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TAGIHAN KLAIM RAWAT JALAN PASIEN PKMS DI PELAYANAN DASAR

PUSKESMAS : NUSUKAN BULAN : Januari


KOTA : SURAKARTA TANGGAL : 12-17 Januari 2015
PROPINSI : JAWA TENGAH

Kepada Yth :
Kepala Dinas Kesehatan Kabupaten SURAKARTA
di tempat

Bersama ini kami ajukan rincian Klaim Pelayanan Kesehatan Umum Rawat Jalan Peserta PKMS :
Jenis Jenis Tahun/B Pelayanan Kesehatan& Besaran Tarif sesuai Perda
No Tgl Nama No. Peserta L/P Kode Diagnosis Total
Pasien PKMS ulan Retribusi BP Umum Gigi KIA Laborat
1 '12/01 FEBRI IRAWAN 05.02.04.012100 PKMS SILVER L '27 / 3 Influensa bukan karena Virus 7500 7,500
2 '12/01 MULYANTI 05.02.02.213615 PKMS GOLD P '36 / 4 Konsultasi / Penjelasan KB 7500 7,500
3 '12/01 ETIK 05.01.01.255743 PKMS GOLD P '51 / 0 Obs. Febris 7500 7,500
4 '12/01 TARMINI 04.09.02.133120 PKMS SILVER P 62/11 Angina Pektoris 7500 7,500
5 '12/01 SABELA PUTRI 05.01.04.115357 PKMS SILVER P '10 / 8 Gastritis 7500 7,500
6 '12/01 WARNO TRISNO 05.02.01.000096 PKMS SILVER L `74/7 NIDDM (tdk tgt insulin) 7500 7,500
7 '12/01 EMANUEL SUWARDI 05.02.01.251118 PKMS GOLD L '68 / 7 Gagal Jantung 7500 7,500
8 '12/01 HARTANTI 05.01.02.236393 PKMS SILVER P '48 / 2 Influensa karena Virus 7500 7,500
9 '12/01 NGATMINI 05.02.02.076510 PKMS GOLD P '28 / 3 Konsultasi / Penjelasan KB 7500 7,500
10 '12/01 SATINI 05.02.02.271053 PKMS SILVER P `57/7 Hipertensi Essensial 7500 7,500
11 '12/01 RATNASARI 05.02.01.251119 PKMS GOLD P '52 / 6 Hipertensi Essensial 7500 7,500
12 '12/01 SURATI 05.02.01.147975 PKMS SILVER P `62/ Cephalgia krn Neurologi 7500 7,500
13 '12/01 RAFFA ADE 05.01.04.244617 PKMS SILVER L '2 / 5 Herpes simpleki 7500 7,500
14 '12/01 PRIHATIN 05.02.02.160416 PKMS SILVER P '48 / 4 Konsultasi / Penjelasan KB 7500 7,500
15 '12/01 VERA DINA PW 05.02.05.273244 PKMS SILVER P `0/10 Diare infeksi/ + antibiotika 7500 7,500
16 '12/01 NUR SIDA 05.01.03.229091 PKMS SILVER P '21 / 0 Myalgia (keju kemeng) 7500 7,500
17 '12/01 SEFIL PATRICIA A 05.02.03.237121 PKMS SILVER L '3 / 7 Influensa bukan karena Virus 7500 7,500

18 '12/01 RASYA SAPUTRA 05.02.03.269270 PKMS SILVER L `2/11 Influensa bukan karena Virus 7500 7,500
19 '12/01 ATHA NOVIA 05.02.03.078539 PKMS SILVER P '10 / 2 Appendicitis 7500 7,500
20 '12/01 BUDI SETYORINI 05.02.02.260345 PKMS SILVER P '52 / 4 Influensa bukan karena Virus 7500 7,500

21 '12/01 RAIHAN AL FITRAH S 05.02.03.14004 PKMS SILVER P `12/1 Influensa bukan karena Virus 7500 7,500

22 '12/01 EVAN ABBIYU 05.02.03.008488 PKMS GOLD L '7 / 2 Influensa bukan karena Virus 7500 7,500
23 '12/01 TUKIYEM 05.02.02.022045 PKMS SILVER P '56 / 10 Hipertensi Essensial 7500 7,500
24 '12/01 MAULIANA TRI W 05.02.02.020537 PKMS SILVER P `39/10 Konsultasi / Penjelasan KB 7500 7,500
25 '12/01 YANUAR RENO 05.02.03.161605 PKMS SILVER L '7 / 0 Influensa bukan karena Virus 7500 7,500
26 '12/01 RIKA ANGGITA 05.01.03.052848 PKMS SILVER P '11 / 8 Gastritis 7500 7,500
27 '12/01 NURDIN WIDYO A 05.02.03.020538 PKMS SILVER L `11/0 Influensa bukan karena Virus 7500 7,500

