1.

Petugas Entri Data

REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

1 2 3 4 5 V
7 2 0 3 0 0 7 Bulan : 2022
NAMA FASKES/ PUSKESMAS TOAYA 7 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

PESERTA KB JENIS TINDAKAN Kasus PENGGUNAAN

SUMBER ALOKON

STATUS PESERTA KB (Kode)

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
ISTRI

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN

KOMPLIKASI BERAT
PENCABUTAN DAN

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN

PENCABUTAN
NAMA SUAMI

KEGAGALAN
PEMBERIAN/
TANGGAL

OPERATIF/
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

LAINNYA

MANDIRI
LAHIR

TIDAK

APBN

APBD
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1 15-June-2022 DAFID 7 2 0 3 1 0 4 5 0 7 9 8 0 0 0 5 FADLIAN 05-July-1998 DESA TOAYA 3 0 0 0 3 1 0 0 1 0 0 0

2 15-June-2022 EGI 7 2 0 3 1 0 5 3 1 0 0 2 0 0 0 5 GINALIFTAYANA HUMONGGII 13-October-2002 DESA LERO TATARI 1 1 0 0 3 1 0 0 1 0 0 1

3 15-June-2022 FARDIN 7 2 0 3 1 0 5 0 1 0 8 5 0 0 0 3 ANITA 10-October-1985 DESA LERO TATARI 3 1 0 0 3 0 0 1 1 0 0 1

4 15-June-2022 MOH MUKTAMAR 7 2 0 3 1 0 5 1 0 7 0 3 0 0 0 1 MURDIANA 11-July-2003 DESA TOAYA VUNTA 1 1 0 0 3 1 0 0 1 0 0 1

5 15-June-2022 RONA 7 2 0 3 1 0 5 5 1 1 8 3 0 0 0 3 NOVRIANTI 15-November-1983 DESA MARANA 3 1 0 0 3 0 0 1 1 0 0 1

6 15-June-2022 RULI 7 2 0 3 1 0 4 1 0 7 7 8 0 2 9 4 INDRAWATI 22-July-1978 DESA TOAYA 3 1 0 0 3 1 0 0 1 0 0 1

7 15-June-2022 RULI 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 INDRAWATI 22-June-1978 DESA TOAYA 3 0 0 0 3 1 0 0 1 0 0 0

8 15-June-2022 SAIFUL 7 2 0 3 1 0 4 4 1 0 0 9 3 0 0 0 EKA 04-October-1993 DESA TOAYA 3 0 0 0 3 1 0 0 1 0 0 0

9 15-June-2022 SAIFUL 7 2 0 3 1 0 4 4 1 0 9 3 0 0 0 3 EKA 04-October-1993 DESA TAOAYA 1 1 0 0 3 1 0 0 1 0 0 1

10 15-June-2022 SUMARLIN 7 2 0 3 1 0 6 5 0 6 8 9 0 0 0 5 YULIDA 25-June-1989 DESA TOAYA 1 1 0 0 3 0 0 1 1 0 0 1

11 15-June-2022 SUMARLIN 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 YULIDA 25-May-1985 DESA TOAYA 3 0 0 0 3 1 0 0 1 0 0 0

12 19-June-2022 HENDRA 7 2 0 3 1 0 5 6 0 7 0 0 0 0 0 1 NIRFAYANTI 16-July-2000 DESA TOAYA 3 0 0 0 4 1 0 0 1 0 0 0

13 20-June-2022 VEDRIANSYAH 7 2 0 3 1 0 4 6 0 5 9 0 0 0 0 4 SAMSIA 05-May-1990 DESA TOAYA 3 0 0 0 4 1 0 0 1 0 0 0

14 22-June-2022 BAKRI 7 2 0 3 1 0 5 8 1 0 9 6 0 0 0 1 LISDAYANTI 18-October-1996 DESA TOAYA 3 0 0 0 4 1 0 0 1 0 0 0

