PUSKESMAS BAMBAN

JL. A. YANI KM. 12 KEC. ANGKINANG, KANDANGAN, KALIMANTAN SELATAN

Telp : 05173712401, HP : 082150996268, E-mail : puskesmasbamban@gmail.com

SENSUS HARIAN PASIEN POLIKLINIK

PERIODE 01-06-2023 s.d. 30-06-2023

Poliklinik : UMUM
Tanggal : 03-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 040473 MUHAMMAD SANUSI RIANUR KAYU ABANG RT 02 L 7 Th V BPJS R509 Fever, unspecified

2 040459 NUR BAINAH KAYU ABANG RT 02 P 41 Th V BPJS K30 Dyspepsia

3 020163 MASLIANI BAMBAN P 77 Th V BPJS Hypertensive heart

I11.0 disease with (congestive)
heart failure

4 010001 RUMSITA BAMBAN UTARA RT.01 P 61 Th V BPJS K30 Dyspepsia

5 010776 SALASIAH BAMBAN UTARA RT 03 P 39 Th V BPJS Essential (primary)

I10
hypertension

6 010986 MARIATUL JANAH BAMBAN UTARA RT.003 P 55 Th V BPJS Suppurative and

H66
unspecified otitis media

7 020286 MALIKA NUR SALSABILA FITA BAMBAN RT.003 P 12 Th V BPJS Other specified
congenital
Q68.8
musculoskeletal
deformities

8 050015 SUPARDI PANDULANGAN RT 01 L 68 Th V BPJS F20 Schizophrenia

Essential (primary)
I10
hypertension

9 010481 IDA ARIYATI BAMBAN UTARA RT 01 P 45 Th V BPJS Essential (primary)

I10
hypertension
M10.0 Idiopathic gout
Other specified
congenital
Q68.8
musculoskeletal
deformities

10 020079 SITI KHOLIFAH BAMBAN RT 04 P 42 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus

11 040840 IBNU ATHOILLAH KAYU ABANG RT 02 P 12 Th V BPJS H92.0 Otalgia

 12 030575 ABDUL HADI BAMBAN SELATAN RT 02 L 46 Th V BPJS K30 Dyspepsia

Poliklinik : UMUM
Tanggal : 05-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 010355 LISMIATI BAMBAN UTARA RT.03 P 50 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus
Essential (primary)
I10
hypertension

2 040330 PAUJI KAYU ABANG RT,001 L 29 Th V BPJS F20 Schizophrenia

3 040355 SAPARNI KAYU ABANG RT 02 L 27 Th V BPJS Thyrotoxicosis

E05
[hyperthyroidism]

4 010204 SAMNAH BAMBAN UTARA RT 01 P 59 Th V BPJS H10 Conjunctivitis

5 010971 AINUN HIKMAH BAMBAN UTARA RT 03 P 18 Th V BPJS Acute upper respiratory

J06.9
infection, unspecified

6 030108 AHMAD SANINA BAMBAN SELATAN RT 02 L 26 Th V BPJS K30 Dyspepsia

7 060217 NURDIANSYAH PENGAMBAU HILIR LUAR RT.004 L 37 Th V UMUM

8 020028 NURIANI BAMBAN RT 01 P 68 Th V BPJS Essential (primary)
I10
hypertension

9 010014 WARDANIAH BAMBAN UTARA RT.001 P 64 Th V BPJS

10 010622 RAHMAWATI BAMBAN UTARA RT 03 P 21 Th V BPJS
11 030436 SAIDUL HUSEN BAMBAN SELATAN RT.002 L 28 Th V BPJS
12 010988 KAMSINAH BAMBAN UTARA RT.001 L 75 Th V BPJS Hypertensive heart
I11
disease

13 010842 SYAHBUDIN BAMBAN UTARA RT 01 L 68 Th V BPJS Senile cataract,

H25.9
unspecified
Hypertensive heart
I11
disease
M10 Gout

14 010368 MUSYAWARAH BAMBAN UTARA RT 01 P 74 Th V BPJS Cutaneous abscess,

L02
furuncle and carbuncle

15 010721 FARID SUHADA BAMBAN UTARA RT.004 L 27 Th V BPJS Benign neoplasm,

D219 connective and other soft
tissue, unspecified
 16 020014 MASRITA BAMBAN RT 02 P 39 Th V BPJS Haemorrhoids,
K64.9
unspecified

17 010138 RUSINAH BAMBAN UTARA RT2 P 65 Th V BPJS Primary generalized

M15.0
(osteo)arthrosis
R05 Cough

18 010030 ISA ANSYARI BAMBAN UTARA RT 01 L 58 Th V BPJS Insulin-dependent

E10
diabetes mellitus

19 020059 MULYADI BAMBAN RT 01 L 67 Th V BPJS I20 Angina pectoris

M10 Gout

20 030057 RABIYATUL KAPSIAH BAMBAN SELATAN RT 01 P 49 Th V BPJS Hypertensive heart

I11
disease
K30 Dyspepsia
L23 Allergic contact dermatitis
M54.5 Low back pain

21 050092 AYLA VARISHA GUMBIL RT 04 P 7 Th V BPJS Acute upper respiratory

J06.9
infection, unspecified

22 010014 WARDANIAH BAMBAN UTARA RT.001 P 64 Th V BPJS A06.0 Acute amoebic dysentery

Poliklinik : UMUM
Tanggal : 06-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 050500 GAZALI RAHMAN LONGAWANG RT.002 L 30 Th V BPJS Essential (primary)

I10
hypertension

2 020079 SITI KHOLIFAH BAMBAN RT 04 P 42 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus

3 020070 syahriani BAMBAN RT01 L 47 Th V BPJS F32 Depressive episode

4 040841 MARLINAH KAYU ABANG RT.001 P 51 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus

5 060028 ROSDANI PENGAMBAU L 1 Bl V BPJS H10 Conjunctivitis

H25 Senile cataract

6 010989 CANDRA PERMANA BAMBAN UTARA RT.003 L 20 Th V BPJS

7 050501 NORHIDAYAH TELAGA LANGSAT RT.001 P 52 Th V UMUM Essential (primary)
I10
hypertension

8 020105 TABERANI BAMBAN RT.003 L 66 Th V BPJS F03 Unspecified dementia

 9 030119 MULIADI BAMBAN SELATAN RT.002 L 28 Th V BPJS Generalized anxiety
F411
disorder

