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The document summarizes patient information from the obgyn department. It includes 106 patient records with details like patient ID, name, date of birth, age, gender, date of admission, date of discharge, length of stay, payment method, discharge status and more. The total number of patients are broken down by payment method with 17 paying through BPJS, 2 through self-pay and the rest utilizing other insurance methods.

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rekam medis
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148 views186 pages

Permata New

The document summarizes patient information from the obgyn department. It includes 106 patient records with details like patient ID, name, date of birth, age, gender, date of admission, date of discharge, length of stay, payment method, discharge status and more. The total number of patients are broken down by payment method with 17 paying through BPJS, 2 through self-pay and the rest utilizing other insurance methods.

Uploaded by

rekam medis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Ruangan obgyn

Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM Jampersal JR

1 03.89.89 miftahul fitria 1 1/9/1997 23 1


2 03.65.86 erik irnawati 1 2/7/1988 32
3 03.17.92 lia ismawati 1 7/6/1997 24
4 03.97.85 siswati 1 3/3/1982 39 1
5 03.91.29 sri ningsih 1 02-04-2001 20 1
6 03.97.76 wiwik indawati 1 1/6/1912 31
7 03.91.84 rahmawantri 1 6/28/90 30
8 03.98.46 minarti 1 8/8/1978 42 1
9 03.98.51 aris faridah 1 1/6/1992 28
10 03.98.32 sugiasih 1 12/12/1979 41
11 03.91.61 azzahra sabaria 1 5/12/1998 22
12 03.98.36 reva widiastutik 1 5/17/96 24
13 03.98.35 handika noviana 1 10/5/1994 26 1
14 03.98.82 novi rohani 1 11/18/97 23 1
15 03.98.96 ita sari 1 2/26/98 23
16 03.98.89 kiki marta 1 4/18/2000 20 1
17 03.98.04 siti nurul hasanah 1 4/30/2001 19 1
18 03.88.55 ami muzdalifah 1 9/3/1996 25 1
19 03.10.74 sulikah 1 7/1/1987 35 1
20 03.95.88 nurul jannah 1 8/15/2000 20 1
21 03.96.64 nur aida 1 10/6/1987 33 1
22 03.89.70 nikend ayu lestari 1 12-04-2000 20 1
23 03.26.96 siti nur hayati 1 4/6/2000 20
24 03.99.58 nur fadilah 1 7/15/89 31 1
25 03.99.87 etik wulandari 1 3/15/2001 20 1
26 03.10.74 sulikah 1 7/1/1987 35 1
27 03.01.25 indah misreni 1 9/9/1992 28 1
28 03.95.81 erika andriani 1 4/5/1998 22 1
29 03.81.57 sunik ernawati 1 10/5/1998 42 1
30 04.00.20 musriati 1 12/25/73 47 1
31 03.95.95 safitri ernawati 1 2/6/1986 34 1
32 01.08.56 nur azizah 1 9/9/1993 27 1
33 04.00.46 jundatul ismah 1 11-03-2000 20
34 04.00.51 ariyanti 1 3/4/1983 38 1
35 04.00.82 debi eka septiani 1 9/23/98 22
36 04.00.85 dinda agustin 1 9/8/1997 23 1
37 04.01.01 elok faiqotul 1 12/12/1991 30 1
38 04.00.97 reni sugiarti 1 2/8/1986 34
39 03.94.76 mistianing 1 12-04-2000 20
40 03.99.58 nur fadilah 1 7/15/89 31 1
41 03.99.19 navilatul mudrikah 1 6/8/2001 19
42 04.01.66 sri buati 1 12/12/1976 44 1
43 04.01.65 siti asiyah 1 4/1/1981 40 1
44 03.92.42 altahtul fitria 1 12/22/2001 19 1
45 01.30.97 nuril zuhriyah 1 3/8/1996 24 1
46 04.02.19 ita suriyani 1 2/1/1990 31 1
47 03.54.32 nuril fadilah 1 7/9/1989 31 1
48 03.98.07 siti marhumah 1 3/29/93 27
49 04.02.13 vina puji lestari 1 02-09-2002 18
50 04.02.42 mila oktavia 1 10/15/2000 20 1
51 04.02.46 lisye fatmalasari 1 4/17/94 26
52 02.00.12 chamsiyatul laka 1 8/13/81 39 1
53 03.93.44 munipah 1 6/4/1977 43 1
54 04.02.56 siarni 1 10/12/1985 35 1
55 03.99.33 parmawati 1 9/22/86 34
56 00.79.48 lailatul mufidah 1 10/24/85 35 1
57 02.55.76 saidatul khoiriyah 1 11/9/1997 23 1
58 01.86.76 yuniar lailatul 1 6/23/98 22 1
59 03.73.60 efi nurfita 1 12/2/1993 28 1
60 02.66.78 tusiyawati 1 8/17/73 47 1
61 03.92.99 hesti wahyuningsih 1 6/28/98 22
62 04.03.08 rika 1 07-10-2000 20 1
63 03.74.44 solikha 1 5/25/87 33 1
64 04.03.32 dinda agustin 1 8/3/2002 18
65 02.05.97 yuli malania 1 3/3/1984 37 1
66 03.83.18 siti romelah 1 9/14/98 2
67 03.98.12 eki lestari 1 7/11/1987 33
68 03.94.53 itasari 1 8/14/98 22 1
69 01.04.23 siti maryam 1 4/21/92 28 1
70 02.28.32 ani duwi safriana 1 2/9/1986 34
71 03.96.22 kristiawati 1 8/21/95 25
72 03.99.63 khusnul khotimah 1 5/5/1982 37
73 03.66.44 ainul qomariyah 1 10/2/1972 49 1
74 00.21.61 siti munfarida 1 7/10/1995 25 1
75 00.26.60 novi puji astutik 1 11/13/96 24
76 03.89.72 yiyin meila saskiya 1 5/21/2004 16 1
77 04.04.30 sundriana puspita dewi 1 4/8/1980 40
78 02.29.48 anis fitriyah 1 5/13/85 36 1
79 03.97.40 yulia fatmawati 1 7/7/1993 27 1
80 03.66.37 anggun musholifa 1 07-11-2006 14 1
81 02.41.91 ririn wulandari 1 4/9/1988 32 1
82 04.04.50 melati sri sekar 1 3/25/93 28 1
83 04.04.28 weni munifatul 1 7/14/92 29 1
84 04.00.20 musriati 1 12/25/73 47 1
85 04.04.86 nurul juma'ati 1 9/9/1990 30
86 03.73.32 misrifah 1 6/30/79 41 1
87 04.04.69 nisa musafira 1 6/14/2002 18 1
88 04.01.45 pepi nur adila 1 4/20/96 22
89 04.04.68 yulia 1 1/7/1987 33 1
90 04.05.06 siti aisyah 1 1/19/93 28
91 04.04.92 rumiati 1 10/4/1974 47 1
92 03.92.92 desi sri wijayanti 1 7/16/96 24
93 03.95.81 erika andriani 1 4/5/1998 22 1
94 04.05.47 nuke farisha 1 11/18/98 22 1
95 04.05.18 hasanah 1 5/7/1982 31
96 03.02.99 wiwin indawati 1 4/9/1987 33 1
97 03.95.13 nanik indrawati 1 7/18/86 24 1
98 00.16.15 mira dwi 1 12/11/1996 23 1
99 04.01.14 lailatul fitriyah 1 4/18/85 35 1
100 04.05.30 hermin 1 11/19/78 37 1
101 02.98.01 siti rohimah 1 6/18/91 30
102 04.05.24 wiwin 1 7/31/82 38 1
103 03.95.81 erika andriani 1 4/5/1998 22 1
104 03.87.34 fitrianda febriyanti 1 10/2/1999 22
105 04.05.60 mulyana 1 12/3/1996 24
106
107
108
109
110
111
JUMLAH 0 29 2 17 0 0 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN = 5 B,
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
Cara bayar Tanggal Lama BRM
dirawat kembali Hidup Mati
Sembuh APS
BPJS TK PG JKN RG Kemkes Lain MRS KRS < 48 > 48 < 48 > 48

28 1 4 1 1
1 30 1 2 1 1
1 30 1 2 1 1
30 1 2 1 1
30 1 2 1 1
1 30 1 2 1 1
1 30 1 2 1 1
1 3 2 1 1
1 1 2 1 1 1
1 1 3 2 1 1
1 1 3 2 1 1
1 1 3 2 1 1
1 3 2 1 1
3 4 1 1 1
1 3 4 1 1 1
3 4 1 1 1
4 5 1 1 1
3 5 2 1 1
5 5 1 1
5 6 1 1 1
5 7 2 1 1
5 7 2 1 1
1 5 7 2 1 1
6 7 1 1 1
6 8 2 1 1
6 7 1 1 1
6 8 2 1 1
8 9 1 1 1
8 9 1 1 1
8 9 1 1 1
7 9 2 1 1
7 9 2 1 1
1 8 9 1 1 1
8 9 1 1 1
1 10 11 1 1 1
10 12 2 1 1
11 12 1 1 1
1 11 12 1 1 1
1 12 13 1 1 1
13 14 1 1 1
1 12 13 1 1 1
13 15 2 1 1
13 14 1 1 1
14 16 2 1 1
14 16 2 1 1
15 17 2 1 1
15 17 2 1 1
1 15 17 2 1 1
1 15 18 3 1 1
16 18 2 1 1
1 16 18 2 1 1
16 17 1 1 1
13 16 3 1 1
17 19 2 1 1
1 17 18 1 1 1
17 19 2 1 1
18 20 2 1 1
18 20 2 1 1
19 20 1 1 1
19 21 2 1 1
1 19 20 1 1 1
19 21 2 1 1
19 21 2 1 1
1 20 21 1 1 1
21 23 2 1 1
1 21 23 2 1 1
21 23 2 1 1
21 23 2 1 1
21 23 2 1 1
1 21 24 3 1 1
1 21 24 3 1 1
1 21 24 3 1 1
22 23 1 1 1
22 24 2 1 1
1 22 24 2 1 1
24 25 1 1 1
1 24 25 1 1 1
25 25 1 1 1
26 26 1 1 1
26 27 1 1 1
25 27 2 1 1
26 27 1 1 1
26 27 1 1 1
26 28 2 1 1
1 27 27 1 1 1
26 28 2 1 1
26 28 2 1 1
1 26 28 2 1 1
26 28 2 1 1
1 27 28 1 1 1
27 29 2 1 1
1 27 29 2 1 1
16 17 1 1 1
28 29 1 1 1
1 28 29 1 1 1
28 29 1 1 1
28 30 2 1 1
28 30 2 1 1
28 30 2 1 1
28 30 2 1 1
1 28 30 2 1 1
28 30 2 1 1
29 30 1 1 1
1 29 30 1 1 1
1 29 30 1 1 1

0 10 0 0 0 275 134 46 29 0 0 0 28 0

TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)


Status Pulang
Tindakan
Pindah Alamat (Desa) Diagnosa Primer ICD (Operasi) Pelayanan
Rujuk
Ruang