28 '12/01 DINAR FEBRIANA 05.02.04.117339 PKMS SILVER P '23 / 10 Influensa bukan karena Virus 7500 7,500
29 '12/01 ESTER SUPRIYANA 05.02.02.149214 PKMS SILVER P '32 / 8 Cephalgia non spesifik 7500 7,500
30 '12/01 ROSIANA SUMIROH 05.02.01.198162 PKMS SILVER P 38 / 8 Mens tdk teratur 7500 7,500
31 '12/01 RULLY ARDIAN 05.02.01.230262 PKMS SILVER L `37/9 Karies gigi 7500 7,500
32 '12/01 RAHMAT PRASETYO 05.02.05.056850 PKMS SILVER L '22 / 8 Obs. Febris 7500 7,500
33 '12/01 EZTELYTHA 05.02.05.274342 PKMS SILVER P '1 / 3 Cough / batuk 7500 7,500
34 '12/01 RINAWATI 05.02.02.158761 PKMS SILVER P '36 / 0 Dermatophytosis / jamur 7500 7,500
35 '12/01 WIRYANI 05.02.02.071454 PKMS SILVER P `57 Cephalgia krn Neurologi 7500 7,500

Influensa bukan karena


36 '12/01 WINARSIH 05.01.34.199260 PKMS SILVER P '30 / 11 7500 7,500
Virus/Dermatophytosis / jamur

37 '12/01 DESI DWI HASTUTI 05.02.03.076478 PKMS SILVER P `29 Gastritis 7500 7,500
38 '12/01 DIGDAYANTO 05.01.01.195761 PKMS SILVER L '54 / 9 Hipertensi Essensial 7500 7,500
39 '12/01 TUGINEM 05.02.31.110779 PKMS SILVER P '78 / 5 Myalgia (keju kemeng) 7500 7,500
40 '12/01 PANCANIUTAMI 05.02.02.133844 PKMS SILVER P '39 / 6 Konsultasi / Penjelasan KB 7500 7,500
41 '12/01 SALSABILA 05.02.03.265853 PKMS SILVER P `3/10 Influensa bukan karena Virus 7500 7,500
42 '12/01 IRAWAN SULISTYO 05.02.34.057154 PKMS SILVER L '54 / 4 NIDDM (tdk tgt insulin) 7500 7,500
43 '12/01 NANIK 05.02.02.059762 PKMS SILVER P '36 / 10 Gastritis 7500 7,500
44 '12/01 NOOR SYARIFULLAH 05.02.01.271056 PKMS SILVER L `36/7 Herpes Zoster 7500 7,500
45 '12/01 SUMANTI 05.02.01.012093 PKMS SILVER L '58 / 5 Dermatitis Kontak Alergi 7500 7,500
46 '12/01 EBEN H 05.02.04.158766 PKMS SILVER L '7 / 1 Asma 7500 7,500
47 '12/01 WAKINI 05.02.02.030154 PKMS SILVER P '35 / 7 Konsultasi / Penjelasan KB 7500 7,500
48 '12/01 FEBRI IRAWAN 05.02.04.012100 PKMS SILVER L '27 / 3 Schizophrenia 7500 7,500
49 '12/01 LAYLA 05.01.05.272318 PKMS SILVER P '1 / 4 Influensa bukan karena Virus 7500 7,500
50 '12/01 DENY W 05.02.03.160417 PKMS SILVER P '27 / 1 Konsultasi / Penjelasan KB 7500 7,500
51 '12/01 IQWAN 05.02.01.057098 PKMS SILVER L '47 / 8 Gastritis 7500 7,500
52 '12/01 TRI ANDRIYANI 05.01.02.099229 PKMS SILVER P '37 / 9 Konsultasi / Penjelasan KB 7500 7,500
53 '12/01 ARSENIO 05.02.03.279398 PKMS SILVER L '/3 Influensa karena Virus 7500 7,500
54 '12/01 HARYATI 05.02.02.280472 PKMS SILVER P '53 / 5 Gastritis 7500 7,500
Cough / batuk/Myalgia (keju
55 '12/01 SUKIMAH 05.02.01.058531 PKMS GOLD P` `62/1 7500 7,500
kemeng)
56 '13/01 SITI SUSWIYATUN 05.02.02.273051 PKMS SILVER P '40 / 8 NIDDM (tdk tgt insulin) 7500 7,500
57 '13/01 ENI W 05.02.02.189128 PKMS SILVER P '50 / 6 Myalgia (keju kemeng) 7500 7,500
58 '13/01 IRAWAN SULISTYO 05.02.34.057154 PKMS SILVER L '54 / 4 Cough / batuk 7500 7,500
59 '13/01 APRILO 05.02.06.266722 PKMS SILVER L '1 / 8 Dermatitis Kontak Alergi 7500 7,500
60 '13/01 NOVI HAPSARI 05.02.03.230930 PKMS SILVER P '3 / 2 Cough / batuk 7500 7,500
61 '13/01 CLARISTA RAHMADANI '05.02.03.212923 PKMS SILVER P '7 / 3 Influensa bukan karena Virus 7500 7,500
62 '13/01 DWI KRISTIYARINI 05.02.02.059646 PKMS SILVER P '48 / 4 Gastritis 7500 7,500
63 '13/01 SUYATI 05.02.02.217109 PKMS GOLD P `57 Cephalgia non spesifik 7500 7,500
64 '13/01 MAYMUNA RAHMAD 05.01.01.097879 PKMS SILVER L '32 / 7 Influensa karena Virus 7500 7,500
65 '13/01 NITA SUNARNI 05.01.02.177787 PKMS SILVER P `35/4 Pengawasan kehamilan normal 7500 7,500

