1.

Petugas Entri
Data
REGISTER PELAYANAN KB R/I/KB/20
Lembar 1

1 2 3 4 5 6
3 3 0 8 0 1 6 Bulan : 2023
NAMA FASKES/ PKBRS RSUD MUNTILAN V 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

(Kode) (Kode) ASURANSI

PELAYANAN BERGERAK
STATUS PESERTA KB

INFORMED CONSENT

PASCA KEGUGURAN
PASCA PERSALINAN
ISTRI

BPJS KESEHATAN
NO. TANGGAL ALAMAT NO. HANDPHONE

PEMASANGAN
PENCABUTAN

PENCABUTAN

KEGAGALAN
PEMBERIAN/

KOMPLIKASI
NAMA SUAMI

OPERATIF/

LAINNYA
TANGGAL

MANDIRI
NIK (NOMOR INDUK KEPENDUDUKAN) NAMA

BERAT
LAHIR

(Kode)

TIDAK

APBN

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

NGRAGOSOKO WETAN 01/04

1 01-Jul-2023 SUGENG 3 3 0 8 0 5 6 9 0 6 8 3 0 0 0 7 MUKIDAH 29-Jun-1983 083841495648 1 1 1 0 9 0 1 0 1 0 0 0
SRUMBUNG,MAGELANG
SARON 04/09, RAMBEANAK,
2 01-Jul-2023 EFRI 3 3 0 8 0 8 4 8 0 5 9 8 0 0 0 2 LUTFIA MEITA HAPSARI 08-May-1998 088216331009 1 1 1 0 2 0 1 0 1 0 0 0
MUNGKID

3 01-Jul-2023 RATNA N 3 3 0 8 0 8 4 5 1 0 9 5 0 0 0 3 AMIFATUN NADHIA 22-Oct-1995 NGAMPEL 04/01.SENGI.DKN 085742412310 1 1 1 0 9 0 1 0 1 0 0 0

4 01-Jul-2023 ICHSANUDIN 3 3 0 8 0 6 5 1 1 0 8 7 0 0 0 2 SRI HARJANI 11-Oct-1987 BABADAN II 02/07 PATEN DUKUN 0 1 1 1 0 9 0 1 0 1 0 0 0

RINA PERDANA NUR

5 01-Jul-2023 SUNU 3 3 0 2 0 4 6 5 0 1 9 5 0 0 0 3 25-Jan-1995 PANGGUNGAN 2/17, SAWANGAN 081229969664 1 1 1 0 8 0 1 0 1 0 0 0
AMALIA
DSN BETENG 1/9, BLIGO,
6 01-Jul-2023 AGUS 3 3 0 8 0 3 4 9 0 4 8 9 0 0 0 1 FITRIANA ATMAJATI 09-Apr-1989 0 1 1 1 0 9 0 1 0 1 0 0 0
NGLUWAR
CURAH 3 003/015 SOKORINI
7 01-Jul-2023 NURUL HANAFI 3 3 0 8 0 8 5 5 0 2 0 0 0 0 0 2 FINA FEBRIANI 20-Feb-2001 081933529846 1 1 1 0 9 0 1 0 1 0 0 0
MUNTILAN

8 01-Jul-2023 ZULKIFLI 3 3 0 4 1 6 6 0 0 7 8 2 0 0 0 3 RODLIYAH 20-Jul-1982 BATIKAN 02/15 PABELAN MUNGKID 085200331127 1 1 1 0 9 0 1 0 1 0 0 0

9 01-Jul-2023 SARIFUDIN 3 3 0 8 0 6 4 1 0 3 9 1 0 0 0 3 WIDHI HANIFA 01-Mar-1991 DSN GUWO 1/5, SEWUKAN, DUKUN 0 1 1 1 0 9 0 1 0 1 0 0 0

MANGUNSARI 1/2, MRANGGEN,

10 01-Jul-2023 RUDI M 3 3 0 8 0 5 6 8 0 6 9 5 0 0 0 4 MEGA KUSUMAWATI 28-Jun-1995 081328281913 1 1 1 0 9 0 1 0 1 0 0 0
SRUMBUNG
GROWONG 01/14 PUCUNGREJO,
11 01-Jul-2023 M. NASIR 3 3 0 8 0 8 5 0 1 1 0 0 0 0 0 5 WIDIYA ARIFAH 10-Nov-2000 0 1 1 1 0 9 0 1 0 1 0 0 0
MUNTILAN