PASIRIAN abortus incomplite CURRETAGE obgyn


gondoruso post sc 4 jam sc obgyn
pronojiwo post sc 2 jam sc obgyn
pronojiwo post sc 3 jam sc obgyn
condro post sc 4 jam sc obgyn
pronojiwo post sc 4 jam sc obgyn
selokawar post sc 4 jam sc obgyn
purorejo menometroragia + anemia gynec
kalibendo pp 6 jam spt od obgyn
bulurejo post sc 3 jam sc obgyn
jogoyudan post sc 3 jam sc obgyn
bulurejo post sc 3 jam sc obgyn
nguter post sc 3 jam sc obgyn
gondoruso pp 6 jam spt od obgyn
pasirian pp 6 jam spt od obgyn
nguter pp 6 jam spt induksi obgyn
tempeh post ve 6jam ve obgyn
penanggal post ve 6jam ve obgyn
hcu bades pua + anemia gynec
penanggal pp 6 jam spt od obgyn
pronojiwo post sc 4 jam sc obgyn
tumpeng post sc 4 jam sc obgyn
kalibendo post sc 4 jam sc obgyn
jarit post op ket op ket obgyn
madurejo abortus incomplite curetage obgyn
bades pua + anemia gynec
jarit post sc 3 jam sc obgyn
candipuro heg obgyn
gondoruso post ve 4 jam ve obgyn
jarit myoma uteri gynec
jember post sc 2,5 jam sc obgyn
selokawar post sc 3 jam sc obgyn
jarit post sc 2,5 jam sc obgyn
bades post kuretage curetage obgyn
pasirian post sc 2 jam sc obgyn
kebonsari hamil dg hemoroid interna grade 3 obgyn
madurejo post sc 2 jam sc obgyn
jarit post partum 6 jam spt od obgyn
pronojiwo post ve 6 jam ve obgyn
jarit post op ket + anemia gynec
jokarto pp 6 jam spt od obgyn
jarit post ve 6 jam ve obgyn
pronojiwo post kuretage curetage obgyn
selokawar burst abdomen debridement gynec
tumpeng post partum 6 jam spt b obgyn
jarit post ve 6 jam ve obgyn
bades post sc 3 jam sc obgyn
bades post sc 4 jam sc obgyn
pasirian post sc 3 jam sc obgyn
besuk post sc 2 jam sc obgyn
tumpeng post sc 2 jam sc obgyn
pasirian post kuretage curetage obgyn
sumberwuluh post sc 2 jam sc obgyn
bago retensio plasenta curetage obgyn
nguter post ve 6 jam ve obgyn
candipuro post kuretage curetage obgyn
bades post ve 6 jam ve obgyn
sumbermujur post sc 2 jam sc obgyn
sememu post sc 2 jam sc obgyn
sememu pua gynec
pasirian pp 6 jam spt induksi obgyn
bades post ve 6 jam ve obgyn
sememu post sc 1 jam sc obgyn
kalibendo post ve 6 jam ve obgyn
selokawar kista ovarium gynec
bades post sc 4 jam sc obgyn
labruk post sc 3 jam sc obgyn
supiturang post sc 2 jam sc obgyn
tambahrejo post sc 4 jam sc obgyn
pasirian post sc 3 jam sc obgyn
penanggal post sc 2 jam sc obgyn
tambahrejo post sc 2 jam sc obgyn
sememu pp 6 jam spt od obgyn
gesang post sc 3 jam sc obgyn
candipuro post sc 3 jam sc obgyn
tumpeng post ve 2 jam ve obgyn
nguter pp 6 jam spt od obgyn
sememu post ve 6 jam ve obgyn
selokanyar post partum 6 jam spt b obgyn
sememu dub gynec
pasirian post sc 1/4 jam sc obgyn
jarit post partum 6 jam ekstraksi total obgyn
kalibendo post sc hari ke 3 sc obgyn
jarit myoma uteri myomektomi gynec
penanggal pp 6 jam spt od obgyn
selokawar post sc 4 jam sc obgyn
selokanyar post sc 4 jam sc obgyn
bades post sc 3 jam sc obgyn
jarit post sc 4 jam sc obgyn
bades post partum 6 jam spt b obgyn
sumbermujur post kuretage curetage obgyn
condro post sc 6 jam sc obgyn
candipuro heg + colig abdomen obgyn
pulo hamil dg post kll + dislokasi genus obgyn
orooro ombo pp 6 jam spt od obgyn
bades pp 6 jam spt od obgyn
sidomulyo post sc 4 jam sc obgyn
jarit post sc 3 jam sc obgyn
sememu post sc 2 jam sc obgyn
candipuro post sc 4 jam sc obgyn
bades post sc 4 jam sc obgyn
selokawar post kuretage curetage obgyn
candipuro heg obgyn
pasirian pp 6 jam spt od obgyn
kertosari pp 6 jam spt od obgyn

0
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM Jampersal JR

1 04.05.54 siti mujanah 1 10/11/1978 42 1


2 04.05.89 ika suryaningsih 1 12/4/1988 33 1
3 00.22.87 dinda dwi meiranti 1 5/23/99 21 1
4 02.52.48 cahaya dwiningtyas 1 10-10-2003 17 1
5 04.05.27 mila nurvita 1 5/9/1990 30
6 04.05.94 rubiyeh 1 3/15/81 40 1
7 04.06.03 siti romlah 1 3/23/94 27 1
8 04.06.20 kristi sukma 1 3/5/1994 27
9 02.25.04 sri indrayani 1 1/4/1968 53 1
10 03.13.02 desta dwi ayu 1 12/27/97 23 1
11 03.96.38 winda sakliani 1 9/21/91 29 1
12 04.04.64 kristiyani 1 2/16/97 23 1
13 04.06.32 nailul nuril 1 4/6/1995 25
14 04.06.39 umi hidayah 1 12/17/79 41
15 04.06.43 erna stiowati 1 3/26/89 31
16 03.63.37 dewi setyorini 1 1/2/1992 29 1
17 04.01.53 dennisa indah 1 2/17/2009 12 1
18 04.06.58 ana sundari 1 11/25/97 23 1
19 04.06.57 siti zubaidah 1 3/199/98 23
20 04.03.40 nur aini 1 11/25/86 35
21 04.03.82 fitri wahyuningsih 1 4/18/92 29
22 04.06.54 romlah 1 1/25/89 32
23 03.87.77 siti masrukhah 1 11/11/1975 45
24 02.14.65 yulia rahmah 1 8/2/1989 32 1
25 04.06.27 evi wulandari 1 6/12/1991 29 1
26 04.06.76 anita lestari 1 4/22/99 24
27 04.00.00 riska anggraini 1 4/5/1996 24 1
28 04.05.16 dewi dahlia 1 1/2/1984 37 1
29 03.87.00 tri wahyuning 1 2/3/1994 27
30 04.01.76 siti fatimah 1 1/7/1980 42 1
31 03.98.05 widarti 1 10/3/1986 35 1
32 04.07.18 elli astavia 1 5/16/2000 20 1
33 03.82.31 eva ernawati 1 8/17/92 28 1
34 04.07.15 widya mei sari 1 5/10/2000 20 1
35 03.77.45 vina farha wahidiyah 1 1/16/2005 16
36 03.97.59 ririn agustin 1 8/17/89 31 1
37 04.07.21 ilmia novitasari 1 6/29/99 21 1
38 04.07.12 putri kumalasari 1 3/20/95 26 1
39 04.07.11 isti daniati 1 12/7/1985 35
40 03.71.22 vita nahdiya 1 7/1/1995 26
41 01.22.88 nur aisah 1 9/22/73 47 1
42 04.07.96 septi ayu dwi a. 1 7/8/2003 17 1
43 04.06.81 mistah yuliarsih 1 4/7/1985 35 1
44 03.94.24 silaturohmi 1 10/5/1984 36 1
45 04.02.77 nurul hikmah 1 2/14/82 39 1
46 00.59.39 anisa 1 4/24/93 27 1
47 03.96.94 mariyani 1 6/2/1983 37 1
48 04.07.87 hesti permatasari 1 9/6/1995 25
49 01.22.15 dinar eka septianer 1 08-07-2000 20 1
50 04.00.40 nanda fitri 1 2/1/2000 21
51 04.08.19 frilla sylfia 1 12/29/97 23 1
52 04.08.32 siti mutmainah 1 2/2/1999 22
53 04.08.09 puput wulan ayu lestari 1 1/16/97 24
54 04.08.37 sindi fatmawati 1 08-04-2002 19 1
55 01.12.65 ririn nurindahsari 1 1/4/1988 33
56 02.70.54 firdatul eka p. 1 7/8/1999 21 1
57 03.93.65 sulasmini 1 12/11/2003 17 1
58 04.04.70 nur arum w. 1 2/5/1996 25
59 04.08.86 naliyah 1 1/10/1960 60 1
60 03.84.39 iis indrayani 1 6/5/1981 40
61 03.10.74 sulikah 1 7/1/1984 37 1
62 00.24.34 istiqoma riatus s. 1 10/14/97 24 1
63 04.09.40 halimatus sa'diyah 1 1/27/89 32 1
64 04.09.47 andini narapadiyah 1 9/6/1991 29 1
65 04.09.49 yuli astutik 1 1/25/87 34
66 04.09.58 ratna rahmawati 1 5/12/1997 25 1
67 03.68.58 sani agustina 1 8/26/84 36
68 04.06.27 evi wulandari 1 6/12/1991 29 1
69 01.56.81 suken sri wahyuni 1 3/16/78 43 1
70 04.09.84 titing suherni 1 6/3/1989 32
71 04.09.94 nur aini 1 10/7/1997 23 1
72 04.09.47 andini narapadiyah 1 9/6/1991 29 1
73 04.10.12 novalia ike s. 1 4/24/95 26 1
74 04.00.01 uul karomah 1 8/5/1996 24 1
75 04.10.03 siti fatimah 1 5/19/95 26 1
76 04.10.36 jamilaton hasanah 1 7/8/1986 34 1
77 04.10.39 busima 1 10/1/1983 38
78 04.10.27 miatul musrifa 1 1/5/1995 26
79 04.09.33 rustika oktaviyah 1 10-10-2001 19 1
80 04.07.79 ninuk handayani 1 3/17/85 36 1
81 04.01.71 ita purnamasari 1 1/7/1983 37 1
82 01.93.57 yuyun subaedah 1 10/11/1983 37 1
83 04.10.07 ilfin fadilatul 1 7/4/1997 24
84 03.97.44 halimah assadiyah 1 4/1/1998 23 1
85 04.11.13 widya kusuma ningsih 1 5/26/2000 20
86 04.11.28 yani fatima 1 6/1/1981 40 1
87 04.10.91 wiwik kurniawati 1 9/5/1980 41 1
88 04.06.35 luluk widayati 1 10/22/82 38
89 00.82.40 mahdalena novitasari 1 10/11/1998 22 1
90 04.11.11 buyani 1 7/1/1984 37
91 03.96.59 ririn endang 1 2/13/84 37 1
92 04.05.33 yuniarti 1 1/31/98 23
93 01.56.81 suken sri wahyuni 1 3/16/78 43 1
94 04.11.94 elma putridianti 1 10/7/1998 22 1
95 04.12.31 urbaiyah 1 6/11/1977 44
96 00.62.82 tran semiati tyas 1 5/19/2000 21 1
97 04.12.43 tomi 1 12/6/1996 24 1
98 03.99.97 dian ratna sari 1 3/6/1993 27
99 03.94.29 anik sugiati 1 6/12/1982 38 1
100 02.13.93 erlinawati 1 2/21/87 34 1
101 04.11.40 intan indriyani 1 8/21/99 21 1
102
103
104
105
106
JUMLAH 0 29 2 15 0 0 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN = 5 B,
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
Cara bayar Tanggal Lama BRM
dirawat kembali Hidup Mati
Sembuh APS
BPJS TK PG JKN RG Kemkes Lain MRS KRS < 48 > 48 < 48 > 48

