama dyspepsia
Obs
Jl H
Hematuri
dr. Ferisa Antung Rt SMP P B B ✓
a susp
8
BSK
Jl
lapangan Dermatofi
dr. Ferisa 5 oktober SD P B B ✓
losis
rt 6
Jl
Syndrome
dr. Ferisa Cendana SMA P B B ✓
Dispepsia
Rt 08
Jl
belum ISPA,Scabi
dr. Ferisa Transmigr sekolah L L L ✓ ✓
es
asi Rt 11
Amlodipin
,
Jl.
Syndrom Omepraz
Sampurna
dr. Ferisa Rt. 8 P L L ✓ Dyspepsia ole,
+ HT Antasida,
Baroqah
Vit.Bcom
p
Amlodipin
,
HT + ISPA Omepraz
Jl.
+ ole,
dr. Ferisa Propinsi P L L ✓ Syndrom Antasida,
Rt.6 TP
Dyspepsia PCT,
Ambroxol
, Amoxilin
Ambroxol
Jl. Plajau , Noza,
dr. Ferisa Indah P B B ✓ ISPA
Amoxilin,
Baroqah
Vit.C
Ibuprofen
DM ,
dengan Omepraz
Jl. Insulin + olle,
Transmigr HT + Antasida,
dr. Ferisa asi Rt.13 P L L ✓
Combusti Amlodipin
Bersujud o+ ,
Syndrom Neocenta
Dyspepsia Zalf,
Dressing
Jl.
Banyuwa P L L ✓ Serumen Irigasi
dr. Ferisa ngi Rt.7 Prop (AS) Telinga
GA
Amlodipin
Jl. Karang
HT + Post , Dressing
Jawa
dr. Ferisa Indah P B B ✓ Injeksi + Injeksi
VAR VAR k2,
Baroqah
Vit.C
Ambroxol
Jl. Alam , PCT,
dr. Ferisa Muda P B B ✓ ISPA Amoxilin,
Rt.3 GB Vit.Bcom
p
Wkt Playan TTV
Terapi &
Pekerjaan KIE
PCt,
vit c, ctm
Glibenkla
mid,
Metformi
n,
Paraceta
mol,
omeptazo 08.35 08.40 IRT ✓ 113/83 24 36,6 88 156
le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
minta 08.40 08.45 - ✓ 25 36,8 104
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
meprazol 08.45 08.50 swasta ✓ 171/109 25 36,5 93 157
o,allopuri
nol
clozapine,
HLP,Trihe 08.50 08.55 - ✓ 128/94 24 36,7 117 154
xipenidil
Metformi
n,ibuprof
en,amlodi
Wiraswas
pinambro 09.00 09.05 ✓ 181/89 23 36,7 90 155
ta
xol,antasi
d,Vit B12,
furosemid
pct,amox,
domperid
09.10 09.15 Pelajar ✓ 26 36,9 118
on,zink,or
alit
Rujuk Poli
Jiwa,
Ambroxol
09.34 09.38 - ✓ 108/77 24 93 160
,
flutrop,a
mox,Vit c
ibuprofen
09.25 09.30 IRT ✓ 122/85 22 37 87 154
,Vit C
PCT,
lanzopraz
ol,antasid
Wiraswas
, anti 09.30 09.35 ✓ 134/80 24 36,5 72 167
hemoroid ta
,domperi
don
amlodipin
,
ibuprofen
,omepraz 09.50 09.55 swasta ✓ 132/90 22 36,7 84 148
ol,Kalk,
Vit B
Comp
CPT,amlo
dipin,ibuy
09.55 10.00 IRT ✓ 221/130 24 36,5 100 151
profen,Vit
B12
allopurino
l,
amlodipin 10.15 10.20 IRT ✓ 154/111 24 36,7 92 142
,antasid,V
it B12
antacid,p
ct,dompe
10.20 10.25 pelajar ✓ 24 36,6 133
ridon,am
ox
pct,amox,
vit c,
1025 10.30 IRT ✓ 145/82 24 36,6 75 151
cloram
tetes
ambroxol,
noza,amo
09.10 09.15 IRT ✓ 178/80 21 36,7 81 154
x,amlodip
in
ibuprofen
,ciproflox
acin,ome 10.14 10.19 IRT ✓ 146/104 24 35,8 122 164
prazol,he
mafort
furosemid
,amlodipi
n,pctamb 10.43 10.48 IRT ✓ 167/108 24 36,7 90 157
roxol,ctm,
vit c
Rujuk Poli
anak 10.44 10.54 IRT ✓ 22 36,7 150
amlodipin 10.42 10.47 IRT ✓ 196/111 22 36,7 77 156

,antacid,
Rujuk Ke
poli
bedah
RSUD
DHAAN,H 10.15 10.25 IRT ✓ 115/97 24 36,6 82 141
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
10.50 11.00 IRT ✓ 155/88 24 36,7 73 153
konazole
Omepera
zole,Anta 10.40 10.50 SMA ✓ 126/83 24 36,7 82 150
sida
ambroxol,
noza,Amo tidak
10.35 10.45 ✓ 26 38,3 107
ceb zalf
11.30 11.35 IRT ✓ 177/108 24 36,6 86 148 61
11.35 11.40 IRT ✓ 131/85 26 36,7 79 144 30
11.45 11.50 IRT ✓ 129/91 24 36,5 88 152 70
11.30 11.35 IRT ✓ 129/96 26 36,7 96 152 45
11.45 11.50 Pelajar ✓ 26 35,8 102 119 18

tidak
11.50 11.55 ✓ 159/114 24 36,6 87 149 53
bekerja
11.40 11.45 Swasta ✓ 110/83 24 36,6 103 166 81

Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
56
GDS: 280
54 Chol : 220
AU : 4
13
GDS : 119
57
AU : 7.5
57
60
27
53
54
59
GDS : 117
43 AU : 5,8
90 GDS : 118
HB : 13.1
48
AU : 6.3
25
51
65
70
55
47
53 GDS : 100
AU : 6,2
41
67
55
17
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
ir
ah
ur
lL
m
U
Tg
0823
0001928977 63100958 18-09- dr.
1 17033 03 09090005 3408 wafa aisyah 14 th 2009
7718 Rahmah
0001922748 63100950 0852

2 6365 4848 ny. St fatimah 51 th 10-2-1972 dr. Ferisa
254 02720008
5095
0852
0002722623 63100646 dr.
3 24084 5100 An. Hana Hamidah 7 th 6-5-2016
423 05160004 Rahmah
0235
0823
0002722635 63100908
4 25842 4205 Tn. Masran 64 th 8-6-1959 dr. Ferisa
279 06590005
0016
0853
0002520536 63100901
5 13352 8670 Tn. M Syahlan 32 th 1-1-1991 dr. Ferisa
242 01910020 6516
0852
0002824174 63100950 dr.
6 12658 5704 Ny Siti Bahriah 68 th 10-2-1955
168 02550001 8421 Rahmah
0821
0002722578 63100666 dr.
7 26309 5205 An. Nur aqila 8 th 26-1-2015
941 01150009 Rahmah
1011
0821
0001618207 63100948
8 25365 5509 Nn Paridah Riyani 23 th 8-3-2000 dr. Ferisa
378 03000012
1389
0002254858 63720455 0813

9 24631 2159 Ny Tina wati 27 th 12-9-1996 dr.
571 10960004 Rahmah
8712
0002164670 35781218 0851

425 07830003
0567
0812
0002659955 63100968 28-12- dr.
11 16661 3696 Tn sahribulan 56 th
771 12670004 1967 Rahmah
2377
0813
12 26175 0002424302 63100957 4808 Ny normawati 46 th 17-8-1977 dr.
313 08770002 Rahmah
6548
0002220634 63100941 0822

13 24565 ny majuang 74 th 1-2-1949 dr. Ferisa
293 02490001 56686873
;0001922689 63100654 0812

844 08130002 5017 747
0813
0002414353 35780547
15 24702 307 12670001 4799 Ny marpuah 56 th 7-12-1967 dr. Ferisa
9873
0858
0001929859 63101041
694 07730046
3381
0822
17 23773 0001928002 73081352 5184 ny nurhayati 31 th 12-11-
678 11910001 1991 dr. Ferisa
6988
0853
18 21514 0002722677 63100944 4806 ny ramaiyah 59 4-6-1964 dr. Ferisa
693 06640003 9345
0002069869 63100922 0813

048 06110003 2555
0831
0002722704 63100941
20 6562 2355 Ny Siti maisaroh 38 th 1-7-1985 dr. Ferisa
851 07850210
7006
0002722582 63020654 08235152 14-09-
21 29.085 Ny Noorhasanah 49 th dr. Ferisa
214 09730007 5289 1973
0002885215 63100946 06-08-

22 29.086 Ny Masniah 55 th dr. Ferisa
274 08680004 1968
0002722590 63100663 08125016 26-08-

23 28.984
10060001 0950 Tn Mamang
19 th dr. Ferisa
055 2004
0002849409 63100629 08578799 29-05-

24 13.757
0478 An Fajar Fadillah
6 th dr. Ferisa
461 0517000 2017
25
26
27
POLI UMUM
Pembiayaan
Status Status
jl kodeco
km 2.5 SMP P L B ✓ CC
DM,
jl nusa Hiperlipidemia,
SD P L L ✓
indah neuropati,
dyspepsia
jl
Mulawar - P B B ✓ Sup. Epilepsi
man
lap 5
SD L L L ✓ HT
oktober
jl raya
serongga
Jl sei DM, HT, Abses

SMP P L L ✓
belanak mamae
jl
baru
sungai Gangguan cemas

SD P L L ✓
hanau (F41.9) Ispa
Gastritis,
Hemoroid
jl TP SMP P L L ✓ HT, Konjungtivitis
jl pasar HT,DyspepsiaHepe
SD P L L ✓
ampera rurisemia
jl
Dyspepsia,
Tonsilitis
asi
jl
kemakmu semea P L B ✓ Gastritis, OMA
ran
jl
g
sei dua rt SD P L B ✓ Cephalgia

4
Jl usaha
SD P L L ✓ HT, dyspepsia
bersama
Jl H
Obs Hematuria
susp BSK
8
Jl
lapangan
5 oktober
rt 6
Jl
Syndrome
Cendana SMA P B B ✓
Dispepsia
Rt 08
Jl
belum
Transmigr sekolah L L L ✓ ✓ ISPA,Scabies
asi Rt 11
Wkt Playan TTV
Terapi &
Pekerjaan KIE
PCt,
vit c, ctm
Glibenkla
mid,
Metformi
n,
Paraceta
mol,
08.35 08.40 IRT ✓ 113/83 24 36,6 88 156
omeptazo
le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
minta 08.40 08.45 - ✓ 25 36,8 104
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
meprazol 08.45 08.50 swasta ✓ 171/109 25 36,5 93 157
o,allopuri
nol
clozapine,
HLP,Trihe 08.50 08.55 - ✓ 128/94 24 36,7 117 154
xipenidil
Metformi
n,ibuprof
en,amlodi
Wiraswas
pinambro 09.00 09.05 ✓ 181/89 23 36,7 90 155
xol,antasi ta
d,Vit B12,
furosemid
pct,amox,
domperid
09.10 09.15 Pelajar ✓ 26 36,9 118
on,zink,or
alit
Rujuk Poli
Jiwa,
Ambroxol
09.34 09.38 - ✓ 108/77 24 93 160
,
flutrop,a
mox,Vit c
ibuprofen
09.25 09.30 IRT ✓ 122/85 22 37 87 154
,Vit C
PCT,
lanzopraz
ol,antasid Wiraswas
, anti 09.30 09.35 ✓ 134/80 24 36,5 72 167
ta
hemoroid
,domperi
don
amlodipin
,
ibuprofen
,omepraz 09.50 09.55 swasta ✓ 132/90 22 36,7 84 148
ol,Kalk,
Vit B
Comp
CPT,amlo
dipin,ibuy IRT ✓ 221/130 24 36,5 100 151
profen,Vit 09.55 10.00
B12
allopurino
l,
amlodipin 10.15 10.20 IRT ✓ 154/111 24 36,7 92 142
,antasid,V
it B12
antacid,p
ct,dompe
10.20 10.25 pelajar ✓ 24 36,6 133
ridon,am
ox
pct,amox,
vit c,
cloram 1025 10.30 IRT ✓ 145/82 24 36,6 75 151
tetes
ambroxol,
noza,amo
09.10 09.15 IRT ✓ 178/80 21 36,7 81 154
x,amlodip
in
ibuprofen
,ciproflox
acin,ome 10.14 10.19 IRT ✓ 146/104 24 35,8 122 164
prazol,he
mafort
furosemid
,amlodipi
n,pctamb 10.43 10.48 IRT ✓ 167/108 24 36,7 90 157
roxol,ctm,
vit c
Rujuk Poli
10.44 10.54 IRT ✓ 22 36,7 150
anak
amlodipin
10.42 10.47 IRT ✓ 196/111 22 36,7 77 156
,antacid,
Rujuk Ke
poli
bedah
RSUD
DHAAN,H 10.15 10.25 IRT ✓ 115/97 24 36,6 82 141
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
10.50 11.00 IRT ✓ 155/88 24 36,7 73 153
konazole
Omepera
zole,Anta 10.40 10.50 SMA ✓ 126/83 24 36,7 82 150
sida
ambroxol,
noza,Amo tidak
10.35 10.45 ✓ 26 38,3 107
ceb zalf
Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
56
GDS: 280
54 Chol : 220
AU : 4
13
GDS : 119
57
AU : 7.5
57
60
27
53
54
59
GDS : 117
43
AU : 5,8
90 GDS : 118
HB : 13.1
48
AU : 6.3
25
51
65
70
55
47
GDS : 100
53
AU : 6,2
41
67
55
17
ur
Um
1 17033 000192897703 6310095809090005 0823 3408 7718 wafa aisyah
2 6365 0001922748254 6310095002720008 0852 4848 5095 ny. St fatimah
3 24084 0002722623423 6310064605160004 0852 5100 0235 An. Hana Hamidah
4 25842 0002722635279 6310090806590005 0823 4205 0016 Tn. Masran