66 '13/01 RAYHAN 05.02.03.027261 PKMS SILVER L '10 / 1 Influensa bukan karena Virus 7500 7,500
67 '13/01 SURIP 05.02.34.206739 PKMS SILVER P `67/1 Cephalgia krn Neurologi 7500 7,500
68 '13/01 SITI NUR KHASANAH 05.02.03.280699 PKMS SILVER P '18 / 5 Gastritis 7500 7,500
69 '13/01 EKO SAPUTRO '05.02.01239631 PKMS SILVER L '36 / 4 Diare infeksi/ + antibiotika 7500 7,500
70 '13/01 AYU SEPTIANA 05.02.03.281341 PKMS SILVER P `22/3 Pengawasan kehamilan normal 7500 7,500
71 '13/01 MARGARETA 05.01.03.107681 PKMS SILVER P '12 / 9 Diare infeksi/ + antibiotika 7500 7,500
72 '13/01 ZULFA PUTRI 05.02.04.275431 PKMS SILVER P 1/1 Influensa karena Virus 7500 7,500
73 '13/01 SARTINI 05.01.03.156522 PKMS SILVER P '52 / 7 Influensa bukan karena Virus 7500 7,500

74 '13/01 RUSJIATI 05.02.01.267423 PKMS SILVER P '54 / 10 Hordeolum & Chalazion (timbil) 7500 7,500
75 '13/01 SUMINI 05.02.02.247850 PKMS SILVER P '38 / 9 Diare infeksi/ + antibiotika 7500 7,500
76 '13/01 M FAIS 05.01.05.040106 PKMS SILVER L '6 / 2 Influensa bukan karena Virus 7500 7,500
77 '13/01 SRI REJEKI 05.01.02.120307 PKMS SILVER P '56 / 5 Gastritis 7500 7,500
78 '13/01 IRVAN ABDUL R 05.02.02.244124 PKMS GOLD L `2/8 Hordeolum & Chalazion (timbil) 7500 7,500
79 '13/01 MULYO WIJOYO 05.02.01.038313 PKMS SILVER L '67 / 0 Pulpitis 7500 20000 27,500
80 '13/01 YAHAZIEL BILLY 05.02.05.212228 PKMS SILVER L '4 / 8 Influensa bukan karena Virus 7500 7,500