29 2 3 1 1
30 3 3 1 1
1 2 1 1 1
1 2 1 1 1
1 1 2 1 1 1
1 2 1 1 1
1 2 1 1 1
1 3 3 1 1 1
1 4 3 1 1
3 4 1 1 1
3 5 2 1 1
3 5 2 1 1
1 3 5 2 1 1
1 3 5 2 1 1
1 3 4 1 1 1
3 4 1 1 1
3 4 1 1 1
4 5 1 1 1
1 4 6 2 1 1
1 4 6 2 1 1
1 4 6 2 1 1
1 4 6 2 1 1
1 4 6 2 1 1
4 6 2 1 1
4 8 4 1 1
1 5 5 1 1 1
5 6 1 1 1
5 7 2 1 1
1 5 7 2 1 1
5 7 2 1 1
6 7 1 1 1
6 8 2 1 1
6 8 2 1 1
6 8 2 1 1
1 6 8 2 1 1
6 8 2 1 1
6 8 2 1 1
6 8 2 1 1
1 6 8 2 1 1
1 8 9 1 1 1
9 11 2 1 1
10 11 1 1 1
10 11 1 1 1
10 12 2 1 1
10 12 2 1 1
10 12 2 1 1
10 12 2 1 1
1 10 12 2 1 1
10 12 2 1 1
1 11 12 1 1 1
11 12 1 1 1
1 11 12 1 1 1
1 11 13 2 1 1
12 13 1 1 1
1 12 13 1 1 1
8 9 1 1 1
14 15 1 1 1
1 13 14 1 1 1
14 16 2 1 1
1 15 16 1 1 1
17 19 2 1 1
17 18 1 1 1
17 18 1 1 1
18 18 1 1
1 18 19 1 1 1
18 20 2 1 1
1 18 20 2 1 1
19 20 1 1 1
19 21 2 1 1
1 19 20 1 1 1
19 20 1 1 1
20 21 1 1 1
20 21 1 1 1
20 21 1 1 1
20 22 2 1 1
21 23 2 1 1
1 21 23 2 1 1
1 21 23 2 1 1
23 23 1 1 1
22 23 1 1 1
23 23 1 1 1
24 26 2 1 1
1 24 26 2 1 1
24 26 2 1 1
1 24 26 2 1 1
25 26 1 1 1
24 25 2 1 1
1 24 25 2 1 1
24 26 2 1 1
1 25 26 1 1 1
24 25 1 1 1
1 25 27 2 1 1
27 28 1 1 1
27 28 1 1 1
1 28 28 1 1 1
29 30 1 1 1
29 30 1 1 1
1 29 30 1 1 1
29 30 1 1 1
30 31 1 1 1
30 31 1 1 1

0 12 0 0 0 120 137 49 26 3 0 0 29 0

TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)


Status Pulang
Tindakan
Pindah Alamat (Desa) Diagnosa Primer ICD (Operasi) Pelayanan
Rujuk
Ruang

tempursari peb obgyn


nguter heg obgyn
bades pp 6 jam spt od obgyn
gondoruso pp 6 jam spt od obgyn
sumberwuluh pp 6 jam spt od obgyn
sumberwuluh post sc 2 jam sc obgyn
selokawar post sc 2 jam sc obgyn
selokawar pp 6 jam spt brach obgyn
lempeni kista bartholinitis eksisi gynec
gesang pp 6 jam spt brach obgyn
denpasar g1 p0-0 uk 37 mg blm inp jth preskep dg kpd sc obgyn
condro g1 p0-0 uk 40-41 mg blm inp jth preskep dg k sc obgyn
pasrujambe g1 p0-0 uk 41-42 mg blm inp jth preskep dg sc obgyn
besok g1 p0-0 uk 37 mg blm inp jth preskep dg kpd sc obgyn
candipuro post ve 6jam ve obgyn
sumberejo post ve 6jam ve obgyn
nguter pp 6 jam spt od obgyn
penanggal g1 p0-0 uk 41 mg blm inp jth preskep dg oli pp 6 jam obgyn
tumpeng g2 p1- 1uk 37mg blm inp jth preskep dg bsc + sc obgyn
candipuro g2 p10101 uk 38 mg blm inp jth preskep dg k sc obgyn
tumpeng g2 p1-1 uk 40mg blm inp jth preskep dg kpd + sc obgyn
orooroombo g2 p1-1 uk 41mg blm inp jth preskep dg kpd sc obgyn
sememu g5 p20022 uk 37mg blm inp jth presbo dg kp sc obgyn
candipuro g2 p1-1 uk 38mg blm inp jth preskep dg kpd + sc obgyn
selokawar g2 p1-1 uk 29mg blm inp dg apb konservatif obgyn
jarit g1 p0-0 uk 40-41 mg inp jth preskep dg kpd spt od obgyn
selokawar post sc hari ke 1 sc obgyn
tamanayu g3 p10011 uk 38-39mg blm inp jth preskep dg sc obgyn
bago hamil 38mg blm inp jth preskep dg kpd + bsc sc obgyn
bades g3 p2-2 uk 38mg blm inp jth presbo dg kpd sc obgyn
gondoruso g3 p2-2 uk 40 mg inp kala 1 fase laten jth p spt od obgyn
candipuro g1 p0-0 uk 39 mg inp kala 1 fase laten jth p sc obgyn
gondoruso g3 p10011 uk 39-40 mg inp kala 1 fase laten sc obgyn
jarit g1 p0-0 uk 41 mg blm inp jth preskep dg kpd sc obgyn
gondoruso g1 p0-0 uk 39 mg blm inp jth preskep dg kpd sc obgyn
gondoruso g1 p0-0 uk 41 mg inp jth preskep dg kpd + ol sc obgyn
penanggal g2 p1-1 uk 40-41mg inp kala 1 fase laten jth sc obgyn
pasirian g2 p1-1 uk 38mg blm inp jth preskep dg oli sc obgyn
kaliuling g2 p1-1 uk 38 mg blm inp jth preskep dg bsc sc obgyn
bades g1 p0-0 uk 41 mg inp kal 1 fase aktif jth pre ve obgyn
pronojiwo pua a/I ca servic + anemia gynec
kaliwungu ab. Incomplite curetage obgyn
pasirian BO curetage obgyn
bades g3 p2-2 uk 41 mg blm inp jth preskep dg kp spt od obgyn
sumberwuluh g5 p4-2 uk 40 mg blm inp jth preskep dg kp spt od obgyn
bondeli g4 p20012 uk 38mg blm inp jth preskep dg k sc obgyn
sememu g3 p2-2 uk 37 mg blm inp jth preskep dg kpd sc obgyn
jatisari g1 p0-0 uk 40 mg blm inp jth preskep dg kpd sc obgyn
jarit g2 p1-0 uk 38 mg blm inp jth preskep dg bsc sc obgyn
nguter g2 p1-1 uk 40-41mg inp kala 1 fase laten jth spt od obgyn
selokawar pp 6 jam spt b obgyn
tempeh lor pp 4 jam spt od obgyn
pasrujambe g1 p0-0 uk 39 mg blm inp jth preskep dg kpd sc obgyn
penanggal pp 6 jam spt od obgyn
gondoruso g2 p1-1 uk 39mg inp kala 1 fase laten jth pr spt od obgyn
pasirian pp 6 jam spt b obgyn
bades post sc 2 jam sc obgyn
jugosari post ve 6jam ve obgyn
pandanwangi pua a/I ca servic gynec
pasirian post sc hari ke 1 sc obgyn
bades pua a/I ca servic gynec
pulo mola hidatidosa curetage obgyn
besuk post ve 3 jam ve obgyn
1 sumberejo g1 p0-0 uk 41 mg inp kala 1 fase laten jth p sc obgyn
nguter g2 p1-0 uk 38-39 mg inp kal 1 fase laten j sc obgyn
madurejo g1 p0-0 uk 40 mg blm inp jth preskep dg kp sc obgyn
lempeni post sc 2 jam sc obgyn
selokawar g2 p1-1 30mg jth preskep dg apb obgyn
banyuwangi pua a/I ca servic gynec
sumberwuluh pp 6 jam spt b obgyn
sumberwuluh post ve 6jam ve obgyn
sumberejo post sc hari ke 3 sc obgyn
kalibendo pp 6 jam spt od obgyn
candipuro pp 6 jam spt od obgyn
kaliuling post sc 3jam sc obgyn
candipuro early hpp ec sisa plasenta + anemia curetage obgyn
pasirian g2 p2-2 uk 40-41 mg blm inp jth preskep dg sc obgyn
jatirejo post sc 6 jam sc obgyn
tumpeng g1 p0-0 uk 40 mg inp kal 1 fase aktif jth pre spt od obgyn
jarit post ve 6jam ve obgyn
selokawar pp 6 jam spt od obgyn
gesang g3 p2-2 38 mg blm inp jtm preskep dg kpd spt od obgyn
tumpeng g2 p1-1 uk 40 mg blm inp jth preskep dg kpd sc obgyn
jatisari g1 p0-0 uk 40 mg blm inp jth preskep dg kpd sc obgyn
kalibenado g1 p0-0 uk 42 mg blm inp jth preskep dg kpd sc obgyn
besuk pp 6 jam spt b obgyn
mentawa batu pp 6 jam spt b obgyn
bades pp 6 jam spt od obgyn
bades post sc 6 jam sc obgyn
candipuro post sc 5 jam sc obgyn
tambahrejo pp 6 jam spt od obgyn
madurejo pp 6 jam spt od obgyn
banyuwangi pua a/I ca servic gynec
tegal rejo pp 6 jam spt od obgyn
tumpeng pp 6 jam spt od obgyn
tempursari post sc 2 jam sc obgyn
pasirian post sc 2 jam sc obgyn
tumpeng post sc 2 jam sc obgyn
gondoruso pp 6 jam spt od obgyn
tempursari post sc 2 jam sc obgyn
madurejo pp 6 jam spt b obgyn