5 13352 0002520536242 6310090101910020 0853 8670 6516 Tn. M Syahlan
6 12658 0002824174168 6310095002550001 0852 5704 8421 Ny Siti Bahriah
7 26309 0002722578941 6310066601150009 0821 5205 1011 An. Nur aqila
9 24631 0002254858571 6372045510960004 0813 2159 8712 Ny Tina wati
10 27354 0002164670425 3578121807830003 0851 0160 0567 Tn syahdan
11 16661 0002659955771 6310096812670004 0812 3696 2377 Tn sahribulan

12 26175 0002424302313 6310095708770002 0813 4808 6548 Ny normawati
13 24565 0002220634293 6310094102490001 0822 56686873 ny majuang
14 22772 ;0001922689844 6310065408130002 0812 5017 747 An. Nayra
15 24702 0002414353307 3578054712670001 0813 4799 9873 Ny marpuah
16 29083 0001929859694 6310104107730046 0858 44587 3381 Ny jamirah
17 23773 0001928002678 7308135211910001 0822 5184 6988 ny nurhayati
18 21514 0002722677693 6310094406640003 0853 4806 9345 ny ramaiyah
19 5921 0002069869048 6310092206110003 0813 5106 2555 An.Mrizky
20 6562 0002722704851 6310094107850210 0831 2355 7006 Ny Siti maisaroh

21 29.085 0002722582214 6302065409730007 082351525289 Ny Noorhasanah
22 29.086 0002885215274 6310094608680004 Ny Masniah
23 28.984 0002722590055 6310066310060001 081250160950 Tn Mamang
25
26
27
POLI UMUM
Pembiaya
Status Status
r
hi

ur
La
Kunjungan Penyakit
m
Umum
U
l
Tg
18-09- dr.
14 th 2009 jl kodeco km 2.5 SMP P L B
Rahmah
7 th 6-5-2016 dr. jl Mulawarman - P B B

Rahmah

68 th 10-2-1955 dr. Jl sei belanak SMP P L L

Rahmah
8 th 26-1-2015 dr. jl kampung baru SD P L B

Rahmah
27 th 12-9-1996 dr. Jl BB SMA P L B

Rahmah
28-12- dr.
56 th jl BB SMA L L L
1967 Rahmah
46 th 17-8-1977 dr. jl TP SMP P L L
Rahmah
31 th 12-11- sei dua rt 4 SD P L B

1991 dr. Ferisa

14-09-
49 th dr. Ferisa Jl H Antung Rt 8 SMP P B B
1973
06-08- Jl lapangan 5 oktober

55 th dr. Ferisa SD P B B
1968 rt 6
26-08-
19 th dr. Ferisa Jl Cendana Rt 08 SMA P B B
2004
29-05- belum
6 th dr. Ferisa Jl Transmigrasi Rt 11 L L L ✓
2017 sekolah
MUM
Terapi &
PCt,
✓ CC ambroxol, 08.25 08.30 pelajar ✓
vit c, ctm
Glibenkla
mid,
Metformi
n,
Paraceta
✓ 08.35 08.40 IRT ✓
neuropati, dyspepsia omeptazo
le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
✓ Sup. Epilepsi minta 08.40 08.45 - ✓
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
✓ HT meprazol 08.45 08.50 swasta ✓
o,allopuri
nol
clozapine,
✓ Skizofrenia HLP,Trihe 08.50 08.55 - ✓
xipenidil
Metformi
n,ibuprof
en,amlodi
Wiraswas
✓ DM, HT, Abses mamae pinambro 09.00 09.05 ✓
xol,antasi ta
d,Vit B12,
furosemid
pct,amox,
domperid
✓ GEA 09.10 09.15 Pelajar ✓
on,zink,or
alit
Rujuk Poli
Jiwa,
✓ 09.34 09.38 - ✓
(F41.9) Ispa ,
flutrop,a
mox,Vit c
ibuprofen
✓ faringitis ,Vit C 09.25 09.30 IRT ✓
PCT,
lanzopraz
ol,antasid
Wiraswas
✓ Gastritis, Hemoroid , anti 09.30 09.35 ✓
ta
hemoroid
,domperi
don
amlodipin
,
ibuprofen
✓ HT ,omepraz 09.50 09.55 swasta ✓
ol,Kalk,
Vit B
Comp
CPT,amlo
✓ HT, Konjungtivitis dipin,ibuy IRT ✓
profen,Vit 09.55 10.00
B12
allopurino
HT,DyspepsiaHeperuri l,
✓ amlodipin 10.15 10.20 IRT ✓
semia
,antasid,V
it B12
antacid,p
ct,dompe
✓ Dyspepsia, Tonsilitis 10.20 10.25 pelajar ✓
ridon,am
ox
pct,amox,
vit c,
✓ Gastritis, OMA cloram 1025 10.30 IRT ✓
tetes
ambroxol,
noza,amo
✓ ispa.ht 09.10 09.15 IRT ✓
x,amlodip
in
ibuprofen
,ciproflox
✓ Cephalgia acin,ome 10.14 10.19 IRT ✓
prazol,he
mafort
furosemid
,amlodipi
✓ Ht, CC n,pctamb 10.43 10.48 IRT ✓
roxol,ctm,
vit c
Rujuk Poli
✓ ppok 10.44 10.54 IRT ✓
anak
amlodipin
✓ HT, dyspepsia 10.42 10.47 IRT ✓
,antacid,
Rujuk Ke
poli
bedah
RSUD
Obs Hematuria susp
✓ DHAAN,H 10.15 10.25 IRT ✓
BSK
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
✓ Dermatofilosis 10.50 11.00 IRT ✓
konazole
Omepera
✓ Syndrome Dispepsia zole,Anta 10.40 10.50 SMA ✓
sida
ambroxol,
noza,Amo tidak
✓ ISPA,Scabies 10.35 10.45 ✓
ceb zalf
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga
th )
23 36,5 82 165 56
GDS: 280
113/83 24 36,6 88 156 54 Chol : 220
AU : 4
25 36,8 104 13
GDS : 119
171/109 25 36,5 93 157 57
AU : 7.5
128/94 24 36,7 117 154 57
181/89 23 36,7 90 155 60
26 36,9 118 27
108/77 24 93 160 53
122/85 22 37 87 154 54
134/80 24 36,5 72 167 59
GDS : 117
132/90 22 36,7 84 148 43
AU : 5,8
221/130 24 36,5 100 151 90 GDS : 118
HB : 13.1
154/111 24 36,7 92 142 48
AU : 6.3
24 36,6 133 25
145/82 24 36,6 75 151 51
178/80 21 36,7 81 154 65
146/104 24 35,8 122 164 70
167/108 24 36,7 90 157 55
22 36,7 150 47
GDS : 100
196/111 22 36,7 77 156 53
AU : 6,2
115/97 24 36,6 82 141 41
155/88 24 36,7 73 153 67
126/83 24 36,7 82 150 55
26 38,3 107 17
Riwayat PTM
Riwayat
Riwayat Pemeriksa
Perdaraha an
n IVA/Sada
nis
ir
ah
ur
lL
Um
Tg
0823
00019289 63100958 18-09- dr.
1 17033 7703 09090005 3408 wafa aisyah 14 th 2009
7718 Rahmah
00019227 63100950 0852

2 6365 4848 ny. St fatimah 51 th 10-2-1972 dr. Ferisa
48254 02720008
5095
0852
00027226 63100646 An. Hana dr.
3 24084 5100 7 th 6-5-2016
23423 05160004 Hamidah Rahmah
0235
0823
00027226 63100908
4 25842 4205 Tn. Masran 64 th 8-6-1959 dr. Ferisa
35279 06590005
0016
0853
00025205 63100901
5 13352 8670 Tn. M Syahlan 32 th 1-1-1991 dr. Ferisa
36242 01910020 6516
0852
00028241 63100950 Ny Siti dr.
6 12658 5704 68 th 10-2-1955
74168 02550001 8421 Bahriah Rahmah
0821
00027225 63100666 dr.
7 26309 5205 An. Nur aqila 8 th 26-1-2015
78941 01150009 Rahmah
1011
0821
00016182 63100948 Nn Paridah
8 25365 5509 23 th 8-3-2000 dr. Ferisa
07378 03000012 Riyani
1389
00022548 63720455 0813

9 24631 2159 Ny Tina wati 27 th 12-9-1996 dr.
58571 10960004 Rahmah
8712
00021646 35781218 0851

70425 07830003
0567
0812
00026599 63100968 28-12- dr.
11 16661 3696 Tn sahribulan 56 th
55771 12670004 1967 Rahmah
2377
0813
12 26175 00024243 63100957 4808 Ny normawati 46 th 17-8-1977 dr.
02313 08770002 Rahmah
6548
00022206 63100941 0822

34293 02490001 56686873
;0001922 63100654 0812

689844 08130002 5017 747
0813
00024143 35780547
15 24702 53307 12670001 4799 Ny marpuah 56 th 7-12-1967 dr. Ferisa
9873
0858
00019298 63101041
59694 07730046
3381
0822
17 23773 00019280 73081352 5184 ny nurhayati 31 th 12-11-
02678 11910001 1991 dr. Ferisa
6988
0853
18 21514 00027226 63100944 4806 ny ramaiyah 59 4-6-1964 dr. Ferisa
77693 06640003 9345
00020698 63100922 0813

69048 06110003 2555
0831
00027227 63100941 Ny Siti
20 6562 2355 38 th 1-7-1985 dr. Ferisa
04851 07850210 maisaroh
7006
00027225 63020654 08235152 Ny 14-09-
21 29.085 49 th dr. Ferisa
82214 09730007 5289 Noorhasanah 1973
00028852 63100946 06-08-

22 29.086 Ny Masniah 55 th dr. Ferisa
15274 08680004 1968
00027225 63100663 08125016 26-08-

23 28.984 Tn Mamang 19 th dr. Ferisa
90055 10060001 0950 2004
00028494 63100629 08578799 An Fajar 29-05-