81 '13/01 ROSITA AGUSTINA 05.02.03.240072 PKMS SILVER P '2 / 7 Influensa bukan karena Virus 7500 7,500
82 '13/01 IWAN BUDI SUSANTO '05.02.03.137576 PKMS SILVER L '29 / 11 Cough / batuk 7500 7,500
83 '13/01 THERESIA 05.01.04.244240 PKMS SILVER P '9 / 1 Dermatitis Kontak Alergi 7500 7,500
84 '13/01 SULISWATI 05.02.02.057152 PKMS SILVER P '55 / 1 Hipertensi Essensial 7500 7,500
85 '13/01 SUMINAH '050231142320 PKMS SILVER P '68 / 4 Hipertensi Essensial 7500 7,500
86 '13/01 JUFRI G 05.02.04.270103 PKMS SILVER L '1 / 2 Influensa bukan karena Virus 7500 7,500
87 '13/01 FAHRUL I 05.02.03.030286 PKMS SILVER L '10 / 0 Cephalgia non spesifik 7500 7,500
88 '13/01 NOVITASARI 05.02.04.098759 PKMS SILVER P '9 / 11 Influensa bukan karena Virus 7500 7,500
89 '13/01 F A SURONO 05.02.01.238414 PKMS SILVER L '66 / 3 Otitis Media 7500 7,500
90 '13/01 ANITA SARI 05.01.02.244238 PKMS SILVER P '39 / 6 Dermatitis Kontak Alergi 7500 7,500
91 '13/01 SULARMI 05.01.02.192123 PKMS SILVER P '74 / 0 Hipertensi Essensial 7500 7,500
92 '13/01 OKTAVIANI P L 05.02.05.272102 PKMS SILVER P `3/3 Diare non infeksi 7500 7,500
93 '13/01 DAVINA LUTVIANA S 05.01.03.156651 PKMS SILVER P `11/8 Obs. Febris 7500 7,500
94 '14/01 TARTO 05.02.01.071802 PKMS SILVER L '48 / 0 Cephalgia non spesifik 7500 7,500
95 '14/01 SULAR 05.02.01.261723 PKMS SILVER L `54/1 Asma 7500 7,500
96 '14/01 SUIMAH 05.13.02.087318 PKMS SILVER P '63 / 1 Hipertensi Essensial 7500 7,500
97 '14/01 NINDY 05.02.03.035768 PKMS SILVER P '8 / 4 Influensa bukan karena Virus 7500 7,500
98 '14/01 JOYO KARTONO 05.01.01.126260 PKMS GOLD P `81/6 Hipertensi Essensial 7500 7,500
99 '14/01 MUKIBATUL 05.02.02.151442 PKMS SILVER P '32 / 0 Pengawasan kehamilan normal 7500 7,500

100 '14/01 ERIIC YOGA T 05.02.03.102486 PKMS GOLD L `11/2 Influensa bukan karena Virus 7500 7,500
101 '14/01 LINA 05.01.02.229575 PKMS SILVER P '30 / 6 Dermatitis Kontak Alergi 7500 7,500
102 '14/01 VICTORINA KUSTINI 05.01.02.028419 PKMS SILVER P `56/3 Hipertensi Essensial 7500 7,500
103 '14/01 SRI JANTIYAH 04.11.02.236467 PKMS SILVER P `55 Artritis yang lain 7500 7,500
104 '14/01 FANIA AZURA 05.01.04.274736 PKMS SILVER P '1 / 4 Diare infeksi/ + antibiotika 7500 7,500
105 '14/01 MURTININGSIH 05.02.02.265197 PKMS SILVER P '31 / 2 Influensa bukan karena Virus 7500 7,500
106 '14/01 DWI RUSNANI 05.02.02.037386 PKMS SILVER P '34 / 9 Gastritis 7500 7,500
107 '14/01 SARTINI 05.02.02.246983 PKMS GOLD P '38 / 3 Pengawasan kehamilan normal 7500 7,500
108 '14/01 RAKIMIN HADI S 05.02.01.106842 PKMS GOLD L `79/7 Hipertensi Essensial 7500 7,500
109 '14/01 CAHYO FIRNANDO 05.02.03.193804 PKMS SILVER L '19 / 8 Influensa bukan karena Virus 7500 7,500
110 '14/01 MARYAM K 05.02.34.158267 PKMS SILVER P '29 / 5 Kontrol Post Partum 7500 7,500
111 '14/01 SUMARNI 05.02.02.267648 PKMS SILVER P '34 / 9 Pengawasan kehamilan normal 7500 7,500
112 '14/01 DAVIT YULIANTO 05.02.05145454 PKMS SILVER L '7 / 11 Pulpitis 7500 7,500
113 '14/01 DYAN TRI V 05.01.02.165421 PKMS SILVER P '30 / 1 Pengawasan kehamilan normal 7500 7,500