10 040154 FUJIANA RAMADHANI KAYU ABANG RT.03 L 13 Th V BPJS H52.1 Myopia

11 040046 NURJANAH KAYU ABANG RT 01 P 51 Th V BPJS Essential (primary)

I10
hypertension
M79.1 Myalgia

12 010061 RIZKIYA NIDA BAMBAN UTARA RT.003 P 9 Th V BPJS Acute nasopharyngitis

J00
[common cold]

13 050224 BURHANUDDIN GUMBIL RT.003 L 68 Th V BPJS Essential (primary)

I10
hypertension
R05 Cough

14 030069 RANTI YULIDA BAMBAN SELATAN P 32 Th V BPJS H00 Hordeolum and chalazion

15 050503 MARFUAH JL.H.M.RUSLI RT.009 P 30 Th V UMUM

KANDANGAN KOTA
16 030128 MUHAMMAD YASIN ZAINI BAMBAN SELATAN RT01 L 11 Th V BPJS Cutaneous abscess,
L02
furuncle and carbuncle

17 060209 NOVIA TRI ERLIANI BANJARMASIN P 35 Th V UMUM

Poliklinik : UMUM
Tanggal : 07-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 020187 MARTASIAH BAMBAN RT.003 P 60 Th V BPJS Essential (primary)

I10
hypertension
M54.5 Low back pain

2 030108 AHMAD SANINA BAMBAN SELATAN RT 02 L 26 Th V BPJS K30 Dyspepsia

3 010414 KAMARIATI BAMBAN UTARA RT 04 P 37 Th V BPJS R05 Cough

4 030233 WAHIDAH BAMBAN SELATAN RT 02 P 58 Th V BPJS M54.5 Low back pain

M79.1 Myalgia

5 020009 ASMUNI BAMBAN RT03 L 52 Th V BPJS R05 Cough

6 020194 WARNA SARI BAMBAN RT 04 P 35 Th V BPJS H92.0 Otalgia

7 010070 SITA KHAIRIANI BAMBAN UTARA RT 02 P 38 Th V BPJS B37.0 Candidal stomatitis

8 020251 MUHAMMAD FAQIH RAHMAN BAMBAN RT 03 L 7 Th V BPJS F80.9 Developmental disorder

of speech and language,
 unspecified

Poliklinik : UMUM
Tanggal : 08-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 010881 MAHYUDI BAMBAN UTARA RT.003 L 62 Th V BPJS G20 Parkinson-s disease

K30 Dyspepsia
M10.0 Idiopathic gout

2 010588 MASERANI BAMBAN UTARA RT.002 L 59 Th V BPJS D68.6 Other Thrombophilia

Non-insulin-dependent
E11
diabetes mellitus
I50.0 Congestive heart failure

3 040840 IBNU ATHOILLAH KAYU ABANG RT 02 P 12 Th V BPJS H66.9 Otitis media, unspecified

4 020425 BARKAT ALI BAMBAN RT.002 L 23 Th V BPJS

5 010353 DARANI BAMBAN UTARA RT.03 L 55 Th V BPJS Cluster headache
G44.0
syndrome
K30 Dyspepsia

6 050057 ERNA HARTATI LONGAWANG RT 01 P 53 Th V BPJS Disorders of initiating and

G47.0 maintaining sleep
[insomnias]
K12.1 Other forms of stomatitis
R63.0 Anorexia

7 010791 DAHLIATI BAMBAN UTARA RT 02 P 38 Th V BPJS H11.0 Pterygium

8 040130 BARNIAH KAYU ABANG RT 04 P 37 Th V BPJS J45 Asthma

9 010842 SYAHBUDIN BAMBAN UTARA RT 01 L 68 Th V BPJS Senile cataract,

H25.9
unspecified

10 030576 MARIATUL KIFTIAH BAMBAN SELATAN RT 01 L 52 Th V BPJS K12.1 Other forms of stomatitis

11 050236 MUHAMMAD AL FARIZA LONGAWANG RT 01 L 23 Th V BPJS K30 Dyspepsia

12 010102 RUZANI MAULANA BAMBAN UTARA RT01 L 24 Th V BPJS Localization-related

(focal) (partial) idiopathic
G40.0 epilepsy and epileptic
syndromes with seizures
of
G40.9 Epilepsy, unspecified
 13 010006 SITI JAMILAH BAMBAN UTARA RT 03 P 45 Th V BPJS Essential (primary)
I10
hypertension
M54.5 Low back pain

14 040832 UDIN DAHUB KAYU ABANG RT 01 L 60 Th V BPJS Open wound of other

S91.3
parts of foot

15 010808 SYAHRUL RAMADANI BAMBAN UTARA RT 03 L 22 Th V BPJS

Poliklinik : UMUM
Tanggal : 09-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 010027 JARJANI BAMBAN RT 04 L 65 Th V BPJS Other and unspecified

R10.4
abdominal pain

2 040044 ABDUL HADI KAYU ABANG RT 04 L 55 Th V BPJS M54.5 Low back pain

3 040304 YUSRI KAYU ABANG L 55 Th V BPJS Haemorrhoids,

K64.9
unspecified

4 050200 BARNAWI LONGAWANG RT 02 L 66 Th V BPJS Haemorrhoids,

K64.9
unspecified

5 020008 JAINUL ILMI BAMBAN RT 03 L 60 Th V BPJS Essential (primary)

I10
hypertension

6 010001 RUMSITA BAMBAN UTARA RT.01 P 61 Th V BPJS

7 020016 SITI FAUZIAH BAMBAN RT .04 P 19 Th V BPJS Polyneuropathy,
G62.9
unspecified

8 020017 RUSMALIADI BAMBAN L 59 Th V UMUM H15.1 Episcleritis

9 020670 ERNAWATI BAMBAN RT.02 P 50 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus

10 010021 HANDRA BAMBAN UTARA L 56 Th V BPJS Urinary tract infection,

N39.0
site not specified

11 020033 MUHIBZI SUFI BAMBAN RT 01 L 48 Th V BPJS Hypertensive heart

I11
disease
M10 Gout

12 020017 RUSMALIADI BAMBAN L 59 Th V UMUM

13 010988 KAMSINAH BAMBAN UTARA RT.001 L 75 Th V BPJS Senile cataract,
H25.9
unspecified
14 030050 NOR HAYAH BAMBAN SELATAN RT 03 P 55 Th V BPJS Other proliferative
H35.2
retinopathy
Postprocedural disorders
H59 of eye and adnexa, not
elsewhere classified
Essential (primary)
I10
hypertension