09461 0517000 0478 Fadillah 2017
25
26
27
00027227 63100910 08524826 Tn M

29 29055 23942 08680012 0484 charullah 55 th 10-8-1968 dr. Ferisa
POLI UMUM
Pembiayaan
Status Status
Alamat Pendidikan JK
jl kodeco km
2.5 SMP P L B ✓
jl
- P B B ✓
Mulawarman
lap 5 oktober SD L L L ✓
jl raya
SD L L L ✓
serongga
jl kampung
SD P L B ✓
baru
sungai hanau SD P L L ✓
Jl BB SMA P L B ✓
jl BB SMA L L L ✓
jl TP SMP P L L ✓
jl pasar
SD P L L ✓
ampera
jl
kemakmuran semea P L B ✓
jl sarigadung - P B B ✓
sei dua rt 4 SD P L B ✓
jl kodeco SD P L L ✓
jl bb SMP L B B ✓
Jl usaha
SD P L L ✓
bersama
Jl H Antung Rt
SMP P B B ✓
8
Jl lapangan 5
SD P B B ✓
oktober rt 6
Jl Cendana Rt
SMA P B B ✓
08
Jl
belum
Transmigrasi L L L ✓ ✓
sekolah
Rt 11
HT urugency,
Gunung besar L B B ✓ dermatofitosis
MUM
Wkt Playan TTV
Terapi &
Tindakan D P TD RR Suhu
PCt,
CC ambroxol, 08.25 08.30 pelajar ✓ 23 36,5
vit c, ctm
Glibenkla
mid,
Metformi
n,
DM, Paraceta
08.35 08.40 IRT ✓ 113/83 24 36,6
neuropati, omeptazo
dyspepsia le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
Sup. Epilepsi minta 08.40 08.45 - ✓ 25 36,8
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
HT meprazol 08.45 08.50 swasta ✓ 171/109 25 36,5
o,allopuri
nol
clozapine,
Skizofrenia HLP,Trihe 08.50 08.55 - ✓ 128/94 24 36,7
xipenidil
Metformi
n,ibuprof
en,amlodi
pinambro 09.00 09.05 ✓ 181/89 23 36,7
mamae xol,antasi ta
d,Vit B12,
furosemid
pct,amox,
domperid
GEA 09.10 09.15 Pelajar ✓ 26 36,9
on,zink,or
alit
Rujuk Poli
Jiwa,
09.34 09.38 - ✓ 108/77 24
(F41.9) Ispa ,
flutrop,a
mox,Vit c
ibuprofen
faringitis 09.25 09.30 IRT ✓ 122/85 22 37
,Vit C
PCT,
lanzopraz
, anti 09.30 09.35 ✓ 134/80 24 36,5
Hemoroid ta
hemoroid
,domperi
don
amlodipin
,
ibuprofen
HT ,omepraz 09.50 09.55 swasta ✓ 132/90 22 36,7
ol,Kalk,
Vit B
Comp
CPT,amlo
HT, Konjungtivitis dipin,ibuy 09.55 10.00 IRT ✓ 221/130 24 36,5
profen,Vit
B12
allopurino
HT,DyspepsiaHepe l,
amlodipin 10.15 10.20 IRT ✓ 154/111 24 36,7
rurisemia
,antasid,V
it B12
antacid,p
Dyspepsia, ct,dompe
10.20 10.25 pelajar ✓ 24 36,6
Tonsilitis ridon,am
ox
pct,amox,
vit c,
Gastritis, OMA cloram 1025 10.30 IRT ✓ 145/82 24 36,6
tetes
ambroxol,
noza,amo
ispa.ht 09.10 09.15 IRT ✓ 178/80 21 36,7
x,amlodip
in
ibuprofen
,ciproflox
Cephalgia acin,ome 10.14 10.19 IRT ✓ 146/104 24 35,8
prazol,he
mafort
furosemid
,amlodipi
Ht, CC n,pctamb 10.43 10.48 IRT ✓ 167/108 24 36,7
roxol,ctm,
vit c
Rujuk Poli
ppok 10.44 10.54 IRT ✓ 22 36,7
anak
amlodipin
HT, dyspepsia 10.42 10.47 IRT ✓ 196/111 22 36,7
,antacid,
Rujuk Ke
poli
bedah
RSUD
Obs Hematuria
DHAAN,H 10.15 10.25 IRT ✓ 115/97 24 36,6
susp BSK
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
Dermatofilosis 10.50 11.00 IRT ✓ 155/88 24 36,7
konazole
Syndrome Omepera
zole,Anta 10.40 10.50 SMA ✓ 126/83 24 36,7
Dispepsia sida
ambroxol,
noza,Amo tidak
ISPA,Scabies 10.35 10.45 ✓ 26 38,3
ceb zalf
amlodipin,
captopril,ceterizin 11.05 11.10 tdk bekerja ✓ 208/123 23 36,8 75
e, ketokonazole
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
Nadi TB BB Lab Penyakit Perdaraha an
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
82 165 56
GDS: 280
88 156 54 Chol : 220
AU : 4
104 13
GDS : 119
93 157 57
AU : 7.5
117 154 57
90 155 60
118 27
93 160 53
87 154 54
72 167 59
GDS : 117
84 148 43
AU : 5,8
100 151 90 GDS : 118
HB : 13.1
92 142 48
AU : 6.3
133 25
75 151 51
81 154 65
122 164 70
90 157 55
150 47
GDS : 100
77 156 53
AU : 6,2
82 141 41
73 153 67
82 150 55
107 17
160 63
ir
ah
ur
lL
m
U
Tg
0823
63100958090 18-09- dr.
1 17033 000192897703 90005 3408 wafa aisyah 14 th 2009
7718 Rahmah
0852
63100950027
2 6365 0001922748254 20008 4848 ny. St fatimah 51 th 10-2-1972 dr. Ferisa
5095
0852
63100646051 An. Hana dr.
3 24084 0002722623423 60004 5100 Hamidah 7 th 6-5-2016
0235 Rahmah
0823
4 25842 0002722635279 63100908065 4205 Tn. Masran 64 th 8-6-1959 dr. Ferisa
90005
0016
0853
63100901019
5 13352 0002520536242 8670 Tn. M Syahlan 32 th 1-1-1991 dr. Ferisa
10020 6516
0852
63100950025 Ny Siti dr.
6 12658 0002824174168 5704 68 th 10-2-1955
50001 Bahriah Rahmah
8421
0821
63100666011 dr.
7 26309 0002722578941 5205 An. Nur aqila 8 th 26-1-2015
50009 Rahmah
1011
0821
63100948030 Nn Paridah
8 25365 0001618207378 5509 23 th 8-3-2000 dr. Ferisa
00012 Riyani
1389
0813
63720455109 dr.
9 24631 0002254858571 2159 Ny Tina wati 27 th 12-9-1996
60004 Rahmah
8712
0851
35781218078
10 27354 0002164670425 30003 0160 Tn syahdan 40 th 18-7-1983 dr. Ferisa
0567
0812
63100968126 28-12- dr.
11 16661 0002659955771 3696 Tn sahribulan 56 th
70004 1967 Rahmah
2377
0813
63100957087 dr.
12 26175 0002424302313 4808 Ny normawati 46 th 17-8-1977
70002 Rahmah
6548
13 24565 0002220634293 63100941024 0822 ny majuang 74 th 1-2-1949 dr. Ferisa

90001 56686873
63100654081 0812
14 22772 ;0001922689844 An. Nayra 10 th 14-2-2013 dr. Ferisa
30002 5017 747
0813
35780547126
15 24702 0002414353307 4799 Ny marpuah 56 th 7-12-1967 dr. Ferisa
70001
9873
0858
63101041077
16 29083 0001929859694 44587 Ny jamirah 50 th 1-7-1973 dr. Ferisa
30046
3381
0822
73081352119 12-11-
17 23773 0001928002678 10001 5184 ny nurhayati 31 th 1991 dr. Ferisa
6988
0853
63100944066
18 21514 0002722677693 4806 ny ramaiyah 59 4-6-1964 dr. Ferisa
40003
9345
0813
10003
2555
0831
63100941078 Ny Siti
20 6562 0002722704851 2355 38 th 1-7-1985 dr. Ferisa
50210 maisaroh
7006
63020654097 08235152 Ny 14-09-

21 29.085 0002722582214 49 th dr. Ferisa
30007 5289 Noorhasanah 1973
63100946086 06-08-
22 29.086 0002885215274 Ny Masniah 55 th dr. Ferisa
80004 1968
63100663100 08125016 26-08-

23 28.984 0002722590055 Tn Mamang 19 th dr. Ferisa
60001 0950 2004
63100629051 08578799 An Fajar 29-05-
24 13.757 0002849409461 6 th dr. Ferisa
7000 0478 Fadillah 2017
25
26
27
29
POLI UMUM
Pembiayaan
Status Status
Alamat Pendidikan JK
jl kodeco km
2.5 SMP P L B ✓
jl
Mulawarman - P B B ✓
lap 5 oktober SD L L L ✓
jl raya
SD L L L ✓
serongga
jl kampung
SD P L B ✓
baru
sungai hanau SD P L L ✓
Jl BB SMA P L B ✓
jl BB SMA L L L ✓
jl TP SMP P L L ✓
jl pasar
SD P L L ✓
ampera
jl
semea P L B ✓
kemakmuran
jl sarigadung - P B B ✓
sei dua rt 4 SD P L B ✓
jl kodeco SD P L L ✓
jl bb SMP L B B ✓
Jl usaha
SD P L L ✓
bersama
Jl H Antung Rt
SMP P B B ✓
8
Jl lapangan 5
SD P B B ✓
oktober rt 6
Jl Cendana Rt
SMA P B B ✓
08
Jl
belum
Transmigrasi L L L ✓ ✓
sekolah
Rt 11
✓
UM
Wkt Playan TTV
Terapi &
Tindakan D P TD RR Suhu
PCt,
CC ambroxol, 08.25 08.30 pelajar ✓ 23 36,5
vit c, ctm
Glibenkla
mid,
Metformi
n,
DM, Paraceta
neuropati, omeptazo 08.35 08.40 IRT ✓ 113/83 24 36,6
dyspepsia le,
antacid,
Vit B 12,
simvastati
n
Rujuk Poli
anak(ibu
pasien
Sup. Epilepsi minta 08.40 08.45 - ✓ 25 36,8
tunda)
PCT,
Diazepam
Amlodipin
,Nadic,O
HT meprazol 08.45 08.50 swasta ✓ 171/109 25 36,5
o,allopuri
nol
clozapine,
Skizofrenia HLP,Trihe 08.50 08.55 - ✓ 128/94 24 36,7
xipenidil
Metformi
n,ibuprof
en,amlodi
pinambro 09.00 09.05 ✓ 181/89 23 36,7
mamae ta
xol,antasi
d,Vit B12,
furosemid
pct,amox,
domperid
GEA 09.10 09.15 Pelajar ✓ 26 36,9
on,zink,or
alit
Rujuk Poli
Jiwa,
09.34 09.38 - ✓ 108/77 24
(F41.9) Ispa ,
flutrop,a
mox,Vit c
ibuprofen
faringitis 09.25 09.30 IRT ✓ 122/85 22 37
,Vit C
PCT,
lanzopraz
ol,antasid
Gastritis, Wiraswas
Hemoroid , anti 09.30 09.35 ta ✓ 134/80 24 36,5
hemoroid
,domperi
don
amlodipin
,
ibuprofen
HT ,omepraz 09.50 09.55 swasta ✓ 132/90 22 36,7
ol,Kalk,
Vit B
Comp
CPT,amlo
dipin,ibuy
HT, Konjungtivitis 09.55 10.00 IRT ✓ 221/130 24 36,5
profen,Vit
B12
allopurino
l,
HT,DyspepsiaHepe amlodipin
10.15 10.20 IRT ✓ 154/111 24 36,7
rurisemia
,antasid,V
it B12
antacid,p
Dyspepsia, ct,dompe
10.20 10.25 pelajar ✓ 24 36,6
Tonsilitis ridon,am
ox
pct,amox,
vit c,
Gastritis, OMA 1025 10.30 IRT ✓ 145/82 24 36,6
cloram
tetes
ambroxol,
noza,amo
ispa.ht 09.10 09.15 IRT ✓ 178/80 21 36,7
x,amlodip
in
ibuprofen
,ciproflox
Cephalgia acin,ome 10.14 10.19 IRT ✓ 146/104 24 35,8
prazol,he
mafort
furosemid
,amlodipi
Ht, CC n,pctamb 10.43 10.48 IRT ✓ 167/108 24 36,7
roxol,ctm,
vit c
Rujuk Poli
ppok 10.44 10.54 IRT ✓ 22 36,7
anak
amlodipin
HT, dyspepsia 10.42 10.47 IRT ✓ 196/111 22 36,7
,antacid,
Rujuk Ke
poli
bedah
RSUD
Obs Hematuria
DHAAN,H 10.15 10.25 IRT ✓ 115/97 24 36,6
susp BSK
yoscire,o
meperazo
le,Antasid
a
CTM,Keto
Dermatofilosis 10.50 11.00 IRT ✓ 155/88 24 36,7
konazole
Omepera
Syndrome
zole,Anta 10.40 10.50 SMA ✓ 126/83 24 36,7
Dispepsia
sida
ambroxol,
noza,Amo tidak
ISPA,Scabies 10.35 10.45 ✓ 26 38,3
ceb zalf
✓
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
Nadi TB BB Lab Penyakit Perdaraha an
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
82 165 56
GDS: 280
88 156 54 Chol : 220
AU : 4
104 13
GDS : 119
93 157 57
AU : 7.5
117 154 57
90 155 60
118 27
93 160 53
87 154 54
72 167 59
GDS : 117
84 148 43
AU : 5,8
100 151 90 GDS : 118
HB : 13.1
92 142 48
AU : 6.3
133 25
75 151 51
81 154 65
122 164 70
90 157 55
150 47
GDS : 100
77 156 53
AU : 6,2
82 141 41
73 153 67
82 150 55
107 17
ir
ah
ur
lL
m
U
Tg
1 17033 000192897703 6310095809090005 0823 3408 7718 wafa aisyah 14 th
2 6365 0001922748254 6310095002720008 0852 4848 5095 ny. St fatimah 51 th
3 24084 0002722623423 6310064605160004 0852 5100 0235 An. Hana Hamidah 7 th
4 25842 0002722635279 6310090806590005 0823 4205 0016 Tn. Masran 64 th
5 13352 0002520536242 6310090101910020 0853 8670 6516 Tn. M Syahlan 32 th
6 12658 0002824174168 6310095002550001 0852 5704 8421 Ny Siti Bahriah 68 th
7 26309 0002722578941 6310066601150009 0821 5205 1011 An. Nur aqila 8 th
8 25365 0001618207378 6310094803000012 0821 5509 1389 Nn Paridah Riyani 23 th
9 24631 0002254858571 6372045510960004 0813 2159 8712 Ny Tina wati 27 th
10 27354 0002164670425 3578121807830003 0851 0160 0567 Tn syahdan 40 th
11 16661 0002659955771 6310096812670004 0812 3696 2377 Tn sahribulan 56 th
12 26175 0002424302313 6310095708770002 0813 4808 6548 Ny normawati 46 th
13 24565 0002220634293 6310094102490001 0822 56686873 ny majuang 74 th