15 22-June-2022 HAFID 7 2 0 3 1 0 4 9 0 9 8 9 0 0 0 5 NURINTAN 09-September-1989 DESA TOAYA 1 0 0 0 4 1 0 0 1 0 0 0

16 22-June-2022 Tn.x 7 2 0 3 1 0 4 2 0 3 9 6 0 0 0 3 SULFIANTI 24-October-1995 DESA TOAYA 3 0 0 0 4 1 0 0 1 0 0 0

17 15-June-2022 HERMAN 7 2 0 3 1 0 4 8 0 9 8 1 0 0 0 1 ASNI 08-September-1981 DESA LERO TATARI 3 1 0 0 7 1 0 0 1 0 0 1

18 15-June-2022 ADIN 7 2 0 3 1 0 6 8 0 4 0 4 0 0 0 1 REZKAYANTI 21-April-2003 DESA TOA YA VUNTA 1 1 1 0 8 0 0 1 1 0 0 1

19 15-June-2022 AFDAL 7 5 0 4 0 3 7 0 1 2 9 7 0 0 0 1 SISKA PUTRI 30-December-1987 DESA MARANA 1 1 0 0 8 1 0 0 1 0 0 1

20 15-June-2022 ALAN 7 2 0 3 1 0 4 5 0 8 8 8 0 0 0 2 NURAFNI 05-August-1988 DESA LERO 2 1 0 0 8 1 0 0 1 0 0 1

21 15-June-2022 ANGGA SAPUTRA 7 2 0 3 1 0 6 8 0 9 9 2 0 0 0 1 NURLAILA 28-September-1992 DESA TOAYA VUNTA 1 1 1 0 8 1 0 0 1 0 0 1

22 15-June-2022 ASWIN 7 2 0 3 1 0 5 9 0 8 9 9 0 0 0 1 RIA SUNDARI 19-August-1999 DESA LERO 1 1 0 0 8 1 0 0 1 0 0 1

23 15-June-2022 DANANG 7 2 0 3 1 0 6 4 0 3 9 0 0 0 0 2 SRI YUNITA 24-March-1990 DESA TOA YA VUNTA 2 1 0 0 8 0 0 1 1 0 0 1

24 15-June-2022 FAHRUDIN 7 2 0 3 1 0 4 5 0 5 0 0 0 0 0 6 ALMAHIRA 05-May-2000 DESA TOAYA VUNTA 1 1 1 0 8 0 0 1 1 0 0 1

25 15-June-2022 ILWAN 7 2 0 3 1 0 5 4 0 5 8 5 0 0 0 2 MINARTIN 14-May-1985 DESA SUMARI 2 1 0 0 8 1 0 0 1 0 0 1

26 15-June-2022 IRWAN 7 2 0 3 2 4 4 1 0 7 9 0 0 0 0 1 ITA 01-July-1990 DESA TOAYA VUNTA 2 1 0 0 8 0 0 1 1 0 0 1

27 15-June-2022 IRWANSYAH 7 2 0 3 1 0 4 9 0 2 8 3 0 0 0 2 FARNI 09-February-1983 DESA DALAKA 1 1 1 0 8 0 0 1 1 0 0 1

 28 15-June-2022 KARIM 7 2 0 3 1 0 5 1 0 3 9 2 0 0 0 1 PIMA 11-March-1992 DESA SUMARI 1 1 1 0 8 0 0 1 1 0 0 1

29 15-June-2022 MOH TENDISAUD 7 2 0 3 1 0 4 3 0 9 0 4 0 0 0 2 SEPTIANASARI 03-September-2004 DESA TOA YA VUNTA 1 1 1 0 8 1 0 0 1 0 0 1

30 15-June-2022 NADIR 7 2 0 3 1 0 6 2 1 2 8 5 0 0 0 5 IKA SRIYANTI 22-December-1985 DESA LERO 1 1 1 0 8 1 0 0 1 0 0 1