15 010486 NORLAILI BAMBAN UTARA P 48 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus
Essential (primary)
I10
hypertension

16 02-0098 RAKHMIDAYANOR BAMBAN RT.001 P 51 Th V BPJS

17 010776 SALASIAH BAMBAN UTARA RT 03 P 39 Th V BPJS Essential (primary)
I10
hypertension

18 010992 JUMRIADI BAMBAN UTARA 01 L 32 Th V BPJS L23 Allergic contact dermatitis

19 040020 ALIMI KAYU ABANG RT 002 L 48 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus

20 010031 MAIMUNAH BAMBAN UTARA RT 04 P 51 Th V BPJS B35.4 Tinea corporis

Cluster headache
G44.0
syndrome
K30 Dyspepsia

21 040844 SUMIYATI KAYU ABANG RT 04 L 27 Th V BPJS H11.0 Pterygium

22 020401 RUSNAH BAMBAN RT 01 P 65 Th V BPJS Essential (primary)

I10
hypertension

23 050508 RUSDIANNOR TAMIYANG RT 03 L 19 Th V BPJS

24 020737 SRI FITRIANI BAMBAN RT.002 P 19 Th V UMUM
25 040680 FAUZIAH KAYU ABANG RT.02 P 66 Th V BPJS Conjunctivitis,
H10.9
unspecified

26 020738 DAHLIAH BAMBAN RT 04 P 50 Th V BPJS Conjunctivitis,

H10.9
unspecified

27 040845 AHMAD JAILANI KAYU ABANG L 7 Th V BPJS

28 010051 RUSDIAH BAMBAN UTARA P 65 Th V BPJS Non-insulin-dependent
E11
diabetes mellitus

29 040642 LUTPIANTI KAYU ABANG RT.002 P 34 Th V BPJS Cluster headache

G44.0
syndrome
Essential (primary)
I10
hypertension
 30 020298 MUNFIKA HARIYANTI BAMBAN RT.003 P 22 Th V BPJS Acute nasopharyngitis
J00
[common cold]

31 020147 MASERANI BAMBAN RT.003 L 64 Th V BPJS Intra-abdominal and

R19.0 pelvic swelling, mass and
lump

32 030500 SURIYANSYAH BAMBAN SELATAN RT4 L 30 Th V BPJS Acute nasopharyngitis

J00
[common cold]

33 020028 NURIANI BAMBAN RT 01 P 68 Th V BPJS Senile cataract,

H25.9
unspecified
I20.0 Unstable angina

34 060015 NURHAYATI PENGAMBAU HILIR LUAR P 58 Th V BPJS I20.0 Unstable angina

35 030199 FATIMAH BAMBAN SELATAN RT.002 P 62 Th V BPJS Generalized anxiety

F41.1
disorder

36 010847 AMBERUNI BAMBAN UTARA RT 03 L 60 Th V BPJS Polyarthritis, unspecified,

M13.08
other sites

37 040696 MARLIADI KAYU ABANG RT.001 L 45 Th V BPJS Cluster headache

G44.0
syndrome
Essential (primary)
I10
hypertension

38 030007 MARDIAH SUSILAWATI BAMBAN SELATAN RT.002 P 51 Th V BPJS D68.6 Other Thrombophilia

39 020292 MARIANI BAMBAN P 71 Th V BPJS A95.9 Yellow fever, unspecified

Poliklinik : UMUM
Tanggal : 10-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 050509 HUSSEN AL KHADEM HASAN JAMBU HILIR RT.003 L 56 Th V UMUM K30 Dyspepsia
AWADH
2 030057 RABIYATUL KAPSIAH BAMBAN SELATAN RT 01 P 49 Th V BPJS Essential (primary)
I10
hypertension

3 040001 RUKAYAH KAYU ABANG RT 04 P 47 Th V BPJS Cutaneous abscess,

L02.8 furuncle and carbuncle of
other sites

4 020385 SAIKURAHIM BAMBAN RT 002 L 34 Th V BPJS G40.9 Epilepsy, unspecified

5 030170 MUHAMMAD RIZKI SAPUTRA BAMBAN SELATAN RT 01 L 14 Th V BPJS K30 Dyspepsia

R50.9 Fever, unspecified
 6 010059 WARDIAH BAMBAN UTARA RT 03 P 55 Th V BPJS M10.0 Idiopathic gout

7 020722 BARIAH BAMBAN RT.02 P 58 Th V BPJS Essential (primary)

I10
hypertension
M10.0 Idiopathic gout

8 020698 RAHMAD HIDAYAT BAMBAN UTARA RT 03 L 26 Th V BPJS H92.0 Otalgia

9 010277 KASMANIAH BAMBAN UTARA RT.003 P 51 Th V BPJS

10 010376 FATIMAH BAMBAN UTARA RT 02 P 38 Th V BPJS Non-insulin-dependent
E11
diabetes mellitus
Essential (primary)
I10
hypertension

Poliklinik : UMUM
Tanggal : 12-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 010881 MAHYUDI BAMBAN UTARA RT.003 L 62 Th V BPJS G20 Parkinson-s disease

2 050510 SRI MAULINI PANDULANGAN RT.003 L 26 Th V BPJS L03.0 Cellulitis of finger and toe

3 010834 MASTAIDAH BAMBAN UTARA RT 03 P 57 Th V BPJS Thyrotoxicosis

E05
[hyperthyroidism]

4 010753 NORHAYATI BAMBAN UTARA RT 02 P 70 Th V BPJS Conjunctivitis,

H10.9
unspecified

5 010364 NOVI ADRIAN RIDANI BAMBAN UTARA RT 03 L 35 Th V BPJS Disorders of initiating and
G47.0 maintaining sleep
[insomnias]
R05 Cough

6 010392 FAISAL MAILADI BAMBAN UTARA L 32 Th V BPJS Congenital malformation

Q24.9
of heart, unspecified

7 030578 JOKO PURNOMO BAMBAN SELATAN L 55 Th V BPJS Sequelae of respiratory

B90.9 and unspecified
tuberculosis
R04.2 Haemoptysis

8 050511 WIYONO HERIYANTO TAWIA RT 01 L 31 Th V UMUM

9 050424 NOR JANNAH GUMBIL RT 01 P 48 Th V UMUM Thyrotoxicosis
E05
[hyperthyroidism]