14 22772 ;0001922689844 6310065408130002 0812 5017 747 An. Nayra 10 th
15 24702 0002414353307 3578054712670001 0813 4799 9873 Ny marpuah 56 th
0858 44587
16 29083 0001929859694 6310104107730046 Ny jamirah 50 th
3381
17 23773 0001928002678 7308135211910001 0822 5184 6988 ny nurhayati 31 th
18 21514 0002722677693 6310094406640003 0853 4806 9345 ny ramaiyah 59
19 5921 0002069869048 6310092206110003 0813 5106 2555 An.Mrizky 12 th
20 6562 0002722704851 6310094107850210 0831 2355 7006 Ny Siti maisaroh 38 th
21 29.085 0002722582214 6302065409730007 082351525289 Ny Noorhasanah 49 th
22 29.086 0002885215274 6310094608680004 Ny Masniah 55 th
23 28.984 0002722590055 6310066310060001 081250160950 Tn Mamang 19 th
24 13.757 0002849409461 631006290517000 085787990478 An Fajar Fadillah 6 th
25
26
27
Nn Reina Najwah
29 29066 Umum 6310066106070003 083135411094 16 th
Juniarti
30 1718 0001079743331 6310094107660078 081348590395 Ny Umi Suwaibah 57 th

POLI UMUM
Status Status
r
hi

ur
La
Kunjungan Penyakit
Um
l
Tg
18-09-2009 dr. Rahmah jl kodeco km 2.5 SMP P L B
10-2-1972 dr. Ferisa jl nusa indah SD P L L
6-5-2016 dr. Rahmah jl Mulawarman - P B B
8-6-1959 dr. Ferisa lap 5 oktober SD L L L
1-1-1991 dr. Ferisa jl raya serongga SD L L L
10-2-1955 dr. Rahmah Jl sei belanak SMP P L L
26-1-2015 dr. Rahmah jl kampung baru SD P L B
8-3-2000 dr. Ferisa sungai hanau SD P L L
12-9-1996 dr. Rahmah Jl BB SMA P L B
18-7-1983 dr. Ferisa jl belibis S1 L L B
28-12-1967 dr. Rahmah jl BB SMA L L L
17-8-1977 dr. Rahmah jl TP SMP P L L
1-2-1949 dr. Ferisa jl pasar ampera SD P L L

14-2-2013 dr. Ferisa jl transmigrasi SD P L B
7-12-1967 dr. Ferisa jl kemakmuran semea P L B
1-7-1973 dr. Ferisa jl sarigadung - P B B
12-11-1991 dr. Ferisa sei dua rt 4 SD P L B
4-6-1964 dr. Ferisa jl kodeco SD P L L
22-6-2011 dr. Ferisa jl bb SMP L B B
1-7-1985 dr. Ferisa Jl usaha bersama SD P L L
14-09-1973 dr. Ferisa Jl H Antung Rt 8 SMP P B B
Jl lapangan 5 oktober
06-08-1968 dr. Ferisa rt 6 SD P B B
26-08-2004 dr. Ferisa Jl Cendana Rt 08 SMA P B B
belum
29-05-2017 dr. Ferisa Jl Transmigrasi Rt 11 L L L
sekolah
jl perum BHP Rt 3 Ds
21-6-2007 dr Ferisa SMP P B B
GB
Jl Kodeco Km 2,5 Ds
7/1/1966 dr Ferisa SMP P L L
Gunung Antasari
I UMUM

Umum BPJS SKTM D P
✓ CC PCt, ambroxol, vit c, ctm 08.25 08.30
DM, Hiperlipidemia, Glibenklamid, Metformin,

✓
neuropati, dyspepsia Paracetamol, omeptazole, 08.35 08.40
antacid, Vit B 12, simvastatin
✓ Sup. Epilepsi Rujuk Poli anak(ibu pasien

minta tunda) PCT, Diazepam 08.40 08.45
Amlodipin,Nadic,Omeprazol
✓ HT 08.45 08.50
o,allopurinol
✓ Skizofrenia clozapine, HLP,Trihexipenidil 08.50 08.55
Metformin,ibuprofen,amlodi
DM, HT, Abses
✓ pinambroxol,antasid,Vit B12, 09.00 09.05
mamae
furosemid
pct,amox,domperidon,zink,o
✓ GEA 09.10 09.15
ralit
Gangguan cemas Rujuk Poli Jiwa, Ambroxol,

✓ 09.34 09.38
(F41.9) Ispa flutrop,amox,Vit c
✓ faringitis ibuprofen,Vit C 09.25 09.30
PCT, lanzoprazol,antasid,
✓ Gastritis, Hemoroid 09.30 09.35
anti hemoroid,domperidon
amlodipin,
✓ HT ibuprofen,omeprazol,Kalk, 09.50 09.55
Vit B Comp
CPT,amlodipin,ibuyprofen,Vi
✓ HT, Konjungtivitis 09.55 10.00
tB12
✓ HT,DyspepsiaHeperuri allopurinol,
semia amlodipin,antasid,Vit B12 10.15 10.20
antacid,pct,domperidon,am
✓ Dyspepsia, Tonsilitis 10.20 10.25
ox
✓ Gastritis, OMA pct,amox,vit c, cloram tetes 1025 10.30
ambroxol,noza,amox,amlodi
✓ ispa.ht 09.10 09.15
pin
ibuprofen,ciprofloxacin,ome
✓ Cephalgia 10.14 10.19
prazol,hemafort
furosemid,amlodipin,pctamb
✓ Ht, CC 10.43 10.48
roxol,ctm,vit c
✓ ppok Rujuk Poli anak 10.44 10.54
✓ HT, dyspepsia amlodipin,antacid, 10.42 10.47
Rujuk Ke poli bedah RSUD

Obs Hematuria susp
✓ DHAAN,Hyoscire,omeperazo 10.15 10.25
BSK
le,Antasida
✓ Dermatofilosis CTM,Ketokonazole 10.50 11.00
✓ Syndrome Dispepsia Omeperazole,Antasida 10.40 10.50
ambroxol,noza,Amoxillin,sca
✓ ✓ ISPA,Scabies 10.35 10.45
biceb zalf
✓ Disminore Ibuprofen,ATS 11.35 11.40
✓ Dm Terapi Insulin Rujuk Poli Peny Dalam` 11.41 11.46

TTV
Pekerjaan KIE
pelajar ✓ 23 36,5 82 165 56
GDS: 280
IRT ✓ 113/83 24 36,6 88 156 54 Chol : 220
AU : 4
- ✓ 25 36,8 104 13
GDS : 119
swasta ✓ 171/109 25 36,5 93 157 57
AU : 7.5
- ✓ 128/94 24 36,7 117 154 57
Wiraswasta ✓ 181/89 23 36,7 90 155 60
Pelajar ✓ 26 36,9 118 27
- ✓ 108/77 24 93 160 53
IRT ✓ 122/85 22 37 87 154 54
Wiraswasta ✓ 134/80 24 36,5 72 167 59
GDS : 117
swasta ✓ 132/90 22 36,7 84 148 43
AU : 5,8
IRT ✓ 221/130 24 36,5 100 151 90 GDS : 118
IRT ✓ 154/111 24 36,7 92 142 48 HB : 13.1

AU : 6.3
pelajar ✓ 24 36,6 133 25
IRT ✓ 145/82 24 36,6 75 151 51
IRT ✓ 178/80 21 36,7 81 154 65
IRT ✓ 146/104 24 35,8 122 164 70
IRT ✓ 167/108 24 36,7 90 157 55
IRT ✓ 22 36,7 150 47
GDS : 100
IRT ✓ 196/111 22 36,7 77 156 53
AU : 6,2
IRT ✓ 115/97 24 36,6 82 141 41
IRT ✓ 155/88 24 36,7 73 153 67
SMA ✓ 126/83 24 36,7 82 150 55
tidak bekerja ✓ 26 38,3 107 17
SMP ✓ 124/90 22 36,6 92 158 53
SMP ✓ 138/73 22 36.7 100 162 67

Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
Penyakit Perdaraha an
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
ir
ah
ur
lL
Um
Tg
0823
00019289 63100958 18-09- dr. jl kodeco km
1 17033 3408 wafa aisyah 14 th
7703 09090005 2009 Rahmah 2.5
7718
0852
00019227 63100950 ny. St
48254 02720008 fatimah
5095
0852
00027226 63100646 An. Hana dr. jl
3 24084 5100 7 th 6-5-2016
0235
0823
35279 06590005
0016
00025205 63100901 0853 Tn. M jl raya

5 13352 8670 32 th 1-1-1991 dr. Ferisa
0852
00028241 63100950 Ny Siti dr.
6 12658 5704 68 th 10-2-1955 Jl sei belanak
8421
00027225 63100666 0821 jl kampung

7 26309 5205 An. Nur aqila 8 th 26-1-2015 dr.
78941 01150009 Rahmah baru
1011
0821
00016182 63100948 Nn Paridah
07378 03000012 1389 Riyani
00022548 63720455 0813

9 24631 2159 Ny Tina wati 27 th 12-9-1996 dr. Jl BB
58571 10960004 Rahmah
8712
0851
00021646 35781218
70425 07830003
0567
0812
00026599 63100968 Tn 28-12- dr.
11 16661 55771 12670004 3696 sahribulan 56 th 1967 jl BB
2377 Rahmah
0813
12 26175 00024243 63100957 4808 Ny 46 th 17-8-1977 dr. jl TP
6548
00022206 63100941 0822 jl pasar

34293 02490001 56686873 ampera
14 22772 ;0001922 63100654 0812 An. Nayra 10 th 14-2-2013 dr. Ferisa jl transmigrasi
689844 08130002 5017 747
00024143 35780547 0813 jl