114 '14/01 ETIK YANININGSIH 05.02.02.271490 PKMS SILVER P '34 / 6 Pengawasan kehamilan normal 7500 7,500
115 '14/01 MUH REVAN R 05.02.06.264768 PKMS SILVER L '1 / 5 Vomitus 7500 7,500
116 '14/01 BRIGITA 05.03.03.034822 PKMS SILVER P '13 / 5 Influensa karena Virus 7500 7,500
117 '14/01 ARGA PUTRA '050203270631 PKMS SILVER L '1 / 10 Influensa karena Virus 7500 7,500
118 '14/01 SUGENG 05.02.01.145434 PKMS SILVER L '50 / 1 Myalgia (keju kemeng) 7500 7,500
119 '14/01 SUPARNI 05.01.01.245568 PKMS SILVER P '76 / 1 Pulpitis 7500 7,500
120 '14/01 SRI RAHAYU 05.02.02.275746 PKMS SILVER P '24 / 0 Pengawasan kehamilan normal 7500 7,500
121 '14/01 YUDO TYASONO 05.02.01.027301 PKMS SILVER L '70 / 0 Gagal Jantung 7500 7,500
122 '14/01 RISKA NUR F 05.01.07.014285 PKMS SILVER P '10 / 5 Conjunctivities 7500 7,500
123 '14/01 DITO 05.02.06.196682 PKMS SILVER L '4 / 8 Infeksi non spesifik 7500 7,500
124 '14/01 INTAN ANGGRAENI 05.02.03.054944 PKMS SILVER P `18/5 Pengawasan kehamilan normal 7500 7,500
125 '14/01 ENDANG SUWARNI '050302064808 PKMS SILVER P '39 / 2 Influensa karena Virus 7500 7,500
126 '15/01 FEBRIYANO BARA 05.02.04.270951 PKMS SILVER L `2/11 Influensa bukan karena Virus 7500 7,500
127 '15/01 NABILAH ZASKIA 05.02.03.278221 PKMS SILVER P '6 / 9 Obs. Febris 7500 7,500
128 '15/01 SUWARDI 05.02.01.027592 PKMS SILVER L '67 / 9 Angina Pektoris 7500 7,500
129 '15/01 SUTINO 05.02.01.071343 PKMS SILVER L `64/1 Hipertensi Essensial 7500 7,500
130 '15/01 ADINDA FAJAR PUTRI 05.01.05.066173 PKMS SILVER P '13 / 2 Supernumerary teeth 7500 7500 15,000
131 '15/01 ARIS MUHAMAD 05.03.05.089618 PKMS SILVER L '11 / 9 Influensa bukan karena Virus 7500 7,500
132 '15/01 MULYANTI 05.02.02.213615 PKMS SILVER P '36 / 5 Gout Artritis 7500 7,500
133 '15/01 MARYATI 05.01.02.214853 PKMS SILVER P '60 / NIDDM (tdk tgt insulin) 7500 7,500
134 '15/01 ANGGUN 05.02.03.232194 PKMS SILVER P `3/3 Influensa bukan karena Virus 7500 7,500
135 '15/01 SUYATI 05.02.02.217109 PKMS GOLD P `57 Cough / batuk 7500 7,500
136 '15/01 SABINA ANGGELINA 05.02.03278009 PKMS SILVER P `1 Influensa karena Virus 7500 7,500
137 '15/01 SRI WIYANTI 05.02.02.247379 PKMS GOLD P '44 / 8 Cephalgia non spesifik 7500 7,500
138 '15/01 LESTARI 05.02.02.107453 PKMS SILVER P `37/10 Cephalgia krn Neurologi 7500 7,500
139 '15/01 CARISSA OKTAVIANA 05.02.03.281166 PKMS SILVER P '1 / 2 Influensa karena Virus 7500 7,500
140 '15/01 ERSY AWANDARI 05.02.02.057099 PKMS SILVER P '39 / 5 Myalgia (keju kemeng) 7500 7,500
141 '15/01 RADO KURNIAWAN 05.02.03.262825 PKMS SILVER L `2/3 Gastritis 7500 7,500
142 '15/01 WAHYU H 05.02.02.255302 PKMS GOLD P '29 / 9 Ginggivitis 7500 7,500
143 '15/01 DRAJAD H 05.02.03.009338 PKMS SILVER L '12 / 8 Pulpitis 7500 7,500
144 '15/01 TUMINI 05.02.02.247486 PKMS GOLD P 29 / 3 Cephalgia krn Neurologi 7500 7,500
145 '15/01 APRILIA 05.01.03.097917 PKMS SILVER P '11 / 9 Influensa bukan karena Virus 7500 7,500