12 01-Jul-2023 AAN PRASETYO 3 3 0 8 0 5 6 5 0 3 9 8 0 0 0 1 RINI SUSANTI 25-Mar-1998 GATAKAN 004/011 GULON SALAM 089602655386 1 1 1 0 9 0 1 0 1 0 0 0

13 01-Jul-2023 EDI WAHYONO 3 3 0 8 0 5 5 5 0 7 0 1 0 0 0 1 YULIA IKA SAPUTRI 15-Jul-2007 CANDI 2/8 MRANGGEN, SRUMBUNG 081252348737 1 1 1 0 9 0 1 0 1 0 0 1

14 01-Jul-2023 AHMAD ARIFIN 3 3 0 8 0 2 5 2 0 7 0 0 0 0 0 1 NURUL AKHADIYAH 12-Jul-2000 PLUBERAN 03/08 SUCEN, SALAM 085893888816 1 1 1 0 9 0 1 0 1 0 0 0

15 01-Jul-2023 YANTO 3 3 0 9 0 1 4 1 0 3 0 0 0 0 0 1 IKA SETIANA 01-Mar-2000 STABELAN 01/05 SELO BOYOLALI 085877733254 1 1 1 0 9 0 1 0 1 0 0 0

16 01-Jul-2023 NURHADI 3 5 1 6 1 3 5 1 0 9 8 6 0 0 0 2 YUYUN ARIANA 11-Sep-1986 DUKUN I 2/12 DUKUN 0 1 1 1 0 9 0 1 0 1 0 0 0

SENDEN 005/002 SENDEN

17 01-Jul-2023 WIDIYANTO 3 3 0 6 0 6 6 2 0 8 9 6 0 0 0 2 TIA GUSMAWANTI 22-Aug-1996 081227918688 1 1 1 0 9 0 1 0 1 0 0 0
MUNGKID
BAKALAN 01/01 SAWANGAN
18 01-Jul-2023 SETYO EARDI 3 3 0 8 0 7 5 3 1 1 9 6 0 0 0 4 IDA LESTARI 13-Nov-1996 081225071920 1 0 1 0 4 0 1 0 1 0 0 0
SAWANGAN

19 01-Jul-2023 KUWAT 3 3 0 8 0 8 4 4 1 1 9 1 0 0 0 1 NURUL HIDAYAH 11-Apr-1991 PEPE 2/2 MUNTILAN MUNTILAN 0 1 1 1 0 9 0 1 0 1 0 0 0

DUKUHAN 001/015 SUMBER

20 01-Jul-2023 HERUWADI 3 3 0 8 0 6 6 2 0 4 8 9 0 0 0 1 DWI ASTUTIK 22-Apr-1989 085701116268 1 1 1 0 9 0 1 0 1 0 0 0
DUKUN
KRICAAN MESIR KULON 4/7 SALAM
21 01-Jul-2023 M DUBAID 3 3 0 8 0 3 5 5 0 6 9 7 0 0 0 2 NAFIATUL MUSTAHFIROH 15-Jun-1997 0 1 1 1 0 9 0 1 0 1 0 0 0
SALAM

22 01-Jul-2023 ARIF HARI 3 3 0 8 1 5 4 1 1 1 9 3 0 0 0 3 NANI NOVIYANTI, 11-Jan-1993 MACANAN 1/6 DUKUN 085729463955 1 1 1 0 9 0 1 0 1 0 0 0

KARANG SANGGRAHAN 1/2

23 01-Jul-2023 dr. YUDHA FAUZAN 3 5 0 1 1 1 4 3 0 6 9 2 0 0 0 2 PUTRINDA ELLANIKA K 02-Jun-1992 085171127070 1 1 1 0 9 0 1 0 1 0 0 0
PLOSOGEDE, NGLUWAR
M BILAL H. ABENS PRADIPTA SEDAN 001/010 KETUNGGENG
24 01-Jul-2023 3 3 0 8 0 6 5 4 0 1 0 2 0 0 0 1 04-Jan-2002 0 1 1 1 0 9 0 1 0 1 0 0 0
APRIANSYAH WAHYU DUKUN
MUHAMMAD KHADIQ LOSARI 001/001 KALIABU
25 01-Jul-2023 3 3 0 7 0 3 4 8 1 1 9 9 0 0 0 2 MUFIDATUL CHASANAH 08-Nov-1999 085346362909 1 1 1 0 9 0 1 0 1 0 0 0
AL MAKLUF SALAMAN