15 24702 4799 Ny marpuah 56 th 7-12-1967 dr. Ferisa
53307 12670001 kemakmuran
9873
0858
00019298 63101041
59694 07730046
3381
0822
00019280 73081352 12-11-
17 23773 5184 ny nurhayati 31 th dr. Ferisa sei dua rt 4
02678 11910001 1991
6988
0853
00027226 63100944
18 21514 4806 ny ramaiyah 59 4-6-1964 dr. Ferisa jl kodeco
77693 06640003
9345
0813
00020698 63100922
69048 06110003
2555
0831
00027227 63100941 Ny Siti Jl usaha
20 6562 2355 38 th 1-7-1985 dr. Ferisa
Ny
00027225 63020654 08235152 14-09- Jl H Antung Rt
21 29.085 Noorhasana 49 th dr. Ferisa
82214 09730007 5289 1973 8
h
22 29.086 00028852 63100946 Ny Masniah 55 th 06-08- Jl lapangan 5

dr. Ferisa oktober rt 6
15274 08680004 1968
00027225 63100663 08125016 26-08- Jl Cendana Rt
90055 10060001 0950 2004 08
00028494 63100629 08578799 An Fajar 29-05- Jl Transmigrasi

09461 0517000 0478 Fadillah 2017 Rt 11
25
26
27
POLI UMUM
Status
Pendidik Status Terapi &
JK Kunjunga Diagnosis
an Penyakit Umum BPJS SKTM Tindakan D P
n
PCt, ambroxol,
SMP P L B ✓ CC 08.25 08.30
vit c, ctm
Glibenklamid,
DM, Metformin,
Hiperlipidemia, Paracetamol,
SD P L L ✓ 08.35 08.40
neuropati, omeptazole,
dyspepsia antacid, Vit B
12, simvastatin
Rujuk Poli
anak(ibu pasien
- P B B ✓ Sup. Epilepsi 08.40 08.45
minta tunda)
PCT, Diazepam
Amlodipin,Nadi
SD L L L ✓ HT c,Omeprazolo,a 08.45 08.50
llopurinol
clozapine,
SD L L L ✓ Skizofrenia HLP,Trihexipeni 08.50 08.55
dil
Metformin,ibup
rofen,amlodipi
DM, HT, Abses
SMP P L L ✓ nambroxol,ant 09.00 09.05
mamae
asid,Vit B12,
furosemid
pct,amox,domp
SD P L B ✓ GEA eridon,zink,oral 09.10 09.15
it
Rujuk Poli Jiwa,
Gangguan cemas Ambroxol,
SD P L L ✓
(F41.9) Ispa flutrop,amox,Vi 09.34 09.38
tc
SMA P L B ✓ faringitis ibuprofen,Vit C 09.25 09.30
PCT,
lanzoprazol,ant
Gastritis,
S1 L L B ✓ asid, anti 09.30 09.35
Hemoroid
hemoroid,dom
peridon
amlodipin,
ibuprofen,ome
SMA L L L ✓ HT prazol,Kalk, Vit 09.50 09.55
B Comp
CPT,amlodipin,i
SMP P L L ✓ HT, Konjungtivitis buyprofen,VitB 09.55 10.00
12
allopurinol,
HT,DyspepsiaHepe
SD P L L ✓ amlodipin,anta 10.15 10.20
rurisemia
sid,Vit B12
antacid,pct,do
SD P L B ✓ Dyspepsia, mperidon,amo
Tonsilitis 10.20 10.25
x
pct,amox,vit c,
semea P L B ✓ Gastritis, OMA 1025 10.30
cloram tetes
ambroxol,noza,
- P B B ✓ ispa.ht amox,amlodipi 09.10 09.15
n
ibuprofen,cipro
SD P L B ✓ Cephalgia floxacin,omepr 10.14 10.19
azol,hemafort
furosemid,amlo
SD P L L ✓ Ht, CC dipin,pctambro 10.43 10.48
xol,ctm,vit c
SMP L B B ✓ ppok Rujuk Poli anak 10.44 10.54

amlodipin,anta
SD P L L ✓ HT, dyspepsia 10.42 10.47
cid,
Rujuk Ke poli
bedah RSUD
Obs Hematuria
SMP P B B ✓ DHAAN,Hyoscir 10.15 10.25
susp BSK
e,omeperazole,
Antasida
SD P B B ✓ Dermatofilosis CTM,Ketokonaz 10.50 11.00

ole
Syndrome Omeperazole,A
SMA P B B ✓ 10.40 10.50
Dispepsia ntasida
belum ambroxol,noza,
L L L ✓ ✓ ISPA,Scabies Amoxillin,scabi 10.35 10.45
sekolah
ceb zalf
TTV Riwayat PT
Pekerjaan KIE Riwayat

Keluarga
pelajar ✓ 23 36,5 82 165 56
GDS: 280
IRT ✓ 113/83 24 36,6 88 156 54 Chol : 220
AU : 4
- ✓ 25 36,8 104 13
swasta ✓ 171/109 25 36,5 93 157 57 GDS : 119

AU : 7.5
- ✓ 128/94 24 36,7 117 154 57
Wiraswas
✓ 181/89 23 36,7 90 155 60
ta
Pelajar ✓ 26 36,9 118 27

- ✓ 108/77 24 93 160 53
IRT ✓ 122/85 22 37 87 154 54
Wiraswas
✓ 134/80 24 36,5 72 167 59
ta
GDS : 117
swasta ✓ 132/90 22 36,7 84 148 43 AU : 5,8
IRT ✓ 221/130 24 36,5 100 151 90 GDS : 118
HB : 13.1
IRT ✓ 154/111 24 36,7 92 142 48
AU : 6.3
pelajar ✓ 24 36,6 133 25
IRT ✓ 145/82 24 36,6 75 151 51
IRT ✓ 178/80 21 36,7 81 154 65
IRT ✓ 146/104 24 35,8 122 164 70
IRT ✓ 167/108 24 36,7 90 157 55
IRT ✓ 22 36,7 150 47

GDS : 100
IRT ✓ 196/111 22 36,7 77 156 53
AU : 6,2
IRT ✓ 115/97 24 36,6 82 141 41
IRT ✓ 155/88 24 36,7 73 153 67
SMA ✓ 126/83 24 36,7 82 150 55
tidak
✓ 26 38,3 107 17
bekerja
Riwayat PTM
Riwayat
Riwayat
Riwayat Pemeriksa
PTM Riwayat
Perdaraha an
( ≥ 15 Alergi
n IVA/Sada
th )
nis
ir
ah
ur
lL
Um
Tg
0823
00019289 63100958 18-09- dr. jl kodeco km
7703 09090005 2009 Rahmah 2.5
7718
0852
00019227 63100950 ny. St
48254 02720008 fatimah
5095
0852
00027226 63100646 An. Hana dr. jl
3 24084 5100 7 th 6-5-2016
0235
0823
35279 06590005
0016
00025205 63100901 0853 Tn. M jl raya

5 13352 8670 32 th 1-1-1991 dr. Ferisa
0852
00028241 63100950 Ny Siti dr.
6 12658 5704 68 th 10-2-1955 Jl sei belanak
8421
00027225 63100666 0821 jl kampung

7 26309 5205 An. Nur aqila 8 th 26-1-2015 dr.
78941 01150009 Rahmah baru
1011
0821
00016182 63100948 Nn Paridah
07378 03000012 1389 Riyani
00022548 63720455 0813

58571 10960004 Rahmah
8712
0851
00021646 35781218
70425 07830003
0567
0812
00026599 63100968 Tn 28-12- dr.
2377 Rahmah
0813
12 26175 00024243 63100957 4808 Ny 46 th 17-8-1977 dr. jl TP
6548
00022206 63100941 0822 jl pasar

34293 02490001 56686873 ampera
689844 08130002 5017 747
00024143 35780547 0813 jl

9873
0858
00019298 63101041
59694 07730046
3381
0822
00019280 73081352 12-11-
02678 11910001 1991
6988
0853
00027226 63100944
77693 06640003
9345
0813
00020698 63100922
69048 06110003
2555
0831
00027227 63100941 Ny Siti Jl usaha
20 6562 2355 38 th 1-7-1985 dr. Ferisa
Ny
00027225 63020654 08235152 14-09- Jl H Antung Rt
82214 09730007 5289 1973 8
h

15274 08680004 1968
00027225 63100663 08125016 26-08- Jl Cendana Rt
90055 10060001 0950 2004 08

09461 0517000 0478 Fadillah 2017 Rt 11
25
26
27
POLI UMUM
Status
n
PCt, ambroxol,
SMP P L B ✓ CC 08.25 08.30
vit c, ctm
Glibenklamid,
DM, Metformin,
SD P L L ✓ 08.35 08.40
12, simvastatin
Rujuk Poli
anak(ibu pasien
minta tunda)
PCT, Diazepam
Amlodipin,Nadi
llopurinol
clozapine,
dil
Metformin,ibup
rofen,amlodipi
DM, HT, Abses
mamae
asid,Vit B12,
furosemid
pct,amox,domp
it
Gangguan Rujuk Poli Jiwa,
Ambroxol,
SD P L L ✓ cemas (F41.9)
Ispa flutrop,amox,Vi 09.34 09.38
tc
PCT,
lanzoprazol,ant
Gastritis,
S1 L L B ✓ asid, anti 09.30 09.35
Hemoroid
hemoroid,dom
peridon
amlodipin,
ibuprofen,ome
B Comp
CPT,amlodipin,i
SMP P L L ✓ HT, buyprofen,VitB 09.55
Konjungtivitis 10.00
12
allopurinol,
HT,DyspepsiaH
eperurisemia sid,Vit B12
antacid,pct,do
x
pct,amox,vit c,
cloram tetes
ambroxol,noza,
n
ibuprofen,cipro
azol,hemafort
furosemid,amlo
xol,ctm,vit c

amlodipin,anta
cid,
Rujuk Ke poli
bedah RSUD
Obs Hematuria
susp BSK
e,omeperazole,
Antasida

ole
SMA P B B ✓ 10.40 10.50
Dispepsia ntasida
sekolah
ceb zalf
TTV Riwayat PT

Keluarga
pelajar ✓ 23 36,5 82 165 56
GDS: 280
IRT ✓ 113/83 24 36,6 88 156 54 Chol : 220
AU : 4
- ✓ 25 36,8 104 13
swasta ✓ 171/109 25 36,5 93 157 57 GDS : 119

AU : 7.5
- ✓ 128/94 24 36,7 117 154 57
Wiraswas
✓ 181/89 23 36,7 90 155 60
ta
Pelajar ✓ 26 36,9 118 27

- ✓ 108/77 24 93 160 53
IRT ✓ 122/85 22 37 87 154 54
Wiraswas
✓ 134/80 24 36,5 72 167 59
ta
GDS : 117
swasta ✓ 132/90 22 36,7 84 148 43 AU : 5,8
IRT ✓ 221/130 24 36,5 100 151 90 GDS : 118
HB : 13.1
IRT ✓ 154/111 24 36,7 92 142 48
AU : 6.3
pelajar ✓ 24 36,6 133 25
IRT ✓ 145/82 24 36,6 75 151 51
IRT ✓ 178/80 21 36,7 81 154 65
IRT ✓ 146/104 24 35,8 122 164 70
IRT ✓ 167/108 24 36,7 90 157 55
IRT ✓ 22 36,7 150 47

GDS : 100
IRT ✓ 196/111 22 36,7 77 156 53
AU : 6,2
IRT ✓ 115/97 24 36,6 82 141 41
IRT ✓ 155/88 24 36,7 73 153 67
SMA ✓ 126/83 24 36,7 82 150 55
tidak
✓ 26 38,3 107 17
bekerja
Riwayat PTM
Riwayat
Riwayat
Riwayat Pemeriksa
PTM Riwayat
Perdaraha an
( ≥ 15 Alergi
n IVA/Sada
th )
nis
ir
ah
ur
lL
Um
Tg
0823
00019289 63100958 18-09- dr. jl kodeco km
7703 09090005 2009 Rahmah 2.5
7718
0852
00019227 63100950 ny. St
48254 02720008 fatimah
5095
0852
00027226 63100646 An. Hana dr. jl
3 24084 5100 7 th 6-5-2016
0235
0823
35279 06590005
0016
00025205 63100901 0853 Tn. M jl raya