0
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM Jampersal JR

1 04.12.40 sapiyah 1 6/20/65 55 1


2 02.77.01 titik wulandari 1 8/29/92 28
3 04.09.83 iin setyowati 1 4/16/81 40
4 04.12.84 supriatiningtyas 1 7/1/1997 24
5 00.35.04 hutamami 1 3/7/1985 35 1
6 01.56.81 suken sri wahyuni 1 3/16/78 43 1
7 04.13.20 evita hakim luay 1 4/9/1998 22 1
8 04.05.34 yuliati 1 3/26/87 34 1
9 02.68.63 ninik ahadiyah 1 8/19/85 35 1
10 04.13.44 dewi setyawati 1 9/28/96 24 1
11 04.11.92 nafiatul jumaroh 1 7/26/2001 20 1
12 01.96.41 dwi althafiyah 1 1/14/96 25 1
13 04.13.39 riski kusnini 1 4/24/94 27
14 04.13.23 naviatin 1 10/1/1980 41 1
15 04.13.76 lia agustiningsih 1 8/24/90 30 1
16 04.13.69 asmaul khasanah 1 9/29/2001 19 1
17 04.14.05 sersi 1 4/6/1993 28 1
18 04.13.93 maryatul ulfah 1 9/20/2001 19
19 04.13.98 romi wijayanti 1 3/18/84 37
20 04.13.77 siti mila hanafia 1 12/22/98 22
21 04.13.76 lia agustiningsih 1 8/24/90 30 1
22 04.13.71 siti hindun 1 10/1/1980 41 1
23 04.14.45 bekti atmaning 1 7/6/1994 27
24 03.53.13 windi widya 1 1/6/1995 26 1
25 04.14.42 farida amalia 1 8/6/1997 22
26 04.14.68 dwi novitasari 1 11/25/90 30 1
27 04.14.94 desi susanti 1 11/30/90 30 1
28 03.87.12 fikro aumila 1 1/6/1999 22 1
29 03.68.29 siti yulifah 1 12/9/1989 31 1
30 01.63.68 reni marisa putri 1 3/3/1991 30
31 04.05.32 khusnul fatimah 1 6/15/88 22
32 04.15.31 umi manzilah 1 10/8/1976 44 1
33 04.15.07 ummiatul fitrianis 1 11/18/97 19 1
34 04.09.28 nahdiyah gluy untari 1 10/23/96 24 1
35 04.15.71 imayun ariani 1 4/14/91 30
36 04.15.38 siti marifatul 1 7/2/1998 28 1
37 04.15.46 usmiatul hasana 1 03-10-2003 18 1
38 04.15.45 siti hardiyanti 1 2/5/1989 31
39 03.88.30 winda purnamasari 1 5/5/1999 22 1
40 05.14.57 ernawati 1 11/3/1993 28
41 04.09.79 lutifiah 1 1/1/1990 31
42 03.96.10 nurifa 1 10/5/1988 33 1
43 03.82.90 laily jiyan fani 1 4/21/2001 20 1
44 04.14.47 rini rismawati 1 3/23/92 29 1
45 04.16.49 sri ama 1 5/20/80 40
46 04.16.23 sudar wati 1 10/8/1987 33
47 04.15.49 titik harianti 1 12/13/95 23 1
48 03.95.81 erika andriani 1 4/5/1998 23 1
49 04.11.24 feni puji lestari 1 5/5/1997 24 1
50 03.94.13 sugianti 1 11/22/84 36 1
51 04.16.56 fandila salsa bela 1 11/5/1999 22
52 04.11.91 siami 1 12/12/1980 40
53 04.16.62 yuni lestari 1 6/17/92 28
54 04.15.11 misilah 1 9/10/1986 35
55 04.15.94 jamila 1 4/26/92 29
56 03.84.75 devi antasari 1 8/1/1991 30
57 02.26.23 tita yuni ariyani 1 8/30/99 21 1
58 04.06.37 hariyanti 1 11/16/86 34
59 04.17.38 nurwulandari 1 02-08-2003 18
60 03.92.24 siti kholilah 1 6/21/82 38 1
61 04.04.59 anggun alfiati jahro 1 6/24/2002 18
62 04.17.47 mutiatul khoiroh 1 10/16/86 34
63 04.17.10 rosnawati 1 6/24/85 35 1
64 04.17.61 ponasri 1 3/9/1957 63 1
65 04.17.01 faridatun hasanah 1 9/21/96 24 1
66 04.17.78 huliyatim 1 1/4/1993 28
67 04.17.75 ani wahyuni 1 4/13/88 33
68 04.17.76 ririn likriatin 1 10/13/86 34 1
69 04.13.54 ifun agustiningsih 1 8/31/2002 18
70 02.34.12 titis puji lestari 1 3/15/92 29
71 04.06.56 nourma sintiya 1 04-07-2001 20 1
72 02.25.04 sri indrayani 1 1/4/1968 53 1
73 04.16.42 siti qoyyimah 1 10/1/1993 27 1
74 04.18.05 iin maifah 1 9/18/83 37
75 04.18.09 istinah 1 6/13/94 27 1
76 03.89.66 norita dian novita 1 6/10/1999 21 1
77 03.91.85 suwarni 1 5/8/1982 38
78 00.71.10 sylvia yusvanti 1 1/24/82 39 1
79 04.13.72 nurul idah 1 3/10/1980 40 1
80 04.06.27 evi wulandari 1 6/12/1991 29 1
81 00.11.63 wulantika 1 6/12/1995 25 1
82 04.18.38 siti fatimah 1 4/7/1995 29
83 04.18.70 ayu angger kristinah 1 10/17/97 23
84 04.18.73 eka cahya asmara 1 7/29/91 29 1
85 04.18.21 rifka dian wulandari 1 8/10/1993 28 1
86 04.18.94 silvia laraswati 1 10/19/98 22
87 00.84.41 siti fitria 1 5/12/1999 21 1
88 03.27.48 siti komania 1 11-01-2000 20
89 04.19.14 siti aisah 1 12/6/1990 30 1
90 04.19.24 siti maria ulfa 1 12/12/1981 39
91 04.19.35 siti kholisah 1 12/2/1987 34 1
92 04.19.41 yusrolana 1 10/3/1989 32 1
93 04.19.56 vindarosa dwi saputri 1 5/7/1997 23 1
94 04.19.78 dini kariyawati 1 3/26/82 39 1
95 04.19.76 fatma kusumawati 1 9/9/1999 22 1
96 04.19.90 vela herlina febrianti 1 6/55/96 25 1
97 04.19.73 surtiningtyas 1 12/31/88 32 1
98 04.20.14 cindy monica 1 12/29/98 22
99 04.09.30 dian vivi sijangga 1 2/1/1996 25 1
100 04.17.82 adita putri damayanti 1 8/18/98 22 1
101 01.56.81 suken sri wahyuni 1 3/16/78 43 1

109
JUMLAH 0 29 0 16 0 3 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
Cara bayar Tanggal Lama BRM
Hidup Mati
dirawat kembali Sembuh APS Rujuk Pindah
BPJS TK PG JKN RG Kemkes Lain MRS KRS < 48 > 48 < 48 > 48 Ruang

29 1 3 1 1
1 30 1 2 1 1
1 31 1 1 1 1
1 31 1 1 1 1
31 2 2 1 1
1 3 2 1 1
1 2 1 1 1
2 3 1 1 1
2 3 1 1 1
2 4 2 1 1
2 4 2 1 1
2 4 2 1 1
1 2 4 2 1 1
3 4 1 1 1
3 4 1 1 1
3 5 2 1 1
4 5 1 1 1
1 4 5 1 1 1
1 4 5 1 1 1
1 3 5 2 1 1
5 6 1 1 1
7 9 2 1 1
1 7 8 1 1 1
7 8 1 1 1
1 7 8 1 1 1
8 9 1 1 1
8 10 2 1 1
8 10 2 1 1
8 10 1 1 1
1 9 10 1 1 1
1 9 10 1 1 1
9 11 1 1 1
9 11 1 1 1
9 11 1 1 1
1 11 11 1 1 1
11 12 1 1 1
10 12 2 1 1
1 10 12 2 1 1
11 12 1 1 1
1 11 12 1 1 1
1 12 13 1 1 1
12 14 2 1 1
13 14 1 1 1
13 14 1 1 1
1 14 15 1 1 1
1 14 16 2 1 1
14 16 2 1 1
15 16 1 1 1
15 16 1 1 1
15 17 2 1 1
1 15 17 2 1 1
1 15 17 2 1 1
1 15 17 2 1 1
1 15 17 2 1 1
1 16 16 1 1 1
1 16 17 1 1 1
16 17 1 1 1
1 16 18 2 1 1
1 17 18 1 1 1
17 18 1 1 1
1 18 18 1 1 1
1 18 19 1 1 1
18 21 3 1 1
18 20 2 1 1
16 18 2 1 1
1 19 20 1 1 1
1 19 20 1 1 1
19 20 1 1 1
1 20 21 1 1 1
1 20 21 1 1 1
20 21 1 1 1
21 23 2 1 1
21 23 2 1 1
1 21 23 2 1 1
21 23 2 1 1
21 23 2 1 1
1 22 23 1 1 1
22 23 1 1 1
22 23 1 1 1
22 23 1 1 1
22 23 1 1 1
1 22 24 2 1 1
1 23 24 1 1 1
23 24 1 1 1
21 22 1 1 1
1 24 25 1 1 1
24 25 1 1 1
1 25 25 1 1 1
25 26 1 1 1
1 25 27 2 1 1
25 27 2 1 1
26 27 1 1 1
26 27 1 1 1
28 29 1 1 1
28 29 1 1 1
28 29 1 1 1
27 29 2 1 1
1 28 29 1 1 1
28 29 1 1 1
20 22 2 1 1
26 28 2 1 1

0 10 0 0 0 235 153 41 29 0 0 0 29 0 0

WAH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)

RNA MERAH
Tindakan
Alamat (Desa) Diagnosa Primer ICD (Operasi) Pelayanan

selokanyar pua a/I ca servic curetage (biopsi)gynec


nguter g2 p1-1 uk 38-39 mg inp kl 1 fs laten sc obgyn
bulurejo post sc 2 jam sc obgyn
kaliuling post sc 2 jam sc obgyn
candipuro pua gynec
banyuwangi pua a/I ca servic + anemia gynec
pasirian post partum 6 jam spt od obgyn
madurejo g2 p1-1 uk 41-42 mg inp kl 1 fs aktspt od obgyn
pasrujambe g4 p20012 37-38 mg inp kl 1 fs latve obgyn
tambahrejo g1 p0-0 39 mg blm inp jth preskepsc obgyn
jarit g1 p0-0 39 mg blm inp jth preskepsc obgyn
selokawar post curetage curetage obgyn
kaliuling post sc 3 jam sc obgyn
sumberwuluh ket laparatomy obgyn
jatisari g2 p1-1 uk 41-42 mg blm inp jth psc obgyn
kloposawit g1 p0-0 40 mg blm inp jth preskepsc obgyn
kalibendo post partum 2 jam spt b obgyn
gesang post partum 6 jam spt od obgyn
tempursari g3 p10011 uk 39-40 mg inp kala 1 sc obgyn
tumpeng post partum 6 jam spt od obgyn
jatisari post sc hari ke 1 sc obgyn
pandanwangi g2 p1-1 37-38 mg blm jth preskepsc obgyn
pasirian g1 p0-0 36-37 mg blm inp jtm prespt od obgyn
pasirian post partum 6 jam spt induksi obgyn
jugosari post partum 6 jam spt od obgyn
malang g4 p20012 41-42 mg inp kl 1 fs aktsc obgyn
pulo ppi obgyn
pronojiwo post sc 2 jam sc obgyn
tumpeng post sc 2 jam sc obgyn
sumberwuluh post sc 2 jam sc obgyn
pasirian g5 p4-4 39-40 mg inp kala 1 fase lspt od obgyn
jokarto post partum 6 jam spt od obgyn
kaliuling post sc 4 jam sc obgyn
gondoruso post sc 4 jam sc obgyn
kertosari post ve 6 jam ve obgyn
bades post sc hari ke 2 sc obgyn
tamanayu g1 p0-0 37 mg blm inp jth presbo sc obgyn
tempursari g3 p10011 41 mg blm inp jth pressc obgyn
pasirian g1 p0-0 37 mg blm inp jth presbo obgyn
gondoruso g2 p1-1 39-40 mg inp kl1 fs laten jth spt od obgyn
kloposawit post sc hari ke 1 sc obgyn
selokanyar post sc 3 jam sc obgyn
tumpeng g1 p0-0 32 mg jth preskep dg kpd obgyn
sumbersari post partum 3 jam spt b obgyn
penanggal post partum 6 jam spt b obgyn
kaliuling post sc 2 jam sc obgyn
jugosari g2 p1-1 uk 41-42 mg blm inp jth psc obgyn
candipuro heg obgyn
jarit g2 p1-1 38-39 mg inp kl1 fs aktif me spt od obgyn
sumbermujur g3 p2-2 40 mg blm inp jth preskep dgspt od obgyn
tempursari g1 p0-0 410 mg blm inp jth preskep sc obgyn
pasirian post sc 3 jam sc obgyn
tumpeng post sc 4 jam sc obgyn
tambahrejo post sc 2 jam sc obgyn
bago post ve 6 jam ve obgyn
bades post partum 6 jam spt od obgyn
bades post ve 6 jam ve obgyn
condro post sc 6 jam sc obgyn
bago g1 p0-0 38-39 mg inp kl 1 fase laten spt b obgyn
bades post partum 6 jam spt od obgyn
bades post partum 6 jam spt od obgyn
selokawar post sc 6 jam sc obgyn
kloposawit post sc hari ke 1 sc obgyn
selokawar pua gynec
sumberrejo peb obgyn
gondoruso post sc 2 jam sc obgyn
nguter post partum 6 jam spt od obgyn
bades ab ortus complite obgyn
jarit post partum 6 jam spt od obgyn
tempurejo post partum 6 jam spt od obgyn
pasirian g1 p0-0 33 mg jth preskep dg ppi+ kpd obgyn
lempeni pua + kista+ anemia curetage (biopsi)gynec
bangil g2 p1-1 39 mg blm inp jth preskep dgsc obgyn
kloposawit g2 p1-1 42 mg blm inp jth preskep dgsc obgyn
tamanayu post sc 3 jam sc obgyn
tumpeng post partum 6 jam spt od obgyn
selokawar g3 p2-2 40 mg inp kala 1 fase laten j sc obgyn
condro post partum 6 jam spt od obgyn
sememu post sc hari ke 1 sc obgyn
selokawar post sc hari ke 1 sc obgyn
jarit post partum 6 jam spt od obgyn
tamanayu post sc 5 jam sc obgyn
selokawar post sc 6 jam sc obgyn
tempeh post curetage curetage obgyn
jokarto g3 p10011 21 mg jth preskep dg ppi obgyn
pasrujambe g1 p0-0 40-41 mg inp kl 1 fase lat sc obgyn
sumberwuluh post sc 2 jam sc obgyn
sememu post partum 6 jam spt od obgyn
selokanyar g2 p1-1 36-37 mg inp jth preskep spt od obgyn
candipuro post sc 3 jam sc obgyn
gondoruso post partum 6 jam spt od + curetageobgyn
pandanarum post partum 2 jam spt b+ spt brach obgyn
madurejo post ve 6 jam ve obgyn
condro g2 p1-1 39-40 mg inp kl1 fs aktif sc obgyn
jarit g1 p0-0 335-36 mg inp kl 1 fase lasc obgyn
pasirian g3 p2-1 uk 39-40 mg inp kl 1 fase sc obgyn
gondoruso heg obgyn
sumberwuluh post partum 6 jam spt od obgyn
gondoruso post partum 6 jam spt od obgyn
candipuro post sc 2 jam sc obgyn
banyuwangi pua a/I ca servic + anemia gynec
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM Jampersal