146 '15/01 FALEN 05.01.04.272317 PKMS SILVER P '3 / 4 Influensa bukan karena Virus 7500 7,500

R RUKIBAN
147 '15/01 05.02.01.029083 PKMS GOLD L 63 / 9 Cephalgia krn Neurologi 7500 7,500
KARTODIHARJO
148 '15/01 KIRANA WIDYASTUTI 05.02.02.009721 PKMS SILVER P 31/8 Pharingitis 7500 7,500
149 '15/01 DENI GEDEON P 05.02.03.009723 PKMS SILVER L `18/2 Pharingitis 7500 7,500
150 '15/01 SRI HARYANTI 05.02.002.234956 PKMS SILVER P '36 / 3 Recurrent depressive disorder 7500 7,500

151 '15/01 ARI SETYAWAN 05.02.01.251736 PKMS SILVER L '28 / 10 Influensa bukan karena Virus 7500 7,500
152 '15/01 PAINAH 05.02.02.062058 PKMS SILVER P '49 / 4 Conjunctivities 7500 7,500
153 '15/01 SRI HARDATI 05.01.02.066164 PKMS SILVER P '52 / 8 Dermatitis Kontak Alergi 7500 7,500
154 '15/01 SUSIWIATI 05.02.01.274639 PKMS SILVER P '50 / 0 Conjunctivities 7500 7,500
155 '15/01 WARTINI 05.03.02.089583 PKMS SILVER P `38/8 Myalgia (keju kemeng) 7500 7,500
156 '15/01 KEMAD 05.02.01.243163 PKMS GOLD L `55/5 Hipertensi Essensial 7500 7,500
157 '16/01 RAHAYU 05.02.02.043680 PKMS SILVER P '61 / 9 Hipertensi Essensial 7500 7,500
158 '16/01 SRI HARYANTI 05.02.02.234956 PKMS SILVER P '36 / 3 Konsultasi / Penjelasan KB 7500 7,500
159 '16/01 SUGIYATI 05.02.02.247703 PKMS SILVER P '48 / 5 Hipertensi Essensial 7500 7,500
160 '16/01 VICTORINA KUSTINI 05.01.02.028419 PKMS SILVER P `56/3 Influensa bukan karena Virus 7500 7,500
161 '16/01 RUBY 05.02.01.281735 PKMS SILVER P '54 / 0 Hipertensi Essensial 7500 7,500
162 '16/01 MULYO WIJOYO 05.02.01.038313 PKMS SILVER L '67 / Hemorroid 7500 7,500
163 '16/01 TARMINI 04.09.02.133120 PKMS SILVER P `62/11 Influensa bukan karena Virus 7500 7,500

164 '16/01 NANING KUSUMA 05.08.02.014623 PKMS GOLD P '32 / 2 Pelayanan Kontrasespsi / KB 7500 7,500
165 '16/01 CHRISTIAN FARREL 05.02.03.227659 PKMS GOLD L '1 / 5 Diare infeksi/ + antibiotika 7500 7,500
166 '16/01 ERVI SOPHIA 05.02.02.042178 PKMS SILVER P '47 / 9 Obs. Febris 7500 7,500
167 '16/01 MUDJIYEM 05.02.02.074326 PKMS SILVER P `55/3 Cephalgia krn Neurologi 7500 7,500
168 '16/01 AYANA A 05.02.05.275824 PKMS SILVER P '1 / 2 Influensa karena Virus 7500 7,500
169 '16/01 SRI HANDAYANI 05.01.02.213731 PKMS SILVER P '30 / 6 Influensa bukan karena Virus 7500 7,500

170 '16/01 SRI WULANDARI 05.02.02.203502 PKMS SILVER P '23 / 11 Pelayanan Kontrasespsi / KB 7500 7,500