5 13352 8670 32 th 1-1-1991 dr. Ferisa
0852
00028241 63100950 Ny Siti dr.
6 12658 5704 68 th 10-2-1955 Jl sei belanak
8421
00027225 63100666 0821 jl kampung

7 26309 5205 An. Nur aqila 8 th 26-1-2015 dr.
78941 01150009 Rahmah baru
1011
0821
00016182 63100948 Nn Paridah
07378 03000012 1389 Riyani
00022548 63720455 0813

58571 10960004 Rahmah
8712
0851
00021646 35781218
70425 07830003
0567
0812
00026599 63100968 Tn 28-12- dr.
2377 Rahmah
0813
12 26175 00024243 63100957 4808 Ny 46 th 17-8-1977 dr. jl TP
6548
00022206 63100941 0822 jl pasar

34293 02490001 56686873 ampera
689844 08130002 5017 747
00024143 35780547 0813 jl

9873
0858
00019298 63101041
59694 07730046
3381
0822
00019280 73081352 12-11-
02678 11910001 1991
6988
0853
00027226 63100944
77693 06640003
9345
0813
00020698 63100922
69048 06110003
2555
0831
00027227 63100941 Ny Siti Jl usaha
20 6562 2355 38 th 1-7-1985 dr. Ferisa
Ny
00027225 63020654 08235152 14-09- Jl H Antung Rt
82214 09730007 5289 1973 8
h

15274 08680004 1968
00027225 63100663 08125016 26-08- Jl Cendana Rt
90055 10060001 0950 2004 08

09461 0517000 0478 Fadillah 2017 Rt 11
25
26
27
POLI UMUM
Status
n
PCt, ambroxol,
SMP P L B ✓ CC 08.25 08.30
vit c, ctm
Glibenklamid,
DM, Metformin,
SD P L L ✓ 08.35 08.40
12, simvastatin
Rujuk Poli
anak(ibu pasien
minta tunda)
PCT, Diazepam
Amlodipin,Nadi
llopurinol
clozapine,
dil
Metformin,ibup
rofen,amlodipi
DM, HT, Abses
mamae
asid,Vit B12,
furosemid
pct,amox,domp
it
Gangguan Rujuk Poli Jiwa,
Ambroxol,
SD P L L ✓ cemas (F41.9)
Ispa flutrop,amox,Vi 09.34 09.38
tc
PCT,
lanzoprazol,ant
Gastritis,
S1 L L B ✓ asid, anti 09.30 09.35
Hemoroid
hemoroid,dom
peridon
amlodipin,
ibuprofen,ome
B Comp
CPT,amlodipin,i
SMP P L L ✓ HT, buyprofen,VitB 09.55
Konjungtivitis 10.00
12
allopurinol,
HT,DyspepsiaH
eperurisemia sid,Vit B12
antacid,pct,do
x
pct,amox,vit c,
cloram tetes
ambroxol,noza,
n
ibuprofen,cipro
azol,hemafort
furosemid,amlo
xol,ctm,vit c

amlodipin,anta
cid,
Rujuk Ke poli
bedah RSUD
Obs Hematuria
susp BSK
e,omeperazole,
Antasida

ole
SMA P B B ✓ 10.40 10.50
Dispepsia ntasida
sekolah
ceb zalf
TTV Riwayat PT

Keluarga
pelajar ✓ 23 36,5 82 165 56
GDS: 280
IRT ✓ 113/83 24 36,6 88 156 54 Chol : 220
AU : 4
- ✓ 25 36,8 104 13
swasta ✓ 171/109 25 36,5 93 157 57 GDS : 119

AU : 7.5
- ✓ 128/94 24 36,7 117 154 57
Wiraswas
✓ 181/89 23 36,7 90 155 60
ta
Pelajar ✓ 26 36,9 118 27

- ✓ 108/77 24 93 160 53
IRT ✓ 122/85 22 37 87 154 54
Wiraswas
✓ 134/80 24 36,5 72 167 59
ta
GDS : 117
swasta ✓ 132/90 22 36,7 84 148 43 AU : 5,8
IRT ✓ 221/130 24 36,5 100 151 90 GDS : 118
HB : 13.1
IRT ✓ 154/111 24 36,7 92 142 48
AU : 6.3
pelajar ✓ 24 36,6 133 25
IRT ✓ 145/82 24 36,6 75 151 51
IRT ✓ 178/80 21 36,7 81 154 65
IRT ✓ 146/104 24 35,8 122 164 70
IRT ✓ 167/108 24 36,7 90 157 55
IRT ✓ 22 36,7 150 47

GDS : 100
IRT ✓ 196/111 22 36,7 77 156 53
AU : 6,2
IRT ✓ 115/97 24 36,6 82 141 41
IRT ✓ 155/88 24 36,7 73 153 67
SMA ✓ 126/83 24 36,7 82 150 55
tidak
✓ 26 38,3 107 17
bekerja
Riwayat PTM
Riwayat
Riwayat
Riwayat Pemeriksa
PTM Riwayat
Perdaraha an
( ≥ 15 Alergi
n IVA/Sada
th )
nis
Hari/ Tanggal : Jumat,28 Juli 2023
Petugas :Anton, Totok, Erni, Sumarning
ir
ah
ur
lL
Um
Tg
an. Devka
00027225 63100608 8 okt jl banyuwangi
1 19387 90339 10170001 tdk ada putra 6 th 2017 dr ferisa rt 17 TP
prayitno
2 22682 00022641 63030258 08215370 ny riska 25 th 18 agst jl BB bersujud

dr ferisa rt 9
45085 08960003 7323 agustina 1998
tdk ada 62020810 08134711 Tn M

10-09- jl pasar
3 28786 38 th dr rahma ampera rt 4 TP
09840002 5867 suhaimi 1984
00027380 63100909 08310426 jl nurul yakin

4 29087 an M amin 13 th 9-6-2010 dr ferisa
52191 06100004 9669 sejaterah
00019613 63100901 08224398 an darius jl banyuwangi

5 15631 gerardo 13 th 1-6-2010 dr rahma
67186 06100004 8135 rt 7 TP
stmorang
00023705 63100630 08578734 tn hestino 30 agst jl transmigrasi

6 15340 23 th
48114 08980002 367 akbar 1996 dr rahma rt 9 baroqah
00022206 63100964 08125104 24-10-

7 28751
21287 10700002 4912 ny mardiah
53 th dr rahma jl kediri rt 6 TP
1970
00019227 63100904 08235441 04-06- jl mangga rt 2

8 19166
81069 06520004 7537 Tn amron
71 th dr rahma bersujud
1952
00008955 tdk di 08133120 jl banyuwangi
9 17261 tn nur aslam 59 th 12-8-1965 dr rahma
34029 tulis 2771 rt 7 TP
jl raya
00029080 63100953 08214982
10 5323 ny Jumiati 39 th 13-2-1982 dr rahma serongga rt 4
07605 12830003 0012
GB
00015461 63100661 08539848

11 505 an siti aisyah 10 th 21-3-2013 dr rahma jl prov rt 10
08187 03130001 5361 TP
00027226 63100958 08214881 ny siti

12 27052 33075 09810004 1082 hamidah 40 th 18-9-1981 dr rahma Jl. Senada rt 1
00028241 63100905 Jl. PNPM

13 21176 Tidak Ada Ny Siarah 62 th 5-9-1961 dr rahma
7429 09610002 RT.18
00008959 63100912 09134960 Jl. Lapangan 5

14 15252 84209 07720005 1477 Tn. Arsuni 51 th 1-12-1971 dr. Ferisa Okt RT.6
15 27871 27226361 63100950 Tidak Ada Ny. 43 th 10-6-1980 dr. Ferisa Jl. Provinsi
06800014 Normayanti RT.6
16 22344 00014521 63100922 08125067 Tn. Fahri Rija 43 th 22-1-1977 dr. Ferisa Jl. Insgub
53262 01770004 762 Rahim
Non 63100942 08525102 Ny. Nur Jl. Lapangan 5

17 18822 AKTIF 02680004 1699 Aminah 52 th 02-2-1968 dr. Rahma Okt RT.6
20268 00019288 63100921 08314222 Ny. Dahlia

Jl. Pasar
18 50 th 5-3-1969 dr. Rahma
63675 01900001 1436 Ampera
POLI UMUM
:
Status
Pendidik Status
JK Kunjunga Diagnosis Terapi & Tindakan
an Penyakit Umum BPJS SKTM D P
n
npza,ambroxol,d
examethasone,a
TK L B B ✓ urtikaria,ispa moxicilin,salicilk 08.15 08.20
talk
sundrome
smp P L L ✓ dispepsia, omz,antasid,diaz
epam 09.00 09.05
insomnia
ibuprofen,omz,a
dyspepsia
smp L B B ✓ ntasid,domperid 08.55 09.00
syindrom
one, vit b komp
paracetamol,
SD L B B ✓ FARINGITIS amoxicilin,vit b 09.00 09.05
comp
asam
SD L L L ✓ dressing luka mefenamat, 08.12 09.18
amoxicilin
ibuprofen,
SMK L L L ✓ comond cold ambroxol,ctm, 09.10 09.10
ctm,vit c
metformin,
glimepirid,
SMA L L L ✓ DM type 2 09.20 09.25
omz,ibuprofen,
vit b 12
captopril,amlodi
pin,pct
HT grade
SD L L L ✓ bethasistin,antas 09.52 09.30
2+vertogo
id,
betamethasone
clozapine,Trihex
SMP L L L ✓ skizofrenia yphenidyl,Trifluo 08.25 08.30
perazine
ibuprofen,
HT grade
ambroxol,amlodi
SD P L L ✓ 2+commond 08.35 08.40
pin,omz,vit b
cold
comp
ibuprofen, ctm,
TK P B B ✓ commond cold 08.40 08.45
ambroxol,vit c
furosemide,
ht grade 2 + amlodipin,pct,
SD P L L ✓ insomnia diazepam,vit b 09.45 09.50
comp
Omeprazole,
Syndrom
antasida, NAC,
SD P L L ✓ Dispepsia, CC, 08.45 08.50
Cetirizine,
HT Amlodipin
Amlodipin,
HT, Ibuprofen,
SD L L L ✓ Hiperlipidemia Simvastatin, Vit. 08.50 08.55
B12
Amlodipin,
SD P L L ✓ HT, ISPA Ambroxol, Noza, 08.55 09.00
amoxilin, Dexa,
ISPA, HT, Codein,

D3 L L L ✓ Neuropati DM, Amoxilin, Noza,
DM dengan Amlodipin,Vit C, 09.00 09.05
Therapy Insulin Teruskan Insulin
pct,
bethahistine,
SD P L L ✓ CC, Vertigo Ambroxol, 09.35 09.40
Amoxilin, Vit
Bcom
Rujuk SP.M
HT gr II, LBP, RSUD,
Ibuprofen,
SLTP P L L ✓ Post Op 09.40 09.45
Captopril,
Katarak
Amlodipin, Vit
BC, Antasida
TTV Riwayat P

Keluarga
tdk bekerja ✓ 26 36,6 101 115 19
IRT ✓ 110/74 21 36,7 112 159 62
pedagang ✓ 134/91 21 36,8 67 160 65
pelajar ✓ 26 36,7 102 152 40
pelajar ✓ 26 36,8 102 16 42
wiraswasta ✓ 124/83 21 36,7 81 167 67
IRT ✓ 129/79 22 36,6 86 146 49
tdk bekerja ✓ 165/83 22 36,7 68 155 60

tdk bekerja ✓ 114/69 23 36,5 69 161 63
IRT ✓ 161/109 22 36,5 97 160 70
pelajar ✓ 26 36,7 102 128 23
IRT ✓ 166/109 22 36,7 102 158 63 HT
IRT ✓ 167/102 21 36,7 74 148 53
GDS :
110,
wiraswasta ✓ 158/95 21 36,7 64 160 59 Chol :261,
AU : 4,6
IRT ✓ 149/90 21 36,7 82 144 32 gds : 85, HT,DM

HB : 12,5
swasta ✓ 136/88 23 36,7 82 164 75
IRT ✓ 118/73 23 36,2 83 156 42
IRT ✓ 167/116 21 36,6 72 149 65