26 01-Jul-2023 TEGUH AMANTO 3 3 0 8 0 4 4 9 0 7 0 1 0 0 0 2 RIZQI WAHYU NUGRAENI 09-Jul-2001 JUMOYO LOR 6/1 JUMOYO, SALAM 0 1 1 1 0 9 0 1 0 1 0 0 0

GATAK LAMAT 3/1, PUCUNGREJO,

27 01-Jul-2023 IBNU FEBRI W. 3 3 0 8 0 8 6 2 0 1 8 7 0 0 0 8 CHRISTY IDA NOFITA 22-Jan-1987 083109822441 1 1 1 0 11 0 0 1 0 0 0 0
MUNTILAN
 GANJURAN 5/2 PLOSOGEDE
28 01-Jul-2023 ADI RIWAYATNO 3 3 0 8 0 3 7 1 0 7 9 1 0 0 0 3 ESTI ROFIANA 31-Jul-1991 081329112580 1 1 1 0 9 0 1 0 1 0 0 0
NGLUWAR

29 01-Jul-2023 FEBRI 3 3 0 8 0 6 5 9 1 1 9 1 0 0 0 2 MIFTAHUL JANAH 19-Nov-1991 PUCANGANOM 3/8, SRUMBUNG 087834491485 1 1 1 0 9 0 1 0 1 0 0 0

30 01-Jul-2023 SURADI 3 3 0 8 0 6 4 5 0 7 8 6 0 0 0 4 WARSIH UTAMI 05-Jul-1986 KEPIL 001/010 KRINJING DUKUN 0 1 1 1 0 9 0 1 0 1 0 0 0

SRUMBUNG 004/012 KRADENAN

31 01-Jul-2023 IRVANI 3 2 7 3 2 9 6 8 0 8 8 2 0 0 0 1 WAGIYATI 28-Aug-1982 08882269132 1 1 1 0 8 0 1 0 1 0 0 0
SRUMBUNG

32 01-Jul-2023 KARYADI 3 3 0 8 0 4 6 8 0 6 8 2 0 0 0 5 ISTIQOMAH 28-Jun-1982 KARAHARJAN 3/4 MUNTILAN 083825349280 1 1 1 0 9 0 1 0 1 0 0 0

33 01-Jul-2023 PANUJI 3 3 0 8 0 9 4 9 1 1 9 8 0 0 0 3 SITI SARIFATUN NISAK 11-Sep-1998 JARAKAN 4/11 BOJONG MUNGKID 085697321676 1 1 1 0 9 0 1 0 1 0 0 0

34 01-Jul-2023 JOKO NASIR 3 3 0 8 0 6 5 7 1 2 9 5 0 0 0 3 JANI 01-Dec-1995 SENGI 4/5 SENGI DUKUN 085721827729 1 1 1 0 9 0 1 0 1 0 0 0

KETAWANG 02/02 KETAWANG,

35 01-Jul-2023 SARJIYANTO 3 3 0 8 1 6 5 1 0 7 9 1 0 0 0 1 SURYATI, 11-Jul-1991 081578568644 1 1 1 0 9 0 1 0 1 0 0 0
GRABAG

36 01-Jul-2023 ANDI 3 3 0 8 0 8 4 5 0 1 8 9 0 0 0 5 NANI ARI MURTI 05-Jan-1989 JAMBEAN 9/4 MENAYU MUNTILAN 0 1 1 1 0 9 0 1 0 1 0 0 0

NGENTAK 002/003 KALIBENING

37 01-Jul-2023 JADI NUR K 3 3 0 8 0 6 5 2 0 6 8 1 0 0 0 2 ARIF RUBIYANTI 12-Jun-1981 081903917197 1 1 1 0 11 0 1 0 0 0 0 0
DUKUN
NEPEN 2/5 GUNUNGPRING
38 01-Jul-2023 BUDI PRIHATIN 3 3 0 8 0 8 6 5 0 9 8 0 0 0 0 4 KISMIYATI 25-Sep-1980 082329444655 4 1 0 0 9 0 0 0 0 0 0 0
MUNTILAN
KAUMAN 02/06 JAMUS KAUMAN
39 01-Jul-2023 RAHMAD 3 3 0 8 0 3 6 8 0 3 8 8 0 0 0 1 TRI MARYANI 28-Mar-1988 0 1 1 1 0 9 0 1 0 1 0 0 0
NGLUWAR
SUDISARI II 03/02 ADIKARTO,
40 01-Jul-2023 ANDRI 3 3 0 8 0 8 5 0 0 8 9 3 0 0 0 1 EKA AGUSTIN INDRIWATI 10-Aug-1993 0 1 1 1 0 9 0 1 0 1 0 0 0
MUNTILAN