31 15-June-2022 OGIN 7 2 0 3 1 0 5 5 0 7 0 1 0 0 0 1 VALEN JESIKA 15-July-2001 DESA DALAKA 1 1 1 0 8 1 0 0 1 0 0 1

32 15-June-2022 RAIS 7 2 0 8 1 3 6 9 0 6 8 4 0 0 0 1 RISNA 29-June-1983 DESA ENU 1 1 1 0 8 1 0 0 1 0 0 1

33 15-June-2022 RONAL 7 2 0 3 1 0 4 9 0 8 9 4 0 0 0 2 INDRIANA 09-August-1994 DESA TOAYA 2 1 0 0 8 0 0 1 1 0 0 1

34 15-June-2022 RUSTAM 7 2 0 3 1 0 5 0 0 2 9 3 0 0 0 4 ETRASIA 10-February-1993 DESA KUMBASA 2 1 0 0 8 0 0 1 1 0 0 1

35 15-June-2022 SAIFUL 7 2 0 3 1 1 4 5 0 5 9 4 0 0 0 1 RAHMAWATI 05-May-1994 DESA LERO 1 1 1 0 8 0 0 1 1 0 0 1

36 15-June-2022 SALIM 7 2 0 3 1 0 4 3 0 8 0 2 0 0 0 5 SALSABILA 03-August-2002 DESA TOA YA VUNTA 2 1 0 0 8 0 0 1 1 0 0 1

37 15-June-2022 SAPRIN 7 2 0 3 1 0 4 6 0 2 9 0 0 0 0 3 SADRIA 06-February-1990 DESA LERO 1 1 0 0 8 1 0 0 1 0 0 1

38 15-June-2022 TAHER 7 2 0 3 1 0 5 8 0 8 9 3 0 0 0 6 ZIKRIANA 18-August-1993 DESA TOAYA VUNTA 3 1 0 0 8 1 0 0 1 0 0 1

39 15-June-2022 TENGKU 7 2 0 3 1 0 6 0 1 1 0 0 0 0 0 1 RAHMA INAYAH 18-November-2000 DESA TOAYA VUNTA 2 1 0 0 8 1 0 0 1 0 0 1

40 15-June-2022 Tn.x 7 2 0 3 1 0 4 3 0 5 7 8 0 0 0 2 PAHARIA 03-May-1978 DESA DALAKA 1 1 1 0 8 1 0 0 1 0 0 1

41 15-June-2022 ARDIN 7 2 0 3 1 0 4 7 0 3 8 1 0 0 0 5 NURTIN 07-March-1981 DESA LERO TATARI 1 1 1 0 9 0 0 1 1 0 0 1

42 15-June-2022 FERDI 7 2 0 3 1 1 6 9 0 7 9 1 0 0 0 1 GANTI TANGKUNA 29-July-1991 DASA APE MALIKO 1 1 0 0 9 1 0 0 1 0 0 1

43 15-June-2022 JESRULDIN 7 2 0 3 1 0 5 9 0 7 9 8 0 0 0 5 ANDERIYANA 19-July-1998 DESA MASAINGI 1 1 1 0 9 1 0 0 1 0 0 1

44 15-June-2022 RANDIKA 7 2 0 3 1 0 5 1 0 1 0 3 0 0 0 5 REZKY SAPUTRA 11-January-2003 DESA LERO TATARI 1 1 1 0 9 1 0 0 1 0 0 1

45 15-June-2022 SARIFUDIN 7 2 0 3 1 0 4 6 1 2 9 9 0 0 0 4 MELINDA TANGKUNA 06-December-1999 DESA APE MALIKI 1 1 0 0 9 1 0 0 1 0 0 1

46 15-June-2022 SYARIF HIDAYAT 7 2 0 3 1 0 0 4 4 1 2 9 5 0 0 3 NENENG KHAIRUNISA 04-December-1995 DESA TOAYA VUNTA 1 1 1 0 9 1 0 0 1 0 0 1