10 040625 SUNARTI KAYU ABANG RT 02 P 37 Th V BPJS Acute nasopharyngitis

J00
[common cold]
 11 030102 SARBANI BAMBAN SELATAN RT 02 L 65 Th V BPJS Essential (primary)
I10
hypertension
K30 Dyspepsia

12 010047 JUMRAH BAMBAN UTARA RT 02 P 47 Th V BPJS Essential (primary)

I10
hypertension

13 030188 NORMELIYANI BAMBAN SELATAN RT.002 P 16 Th V BPJS Thyrotoxicosis

E05
[hyperthyroidism]
R05 Cough

14 050226 MELLY HERDAYANI PANDULANGAN RT 01 P 13 Th V BPJS Acute nasopharyngitis

J00
[common cold]

15 010390 HJ.RAUDAH BAMBAN UTARA P 52 Th V BPJS M79.1 Myalgia

16 010995 MUHAMMAD ABRARI BAMBAN UTARA RT 02 L 7 Th V BPJS B86 Scabies

17 010245 MURSIDAH BAMBAN UTARA RT 01 P 61 Th V BPJS Essential (primary)

I10
hypertension
Primary generalized
M15.0
(osteo)arthrosis

18 010845 SAMAIYAH BAMBAN UTARA RT.02 P 46 Th V BPJS Essential (primary)

I10
hypertension

19 010591 MAHYUNI BAMBAN UTARA RT.003 L 46 Th V BPJS R07.4 Chest pain, unspecified

20 030014 SYARIAH BAMBAN SELATAN RT01 P 72 Th V BPJS R63.0 Anorexia

Poliklinik : UMUM
Tanggal : 13-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 060219 MUHAMMAD RISWANDI PANGGUNG RT.004 L 23 Th V UMUM

2 040846 MURDIANA KAYU ABANG RT 04 P 23 Th V BPJS K29.7 Gastritis, unspecified

3 040326 JATIAH KAYU ABANG RT 03 L 77 Th V BPJS Essential (primary)

I10
hypertension
K30 Dyspepsia

4 040642 LUTPIANTI KAYU ABANG RT.002 P 34 Th V BPJS Essential (primary)

I10
hypertension
K30 Dyspepsia

5 030064 RAHMAH BAMBAN SELATAN RT 02 P 33 Th V BPJS F45 Somatoform disorders

 6 020079 SITI KHOLIFAH BAMBAN RT 04 P 42 Th V BPJS Non-insulin-dependent
E11
diabetes mellitus

7 020739 ISAH BAMBAN RT 03 P 63 Th V BPJS Conjunctivitis,

H10.9
unspecified
Essential (primary)
I10
hypertension

8 010493 SARHANAH BAMBAN UTARA RT 03 P 47 Th V BPJS R33 Retention of urine

9 030069 RANTI YULIDA BAMBAN SELATAN P 32 Th V BPJS Haemorrhoids,

K64.9
unspecified

10 040848 JAINAL ABIDIN KAYU ABANG RT 03 L 46 Th V BPJS Senile cataract,

H25.9
unspecified

11 050011 BAHRAH GUMBIL P 66 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus

12 010997 ZULFI FAHRIN BAMBAN UTARA RT 04 L 28 Th V BPJS K30 Dyspepsia

Poliklinik : UMUM
Tanggal : 14-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 050094 ALFIANOR PANDULANGAN L 25 Th V BPJS F20 Schizophrenia

2 020657 JUBAIDAH BAMBAN RT 03 P 56 Th V BPJS Senile cataract,

H25.9
unspecified

3 040849 ILMI KAYU ABANG RT 01 L 27 Th V BPJS Rubella [German

B06
measles]

4 040035 RUSLI KAYU ABANG RT.02 L 67 Th V BPJS J45.9 Asthma, unspecified

5 020401 RUSNAH BAMBAN RT 01 P 65 Th V BPJS Essential (primary)

I10
hypertension
Acute nasopharyngitis
J00
[common cold]

6 010181 TASAR BAMBAN UTARA RT 02 L 58 Th V BPJS Polyneuropathy,

G62.9
unspecified

7 030339 YANTI BAMBAN SELATAN RT.003 P 35 Th V BPJS M79.1 Myalgia

8 040327 MASLINAH KAYU ABANG RT 03 P 44 Th V BPJS Essential (primary)

I10
hypertension
R05 Cough
 9 040850 JUBAIDAH KAYU ABANG RT.002 P 42 Th V BPJS K30 Dyspepsia

10 020280 YUSERI BAMBAN UTARA RT2 L 58 Th V BPJS Open wound of lower leg,
S81.9
part unspecified

11 050430 ASIATI PANDULANGAN P 58 Th V BPJS Schizophrenia,

F20.9
unspecified

12 010173 MUHAMMAD HAMBALI BAMBAN UTARA RT 02 L 24 Th V BPJS L23 Allergic contact dermatitis

13 010999 ABIDIN BAMBAN UTARA RT.002 L 65 Th V BPJS Conjunctivitis,

H10.9
unspecified
L23 Allergic contact dermatitis

14 030581 NORHASANAH BAMBAN SELATAN RT.002 P 15 Th V BPJS R05 Cough

15 030383 MASLIANA BAMBAN SELATAN RT.002 P 57 Th V BPJS Essential (primary)

I10
hypertension
Rheumatoid arthritis,
M06.9
unspecified

16 030020 JUBAIDAH BAMBAN SELATAN RT.002 P 41 Th V BPJS

Poliklinik : UMUM
Tanggal : 15-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 010605 NOOR HASANAH BAMBAN UTARA RT 02 P 46 Th V BPJS Disorders of initiating and

G47.0 maintaining sleep
[insomnias]
Essential (primary)
I10
hypertension

2 020105 TABERANI BAMBAN RT.003 L 66 Th V BPJS G30 Alzheimer disease

3 010174 NAZIRA USWATUN HASANAH BAMBAN UTARA RT 04 P 21 Th V BPJS R50.9 Fever, unspecified

4 010425 SADIA BAMBAN UTARA RT 02 L 65 Th V BPJS Essential (primary)

I10
hypertension
Acute nasopharyngitis
J00
[common cold]

5 050513 MUHAMMAD RASYIDI JL. S. PARMAN L 29 Th V BPJS

6 010785 RAHMAD HIDAYAT BAMBAN UTARA RT 03 L 19 Th V BPJS
7 020021 SHINTA NORDIANDRA BAMBAN RT 04 P 10 Th V BPJS H10 Conjunctivitis
Poliklinik : UMUM
Tanggal : 16-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 020008 JAINUL ILMI BAMBAN RT 03 L 60 Th V BPJS Essential (primary)