1 03.63.72 irma rotur r. 1 7/24/98 23 1


2 04.54.70 ririn mariana 1 3/3/1983 38 1
3 04.54.66 rista dwi yana 1 5/5/1995 26
4 04.54.93 sutimah 1 6/15/92 29 1
5 04.54.98 siti rusdiya 1 5/15/95 26 1
6 04.26.95 winda rahmawati 1 6/8/1992 29 1
7 04.55.15 melisa 1 10/1/1993 28 1
8 04.55.49 yusnia fitriani 1 08-04-2004 17 1
9 04.55.54 yulanda kartikasari 1 1/7/1996 25
10 04.48.04 dwi purnamawati 1 10/23/88 33
11 00.50.95 siti nur hasanah 1 1/27/2001 20 1
12 04.55.66 umriyah saadah 1 4/29/90 31 1
13 04.26.72 binti hayani 1 10/22/94 27 1
14 04.55.83 siti aisah 1 1/21/2003 18 1
15 04.55.87 rina mulatifah 1 8/20/85 36
16 04.55.90 suci nur azizah 1 11/29/2001 20 1
17 00.77.97 siti fatimah 1 04-11-2003 18 1
18 04.56.03 faizatul khikmah 1 2/23/2002 19 1
19 04.56.45 faidatul qoimah 1 6/8/1992 29
20 04.56.76 kalima dila setyanda 1 9/23/97 24 1
21 04.56.96 ulil marifah 1 02-03-2002 19 1
22 04.52.69 suci susanti 1 12/19/2002 19 1
23 04.57.29 istiqamah 1 10/1/1985 36 1
24 04.57.21 risma shadila 1 9/18/2001 20 1
25 04.57.04 eva muliawati 1 7/7/1988 33 1
26 04.57.40 mili 1 10/7/1992 29
27 04.56.98 nur faidatul choiroh 1 5/21/80 41 1
28 04.57.59 lembah megasari 1 2/19/95 26 1
29 01.56.81 suken sri 1 3/16/78 43 1
30 03.82.53 supanah 1 1/7/1973 48 1
31 04.56.34 shinta bella 1 01-05-2001 20 1
32 04.57.54 riska mifdatur 1 02-06-2002 19
33 04.57.51 iis nur yati 1 2/11/1995 26
34 04.57.86 rani sri wahyuni 1 1/4/1999 22 1
35 04.57.87 adelia febrianti 1 02-02-2004 17 1
36 04.51.40 aqidatul islamiyah 1 10/10/1999 22 1
37 04.58.19 nina ayu winarsih 1 9/7/1995 26 1
38 04.35.50 farida 1 1/7/1985 36 1
39 02.61.84 dewi wahyuni 1 10/4/1987 34 1
40 01.98.90 yuli astutik 1 7/29/89 32 1
41 04.49.72 siti mianah 1 2/16/84 37 1
42 04.54.72 aisah 1 12-08-2002 19 1
43 04.58.75 riski amelia fatimah 1 10/9/1996 25 1
44 04.58.86 siti aminah 1 10/3/1988 33
45 04.59.17 ella maharani 1 9/6/1991 30
46 04.59.16 tiani 1 6/20/63 58 1
47 04.58.15 unik fitrotul 1 12/2/1981 40 1
48 04.46.04 anisah 1 5/22/98 23 1
49 00.12.52 afrida swastika 1 7/26/97 24 1
50 02.87.52 lilis lestari 1 6/25/2006 15 1
51 04.51.57 siti umilah 1 6/14/89 32 1
52 04.46.03 siti anisa 1 7/25/91 35 1
53 04.52.83 siti maria ulfa 1 10/10/1991 30 1
54 04.59.79 novita handasari 1 9/18/95 26 1
55 04.60.00 himami khufasawati 1 06-06-2005 16 1
56 04.59.91 anggraeni 1 6/15/92 29
57 04.60.11 poniti 1 7/20/83 38 1
58 04.60.16 mahillah 1 5/7/1988 33 1
59 04.43.17 siti kholifa 1 12/28/98 24 1
60 03.43.45 siti sholikhah 1 02-01-2001 20 1
61 04.60.14 nisa indah rahmatdini 1 11/22/97 24
62 04.51.53 vera firista 1 10/24/2002 19
63 02.31.65 ulfa ijatur rofiatun 1 11/11/1997 24
64 04.60.40 siti nurani 1 8/30/87 34 1
65 04.24.64 siti asia 1 9/1/1983 39 1
66 02.67.24 sulaidah 1 12/23/86 35 1
67 04.60.70 masila 1 1/1/1998 24
68 04.61.02 siti aminah 1 9/23/82 39 1
69 03.58.67 khoirul mutmainah 1 8/28/90 31 1
70 04.60.97 sumiati 1 6/16/2004 17 1
71 04.61.12 aidila ekandaru 1 11/6/1992 29 1
72 04.60.95 dewi nur faizah 1 8/10/1999 22 1
73 04.61.13 ernik ernawati 1 9/24/89 31
74 04.32.75 rosendya okta w. 1 10/16/99 22 1
75 04.40.36 ruana 1 9/10/1992 29 1
76 04.61.27 anis marsela 1 5/30/89 32 1
77 02.04.54 m rahayu 1 1/9/1983 38 1
78 04.59.43 nanda kumalasari 1 8/14/2001 20
79 04.52.20 tatik ningsih 1 1/2/1985 36 1
80 04.61.57 nadia khoirun nisa 1 4/25/2000 21
81 04.61.55 nurul hikmah 1 6/20/99 22
82 04.43.42 temu mulyani 1 12/13/82 39
83 04.46.62 titik 1 10/11/1980 41 1
84 01.13.87 santi dela m. 1 8/8/1986 35 1
85 04.49.56 nanik urifah 1 12/10/1986 35 1
86 04.58.07 ismaniah wahyu 1 5/6/1987 29 1
87 04.61.98 ita nur fajrin 1 5/6/1987 34 1
88 04.62.01 fiki jazilah 1 7/21/2007 15 1
89 04.51.01 nurul jadilah 1 8/3/1988 33 1
90 04.62.19 susi ekawati 1 9/9/1994 27 1
91 03.51.65 lia sri rahayu 1 9/2/1999 22 1
92 01.52.54 siti musyarofah 1 8/17/93 28
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
JUMLAH 0 29 7 64 0 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar
Cara bayar Tanggal Lama BRM
dirawat kembali Hidup Mati
JR BPJS TK PG JKN RG Kemkes Lain MRS KRS < 48 > 48 < 48

30 1 2 1
31 1 1 1
1 31 1 1 1
31 2 2 1
1 2 1 1
1 2 1 1
2 3 1 1
3 4 1 1
1 3 5 2 1
1 4 5 1 1
4 5 1 1
4 6 2 1
4 4 1 1
5 6 1 1
1 5 8 3 1
5 7 2 1
6 7 1 1
6 7 1 1
1 7 8 1 1
8 10 2 1
9 11 1 1
9 10 1 1
10 11 1 1
10 12 2 1
10 13 3 1
1 10 12 2 1
11 13 2 1
11 13 2 1
11 15 4 1
11 11 1 1
11 12 1 1
1 11 12 1 1
1 11 13 2 1
12 13 1 1
12 13 1 1
12 14 2 1
13 14 1 1
13 14 1 1
13 15 2 1
14 15 1 1
15 16 1 1
15 17 2 1
15 17 2 1
1 16 17 1 1
1 17 18 1 1
17 19 2 1
17 18 1 1
17 18 1 1
18 20 2 1
19 20 1 1
19 20 1 1
19 21 2 1
19 21 2 1
19 21 2 1
19 21 2 1
1 19 21 2 1
20 21 1 1
20 21 1 1
20 21 1 1
20 22 2 1
1 20 22 2 1
1 21 23 2 1
1 21 23 2 1
21 22 1 1
22 23 1 1
22 24 2 1
1 23 24 1 1
24 26 2 1
24 25 1 1
24 26 2 1
25 26 1 1
24 26 2 1
1 25 26 1 1
25 27 2 1
25 27 2 1
25 26 1 1
25 27 2 1
1 25 26 1 1
26 27 2 1
1 26 28 2 1
1 26 28 2 1
1 26 28 2 1
26 27 1 1
26 27 1 1
26 28 2 1
27 28 1 1
27 29 2 1
27 29 2 1
28 29 1 1
28 30 2 1
28 30 2 1
1 28 30 2 1

0 0 21 0 0 0 1571 1587 45 28 0 1

WAH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)

ARNA MERAH
si Keluar Status Pulang
Diagnosa Tindakan
Mati Alamat (Desa) ICD Pelayanan
Sembuh APS Rujuk Pindah Primer (Operasi)
> 48 Ruang

1 bades post sc 2 jam sc obgyn


1 sumbermujur post sc 2 jam sc obgyn
1 pulo post sc 6 jam sc obgyn
1 jugosari post sc 2 jam sc obgyn
1 jatisari heavy menstrual bleeding gynec
1 gondoruso post ve 6 jam ve obgyn
1 sumbermujur post sc 2 jam sc obgyn
1 kertowono hamil dg OF H2+ TF obgyn
1 penanggal post partum 6 jam ekstraksi total obgyn
1 candipuro post sc 5 jam sc obgyn
1 candipuro post sc 3 jam sc obgyn
1 bades post sc 2 jam sc obgyn
1 sumbermujur abortus imminent obgyn
1 jugosari heg obgyn
1 yosowilangun post sc 3 jam sc obgyn
1 penanggal post partum 6 jam spt od obgyn
1 sememu post partum 6 jam spt b obgyn
1 kalibendo post sc 3 jam sc obgyn
1 bades post partum 6 jam spt od obgyn
1 ampelgading heg obgyn
1 tumpeng heg obgyn
1 nguter abortus complite obgyn
1 tumpeng post partum + leukosispt b obgyn
1 candipuro post partum 6 jam spt od obgyn
1 jarit post partum + sisa pl spt ind + cureta obgyn
1 sumberwuluh post partum 6 jam spt od obgyn
1 jarit ket laparatomi obgyn
1 sumberwuluh bo curetage obgyn
1 banyuwangi pua + anemia gynec
selokawar pua + anemia gynec
1 gondoruso post partum 6 jam spt od obgyn
1 jarit post partum 6 jam spt b obgyn
1 jarit post sc 4 jam sc obgyn
1 kloposawit post sc 2 jam sc obgyn
1 nguter post curetage curetage obgyn
1 sumberanyar post sc 3 jam sc obgyn
1 jokarto post sc 2 jam sc obgyn
1 madurejo post partum 6 jam spt b obgyn
1 pasirian post sc 3 jam sc obgyn
1 selokawar heg+ asma bronchiale obgyn
1 sememu post partum 6 jam spt od obgyn
1 sumberejo post sc 2 jam sc obgyn
1 sumberwuluh hamil dg OF H3 obgyn
1 sememu post partum 2 jam spt b obgyn
1 tumpeng post partum 6 jam spt induksi obgyn
1 sumberwuluh pua gynec
vip lempeni myoma uteri kistektomi gynec
1 candipuro post partum 6 jam spt od obgyn
1 jatiroto post sc 2 jam sc obgyn
1 selokawar post partum 6 jam spt od obgyn
1 bades post partum 6 jam spt od obgyn
1 sememu post sc 4 jam sc obgyn
1 candipuro post sc 4 jam sc obgyn
1 jugosari post sc 4 jam sc obgyn
1 selokanyar endometriosis gynec
1 jugosari post sc 2 jam sc obgyn
1 sumberejo post sc 3 jam sc obgyn
1 pasirian post partum 6 jam spt b obgyn
1 selokanyar post partum 6 jam spt b obgyn
1 bades post sc 2 jam sc obgyn
1 kalibendo post sc 1 jam sc obgyn
1 dorogowok post sc 2 jam sc obgyn
1 bades post sc 2 jam sc obgyn
1 gesang post partum 6 jam spt od obgyn
1 gondoruso post partum 6 jam spt od obgyn
1 selokawar hamil 4-5mg dg ab.imminens + dm tipobgyn
1 kertosari post sc 1 jam sc obgyn
1 sumberejo post sc 3 jam sc obgyn
1 madurejo ppi obgyn
1 penanggal post sc 4 jam sc obgyn
1 sumberwuluh post sc 4 jam sc obgyn
1 penanggal post curetage curetage obgyn
1 kalibendo post partum 6 jam spt induksi obgyn
zamrud jarit apendiksitis op apendik obgyn
1 kalibendo post sc hari ke 1 sc obgyn
1 pandanarum post partum 6 jam spt od obgyn
1 kertosari post sc 4 jam sc obgyn
1 bago post sc 4 jam sc obgyn
1 tumpeng post sc 7 jam sc obgyn
1 pasirian post partum 6 jam spt od + curetagobgyn
1 sumberwuluh post sc 6 jam sc obgyn
1 gondoruso post partum 6 jam spt od obgyn
1 tempurejo bartholinitis insisi gynec
1 gesang post curetage curetage obgyn
1 selokawar post sc 3 jam sc obgyn
1 situbondo post sc 2 jam sc obgyn
1 sememu post sc 4 jam sc obgyn
1 candipuro heavy menstrual bleeding gynec
1 tanggul post sc 4 jam sc obgyn
1 candipuro post sc 3 jam sc obgyn
1 kalibendo post sc 2 jam sc obgyn
1 kalibendo post sc 2 jam sc obgyn