Riwayat PTM
Riwayat
Riwayat
Riwayat Pemeriksa
PTM Riwayat
Perdaraha an
( ≥ 15 Alergi
n IVA/Sada
th )
nis
DM type
2
HT
HT
HT
HT
HT
DM
HT
+- Hari/ Tanggal : Sabtu,29 Juli 2023
Petugas :imelda,erni,jumairiah,widya
1 28.442 0001922802434 6310090212830003 083150401642
2 19.767 0001881722417 6310066308150002 083150401642
3 18.106 0002722705299 6310091607650004 081254549771
4 18.106 Tidak ada di status 6310095801800004 081254549771

5 28.287 Umum 3515122205550002 Tidak ada
6 20.785 Umum 7310062810110001 085219472546
7 21.159 0001928348188 6310091805900006 081348161501
8 28.936 Tidak ada di status 6310092001740007 081350424942
9 29.088 Umum 6310094802060007 083128626957

10 25.973 0002722705852 610096505760002 081251940513
11 29.049 0002278642443 6310090102580004 083159609990
12 29.089 Umum Tidak ada KK 085251566630
13 10.145 0002220178937 6310091903560002 082299542545

14 19.308 00027226780011 6310095507680011 Tidak ada
15 26.472 0001928761931 6310091308970002 082156394113
16 11.347 0002728801237 6310094908650002 082154138124
17 11.347 0002738801092 6310092909580002 082154138124
18 1.320 10.56'0002722841818 Tidak ada KK 081349779291
19 27.887 Umum 6310090509630002 081251773448

20 15.866 000201435849 631006911770001 081331566054
21 24.582 Umum 6310091507890003 085246634892
22 24.353 0003054576914 6302064804000003 085787459350

POLI UMUM
Status
ir
ah
Nama Dokter Alamat Pendidikan JK
ur
Kunjungan
lL
m
U
Tg
RT.13
Tn.Rustam Ipansyah 39 th 2-12-1983 dr.Rahmah Bersujud SMA L L
Jl.Kersik
An.Atika Raudatul Jannah 8 th 23-8-2015 dr.Rahmah SD P L
Putih RT.7
Tn.Bangun Napitupulu 58 th 16-7-1965 dr.Rahmah RT.2 GB SMA L L
Ny.Linda Sinabatur 43 th 18-1-1980 dr.Rahmah RT.2 GB - P L

Tn.Subantu 68 th 22-5-1955 dr.Rahmah RT.15 TP SMP L L
An.Resky Aditiya 12 th 28-10-

2011 dr.Rahmah RT.4 GB SMP L B
Tn.A Imam Safi'i 33 th 18-5-1990 dr.Rahmah RT.1 TP MA L B
Tn.Ihsan 49 th 20-1-1974 dr.Rahmah RT.2 TP SD L L
An.Aliyya Raudah Natasya 17 th 8-2-2006 dr.Rahmah RT.7 TP MTs P B

Ny.Marlina 47 th 25-5-1976 dr.Rahmah RT.8 GB SD P L
Tn.Nanang Rusmani 65 th 1-2-1958 dr.Rahmah Gg.Mawa - L L

r RT.9 TP
RT.4
An.A Darul Ikhsan 13 th 6-3-2010 dr.Rahmah Bersujud SMP L B
Tn.Sanib 65 th 19-3-1956 dr.Rahmah RT.10 GA SMP L L

Jl.Mahaka
Ny.Suwarti 55 th 15-7-1968 dr.Rahmah m RT.11 TK P L
Bersujud
Tn.Riyan 16 th 13-8-1997 dr.Rahmah RT.10 GB SMK L B
Ny.Karsinem 58 th 9-8-1965 dr.Rahmah RT.15 TP SMA P B
Tn.Sutrisna 64 th 29-9-1958 dr.Rahmah RT.15 TP STM L B
28-10- RT.14
An.M Abid Pemuda A 6 th dr.Rahmah Bersujud - L B
2016
RT.13
Tn.Nawir 60 th 5-9-1963 dr.Rahmah Bersujud SD L L
29-11- Perum
Ny.Eva Sulistyowati 46 th dr.Rahmah Pelita S1 P B
1977
Tn.M Jani 37 th 15-7-1986 dr.Rahmah RT.10 BTL Diploma L L
Ny.Pika Nor A 23 th 8-4-2000 dr.Rahmah RT.7 GA - P L

UMUM
:
Status Terapi &

Penyakit Umum BPJS SKTM Tindakan D P
Cetrizine,
Ibuprofen
Dermatiti Wiraswas
L ✓ s , 08.42 08.52 ta ✓
Betameta
sone zalf
Obs.Febri Ibuprofen
B ✓ , Novakid 08.52 09.02 Pelajar ✓
s H1
zyr
Kotrimoks
asole,
GEA Omepras
Wiraswas
B ✓ tanpa ole, PCT, 08.37 08.45 ✓
ta
dehidrasi Hyocine,
Amlodipin
e, Bcomp
Nadic,
Omepras
HT+Hiper ole,
L ✓ kolesterol Amlodipin 08.43 08.53 IRT ✓
emia e,
Simvastati
n, Kalk
Furosemi
de,
Amlodipin
HT
e,
urgency + Wiraswas
L ✓ Ambroxol 09.07 09.17 ✓
Asma ta
,
bronkhial
Salbutam
ol, Amox,
Ibuprofen
Ciprofloxa
cin,
VL +
B ✓ Common Ibuprofen 09.12 09.22 Pelajar ✓
,
cold
Ambroxol
, VitC
Ibuprofen
Haemoroi ,
Metronda
d gr II + sole, VitC, Wiraswas
B ✓ 09.30 09.40 ✓
Abses ta
Anti
femoralis haemoroi
d supp
Omepras
TB on ole,
treatment Domperid Wiraswas
L ✓ 09.42 09.52 ✓
+ oen, PCT, ta
dispepsia Hyocine,
Bcomp
Ciprofloxa
cin,
Susp.Thyp Ibuprofen
B ✓ 09.55 10.l05 Pelajar ✓
oid fever ,
Omepras
ole, VitC
Captopril,
Amlodipin
e,
Simvastati
HT gr II +
n,
L ✓ Dislipide 09.40 09.50 IRT ✓
Ibuprofen
mia
,
Omepras
ole,
Bcomp
Rujuk poli
penyakit Wiraswas
B ✓ CAD 09.50 10.00 ✓
dalam ta
RSMP
wound
dressing,
vulnus Asmef,
B ✓ ekskoriat Amox, 09.55 10.05 Pelajar ✓
um VitC,
Gentamici
n zalf kulit
Captopril,
Amlodipin
HT
e,
urgency +
stenosis Omepras Wiraswas
L ✓
lumbal + ole, 10.05 10.15 ✓
ta
Ibuprofen
dispepsia
sindrom , Kalk,
Trombop
hob gel
Captopri;l
,
Amlodipin
e,
Ibuprofen
,
HT gr II +
L ✓ Antasida, 10.10 10.20 IRT ✓
Katarak
Bcomp,
Sarankan
ke poli
mata
RSUD
DHAAN
Ibuprofen
Obs febris , VitC,
B ✓ 10.35 10.45 Pelajar ✓
H1
Antasida
Rujuk poli
penyakit
B ✓ Gerd 10.20 10.30 IRT ✓
dalam
RSMP
Rujuk poli
penyakit
LBP ec Wiraswas
B ✓ saraf 10.31 10.41 ✓
Susp HNP ta
RSUD
DHAAN
Ibuprofen
Common , CTM,
B ✓ 10.45 10.55 Pelajar ✓
cold Ambroxol
, VitC
Metformi
n,
DM tipe II
Glimepiri
+
de,
Hiperglike Wiraswas
L ✓ Captopril, 10.56 11/.06 ✓
mia + ta
Neuropat Ibuprofen
,
y
Omepras
ole, B12
Rujuk poli
mata
B ✓ Ambyopia 11.05 11.10 Swasta ✓
RSUD
DHAAN
VL + aff Kary.hono
B ✓ Common 10.30 10.40 ✓
hecting rer
cold
post op
wound
B ✓ kista 10.50 10.55 IRT ✓
dressing
ganglion
TTV Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga
th )
124/99 22 36,7 92 159 57 - - - -
- 24 36,7 - 119 18 - - - -
153/93 22 36,8 110 162 66 - - - -
AU:5,5 ;
140/92 22 36,6 76 153 97 - -
Chol:232
194/111 22 35,6 69 161 71 - - - -
- 24 36,7 - 147 44 - - - -
141/93 24 36,5 97 170 87 - - - -
110/70 25 36,4 131 155 37 GDP:64 - - -
125/84 22 36,5 72 157 75 - - - -

GDS:108 ;
156/113 24 36,6 76 151 63 Chol:250 ; - - -
AU:6,6
142/77 24 36,5 65 163 65 - - - -
- 22 36,5 - 166 80 - - - -
193/115 22 36,9 130 165 67 - - - -

176/109 24 36,7 76 152 44 - - - -
137/93 22 36,8 87 165 59 - - - -
153/91 24 36,6 78 155 55 - - - -
148/84 22 36,7 94 163 62 - - - -
- 24 36,7 - 112 20 - - - -
GDS:316 ;
152/87 22 36,6 91 155 80 - - -
AU:7,7
131/93 22 36,5 90 158 72 - - - -
132/95 22 36,6 85 172 76 - - - -
97/73 22 36,8 96 164 57 - - - -

Riwayat PTM
Riwayat
Riwayat Pemeriksa
Perdaraha an
n IVA/Sada
nis
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
+- Hari/ Tanggal : Senin,31 Juli 2023
Petugas :Bertha, Etty,Widya
1 535 0002722561569 6310090305940003 Tidak Punya
2 4371 0001406244981 6310061911120003 081255489339
3 4371 Umum 6310092709110007 081255489339
4 28889 0000398051346 3202185682910007 082298006654
5 17518 0002722635865 6310095111730001 081350452494
6 287 0002739138265 6310096111780002 085820555423
7 19863 0003049369644 6310094510720006 085845278307
8 25326 0002722710914 6310094708880008 081350059665
9 26786 0000894237085 6310095506620002 Tidak Punya
10 18791 0003051189314 6310091210590003 081348191967
11 6349 0002722723942 6310091008680012 085248260484
12 693 0000012263376 6310096504520003 082153118901
13 27294 0000894949312 6310096904000002 082255403756

14 29091 0002440728674 1804185006940001 089532736080
15 29055 0002721250754 6310091708650006 Tidak Punya
16 22.640 0002196412053 6310062702150002 082357626666
17 22.793 0002673061079 6310090204880012 082158369377
18 27.768 Umum 6308051511870003 082268635966
19 076 0001928864621 6310066107100001 085849740255
20 28.099 0002722925248 6310092506770002 088515866477
21 25.540 0002694135976 6310094906920003 082152234547
22 26. 607 0002776493136 3504074802900001 081210625874
16 22.253 0001932131979 6310094312910002 081347237180
17 26.022 0002722838411 6310090503040002 082153906862
18 28.991 0002722552929 6310060307020006 081253483501
19 26.969 0002936354488 6310060711630004 Tidak Ada
20 18.040 0002824175722 6310096110890001 083847298424
21
22
POLI UM
UGD: Abdilah
ir
ah
Nama Dokter Alamat Pendidikan
ur
lL
m
U
Tg
Jl Pada Idi Rt 9 Ds
Zainudin 27 th 3/5/1994 dr.Ferisa SD
Sejahtera
Jl Lap 5 Okt Ds
An Riski maulana 11 th 19/11/2012 dr.Rahmah Bersujud SD
Jl Lap 5 Okt Ds
An Syahril Maulana 12 th 27/9/2011 dr.Rahmah Bersujud SD
Jl Perum Alif Azhar Rt 1