41 01-Jul-2023 WAHYUDIN 3 3 0 8 0 6 5 3 1 0 9 9 0 0 0 1 ISNAENI 13-Oct-1999 GOWOK RINGIN 3/6 SENGI DUKUN 085713044420 1 1 1 0 9 0 1 0 1 0 0 0

42 01-Jul-2023 RISKA FAVORIT 3 3 0 8 0 7 6 5 0 4 9 8 0 0 0 3 PUTRI HIDAYAH 25-Apr-1998 KLANGON 002/007 SAWANGAN 085875064729 1 0 1 0 6 0 1 0 1 0 0 0

JAMBLANGAN 26/11 BRINGIN

43 01-Jul-2023 ZAINUDIN 3 3 0 8 0 5 5 5 1 0 9 0 0 0 0 5 IRIN YULIANA 15-Oct-1990 089669991040 1 1 1 0 9 0 1 0 1 0 0 1
SRUMBUNG

44 01-Jul-2023 HERMAWAN 3 3 0 8 0 8 4 8 0 3 0 6 0 0 0 1 HERLINA WULANDARI 08-Mar-2006 NGABLAK 1/20 KEJI MUNTILAN 0 1 1 1 0 9 0 1 0 1 0 0 0

SITI JLUPO GUNUNG 13/03

45 01-Jul-2023 AHMAD SODIQ 3 3 0 8 0 5 6 3 0 5 9 6 0 0 0 2 23-May-1996 087830437763 1 1 1 0 9 0 1 0 1 0 0 0
WAKHIDATUSSHOLIKHA KEMBANGKUNING, WINDUSARI

46 01-Jul-2023 ISMAIL 1 8 7 1 1 1 6 6 0 2 8 4 0 0 0 2 ERISNA MALAU 26-Feb-1984 TLATAR 3/3 MUNTILAN MUNTILAN 081327295860 1 1 1 0 9 0 1 0 1 0 0 0

PAGERSARI 002/009 MRANGGEN

47 01-Jul-2023 NURMAKI 3 3 0 8 0 5 4 7 1 0 0 0 0 0 0 2 NURAINI INDAH LESTARI 07-Oct-2000 085643857183 1 1 1 0 9 0 1 0 1 0 0 0
SRUMBUNG

48 01-Jul-2023 SULIS 3 3 0 8 0 6 4 6 0 9 9 9 0 0 0 1 SUYATMI 26-Sep-1999 LARANGAN 1/10 JUMOYO SALAM 081559835806 1 1 1 0 8 0 1 0 1 0 0 0

49 01-Jul-2023 NUR ROIS 3 3 0 8 0 4 6 5 0 7 8 6 0 0 0 4 SITI ROCHANI 25-Jul-1986 KUNCEN 03/08 SELOBORO SALAM 081802713273 1 1 1 0 9 0 1 0 1 0 0 0

TEGALANCAR 4/5 KRADENAN

50 01-Jul-2023 MUH.IRFANGI 3 3 0 8 0 5 6 5 0 3 9 2 0 0 0 5 RESIAH 25-Mar-1992 0 1 1 1 0 9 0 1 0 1 0 0 0
SRMBG
DSN CUNGKUP 02/02 BANYUADEM
51 01-Jul-2023 ARGI YULISTIAN 3 3 0 8 0 5 5 5 0 3 0 4 0 0 0 2 RAHMAWATI 15-Mar-2004 0895378206165 1 1 1 0 9 0 1 0 1 0 0 0
SRUMBUNG
DWI ANIDA NURUL DSN KRADENAN 015/005
52 01-Jul-2023 KRIS YULIANTO 3 3 0 8 0 8 5 2 0 3 0 0 0 0 0 4 12-Mar-2000 081391709759 1 1 1 0 9 0 1 0 1 0 0 0
FAIZAH BATURONO, SALAM

53 01-Jul-2023 PUJI HANANTO 3 3 0 8 0 6 4 1 0 3 0 3 0 0 0 2 HERA FATMAWATI 01-Mar-2003 SETRAN 03/15 BANYUDONO 087722770558 1 1 1 0 9 0 1 0 1 0 0 0