1) Keterangan Kode
STATUS PESERTA KB KODE JENIS ALOKON (Diisi Pada Jenis Tindakan dan Kasus)
1 : Peserta KB Baru 3 : Peserta KB Ulangan 1 : Suntikan 1 Bulanan 3 : Suntikan 3 Bulanan 5 : Pil Progestin 7 : Implan 1 Batang 9 : IUD 11 : Tubektomi
2 : Peserta KB Ganti 4 : Komplikasi 2 : Suntikan 3 Bulanan 4 : Pil Kombinasi 6 : Kondom 8 : Implan 2 Batang 10 : Vasektomi
2) SELAIN STATUS PESERTA KB, JENIS TINDAKAN DAN KASUS DIISI TANDA CENTANG (V)
1. Petugas Entri Data Lamp.R/I/KB/20
LAMPIRAN R/I/KB/20 Lembar 3

1 2 3 4 5 V
7 2 0 3 0 0 7 Bulan : 2022
NAMA FASKES/ PUSKESMAS TOAYA 7 8 9 10 11 12
:
JARINGAN/JEJARING Kode Provinsi Kode No. Register Faskes No. Jaringan/
Kabupaten/ Jejaring Faskes
Kota

RINGKASAN HASIL PELAYANAN KB

PESERTA KB BARU (PB) PESERTA KB ULANGAN PELAYANAN KASUS

PEMBERIAN INFORMED PB DAN KESERTAAN JKN PEMBERIAN INFORMED

NO. METODE KONTRASEPSI CONSENT CONSENT (Untuk
(Untuk PB) PB PASCA PB PASCA Peserta KB Ulangan)
GANTI CARA PELAYANAN ULANG PENCABUTAN KOMPLIKASI BERAT KEGAGALAN
PERSALINAN KEGUGURAN
PB JKN PB NON JKN TOTAL PB

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1 IUD 1 1 0 1 1 0 0 0 0 0 0 0
2 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
3 PIL 0 0 0 0 0 0 0 0 1 0 0 0
4 IMPLAN 1 1 0 1 1 0 0 0 0 0 0 0
5 IMPLAN 0 0 0 0 0 0 1 1 0 0 0 0
6 IMPLAN 1 1 0 1 1 0 0 0 0 0 0 0
7 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0
8 SUNTIKAN 1 1 0 1 0 0 0 0 0 0 0 0
9 IMPLAN 1 0 0 0 1 0 0 0 0 0 0 0
10 SUNTIKAN 0 0 0 0 0 0 0 0 1 0 0 0
11 IMPLAN 0 0 0 0 0 0 1 1 0 0 0 0
12 IMPLAN 1 1 0 1 0 0 0 0 0 0 0 0
13 PIL 0 0 0 0 0 0 0 0 1 0 0 0
14 IUD 1 1 0 1 0 0 0 0 0 0 0 0
15 IUD 1 0 0 0 1 0 0 0 0 0 0 0
16 IMPLAN 0 0 0 0 0 0 1 0 1 0 0 0
17 IMPLAN 1 0 0 0 1 0 0 0 0 0 0 0
18 IMPLAN 0 0 0 0 0 0 1 1 0 0 0 0
19 PIL 0 1 0 1 0 0 0 0 0 0 0 0
20 IMPLAN 0 0 0 0 0 0 1 1 0 0 0 0
21 SUNTIKAN 0 0 0 0 0 0 1 0 1 0 0 0
22 IUD 1 1 0 1 1 0 0 0 0 0 0 0

JUMLAH 24 18 0 18 15 0 13 8 13 0 0 0

Donggala , 11-September-2022
Pimpinan Faskes KB/Jaringan/Jejaring*

197504282006042016
NIP/NRP
* Coret yang tidak perlu