Ny Wulan Febriani 32 th 16/2/1991 dr.Ferisa Ds GB SLTA
Ny Sulis Amaroh` 49 th 11/11/1973 Jl Lap 5 Okt Rt 5 Ds SMP

dr.Ferisa Bersujud
Ny Hadijah 44 th 21/11/1978 Jl Perjuangan Rt 7 Kel SMP

dr.Rahmah TP
Ny Zalekha 51 th 5/10/1972 dr.Rahmah Jl Pasar Sabtu Rt 19 TP SD
Jl Usaha Bersama Ds
Ny Maryana 35 th 7/8/1988 dr.Rahmah GB SD
Ny Nor bahriah 61 th 15/6/1962 dr.Ferisa Jl BB Rt 9 Ds Bersujud SD
Tn sugianor 63 th 12/10/1959 dr.Rahmah Jl TP Rt 7 Kel TP SD
Tn M Chairullah 55 th 10/8/1968 Jl Raya Serongga Km 7

dr.Ferisa SMP
Rt 5 Ds GB
Ny St Hadijah 70 th 25/4/1952 dr.Rahmah Jl BB Rt ( Ds Bersujud SD
Pasar Ampera Rt 2 Kel

Ny Maulida 22 th 29/7/2000 dr.Ferisa SMK
TP
Jl banyuwangi Rt 3 Ds
Ny Lala Tiara wati 29 th 10/6/1994 dr.Ferisa SMA
GA
Jl Hidayah Gg Kelapa 2
Tn Hakim 58 th 17/8/1965 dr.Rahmah Rt 7 Ds Bersujud SD
An.M Fahry 8 th 27-2-2015 dr.Ferisa RT.6 GA SD
Tn.Suriyansyah 35 th 2-4-1988 dr.Rahmah Jl.Gema Citra SD
Tn.Ifaryansyah 35 th 15-11-1987 dr.Rahmah Jl.Banyuwangi RT.7 GA SD
An.Anggita Ayu Nur Sholeha 13 th 21-7-2010 dr.Rahmah Jl.Perjuangan RT.1 TP SD
Tn.Rusmani 46 th 25-6-1977 dr.Rahmah Gg.Bersama RT.3 TP SD
Ny.Suryani 31 th 29-6-1992 dr.Ferisa Jl.BB RT.8 SLTP
Ny. Rina Lestari 33 Th 08-02-1990 dr.Ferisa Jl. Mulawarman RT.05 S2
Ny. Mega Nanda 32 Th 06-03-1991 dr.Rahmah Jl. Kediri RT.16 SMA
Tn. M. Saleh 19 Th 05-03-2004 dr.Rahmah Jl. Singosari RT.15 /TP SMK
Tn. Ragil Mulia 21 Th 03-07-2002 dr.Ferisa Gg. Mulia RT.01/ TP SMK
Tn. Achmad Saini 60 Th 07-11-1963 dr.Ferisa Jl. Ketapi RT.05/ DB SD
Jl. Lapangan 5 Oktober

Ny. Muslimah 34 Th 21-10-1989 dr.Ferisa SD
RT.05/DB
POLI UMUM
:
Pembiayaan
Status Status
JK Diagnosis Terapi & Tindakan
L B B ✓ Serumen Prop AS Phenol Gliserol,Asmef
ibuprofen,amok,Ambr
P B B ✓ CC+Limfodenitis
oxol,Vit C
PCT,Ambroxol,CTM,Vit
L B B ✓ CC
C
P B B ✓ Cefalgia Ibuprofen,Hemafort
Glimepirid,Metformin,
P L L ✓ DM Type II + Susp Amlodipin,Omeprazole
Ulkus Peptik+ HT
,ATS
Metformin,Amlodipin,
P L L ✓ DM Type II +HT Gr II + Simvastatin,B12,ibupro
Kolik abdomen
fen,hiosin,omeprazole
DM type II dgn insulin

P L L ✓ Rujuk Poli Peny dalam
+HT
P B B ✓ Frozen Shoulder` Ibuprofen,Bcomp,ATS
P L L ✓ HT Amlodipin
Post op Ekstripasi
L B L ✓ Dressing,Ganti perban
ptergium
Amlodipin,Simvastatin,
L L L ✓ HT+Hyperlipidemia Nadik,Bcomp
PCT,Omeprazole,ATS,A
P L L ✓ HT Gr I +Dyspepsia mlodipin,Bcomp
Ambroxol,Cetririzine,A
P` B B ✓ ISPA
mok,PCT
Ambroxol,Noza,Amok,
P B B ✓ ISPA
ATS
Metformin,Captopril,A
DM type II + Ht
L B B ✓ mlodipin,PCT,Omepraz
Urgency ole,B12
Diare akut tanpa Zinc, PCT,

L B B ✓ Kotrimoxasole,
dehidrasi
Domperidone
Rujuk poli jiwa RSUD

DHAAN, PCT,
L L L ✓ Common cold + F41.9
Ambroxol, Amox, CTM,
VitC
Cek TCM, Ambroxol,

L B B ✓ Susp.TB dd bronkhitis PCT, VitC
PCT< Ambroxol, Amox,

Common cold +
P L B ✓ CTM, VitC, Gentamicin
Konjungtivitis viral
eye drop
Febol glicerol, PCT,

L B B ✓ Serumen obsturans
Kontrol 3 hari lagi
Neuropati, susp kista
P B B ✓ ganglion Nadic, B12
P L L ✓ Episode Depresi dgn Rujuk Poli Jiwa RSUD

Tentamen Suicide DHAAN , Vit BC
P B B ✓ ISPA Ambroxol, PCT,

Amoxilin, Vit BC
Rujuk Poli Orthopedi

L B B ✓ Malunion Fracture
(Tunda Minggu depan)
L B B ✓ Scabies Cetirizin, Scabimed
L B B ✓ HT Urgency Amlodipin, Captropil
Anemia, Syndrom Betahistin, Antacida,

P B B ✓
Dispepsia Hemafort
✓
✓
Wkt Playan TTV
Pekerjaan KIE
D P TD RR Suhu Nadi TB BB
08.42 08.52 Wiraswasta ✓ 152/104 26 36,7 96 163 50
Tidak
08.52 09.02 ✓ 26 36,6 96 128 36
Bekerja
Tidak
08.37 08.45 ✓ 24 36,6 88 138 31
Bekerja
08.43 08.53 IRT ✓ 143 26 36,7 84 156 69
09.07 09.17 IRT ✓ 142/89 24 36,6 81 149 52
09.12 09.22 IRT ✓ 138/100 24 36,6 69 154 60
09.30 09.40 IRT ✓ 141/88 24 36,4 104 150 49
09.42 09.52 IRT ✓ 171/101 24 36,8 109 156 61
09.55 10.l05 IRT ✓ 168/108 18 36,5 92 153 88
09.40 09.50 Wiraswasta ✓ 14/100 24 36,7 98 160 70
09.50 10.00 Wiraswasta ✓ 162/102 24 36,7 92 160 65
09.55 10.05 IRT ✓ 129/870 24 36,7 79 154 52
10.05 10.15 Swasta ✓ 118/98 24 36,8 123 148 49

10.10 10.20 IRT ✓ 124/86 24 36,5 81 153 65
10.35 10.45 Wiraswasta ✓ 187/96 24 36,7 87 164 70
10.22 10.27 Pelajar ✓ - 26 36,9 96 128 24
10.46 10.52 Swasta ✓ 95/71 24 36,7 83 164 71
1027 10.32 Wiraswasta ✓ 108/70 24 37,4 134 159 45
10.45 10.50 Pelajar ✓ 87/69 24 36,7 82 152 35
10.47 10.52 Wiraswasta ✓ 141/102 24 36,5 73 - 95
10.38 10.43 IRT ✓ 125/87 24 36,8 71 142 40
10.50 10.55 IRT ✓ 118/84 24 36,6 86 159 61
10.20 10.25 IRT ✓ 120/90 26 36,6 83 - 79
10.31 10.36 Pelajar ✓ 112/71 24 36,8 72 - 48
10.45 10.55 Wiraswasta ✓ 143/131 24 36,7 97 160 45
11.35 11.40 Wiraswasta ✓ 190/127 23 36,5 105 - 73
11.05 11.10 IRT ✓ 115/83 26 36,7 85 143 50
10.30 10.40 ✓
10.50 10.55 ✓
Riwayat PTM
Riwayat
Riwayat
PTM Riwayat
( ≥ 15 Alergi
Keluarga n IVA/Sada
th )
nis
- - - - -
- - - - -
- - - - -
HB:11,5
Chol:178 - - - -
HB: 12,8 - - - - -
GDP: 358
- - - - -
- - - - -
GDS:113,
Kol:176 - - - - -
AU:3,3
- - - - -
- - - - -
GDS:108
Chol:208 - - - - -
AU:5,1
- - - - -
- - - - -
- - - - -
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- - - - - -
- - - - -
- - - - -
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Register Poli Umum Agustus 2023

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Register Poli Umum Agustus 2023

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Hari/ Tanggal : Selasa, 01 Agustus 2023

Petugas : Imelda, Ety,Widya

No Register No BPJS NIK No Telpon

1 17.707 0001971296763 6310066027900001

2 10.851 Tdk ada 6310092012610001 081295836107

3 29.094 00016798972953 6310091907820005 082154659591

4 26.585 0002722640995 631009410770179 085391712650

5 29.095 Umum 6310094805810006 081349625247

6 29.096 Non aktif 6302181704880001 081348746890

7 28.710 0001847821533 6302180609930001 085754318106

8 29.097 0002722829062 6310065206110001 082152713560

9 16.790 0002722622962 6310090707610002 tdk ada

10 13.400 0001807008265 6310094502660005 085249931946

11 10.905 0002722598954 6310066604140004 085753173261

13 27.354 faskes lain 3578125201090001 085101600567

14 6189 0002520856506 6310094107650115 082149820021

15 28.105 TDK ada 6310094506680006 082155053833

16 13.554 0001928864654 6310095505630006 085751481095

17 22.576 0000206467108 6310091902830004 081348537247

19 18.616 0002722634109 6310093009650003 085246036996

20 18.616 0002722634133 6310094407040008 085246036996

21 16.292 0002722618405 6310090107760124 082353381531

22 16.292 0003068517745 3529106206750002 082353381531

23 6717 0001929869302 6310096010730004 082153054531

24 6717 0002722851189 6310064407180002 082153054531

25 6717 0001929869291 6310092507660005 082153054531

26 24.457 0002722686175 6310091212490004 081351442023

Tn.Nurdin 62 th 20-12-1961 dr.Ferisa

Tn.Muttakin 41th 19-07-1982 dr.rahma

Ny.Isnaniah 49th 01-07-1973 dr.Ferisa

Ny. Partini 42th 08-05-1981 dr.rahma

Tn. Ahmad Yani 35th 17-04-1988 dr.rahma

Tn. Rusdiansyah 31th 06-09-1993 dr.Ferisa

Ny.Nor Halimah 12th 12-06-2011 dr.rahma

Ny.Mimi astuti 56th 05-02-1966 dr.ferisa

An. Nuraqia Hidayati 9th 26-04-2014 dr.rahma

Ny.Intang 58th 01-07-1965 dr.rahma

Ny. St.Muhani 55th 05-06-1968 dr.Ferisa

Ny.Lasinem 60th 15-05-1963 dr.ferisa

Tn.M.Zaki Yamani 40th 19-02-1983 dr.rahma

Tn.kaspul Anwar 57th 30-09-1965 dr.rahma

Ny. Sa'Tiya 47th 22-06-1975 dr.Ferisa

Ny. Ningsih 50th 20-10-1973 dr.rahma

An. Nur Azmya Aira 5,1 th 04-07-2018 dr.rahma

Tn.Sunarto 57th 25-07-1966 dr.rahma

Tn.Johan 71th 12-12-1949 dr.rahma

Perum.griya bumi raya SMA P L L ✓

Jl. Padat karya RT.02 SMK L B B ✓

Jl. Petiti gg.dahlia S1 P B B ✓

Jl.banyuwangi RT.03 SMA L B B ✓

JlSimpang sari Rt.15 SD L L L ✓

Jl Belibis RT.04 SMP L L B ✓

Jl.Anang kacil Rt.04 SD P L L ✓

Jl. Karang jawa RT.04 SD P L L ✓

Jl.Sabar subur RT.02 S2 L B B ✓

Jl. Kebanjiran RT.02 SMP L B B ✓

Jl. Kebanjiran RT.02 SMK P B B ✓

Jl.banyuwangi RT.07 SMP P L L ✓

Jl.banyuwangi RT.07 SMP L B B ✓

bersujud RT.03 SMA L B B ✓

Diagnosis Terapi & Tindakan

PCT, Amox, Ctm, Amroxol,