I10
hypertension

2 010001 RUMSITA BAMBAN UTARA RT.01 P 61 Th V BPJS M79.1 Myalgia

3 030582 MUHAMMAD NAZRIL IQBAL BAMBAN SELATAN RT 03 L 12 Th V BPJS

4 030007 MARDIAH SUSILAWATI BAMBAN SELATAN RT.002 P 51 Th V BPJS M79.1 Myalgia

5 040852 AKHMAD HAIDI ANWAR KAYU ABANG RT 02 L 24 Th V BPJS R05 Cough

6 010304 KASKUNI BAMBAN UTARA RT.001 L 52 Th V BPJS J33.8 Other polyp of sinus

7 010632 JUAIRIAH BAMBAN UTARA L 60 Th V BPJS K30 Dyspepsia

8 040067 ARIPIN KAYU ABANG RT.01 L 54 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus

9 040066 SALABIAH KAYU ABANG RT 01 P 46 Th V BPJS Atopic dermatitis,

L20.9
unspecified

10 010207 JUMIAH BAMBAN UTARA RT.004 P 55 Th V BPJS I20.0 Unstable angina

11 060028 ROSDANI PENGAMBAU L 1 Bl V BPJS L20 Atopic dermatitis

12 040449 SITI SALMAH KAYU ABANG RT 01 P 61 Th V BPJS K30 Dyspepsia

13 010051 RUSDIAH BAMBAN UTARA P 65 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus

14 030381 NOR ISNA BAMBAN SELATAN RT 03 P 17 Th V BPJS L23 Allergic contact dermatitis

15 020033 MUHIBZI SUFI BAMBAN RT 01 L 48 Th V BPJS M79.1 Myalgia

16 010304 KASKUNI BAMBAN UTARA RT.001 L 52 Th V BPJS

17 020739 ISAH BAMBAN RT 03 P 63 Th V BPJS Hypertensive heart
I11
disease

18 040397 BASTIAH KAYU ABANG RT 01 P 54 Th V BPJS G62 Other polyneuropathies

Polyneuropathy,
G62.9
unspecified
Allergic contact dermatitis
L23.8
due to other agents

19 040078 WARTINI KAYU ABANG RT 03 P 46 Th V BPJS Insulin-dependent

E10
diabetes mellitus
 Hypertensive heart
I11
disease
M10 Gout

20 050200 BARNAWI LONGAWANG RT 02 L 66 Th V BPJS Haemorrhoids,

K64.9
unspecified

21 050515 NURHAYATI GUMBIL RT.001 P 61 Th V BPJS Hypertensive heart

I11
disease
Acute upper respiratory
J06.9
infection, unspecified
K30 Dyspepsia

22 020052 ANANDA KHUMAIRAH BAMBAN RT 02 P 8 Th V BPJS K30 Dyspepsia

23 040816 SITI NORHALIMAH KAYU ABANG RT 01 P 71 Th V BPJS Hypertensive heart

I11
disease

24 040224 MARDIAN KAYU ABANG RT 01 P 66 Th V BPJS K30 Dyspepsia

25 050010 ABDUL HADI PANDULANGAN L 75 Th V BPJS R05 Cough

26 010776 SALASIAH BAMBAN UTARA RT 03 P 39 Th V BPJS Hypertensive heart

I11
disease

27 010862 SITI ASMAH BAMBAN UTARA RT 02 RW 01 P 41 Th V BPJS

28 010405 ABDUL GANI BAMBAN UTARA RT.001 L 38 Th V BPJS F20 Schizophrenia

29 040001 RUKAYAH KAYU ABANG RT 04 P 47 Th V BPJS Cutaneous abscess,

L029 furuncle and carbuncle,
unspecified

30 030050 NOR HAYAH BAMBAN SELATAN RT 03 P 55 Th V BPJS Hypertensive heart

I11
disease
L23 Allergic contact dermatitis

31 020016 SITI FAUZIAH BAMBAN RT .04 P 19 Th V BPJS M79.1 Myalgia

32 050063 RAMSYI KARYADI GUMBIL RT 01 L 51 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus

33 040064 SABRAN KAYU ABANG RT 02 L 55 Th V BPJS Respiratory tuberculosis,

A15 bacteriologically and
histologically confirmed

34 060220 AHMAD DARMI PENGAMBAU HILIR LUAR RT.001 L 46 Th V UMUM S01.0 Open wound of scalp

35 040626 SAUDAH KAYU ABANG RT 02 P 61 Th V BPJS K30 Dyspepsia

36 040016 SADANSYAH KAYU ABANG RT 03 L 52 Th V BPJS K30 Dyspepsia

37 010172 KADERI BAMBAN UTARA RT.002 L 29 Th V BPJS Open wound of

T14.1
unspecified body region
 38 030051 JUMIARTI BAMBAN SELATAN RT 02 P 46 Th V BPJS Insulin-dependent
E10
diabetes mellitus

39 040553 TARMIJI KAYU ABANG RT02 L 65 Th V BPJS I50.0 Congestive heart failure

40 020396 SARMAN BAMBAN RT 01 L 52 Th V BPJS Gastroenteritis and colitis

A09.9
of unspecified origin

41 030499 KASMIATI BAMBAN SELATAN P 55 Th V BPJS M54.5 Low back pain

42 040060 MUHAMMAD REZKY ABDILLAH KAYU ABANG RT 01 L 11 Th V BPJS H92.0 Otalgia

43 010195 PARMIATI BAMBAN UTARA RT 02 P 72 Th V BPJS Rheumatoid arthritis,

M06.9
unspecified

Poliklinik : UMUM
Tanggal : 17-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 060221 MUHAMMAD SABANI JL.SURAPATI RT.008 L 28 Th V UMUM

2 030213 MAHNIAH BAMBAN SELATAN RT 02 P 38 Th V BPJS Acute upper respiratory
J06.9
infection, unspecified

3 030082 MUHAMMAD MUHAIMIN BAMBAN SELATAN RT 02 L 10 Th V BPJS Acute upper respiratory