171 '16/01 HANANDA RADEA 05.02.04.281741 PKMS SILVER L '8 / 9 Influensa bukan karena Virus 7500 7,500
172 '16/01 SUMADI 05.02.01.067336 PKMS SILVER L '49 / 6 Angina Pektoris 7500 7,500
173 '16/01 EMI KURNIAJATI 05.02.01.128324 PKMS SILVER P `36/10 Gastritis 7500 7,500
174 '16/01 ANUGRAH PUTRI 05.02.34.281225 PKMS SILVER P '0 / 7 Influensa bukan karena Virus 7500 7,500
175 '16/01 SUPARMAN 05.02.01.187967 PKMS SILVER L '56 / 0 NIDDM (tdk tgt insulin) 7500 7,500
176 '16/01 YULI RAHMAWATI 05.02.02.098540 PKMS SILVER P '37 / 6 Cystitis (ISK) 7500 7,500
177 '16/01 AIKO JUSTINA 05.02.08.270505 PKMS SILVER P '2 / 1 Obs. Febris 7500 7,500
178 '16/01 ISTIQOMAH '050202060935 PKMS SILVER P '31 / 11 Influensa bukan karena Virus 7500 7,500
179 '16/01 SULASTRI 05.02.02.021976 PKMS SILVER P '63 / 6 NIDDM (tdk tgt insulin) 7500 7,500
180 '16/01 SUPARNI 05.01.01.279154 PKMS SILVER P '66 / 0 Dermatitis Kontak Alergi 7500 7,500
Kontrol kesehatan dengan
181 '16/01 ARSENIO 05.02.03.279398 PKMS SILVER L '/3 7500 7,500
keluhan
182 '16/01 ALWI SURJANATA 04.09.01.278020 PKMS SILVER L `73 Cephalgia krn Neurologi 7500 7,500
183 '16/01 AULIA PUTRI 05.02.01.219687 PKMS GOLD P '4 / 4 Obs. Febris 7500 7,500
184 '16/01 ASIT A 05.01.01.196947 PKMS SILVER L '26 / 4 Conjunctivities 7500 7,500
185 '16/01 VINSENSIUS ARKA 05.01.03.063822 PKMS SILVER P `17/4 Pharingitis 7500 7,500
186 '16/01 ARIS SUPRIYANTO 05.02.03.027964 PKMS SILVER L '31 / 11 Angina Pektoris 7500 7,500
187 '16/01 NAZHIRUL ASROFI Z 05.02.04.275613 PKMS SILVER L `1/9 Influensa bukan karena Virus 7500 7,500
188 '16/01 DEDE SUKAINAH 05.02.01.188021 PKMS SILVER P '50 / 3 Gastritis 7500 7,500
189 '17/01 MUH ARYA 04.02.03.214654 PKMS SILVER L '5 / 5 Influensa bukan karena Virus 7500 7,500

Sehat / Kir Pemeriksaan


190 '17/01 SUNARDI '05.01.01.157248 PKMS SILVER L '60 / 9 7500 7,500
Normal
191 '17/01 RADO KURNIAWAN 05.02.03.262825 PKMS SILVER L 2/4 Cough / batuk 7500 7,500
192 '17/01 DAYAT 05.02.01.210579 PKMS SILVER L `29 Pharingitis 7500 7,500
193 '17/01 JIHAN 05.02.03.273155 PKMS SILVER L '1 / 1 Herpes simplek 7500 7,500
194 '17/01 MARYATI 05.01.01.040535 PKMS GOLD P '64 / 0 Gagal Jantung 7500 7,500
195 '17/01 SUMINAH '05.01.02.157249 PKMS SILVER P '56 / 4 Pharingitis 7500 7,500
196 '17/01 MIA R 05.02.04.265890 PKMS SILVER P '255 / 3 Influensa bukan karena Virus 7500 7,500