TANEN 02/03 NGARGOMULYO

54 01-Jul-2023 RIYADI 3 3 0 8 0 6 5 2 0 7 9 0 0 0 0 2 MARWINI 12-Jul-1990 081390113921 1 1 1 0 9 0 1 0 1 0 0 0
DUKUN
SEMAWUNG 4/17 SEDAYU
55 01-Jul-2023 ADE PUTRA 3 1 7 4 0 1 5 4 0 4 9 7 0 0 0 1 MIRA APRIYANA 14-Apr-1997 088224532943 1 1 1 0 9 0 1 0 1 0 0 0
MUNTILAN

56 01-Jul-2023 MUHAMMAD ALWI 3 3 0 8 2 1 4 3 1 2 8 9 0 0 0 3 SITI QOMARIYAH 03-Dec-1989 BANARAN 1/3 SIDOSARI SALAMAN 089635977694 1 1 1 0 9 0 1 0 1 0 0 0

ANISA USWATUN PENGGARON KIDUL 004/002

57 01-Jul-2023 ERIK SAPUTRA 3 3 0 8 0 7 4 9 0 3 0 4 0 0 0 4 09-Mar-2004 088216617519 1 1 1 0 9 0 1 0 1 0 0 1
KHASANAH GONDOWANGI SAWANGAN
MRANGGEN 4/3 SUKORAME
58 01-Jul-2023 WALDIYANTO 3 3 0 9 0 4 4 4 0 4 0 8 0 0 0 2 ASIH LESTARI 04-Apr-2008 0 1 1 1 0 9 0 1 0 1 0 0 0
BOYOLALI
JL. KAUMAN 11 004/008 KURIPAN
59 01-Jul-2023 GATOT E 3 3 1 5 1 3 6 6 0 3 9 3 0 0 0 4 FITRI SHOLIKATUN, 26-Mar-1993 0 1 1 1 0 9 0 1 0 1 0 0 0
PURWODADI GROBOGAN
PELAS 2/2 PANDANRETNO,
60 01-Jul-2023 AGUNG H 3 3 0 8 0 5 5 6 0 4 8 8 0 0 0 1 ENDAH FITRIYATI 16-Apr-1998 0 1 1 1 0 11 0 1 0 0 0 0 0
SRUMBUNG

61 01-Jul-2023 KOLIK TRI 3 3 0 8 0 8 6 5 0 2 9 3 0 0 0 5 SIAMMI ISTI ARIFAH 25-Feb-1992 KENITEN 02/03 KEJI, MUNTILAN 082324447996 1 1 1 0 9 0 1 0 1 0 0 0

62 01-Jul-2023 KUAT NUR YANTO 3 3 0 8 0 7 6 2 0 1 8 9 0 0 0 2 MARIYAH 22-Jan-1989 GINTUNG 09/05 KETEP SAWANGAN 0 1 1 1 0 9 0 1 0 1 0 0 0

63 01-Jul-2023 KAMYOKO 3 3 0 8 0 8 5 1 0 9 7 5 0 0 0 2 ACHMALIYAH 11-Sep-1975 KEPANJEN 2/1, MENAYU, MUNTILAN 085701703757 1 1 1 0 8 0 1 0 1 0 0 0

64 01-Jul-2023 PUJI 3 3 0 8 0 6 4 3 0 6 9 9 0 0 0 1 NUR KHASANAH 03-Jun-1999 GROGOLAN B 001/013 DUKUN 085727194443 1 1 1 0 9 0 1 0 1 0 0 0