0 28 0 0
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM Jampersal JR

1 04.60.85 siti nurkhasanah 1 5/25/90 31


2 04.18.49 rina retna iswayuni 1 3/22/91 30 1
3 04.61.96 suyani 1 10/27/92 29
4 03.87.09 aisy karima dewi 1 3/4/1997 24 1
5 04.54.09 diah ayu lestari 1 12-08-2002 19 1
6 04.56.04 imia audina pratiwi 1 2/3/1997 24 1
7 04.51.03 yohana 1 5/24/95 26 1
8 04.63.49 yuwilowati indahyani 1 4/2/1980 41 1
9 04.63.26 lutfi maulidiyah 1 5/5/1999 23 1
10 04.38.55 nani puspa romaisah 1 5/3/1992 29 1
11 04.63.59 suliah 1 3/3/1983 38 1
12 04.60.99 vio virgo vernanda 1 1/28/2004 18 1
13 02.10.58 syahvira diska 1 3/26/2003 18 1
14 04.26.25 yuntama 1 12/30/91 30 1
15 04.60.08 subaiyah 1 9/23/69 52 1
16 04.64.02 jamilatul hasanah 1 11/15/96 25
17 04.64.06 nurul farisyi 1 1/7/1999 22 1
18 00.06.35 leny wijayanti 1 12/15/97 24 1
19 03.89.02 nurul ilmiyah 1 11/19/94 27 1
20 04.64.24 siti asmilah 1 4/16/72 49 1
21 04.25.67 siti rohani 1 1/2/1979 43 1
22 04.64.63 alfitrotun nisa r. 1 6/23/95 26 1
23 04.64.38 lia fatma noviandini 1 11/22/91 30 1
24 04.45.77 ifa andriani 1 1/18/2001 21 1
25 04.55.88 erfin novita sari 1 1/11/1991 30 1
26 03.82.86 sri utami 1 12/5/1994 27
27 04.64.65 ayu novitasari 1 11/5/1993 28
28 04.63.33 engga novitasari 1 9/8/1997 24 1
29 04.65.00 lailatur rohmah 1 8/28/95 26 1
30 04.64.96 farida 1 11/6/1990 31 1
31 04.64.74 uswatun hasanah 1 05-08-2003 18 1
32 04.49.49 yulifah 1 10/5/1983 38 1
33 03.40.80 fitria widaningrum 1 3/23/2000 21 1
34 04.63.94 reza leliyah 1 8/15/94 27 1
35 00.37.04 putri meyla wati 1 5/21/95 26 1
36 03.89.02 nurul ilmiyah 1 11/19/94 27 1
37 04.64.89 novita agustin dianasari 1 10/8/1998 23
38 04.59.38 dian 1 1/9/1992 29
39 02.67.24 sulaidah 1 12/23/86 35 1
40 04.64.35 nurul uyun 1 2/3/1986 35
41 04.65.42 khotimah 1 1/29/2001 21
42 04.65.51 firdaus asyarifa 1 10/17/2000 21
43 04.65.58 lailatus soliha 1 1/24/92 30 1
44 04.65.67 ditta andriyani 1 1/24/94 28 1
45 04.62.23 yeti fidiyah ningsih 1 11/22/98 23
46 04.57.50 utin 1 1/7/1976 45 1
47 00.04.45 marsita 1 4/27/68 52 1
48 04.65.85 masnul chotim 1 10/20/80 41 1
49 04.37.88 siti munajaroh 1 4/8/1999 22
50 04.65.88 siti hasanah 1 6/21/90 28
51 04.59.13 helly nistutin 1 9/19/84 37 1
52 04.66.05 siti romlah 1 5/18/80 41 1
53 04.66.08 nurul akhiriyah 1 7/26/2000 21
54 04.51.02 ririn 1 2/14/92 29 1
55 04.66.20 yuni eka wulandari 1 6/18/94 27 1
56 02.78.97 nuriyati 1 2/12/1982 39 1
57 02.75.97 astutik 1 1/6/1983 38 1
58 04.66.34 iik kusumawati 1 2/23/97 24
59 04.66.37 agil catur febriyani 1 2/29/2000 21 1
60 04.66.54 nurlatifah 1 3/28/90 31
61 04.66.56 cindy dwi kumala 1 3/29/99 22 1
62 01.22.88 nur aisyah 1 9/22/73 51 1
63 04.66.83 nafidatul hasanah 1 8/17/2000 20 1
64 04.66.89 yuli rahmawati 1 12/7/1998 23 1
65 04.67.12 dwi candra bareta 1 3/31/95 26 1
66 01.98.06 heni sulistyowati 1 6/16/2000 21 1
67 04.63.94 reza leliyah 1 8/15/94 27 1
68 04.67.31 siti aisyah 1 2/7/1993 28
69 04.67.42 imelda margareta 1 6/28/2004 17 1
70 04.44.31 khumaida sari 1 1/5/1992 29
71 04.67.65 rani puspitasari 1 12-11-2002 19 1
72 04.50.49 nurhayati 1 8/28/83 38
73 04.67.81 halimatus sadiyah 1 7/20/79 27 1
74 04.67.76 senema 1 11/11/1996 59 1
75 04.57.50 utin 1 1/7/1976 45 1
76 04.67.80 yuyun indraningsih 1 11/3/1986 35 1
77 04.67.79 fela indraningsih 1 1/23/2000 22 1
78 04.54.79 aminatul hanah 1 03-03-2003 18 1
79 04.66.40 sinta laili camela 1 12-10-2001 20 1
80 04.48.00 ruri bayu anjani 1 1/16/97 25
81 04.68.13 lia arifa 1 9/12/1994 27
82 04.68.15 maisatul ulfa 1 5/4/1991 30
83 03.05.44 nur aminah 1 1/23/97 25
84 04.67.90 cindy sukmawati 1 4/22/2000 21 1
85 04.68.21 roudatul asfiroh 1 8/15/2005 16 1
86 04.44.17 ita purwati 1 3/14/2005 19 1
87 04.36.55 tutik 1 8/5/1976 45
88 04.68.06 fitria nur indah sari 1 4/5/1997 24 1
89 04.68.38 rohana 1 10/12/1983 38
90 04.68.55 afni nurfifa dewi 1 1/2/1999 23 1
91 04.68.59 diana natalia 1 2/12/1992 29
92 04.67.41 muniroh 1 4/3/1984 37
93 04.66.89 yuli rahmawati 1 12/7/1998 23 1
94 02.75.97 astutik 1 1/6/1983 38 1
95 04.68.37 trisna anggieani 1 10/24/2001 20 1
96 01.46.41 ajeng pujayanti 1 04-01-2000 21 1
97 04.63.94 reza leliyah 1 8/15/94 27 1
98 04.55.40 zannuba savira 1 11/1/2002 21
99 04.68.92 isnami 1 1/5/1981 40 1
100 04.69.13 felita dwi novitasari 1 11/23/98 23 1
JUMLAH 0 29 8 64 0 0 0

bencana
covid

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN = 5 B
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
Cara bayar Tanggal Lama BRM
dirawa kembali Hidup Mati
t Sembuh APS Rujuk Pindah
BPJS TK PG JKN RG Kemkes Lain MRS KRS < 48 > 48 < 48 > 48 Ruang

1 29 2 4 1 1
31 1 1 1 1
1 31 2 2 1 1
31 2 2 1 1
1 2 1 1 1
1 3 2 1 1
2 3 1 1 1
2 4 2 1 1
2 4 2 1 1
3 4 1 1 1
3 4 1 1 1
3 4 1 1 1
3 5 2 1 1
3 5 2 1 1
3 5 2 1 1
1 5 6 1 1 1
1 5 6 1 1 1
5 7 2 1 1
5 7 2 1 1
6 8 2 1 1
7 9 2 1 1
7 9 2 1 1
7 9 2 1 1
7 9 2 1 1
7 9 2 1 1
1 7 9 2 1 1
1 8 9 1 1 1
8 9 1 1 1
8 9 1 1 1
8 10 2 1 1
8 10 2 1 1
8 10 2 1 1
8 10 2 1 1
9 10 1 1 1
8 9 1 1 1
9 10 1 1 1
1 8 10 2 1 1
1 9 10 1 1 1
10 11 1 1 1
1 10 11 1 1 1
1 10 11 1 1 1
1 10 11 1 1 1
10 11 1 1 1
1 11 12 1 1 1
1 10 12 2 1 1
11 13 2 1 1
11 12 1 1 1
11 13 2 1 1
1 11 12 1 1 1
1 1 12 13 1 1 1
12 13 1 1 1
12 13 1 1 1
1 13 14 1 1 1
14 15 1 1 1
14 15 1 1 1
14 16 2 1 1
14 16 2 1 1
1 14 16 2 1 1
14 16 2 1 1
1 15 16 1 1 1
15 17 2 1 1
14 15 1 1
15 17 2 1 1
16 17 1 1 1
1 16 18 2 1 1
17 18 1 1 1
17 19 2 1 hcu
1 17 19 2 1 1
18 19 1 1 1
1 19 20 2 1 1
19 21 1 1 1
1 19 21 2 1 1
20 22 2 1 1
20 22 2 1 1
20 23 3 1 1
20 21 1 1 1
20 22 2 1 1
20 23 3 1 1
21 22 1 1 1
1 21 22 1 1 1
1 22 22 1 1 1
1 22 22 1 1 1
1 21 22 1 1 1
21 23 2 1 1
22 24 2 1 1
22 24 2 1 1
1 22 24 2 1 1
1 21 24 3 1 1
1 1 23 25 2 1 1
1 23 25 2 1 1
1 1 24 26 2 1 1
1 1 23 26 3 1 1
1 24 26 2 1 1
1 25 28 3 1 1
23 24 1 1 1
23 25 2 1 1
24 26 2 1 1
1 26 26 1 1 1
1 25 28 3 1 1
27 28 1 1 1
0 28 0 12 0 219 173 47 0 29 0 0 29 0 0

WAH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)