197 '17/01 KARIS KIRANA 05.01.04.026481 PKMS SILVER L '7 / 2 Influensa bukan karena Virus 7500 7,500
198 '17/01 SURYANI 05.01.02.164033 PKMS SILVER P '38 / 10 Hemorroid 7500 7,500
199 '17/01 NAIL RAKHA ABDULLAH 05.01.03.137925 PKMS SILVER L '11 / 9 Herpes Zoster 7500 7,500
200 '17/01 MUH KEVIN 05.02.04.240104 PKMS SILVER L '2 / 6 Influensa karena Virus 7500 7,500
201 '17/01 CLAUDIA 05.02.03.221197 PKMS SILVER P '4 / 4 Dermatitis Kontak Alergi 7500 7,500
202 '17/01 RADO K 05.02.03.262825 PKMS SILVER L '2 / 3 Influensa bukan karena Virus 7500 7,500
203 '17/01 SUHARNI 05.03.02.168322 PKMS SILVER P '49 / 4 Influensa karena Virus 7500 7,500
204 '17/01 SUYITNO 05.02.01.074289 PKMS SILVER P `57/5 Influensa bukan karena Virus 7500 7,500
205 '17/01 DARMIN 05.02.01.247294 PKMS SILVER L '69 / 6 Stroke 7500 7,500
206 '17/01 RIZAL PUTRA H 05.02.04.281126 PKMS SILVER L 2/9 Influensa bukan karena Virus 7500 7,500
207 '17/01 JASMADI 05.02.01.070534 PKMS SILVER L `59/6 Hipertensi Essensial 7500 7,500
208 '17/01 JONATHAN C 05.01.03.166845 PKMS SILVER L '6 / 0 Commond Cold 7500 7,500
209 '17/01 SUMIYATI 05.02.02.247296 PKMS GOLD P '53 / 2 NIDDM (tdk tgt insulin) 7500 7,500
210 '17/01 EKA HEKMAWATI 05.01.01.229406 PKMS SILVER P '41 / 10 Myalgia (keju kemeng) 7500 7,500
211 '17/01 HANDOKO DIGDO 05.02.01.246397 PKMS GOLD L `45/8 Hipertensi Essensial 7500 7,500
212 '17/01 WINARNI 05.02.02.031364 PKMS SILVER P '56 / 6 Gastritis 7500 7,500
213 '17/01 SURIP 05.02.34.206739 PKMS SILVER P `67/1 Hipertensi Essensial 7500 7,500
214 '17/01 JADI R 05.02.04.267425 PKMS GOLD L '21 / 2 Hernia 7500 7,500
215 '17/01 SUNARNI 05.01.02.069490 PKMS SILVER P '52 / 0 Stroke 7500 7,500
216 '17/01 TUKIRAN 05.01.01.164032 PKMS SILVER L '42 / 11 NIDDM (tdk tgt insulin) 7500 7,500
217 '17/01 VERLITA VANDA 05.02.03.136757 PKMS SILVER P '6 / 11 Supernumerary teeth 7500 7500 15,000
218 '17/01 YANUAR 05.02.03.272130 PKMS SILVER L '0 / 11 Diare non infeksi 7500 7,500
219 '17/01 KENZI 05.02.03.234994 PKMS SILVER L '2 / 10 Stomatitis 7500 7,500
220 '17/01 ANITA SARI 05.02.05.031586 PKMS SILVER P '24 / 10 Pengawasan kehamilan normal 7500 7,500
221 '17/01 JIHAN NAFISA F 05.01.03.272575 PKMS SILVER L '1 / 0 Herpes Zoster 7500 7,500
222 '17/01 WALIDI 05.02.01.046401 PKMS SILVER L '32 / 6 Cephalgia non spesifik 7500 7,500
223 '17/01 RAHAYU 05.01.02.145259 PKMS SILVER P '43 / 11 Pruritus (gatal) 7500 7,500
224 '17/01 PRISKILIA 05.02.04.022059 PKMS SILVER P '25 / 6 Diare infeksi/ + antibiotika 7500 7,500
225 '17/01 SITI NUR KHASANAH 05.02.03.280699 PKMS SILVER P '18 / 5 Gastritis 7500 7,500
226 '17/01 YT KRISTIONO 05.01.01.026473 PKMS SILVER L '42 / 0 Karies gigi 7500 7500 15,000
227 '17/01 NATALIN 05.02.04.269124 PKMS SILVER P '3 / 1 Gastritis 7500 7,500
228 '17/01 ADIMAS JANANTO 05.01.04.066170 PKMS SILVER L '15 / 11 Dermatophytosis / jamur 7500 7,500
229 '17/01 MUH ROFEI 05.02.04.239041 PKMS SILVER L '2 / 7 Influensa bukan karena Virus 7500 7,500

230 '17/01 DWI LESTARI 05.02.02.280345 PKMS SILVER P '24 / 9 Pengawasan kehamilan Risti 7500 7,500
231 '17/01 SUPRIYADI 05.02.01.182748 PKMS SILVER L '59 / 9 Myalgia (keju kemeng) 7500 7,500
232 '17/01 SITI NUR LAELA 05.02.01.251551 PKMS GOLD P `52/1 Cough / batuk 7500 7,500
233 '17/01 ZARA ATIKA 05.02.04.244549 PKMS SILVER P `2/1 Influensa karena Virus 7500 7,500
234 '17/01 AGUNG RACHMANTO 05.02.01.234993 PKMS SILVER L `29/8 Myalgia (keju kemeng) 7500 7,500
JUMLAH 1,755,000 - 42,500 1,797,500

Surakarta,31 Januari 2015

Kepala UPTD Puskesmas Nusukan


Dinas Kesehatan
Kota Surakarta

drg. Agus Susanto,MM


NIP.19590823 198311 1 001

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