GEDANGSAMBU 2/2, GIRITENGAH,

65 01-Jul-2023 ERWIN 3 3 0 8 0 2 4 9 0 1 0 5 0 0 0 2 KIKI RAHMAWATI 19-Jan-2005 0 1 1 1 0 9 0 1 0 1 0 0 0
BOROBUDUR
 CORONGAN 5/23 MAGUWOHARJO
66 01-Jul-2023 M FITRIYANTO 3 3 0 6 0 7 6 2 1 0 9 9 0 0 0 1 IKA WAHYUNI 22-Oct-1999 085778415121 1 1 1 0 9 0 1 0 1 0 0 0
DEPOK SLEMAN
JEMBUL 10/05 SABRANGLOR,
67 01-Jul-2023 ANDI PURNAMA 3 3 0 8 0 8 4 4 0 4 9 6 0 0 0 2 BEKTI NUR KHASANAH 04-Apr-1996 08983464654 1 1 1 0 9 0 1 0 1 0 0 0
TRUCUK
ARIESNA DSN NGAMPEL 004/001 SENGI,
68 01-Jul-2023 PUNGKI KISMORO 3 3 0 8 0 7 6 9 0 7 9 7 0 0 0 4 29-Jul-1997 085878742353 1 1 1 0 9 0 1 0 1 0 0 0
SULISTYANINGRUM DUKUN
KARANG KOPEK WETAN 2/7,
69 01-Jul-2023 SYAHMI R 3 3 0 8 0 3 7 0 0 6 9 5 0 0 0 1 RETNO DWI NUR JAYANTI 30-Jun-1995 0 1 1 1 0 9 0 1 0 1 0 0 0
NGLUWAR
GLEYORAN 2/1 SAMBENG
70 01-Jul-2023 KAMYOKO 3 3 2 3 1 5 5 9 0 8 9 5 0 0 0 3 SITI ASLIMAH 19-Aug-1995 088215018202 1 1 1 0 8 0 1 0 1 0 0 0
BOROBUDUR
TEGALURUNG 02/11, BANYUBIRU,
71 01-Jul-2023 PRASETYO 3 3 0 8 0 6 4 1 0 1 9 8 0 0 0 9 LINDA DEWI, 01-Jan-1998 0 1 1 1 0 9 0 1 0 1 0 0 0
DUKUN
KAPUHAN 03/01 KAPUHAN
72 01-Jul-2023 JOKO SUSILO 3 3 0 8 1 6 4 3 0 2 9 6 0 0 0 1 PARTI 03-Feb-1996 085842956609 1 1 1 0 9 0 1 0 1 0 0 0
SAWANGAN
DWI KARTIKA
73 01-Jul-2023 TEGUH 3 3 0 8 0 4 7 0 0 6 0 3 0 0 0 4 30-Jul-2003 KRICAAN MESIR 4/7 SALAM SALAM 081328126638 1 1 1 0 9 0 1 0 1 0 0 0
KHOIRUNNISA

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 Lamp.R/I/KB/20
Data LAMPIRAN R/I/KB/20 Lembar 4

1 2 3 4 5 6
3 3 0 8 0 1 6 Bulan : 2023
NAMA FASKES/ PKBRS RSUD MUNTILAN V 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
PEMBERIAN INFORMED PB DAN KESERTAAN JKN INFORMED CONSENT
METODE
NO. CONSENT (Untuk Peserta KB
KONTRASEPSI
(Untuk PB) PB PASCA PB PASCA Ulangan) PELAYANAN ULANG KOMPLIKASI BERAT
GANTI CARA PENCABUTAN 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 0 1 1 1 0 0 0 0 0 0
2 IUD 1 0 1 1 1 0 0 0 0 0 0
3 IMPLAN 1 0 1 1 1 0 0 0 0 0 0
4 IMPLAN 1 0 1 1 1 0 0 0 0 0 0
5 IUD 1 0 1 1 1 0 0 0 0 0 0
6 IUD 1 0 1 1 1 0 0 0 0 0 0
7 IUD 1 0 1 1 1 0 0 0 0 0 0
8 IUD 1 0 1 1 1 0 0 0 0 0 0
9 IUD 1 0 1 1 1 0 0 0 0 0 0
10 IUD 1 0 1 1 1 0 0 0 0 0 0
11 IUD 1 0 1 1 1 0 0 0 0 0 0
12 IUD 1 0 1 1 1 0 0 0 0 0 0
13 IUD 1 0 1 1 1 0 0 0 0 0 0
14 IUD 1 0 1 1 1 0 0 0 0 0 0
15 IUD 1 0 1 1 1 0 0 0 0 0 0
16 IUD 1 0 1 1 1 0 0 0 0 0 0
17 IUD 1 0 1 1 1 0 0 0 0 0 0
18 IUD 1 0 1 1 1 0 0 0 0 0 0
19 IUD 1 0 1 1 1 0 0 0 0 0 0
20 IUD 1 0 1 1 1 0 0 0 0 0 0
21 IUD 1 0 1 1 1 0 0 0 0 0 0
22 IUD 1 0 1 1 1 0 0 0 0 0 0

JUMLAH 70 0 71 71 72 0 0 0 0 1 0 0

Magelang , 25-October-2023
Pimpinan Faskes KB/Jaringan/Jejaring*

dr. Ana Roechanah, Sp. PK

( .................................................................................................)
196809192006042002

NIP/NRP
* Coret yang tidak perlu