J06.9
infection, unspecified

4 030583 SITI SYALWA BAMBAN SELATAN RT 01 P 6 Th V UMUM A01.0 Typhoid fever

5 030107 NOR JANNAH BAMBAN SELATAN RT 01 P 26 Th V BPJS F20 Schizophrenia

6 050226 MELLY HERDAYANI PANDULANGAN RT 01 P 13 Th V BPJS Other benign neoplasm

of connective and other
D21.0
soft tissue of head, face
and neck

7 020371 DAHLIAH BAMBAN RT.003 P 51 Th V BPJS Cluster headache

G44.0
syndrome

8 050262 H.ALIANSYAH PAKUAN TIMUR L 67 Th V BPJS L20.8 Other atopic dermatitis

9 020744 ANNOR RAHMAN AKBARI BAMBAN RT 03 L 36 Th V BPJS B30 Viral conjunctivitis

Poliklinik : UMUM
Tanggal : 19-06-2023
 Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 030584 MUHAMMAD NOOR DAFFA BAMBAN SELATAN RT 03 L 6 Th V UMUM Other and unspecified
R10.4
abdominal pain

2 010892 LUKMAN BAMBAN UTARA RT 01 L 64 Th V BPJS N40 Hyperplasia of prostate

3 040233 MASLIANI KAYU ABANG RT.002 P 46 Th V BPJS Angina pectoris,

I20.9
unspecified

4 040327 MASLINAH KAYU ABANG RT 03 P 44 Th V BPJS Essential (primary)

I10
hypertension

5 040642 LUTPIANTI KAYU ABANG RT.002 P 34 Th V BPJS Essential (primary)

I10
hypertension

6 010108 BARKIAH BAMBAN UTARA P 55 Th V BPJS Conjunctivitis,

H10.9
unspecified

7 010971 AINUN HIKMAH BAMBAN UTARA RT 03 P 18 Th V BPJS Acute upper respiratory

J06.9
infection, unspecified

8 010050 AHMAD DJAMILI BAMBAN UTARA RT 04 L 76 Th V BPJS

9 050008 M RIZAL WAHYUDI GUMBIL RT 02 L 19 Th V BPJS Anxiety disorder,
F41.9
unspecified

10 010030 ISA ANSYARI BAMBAN UTARA RT 01 L 58 Th V BPJS Insulin-dependent

E10
diabetes mellitus
Non-insulin-dependent
E11
diabetes mellitus

11 030272 RAIHANAH BAMBAN SELATAN RT 02 P 46 Th V BPJS Essential (primary)

I10
hypertension
R05 Cough

12 020098 RAKHMIDAYANOOR BAMBAN RT 01 P 51 Th V BPJS Thyrotoxicosis

E05
[hyperthyroidism]

13 020113 IKA SARTIKA BAMBAN RT 01 P 20 Th V BPJS Acute sinusitis,

J01.9
unspecified

14 040855 MARNI KAYU ABANG RT 01 P 45 Th V BPJS Conjunctivitis,

H10.9
unspecified

15 010070 SITA KHAIRIANI BAMBAN UTARA RT 02 P 38 Th V BPJS M54.5 Low back pain

16 010820 MUHAMMAD JAINI BAMBAN UTARA RT .02 L 60 Th V BPJS Essential (primary)

I10
hypertension
Sequelae of cerebral
I69.3
infarction

17 030583 SITI SYALWA BAMBAN SELATAN RT 01 P 6 Th V UMUM R50.9 Fever, unspecified

 18 030529 SAMSUL BAHRI BAMBAN SELATAN RT 03 L 59 Th V BPJS Respiratory tuberculosis,
A15 bacteriologically and
histologically confirmed

19 011002 SITI HAMIDAH BAMBAN UTARA RT 02 P 56 Th V BPJS K30 Dyspepsia

20 011003 MUHAMMAD ABRAURY SAUKY L 25 Th V UMUM

21 010314 ARMANI BAMBAN UTARA RT1 P 59 Th V BPJS L23 Allergic contact dermatitis

22 050290 MUHAMMAD NAZRIEL MAFRAH PADANG BATUNG RT 01 L 4 Th V BPJS

FUADI

Poliklinik : UMUM
Tanggal : 20-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 040355 SAPARNI KAYU ABANG RT 02 L 28 Th V BPJS Thyrotoxicosis

E05
[hyperthyroidism]

2 010079 SITI RAHMAH BAMBAN UTARA RT 01 P 28 Hr V BPJS Moderate depressive

F32.1
episode

3 040016 SADANSYAH KAYU ABANG RT 03 L 52 Th V BPJS K29.7 Gastritis, unspecified

4 050057 ERNA HARTATI LONGAWANG RT 01 P 53 Th V BPJS Disorders of initiating and

G47.0 maintaining sleep
[insomnias]

5 010010 ANITA RUSMINI BAMBAN UTARA RT03 P 52 Th V BPJS Hypertension secondary

I15.2
to endocrine disorders
Hyperglycaemia,
R73.9
unspecified

6 020744 ANNOR RAHMAN AKBARI BAMBAN RT 03 L 37 Th V BPJS Conjunctivitis,

H10.9
unspecified

7 050063 RAMSYI KARYADI GUMBIL RT 01 L 51 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus

8 040843 KHAYATA ZEIN KAYU ABANG RT.002 P 7 Th V BPJS Acute upper respiratory
J06.9
infection, unspecified

9 040811 RATNAWATY KAYU ABANG RT02 P 41 Th V BPJS H52.1 Myopia

K12.1 Other forms of stomatitis

10 040843 KHAYATA ZEIN KAYU ABANG RT.002 P 7 Th V BPJS

11 040508 MUHAMMAD RASYA ADITYA KAYU ABANG RT 02 L 7 Th V BPJS L02.9 Cutaneous abscess,
furuncle and carbuncle,
 unspecified

12 011004 AHMAD RIZANI BAMBAN UTARA RT 01 L 33 Th V BPJS Cutaneous abscess,

L02.9 furuncle and carbuncle,
unspecified

13 010813 NINA PARDILLA BAMBAN UTARA RT 01 P 19 Th V BPJS Urinary tract infection,

N39.0
site not specified

14 020485 MUHAMMAD IZZATUNNAFSI BAMBAN UTARA RT 02 L 18 Th V BPJS

15 050516 SAMRAH GUMBIL P 55 Th V UMUM Urinary tract infection,
N39.0
site not specified

16 010101 AHMAD RIDUAN BAMBAN UTARA RT 04 L 20 Th V BPJS

Essential (primary)
I10
hypertension

17 0101011 muhammad siddiq - L 11 Th V BPJS

Essential (primary)
I10
hypertension

Poliklinik : UMUM
Tanggal : 21-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 011005 ZULKIPLI BAMBAN UTARA RT 01 L 36 Th V BPJS