RNA MERAH
Tindakan
Alamat (Desa) Diagnosa Primer ICD (Operasi) Pelayanan

kalibendo hamil dg gagal konservatif+ gawat janin sc obgyn


gondoruso post sc 3 jam sc obgyn
jarit post sc 1 jam sc obgyn
condro hamil dg diare obgyn
madurejo post sc 3 jam sc obgyn
pasirian post sc 3 jam sc obgyn
bades post partum 6 jam spt od obgyn
pulo post sc 2 jam sc obgyn
sumberrejo post sc 1 jam sc obgyn
jarit post partum 6 jam spt od obgyn
sumbermujur post partum 6 jam spt od obgyn
candipuro post sc hari ke 1 sc obgyn
condro heavy menstrual bleeding + disminorea+ anemia gynec
sememu post sc 4 jam sc obgyn
jarit mioma uteri + embended iud HTSUD histeterekt gynec
bago post sc 2 jam sc obgyn
candipuro post sc 1 jam sc obgyn
pasirian heg obgyn
selokawar ppi obgyn
nguter ca servic + anemia gynec
supiturang post sc 3 jam sc obgyn
selokawar post curetage curetage obgyn
pasirian post sc 4 jam sc obgyn
sumbermujur post sc 4 jam sc obgyn
gondoruso post sc 3 jam sc obgyn
bades post sc 3 jam sc obgyn
candipuro post sc 3 jam sc obgyn
madurejo post sc 2 jam sc obgyn
sememu post sc 6 jam sc obgyn
candipuro post sc 6 jam sc obgyn
sumbermujur post sc 3 jam sc obgyn
bago post sc 2 jam sc obgyn
jarit post sc 3 jam sc obgyn
pasirian post sc 4 jam sc obgyn
condro post partum 6 jam spt od obgyn
selokawar post partum 6 jam spt b obgyn
nguter post sc 1 jam sc obgyn
penanggal post partum 6 jam spt b obgyn
selokawar post curetage curetage obgyn
bades post sc 4 jam sc obgyn
tambahrejo post sc 6 jam sc obgyn
selokawar post sc 6 jam sc obgyn
kalibendo post sc 4 jam sc obgyn
pasirian post partum 6 jam spt b obgyn
bades post sc 4 jam sc obgyn
selokawar post op mioma+ milena gynec
candipuro pua curet biops gynec
pasirian hamil dg dhf obgyn
sememu post partum 6 jam spt od obgyn
gucialit post sc 2 jam sc obgyn
sumbermujur post sc 2 jam sc obgyn
gondoruso post partum 6 jam spt od obgyn
kloposawit post partum 6 jam spt od obgyn
sememu post sc 2 jam sc obgyn
condro hamil dg asma broncial obgyn
sememu post sc 2 jam sc obgyn
sumberwuluh post sc 3 jam sc obgyn
sumberwuluh post partum 6 jam spt od obgyn
jarit post sc 2 jam sc obgyn
kalibendo post sc 3 jam sc obgyn
gesang post sc 1 jam sc obgyn
orooroombo ca servic gynec
selokawar post sc 1 jam sc obgyn
pasirian post partum 6 jam spt od obgyn
pasirian post partum 6 jam spt b obgyn
besuk post curetage curetage obgyn
pasirian wound dehisensi post sc histeterek obgyn
jarit post sc 2 jam sc + myomobgyn
candipuro post partum 6 jam spt b obgyn
madurejo post sc 3 jam sc obgyn
selokawar heg obgyn
bago post partum 6 jam spt b obgyn
tempeh lor post sc 4 jam sc obgyn
tempeh prolaps uteri gynec
selokawar wound dehisensi post miomektomy repair gynec
penanggal post partum 6 jam spt b obgyn
besuk post sc 5 jam sc obgyn
sumbermujur post sc 4 jam sc obgyn
sememu post partum diluar dg post hpp+ shok hipovelemic obgyn
nguter post partum 6 jam spt od obgyn
penanggal post partum 6 jam spt b obgyn
nguter post partum 6 jam spt b obgyn
pasirian post partum 6 jam spt induksiobgyn
candipuro post sc 4 jam sc obgyn
condro ppi obgyn
bago post sc 2 jam sc obgyn
jugosari post sc 2 jam sc obgyn
condro hamil 14mg dg heg+ susp c19 obgyn
sumbermujur g2 p1-1 uk 38-39mg inpartu kala 2 dg susp c1ve obgyn
tumpeng post partum 5 jam spt b obgyn
tempursari post sc 1 jam sc obgyn
nguter g3 p2-1 uk 39mg blm inpartu jth presbo+ oligsc obgyn
pasirian post partum hari ke 8 dg rest plasenta+ susp curetage obgyn
sumberwuluh wound dehisensi post sc repair obgyn
pasirian post sc 2 jam sc obgyn
condro ppi obgyn
pasirian post HT subtotal+ wound repair sc endometritis+ burst obgyn
kalibendo post partum 6 jam spt od obgyn
tekung g5 p30013 uk 37-38mg belum inpartu jth pressc obgyn
condro post partum 6 jam spt od obgyn
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P UmumBPJSSKTM
Jampersal
JRBPJS TKPGJKN RG
Kemkes
Lain

1 01.56.81 suken sri 1 3/16/78 43 1


2 04.37.92 niswatur rosadah 1 7/6/1999 22 1 1
3 03.87.25 iin hidayah 1 12/7/1988 33 1 1
4 04.69.45 hana pertiwi 1 2/27/2005 17 1 1
5 04.69.58 rena martha tiniar 1 04-10-2001 20 1
6 02.13.10 vizana tin zamzam 1 6/27/94 27 1
7 04.66.30 poppy wulandari 1 8/15/2001 20 1
8 04.69.31 eni agustin putri 1 8/19/99 22 1
9 01.64.87 nurul fadliyah 1 8/29/91 30 1
10 04.69.50 ernawati 1 7/21/94 27 1
11 04.37.38 kholifatul fitriyah 1 2/25/95 27 1
12 04.62.77 firda manjilatul ainiyah 1 12/23/2003 18 1
13 04.69.69 yuliani 1 4/2/1992 30 1
14 04.69.84 irfaatus siami 1 4/1/1997 25 1
15 04.32.03 khusnul siti khotima 1 2/1/1998 24 1
16 04.70.07 rida oktaviani 1 10-04-2000 21 1
17 04.63.88 shindi antika 1 2/29/2000 22 1
18 04.52.13 emalia 1 9/10/1994 27 1
19 04.68.79 indahwati vironia ningsih 1 7/9/1997 24 1
20 04.70.09 rina maulidia 1 5/23/2002 19 1
21 04.54.25 nursiyah 1 2/26/93 29 1
22 04.70.04 siti harisah 1 7/6/1997 24 1
23 02.99.10 asmaul anilah 1 6/22/1992 29 1 1
24 04.62.85 fadilatul fitria 1 1/18/2000 22 1 1
25 04.70.26 hotimah 1 6/30/80 36 1
26 03.15.70 lasmini 1 4/3/1989 33 1
27 04.62.84 supratini 1 6/24/83 38 1
28 04.70.65 selami 1 12/3/1963 58 1
29 04.59.76 siti nurhaeni 1 10/11/1995 26 1
30 04.68.21 roudlotul asfiroh agustina 1 8/15/2005 16 1
31 04.70.77 endang 1 11/18/78 43 1
32 03.66.47 eni suryana 1 4/24/98 23 1
33 04.70.75 farida 1 7/16/87 34 1
34 01.66.24 susanti 1 2/3/1984 38 1
35 04.66.63 chelia fantika sari 1 7/26/2002 19 1
36 04.71.07 fitriatin 1 6/6/1989 32 1
37 04.60.84 muntri filya 1 4/6/1990 31 1
38 04.71.33 ponira nuraini 1 2/14/83 39 1
39 04.46.66 sukma wulandari 1 1/15/2005 17 1
40 04.63.45 novi puji lestari 1 9/11/1998 23 1
41 04.71.30 nafisatul mukaromah 1 3/2/1993 29 1
42 04.70.51 arik maharani 1 5/19/92 29 1
43 04.70.52 suhartini 1 7/20/76 45 1 1
44 04.62.91 siti wahyuni 1 2/7/1985 36 1
45 02.99.10 asmaul anilah 1 6/22/92 29 1
46 04.71.64 suliati 1 11/4/1993 28 1
47 04.22.27 yuni purwati 1 6/22/94 27 1 1
48 04.71.68 siti nurfaidah 1 1/25/93 29 1 1
49 02.99.99 rini indayani 1 10/10/1997 24 1 1
50 04.71.97 sulis febianti 1 6/2/2004 18 1
51 04.71.94 arimbi 1 1/9/1995 26 1
52 04.72.01 turini 1 6/9/1985 36 1
53 03.42.53 mamik kusworowati 1 3/18/71 50 1
54 04.59.76 siti nurhaeni 1 10/11/1995 26 1
55 02.25.08 andriani 1 7/14/88 33 1
56 04.56.33 ayu sasmita 1 7/14/88 33 1
57 04.66.57 sutriya 1 8/8/1984 37 1
58 04.59.48 ferra dhea danda rista 1 04-03-2004 17 1
59 04.32.03 khusnul siti khotima 1 2/1/1998 24 1 1
60 04.50.52 fatmawati 1 8/16/97 24 1
61 04.67.98 hernik safitri 1 12/6/1979 42 1
62 04.36.78 dini ajeng sulistyo 1 8/22/99 22 1
63 04.72.31 rohila 1 7/15/2001 20 1
64 04.72.34 sagita dwi maharani 1 11/29/88 33 1
65 04.61.19 desvita tekna ningsih 1 12-07-2001 20 1
66 04.72.41 nurul badriyah 1 2/10/1996 25 1
67 03.26.74 siti nur alifah 1 01-10-2005 17 1
68 04.51.75 frety sinta r. 1 11/29/2002 19 1
69 00.35.81 mundayana dian susanti 1 7/14/86 35 1
70 02.53.59 ervina nuri agustin 1 5/1/1989 33 1
71 04.72.74 hamimatul hasanah 1 6/24/96 25 1
72 04.65.24 nurisma fitri anggraeni 1 5/4/1992 29 1
73 04.72.97 sulimawati 1 11/1/2006 16 1
74 04.52.55 siti muawanah 1 6/8/1985 36 1
75 04.73.02 yuliana 1 6/21/80 41 1
76 04.72.99 kartika permatasari 1 12/10/1992 29 1 1
77 04.73.05 sulis eko setya wati 1 8/21/87 34 1
78 04.63.74 siti rochaniyah 1 12/2/1982 40 1
79 02.00.80 mambaul hasanah 1 4/18/88 33 1
80 04.73.65 melati sekar wahyuningtyas 1 5/20/2002 19 1
81 04.73.82 tuti armiati 1 11/25/79 42 1
82 04.73.87 agustin widia ningsih 1 8/17/2003 18 1
83 04.73.70 nur fadila 1 9/23/95 26 1
84 04.74.01 imawati 1 3/20/89 33 1
85 04.66.20 yuni eka wulandari 1 6/18/94 27 1
86 04.63.68 avin ningse widiat niko 1 2/2/1985 37 1
87 02.02.79 ratna dumilah 1 3/27/89 32 1 1
88 04.71.74 khoirun nimah 1 3/18/96 26 1
89 02.88.24 agustyaningsih 1 1/6/1984 37 1
90 04.74.33 muslimah wati 1 5/18/84 37 1
91 04.63.68 avin ningse widiat niko 1 2/2/1985 37 1
92 00.14.00 fitri nurfauza sari 1 1/28/98 24 1
93 02.87.23 ahyun siti nurhasanah 1 10/28/97 24 1
94 04.71.29 santi urifah nita 1 1/22/84 38 1
95 03.16.96 ella nur aifah 1 03-03-2000 22 1
96 04.74.20 khoirotul ayun 1 9/4/1999 22 1 1
97 04.54.09 diah ayu 1 12/28/2002 19 1
98 04.74.63 naning astutik 1 7/21/94 27 1
99 04.74.64 siti nur hasanah 1 8/9/1995 26 1
100 04.74.54 iza rotul ilmia 1 5/6/1999 22 1
101 04.74.71 ita setiawati 1 3/29/95 27 1
102 04.47.65 luluk indayani 1 11/20/83 38 1
103 04.74.75 suliha 1 12/26/63 58 1
104 01.61.59 imra atush shaliha 1 11/26/95 26 1
105
106
107
108
109
110
111
112
113
114
115
116
JUMLAH 0 34 16 55 0 0 0 0 32 0 14 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN = 5 B, 7
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
Tanggal Lama BRM
dirawat kembali Hidup Mati Pindah Alamat (Desa) Diagnosa Primer
Sembuh APS Rujuk
MRS KRS < 48 > 48 < 48 > 48 Ruang