2 010056 SUPRIADI BAMBAN UTARA RT 03 L 69 Th V BPJS Essential (primary)
I10
hypertension
K30 Dyspepsia
M10 Gout

3 040306 MUHAMMAD ALIF FIRDAUS KAYU ABANG RT 03 L 13 Th V BPJS Acute upper respiratory
J06.9
infection, unspecified

4 010005 KAMARUDIN BAMBAN UTARA RT.004 L 62 Th V BPJS Acute upper respiratory

J06.9
infection, unspecified

5 020157 AYINORLIANTI BAMBAN RT.003 P 53 Th V BPJS K02 Dental caries

6 010305 RUHAYAH BAMBAN UTARA RT 04 P 68 Th V BPJS M79.1 Myalgia

7 040573 MUSTAPIAH KAYU ABANG RT 03 P 65 Th V BPJS Polyarthritis, unspecified,

M13.08
other sites

8 010235 SUPIAN HADI SAPUTERA BAMBAN UTARA RT.004 L 39 Th V BPJS M10 Gout

9 050224 BURHANUDDIN GUMBIL RT.003 L 68 Th V BPJS Essential (primary)

I10
hypertension
 K30 Dyspepsia

10 010554 SRI NORAINAH DAMAYANTI BAMBAN UTARA RT 02 P 31 Th V BPJS Examination and

Z02 encounter for
administrative purposes

Poliklinik : UMUM
Tanggal : 22-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 010971 AINUN HIKMAH BAMBAN UTARA RT 03 P 18 Th V BPJS Respiratory tuberculosis,

A15 bacteriologically and
histologically confirmed

2 040261 MUHAMMAD AZKIA REZKY KAYU ABANG RT 02 L 8 Th V BPJS G40 Epilepsy

3 050047 JAMALIAH LONGAWANG RT 04 L 63 Th V BPJS M79.1 Myalgia

4 040625 SUNARTI KAYU ABANG RT 02 P 37 Th V BPJS H10 Conjunctivitis

5 060028 ROSDANI PENGAMBAU L 1 Bl V BPJS Allergic contact dermatitis

L23.0
due to metals
M13.8 Other specified arthritis

6 030161 YEHA FEBRIANTY BAMBAN SELATAN RT 01 P 12 Th V BPJS Gastroenteritis and colitis

A09.9
of unspecified origin

7 020098 RAKHMIDAYANOOR BAMBAN RT 01 P 51 Th V BPJS Thyrotoxicosis

E05
[hyperthyroidism]

8 040858 HERLIANA KAYU ABANG RT 01 P 18 Th V UMUM Examination and

Z02 encounter for
administrative purposes

9 040859 NORHIKMAH KAYU ABANG RT 01 P 18 Th V UMUM Examination and

Z02 encounter for
administrative purposes

10 010976 ARIF RAHMAN BAMBAN UTARA RT003 L 21 Th V BPJS Examination and

Z02 encounter for
administrative purposes

11 010176 ULFIYA LAILA HAFIJA BAMBAN UTARA RT.002 P 9 Th V BPJS H61.2 Impacted cerumen

12 030585 MUHAMMAD IRVAN FADILLAH BAMBAN SELATAN RT.001 L 22 Th V BPJS Examination and
Z02 encounter for
administrative purposes

13 020481 YUDA FITRIADI BAMBAN RT.001 L 20 Th V BPJS Z02 Examination and

encounter for
 administrative purposes

Poliklinik : UMUM
Tanggal : 23-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 010096 MASDIANA BAMBAN UTARA RT 01 P 66 Th V BPJS Essential (primary)

I10
hypertension
K30 Dyspepsia

2 030008 FARIDAH BAMBAN SELATAN RT 01 P 56 Th V BPJS

3 050200 BARNAWI LONGAWANG RT 02 L 66 Th V BPJS K30 Dyspepsia
Haemorrhoids,
K64.9
unspecified

4 040046 NURJANAH KAYU ABANG RT 01 P 51 Th V BPJS M10 Gout

Primary generalized
M15.0
(osteo)arthrosis

5 010830 FATMAIYAH BAMBAN UTARA P 60 Th V BPJS Essential (primary)

I10
hypertension
K30 Dyspepsia

6 010006 SITI JAMILAH BAMBAN UTARA RT 03 P 45 Th V BPJS Essential (primary)

I10
hypertension
L23 Allergic contact dermatitis

7 010776 SALASIAH BAMBAN UTARA RT 03 P 39 Th V BPJS Essential (primary)

I10
hypertension

8 040361 MUJAHADAH KAYU ABANG RT.001 P 43 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus
K30 Dyspepsia

9 020006 MARDIANA BAMBAN P 62 Th V BPJS Primary generalized

M15.0
(osteo)arthrosis

10 020744 ANNOR RAHMAN AKBARI BAMBAN RT 03 L 37 Th V BPJS H10 Conjunctivitis

K30 Dyspepsia

11 020351 RUSNAWATI BAMBAN SELATAN RT3 P 35 Th V BPJS

12 040649 BARSIMAH KAYU ABANG RT 04 P 52 Th V BPJS Primary generalized
M15.0
(osteo)arthrosis

13 050011 BAHRAH GUMBIL P 66 Th V BPJS Non-insulin-dependent

E11
diabetes mellitus
 Primary generalized
M15.0
(osteo)arthrosis

14 040244 MUHAMMAD AWALUDIN KAYU ABANG RT 02 L 55 Th V BPJS

15 010057 MILIYANTI BAMBAN UTARA RT 03 P 45 Th V BPJS
16 040862 SALSA ALZAHRAWATI KAYU ABANG RT 01 P 7 Th V BPJS Conjunctivitis,
H10.9
unspecified

17 050249 JUHRANSYAH L 79 Th V BPJS M10 Gout

18 020014 MASRITA BAMBAN RT 02 P 39 Th V BPJS Haemorrhoids,

K64.9
unspecified

19 020401 RUSNAH BAMBAN RT 01 P 65 Th V BPJS Essential (primary)

I10
hypertension
Acute upper respiratory
J06.9
infection, unspecified

20 011006 MUHAMMAD RAFKA ALFARISI BAMBAN UTARA RT 02 L 3 Th V BPJS Open wound of cheek
S01.4 and temporomandibular
area

21 010195 PARMIATI BAMBAN UTARA RT 02 P 72 Th V BPJS Essential (primary)

I10
hypertension
L23 Allergic contact dermatitis

22 060054 RAKHMANUDDIN PANGGUNG RT 02 L 62 Th V BPJS M10 Gout

23 011007 MUHAMMAD PAJAR HAINUR BAMBAN UTARA RT 02 L 15 Th V BPJS

RASYID
24 040698 SUMIATI KAYU ABANG RT 01 P 51 Th V BPJS M13.8 Other specified arthritis

25 020645 MUHAMMAD ABDAY RATHOMY BAMBAN RT 03 L 6 Th V BPJS H61.2 Impacted cerumen

26 020428 ARTANIAH BAMBAN RT 03 P 46 Th V BPJS M54.5 Low back pain

Poliklinik : UMUM
Tanggal : 24-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 030436 SAIDUL HUSEN BAMBAN SELATAN RT.002 L 28 Th V BPJS K30 Dyspepsia

2 010118 MASLIANA BAMBAN UTARA RT1 P 46 Th V BPJS Insulin-dependent

diabetes mellitus with
E10.6
other specified
complications
E119 Non-insulin-dependent
diabetes mellitus without
 complications

3 030489 MUHAMMAD ILMI YUSUF BAMBAN SELATAN RT 04 L 19 Th V BPJS K02.9 Dental caries, unspecified

4 010001 RUMSITA BAMBAN UTARA RT.01 P 61 Th V BPJS Disorders of initiating and

G47.0 maintaining sleep
[insomnias]
R63.0 Anorexia

5 050518 MUHAMMAD RAYYAN TELAGA LANGSAT RT 04 L 21 Th V BPJS Examination and

Z02 encounter for
administrative purposes

6 020319 MUHAMMAD RAMADHANI BAMBAN RT 01 L 19 Th V BPJS

7 040446 RAHMAT KAYU ABANG RT3 L 23 Th V BPJS Examination and
Z02 encounter for
administrative purposes

8 020535 ISMAIL BAMBAN RT 03 L 39 Th V BPJS Cutaneous abscess,

L02.9 furuncle and carbuncle,
unspecified

9 060214 NUARI JL SIMPANG EMPAT L 46 Th V UMUM Acute nasopharyngitis

J00
[common cold]

10 010002 DJARKASI BAMBAN UTARA RT.01 L 84 Th V BPJS Cutaneous abscess,

L029 furuncle and carbuncle,
unspecified

Poliklinik : UMUM
Tanggal : 26-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 060223 MUHAMMAD ARIFIN JL.MURAKATA RT.006 L 22 Th V UMUM Examination and

Z02 encounter for
administrative purposes

2 040866 SITI ASIAH KAYU ABANG RT 01 P 42 Th V BPJS R50.9 Fever, unspecified

3 030578 JOKO PURNOMO BAMBAN SELATAN L 55 Th V BPJS Respiratory tuberculosis,

A15 bacteriologically and
histologically confirmed

4 030072 ERNAWATI BAMBAN SELATAN RT 02 P 55 Th V BPJS M79.1 Myalgia

5 030349 MUHAMMAD FIRDAUS NUZULA BAMBAN SELATAN RT 02 L 32 Th V BPJS N21.0 Calculus in bladder

6 020747 MAULANA SIDIK BAMBAN RT 01 L 19 Th V BPJS S06 Intracranial injury

 7 030030 DESI ANGGRIANI BAMBAN SELATAN RT 04 P 32 Th V BPJS F32 Depressive episode

8 030102 SARBANI BAMBAN SELATAN RT 02 L 65 Th V BPJS Essential (primary)

I10
hypertension
K30 Dyspepsia

9 050404 NURDIN GUMBIL RT 01 L 76 Th V BPJS H25 Senile cataract

Essential (primary)
I10
hypertension

10 040868 NOOR AINA KAYU ABANG RT 04 P 16 Th V BPJS H66.9 Otitis media, unspecified

11 020351 RUSNAWATI BAMBAN SELATAN RT3 P 35 Th V BPJS H61.2 Impacted cerumen

12 040390 NURBAINAH KAYU ABANG RT 02 P 40 Th V BPJS H52.1 Myopia

13 020098 RAKHMIDAYANOOR BAMBAN RT 01 P 51 Th V BPJS Thyrotoxicosis

E05
[hyperthyroidism]

14 011008 KASMAWATI BAMBAN UTARA RT.001 P 43 Th V BPJS M54.5 Low back pain

15 010483 MUHAMMAD LUTFIANOR BAMBAN UTARA RT 02 L 17 Th V BPJS Open wound of wrist and
RAHMAN S61
hand

16 050520 MASDIANA LONGAWANG RT.002 P 70 Th V UMUM K30 Dyspepsia

17 010316 MUHAMMAD SAYYID ALAWI BAMBAN UTARA RT.003 L 11 Th V BPJS L23 Allergic contact dermatitis

18 010002 DJARKASI BAMBAN UTARA RT.01 L 84 Th V BPJS Cutaneous abscess,

L029 furuncle and carbuncle,
unspecified

Poliklinik : UMUM
Tanggal : 27-06-2023
Pengunjung Asal Rujukan & Golongan Penyakit/
No. No.RM Nama Pasien Alamat L/P Umur Cara Pembayaran Dirujuk Ke
Lama Baru Alamatnya Sebab Penyakit

1 030108 AHMAD SANINA BAMBAN SELATAN RT 02 L 26 Th V BPJS Fracture of shaft of tibia,

S82.20
closed

2 020665 SAKDIAH BAMBAN RT 02 P 42 Th V BPJS Thyrotoxicosis

E05
[hyperthyroidism]

3 050424 NOR JANNAH GUMBIL RT 01 P 48 Th V UMUM Thyrotoxicosis

E05
[hyperthyroidism]
Essential (primary)
I10
hypertension

4 020412 KARTASIAH BAMBAN RT 03 P 63 Th V BPJS I10 Essential (primary)

 hypertension
K29.1 Other acute gastritis

5 040583 JUMIATI KAYU ABANG RT.001 P 38 Th V BPJS Essential (primary)

I10
hypertension

6 010881 MAHYUDI BAMBAN UTARA RT.003 L 63 Th V BPJS G20 Parkinson-s disease

Baru : 163
Lama : 189
Laki-Laki : 163
Perempuan : 189
Total : 352