26 1 3 1 1 banyuwangi pua + anemia


26 1 3 1 1 pasirian g1 p0a0 uk 38mg blm i
27 1 2 1 1 nguter post sc 1 jam
1 3 2 1 1 lempeni post curetage
1 3 2 1 1 pasirian g1 p0-0 uk 15-16mg dg heg+ su
28 1 2 1 1 pasirian post sc 3 jam
28 1 2 1 1 selokawar post sc 3 jam
28 1 2 1 1 kloposawit post partum 6 jam
1 2 1 1 1 sememu post sc 2 jam
1 2 1 1 1 sumberwuluh post sc 2 jam
2 3 1 1 1 bades post sc 3 jam
1 3 2 1 1 bades post sc 3 jam
2 4 2 1 1 penanggal post sc 2 jam
3 4 1 1 1 sememu post sc 2 jam
2 4 2 1 1 pulo ppi
4 7 3 1 1 sumberwuluh hamil dg b20 + bronchitis
4 5 1 1 1 kalibendo post partum 6 jam
4 5 1 1 1 nguter post partum 6 jam
4 5 1 1 1 gesang post partum 6 jam
4 5 1 1 1 sememu post partum 6 jam
4 6 2 1 1 sumbermujur post sc 2 jam
4 5 1 1 1 sememu post partum 6 jam
4 7 3 1 1 kloposawit heg + confirm c19
4 6 2 1 1 kalibendo g1 p0-0 uk 40-41mg in
5 6 1 1 1 supiturang post sc 1 jam
7 8 1 1 1 tamanayu post partum 6 jam
7 8 1 1 1 jarit post partum 6 jam
7 9 2 1 1 pasrujambe pua + anemia
7 9 2 1 1 pasirian post sc 1 jam
8 9 1 1 1 condro post sc 2 jam
8 9 1 1 1 sumberejo post sc 3 jam
8 10 2 1 1 puger post sc 1 jam
8 9 1 1 1 jarit post sc 2 jam
9 10 1 1 1 jarit post curetage
9 10 1 1 1 kloposawit post sc 2 jam
9 11 2 1 1 tempursari post sc 2 jam
11 12 1 1 1 pasirian hamil dg presbo+ bsc+ apb
11 12 1 1 1 candipuro post curetage
10 12 2 1 1 kalibendo post sc 1 jam
11 12 1 1 1 nguter post sc 6 jam
11 12 1 1 1 sememu post partum 6 jam
11 13 2 1 1 gesang post sc 4 jam
11 14 3 1 1 candipuro mioma uteri + c19
11 12 1 1 1 sememu post partum 6 jam
11 17 1 1 berlian 1 kloposawit heg
13 14 1 1 1 bago post partum 6 jam
13 14 1 1 1 gondoruso g4 p3-2 uk 39mg inpar
13 15 2 1 1 jarit g2 p1-1 uk 10mg dg heg + c1
15 17 2 1 1 bades post sc 2 jam + c19
15 17 2 1 1 jarit post repair vulva
14 16 2 1 1 kalibendo heg
15 17 2 1 1 penanggal post sc 2 jam
15 19 4 1 1 gondoruso mioma uteri
16 17 1 1 1 pasirian post sc hari ke 7 dg gastric p
16 18 2 1 1 kaliwungu post sc 6 jam
16 17 1 1 1 bades post partum 6 jam
16 18 2 1 1 bago post sc 1 jam
16 17 1 1 1 gondoruso post partum 6 jam
15 18 3 1 1 pulo g3 p010011 uk 33-34m
16 17 1 1 1 sumberwuluh post partum 6 jam
17 18 1 1 1 nguter post sc hari ke 1
17 18 1 1 1 bades post sc 2 jam
17 18 1 1 1 orooroombo post sc 6 jam
17 18 1 1 1 nguter post curetage
17 18 1 1 1 selokanyar post sc 7 jam
17 18 1 1 1 candipuro post sc 2 jam
17 19 2 1 1 jarit post sc 4 jam
17 19 2 1 1 tambahrejo post sc 6 jam
18 19 1 1 1 jarit post sc 1.5 jam
18 19 1 1 1 tamanayu post sc 2 jam
19 19 1 1 1 selokanyar post partum 6 jam
19 20 1 1 1 gesang post sc 3 jam
20 21 1 1 1 selokanyar post partum 6 jam
20 21 1 1 1 bades post partum 6 jam
20 22 2 1 1 nguter post sc 2 jam
20 22 2 1 1 tumpeng g3 p10011 uk 8-9mg dg heg
21 23 2 1 1 penanggal post sc 3 jam
21 23 2 1 1 kalibendo kista ovari
22 24 2 1 1 nguter mola hidatidosa
23 25 2 1 1 pasirian post sc 2 jam
24 25 1 1 1 penanggal kista fungsional
24 25 1 1 1 kalibendo post sc 2 jam
24 25 1 1 1 sememu post sc 2 jam
25 26 1 1 1 tumpeng ppi
24 26 2 1 1 condro post sc 3 jam
24 26 2 1 hcu kebonsari hamil dg peb+ bsc+ ol
24 26 2 1 1 gondoruso g3 p10011 uk 39-40mg
25 26 1 1 1 bago post partum 6 jam
26 27 1 1 1 pasirian post partum 6 jam
28 28 1 1 1 penanggal post partum 6 jam
27 28 1 1 1 kebonsari post sc hari ke 1
27 29 2 1 1 kalibendo post partum 6 jam
27 29 2 1 1 selokawar heg + febris
28 30 2 1 1 gucialit post partum 6 jam + si
28 29 1 1 1 bades post partum 6 jam
26 28 2 1 1 candipuro g1 p0-0 uk 10-11mg dg heg
28 29 1 1 1 madurejo heavy menstrual bleeding +
29 30 1 1 1 nguter post partum 6 jam
29 31 2 1 1 sememu bo
29 29 1 1 1 sumbersuko post partum 6 jam
29 30 1 1 1 pasrujambe post curetage
29 30 1 1 1 nguter post sc 2 jam
29 31 2 1 1 bades pua
30 31 1 1 1 jarit heg

1647 1638 160 0 104 0 0 102 0 0

bencana
covid

AHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)


Tindakan
ICD (Operasi) Pelayanan

gynec
0a0 uk 38mg blm sc
i obgyn
sc obgyn
curetage obgyn
0-0 uk 15-16mg dg heg+ susp c 19 obgyn
sc obgyn
sc obgyn
partum 6 jam spt induksi obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
obgyn
il dg b20 + bronchitis obgyn
partum 6 jam spt induksi obgyn
partum 6 jam spt b obgyn
partum 6 jam spt induksi obgyn
partum 6 jam spt od obgyn
sc obgyn
partum 6 jam spt od obgyn
+ confirm c19 obgyn
0-0 uk 40-41mg insc obgyn
sc obgyn
partum 6 jam spt b obgyn
partum 6 jam spt od obgyn
gynec
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
curetage obgyn
sc obgyn
sc obgyn
il dg presbo+ bsc+ apb obgyn
curetage obgyn
sc obgyn
sc obgyn
partum 6 jam spt induksi obgyn
sc obgyn
ma uteri + c19 gynec
partum 6 jam spt b obgyn
obgyn
partum 6 jam spt od obgyn
3-2 uk 39mg inparspt b obgyn
1-1 uk 10mg dg heg + c19 obgyn
sc 2 jam + c19 sc obgyn
repair vulva repair obgyn
obgyn
sc obgyn
TAH+ BSO gynec
sc hari ke 7 dg gastric pain obgyn
sc obgyn
partum 6 jam spt induksi obgyn
sc obgyn
partum 6 jam spt b obgyn
010011 uk 33-34m sc obgyn
partum 6 jam spt od obgyn
sc hari ke 1 sc obgyn
sc obgyn
sc obgyn
curetage obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
partum 6 jam spt b obgyn
sc obgyn
partum 6 jam spt b obgyn
partum 6 jam spt brach obgyn
sc obgyn
10011 uk 8-9mg dg heg obgyn
sc obgyn
kistectomy gynec
curetage obgyn
sc obgyn
gynec
sc obgyn
sc obgyn
obgyn
sc obgyn
il dg peb+ bsc+ olsc obgyn
10011 uk 39-40mg sc obgyn
partum 6 jam spt od obgyn
partum 6 jam spt b obgyn
partum 6 jam ekstraksi totaobgyn
sc hari ke 1 obgyn
partum 6 jam spt b obgyn
obgyn
partum 6 jam + sispt b + curet obgyn
partum 6 jam spt od obgyn
0-0 uk 10-11mg dg heg obgyn
y menstrual bleeding + anemi gynec
partum 6 jam spt b obgyn
curetage obgyn
partum 6 jam spt b obgyn
curetage obgyn
sc obgyn
gynec
obgyn
1 04.14.45 bekti atmaning 1 7/6/1994 27 1
2 01.36.85 yuliatin 1 10/11/1987 34
3 04.52.12 indah fatmawati 1 4/8/1988 33
4 02.08.25 sofiyah 1 5/12/1989 32 1
5 04.75.02 ainul hakimah 1 6/5/1992 29 1
6 04.75.16 lailatul imroatus 1 1/5/1995 26 1
7 04.75.25 noni indawati 1 11/18/94 27
8 04.75.28 iis nurul anisah 1 7/31/95 26 1
9 04.42.90 nova dwiyanti 1 11-02-2003 18 1
10 04.75.34 rubema 1 1/10/1986 35 1
11 04.55.36 diah rofiatul m. 1 10/20/98 23 1
12 04.40.51 alfia 1 1/2/1991 31 1
13 04.75.46 nurul aprilia 1 4/27/99 22 1
14 04.75.05 patari ristiyanti 1 8/23/99 22 1
15 04.75.48 vena hariatun hikmah 1 1/23/99 23 1
16 04.68.78 nur hamidah 1 9/17/96 25 1
17 04.75.07 wiwik purwati 1 8/7/1980 41
18 04.75.81 elsi dwi yulanda 1 10-12-2001 20 1
19 03.67.81 dwi lailatur rahmah 1 11/16/2001 20 1
20 04.75.76 roh alyu meiyendi 1 1/5/1997 24 1
21 04.75.91 yunike asiyanti 1 5/6/1992 29 1
22 04.76.01 indrawati 1 11/16/82 39
23 04.76.32 faizatul mukaromah 1 11/10/1998 23
24 04.76.29 melinda dwi sapta 1 08-01-2004 17 1
25 04.76.24 murniah 1 2/23/91 31 1
26 04.73.54 nurida kurniawati 1 1/3/1994 28 1
27 01.98.02 bathi rahayu 1 22/24/84 37
28 04.64.37 binti masruroh 1 9/29/91 30
29 04.76.59 fillya winda maulika sari 1 7/11/1996 25 1
30 00.04.45 marsita saragih 1 4/27/69 52 1
31 04.54.09 diah ayu lestari 1 12/28/2002 19 1
32 04.03.51 nur indayanti 1 7/18/91 30 1
33 04.76.85 suhrotul laila 1 4/26/85 29
34 04.76.93 norma vita indrianti 1 11/17/2000 21 1
35 02.89.21 rohmita mabruroh 1 2/3/1996 26 1
36 04.76.57 khusnul khotimah 1 5/6/1983 38 1
37 04.77.05 nur kholifah 1 1/1/1981 41 1
38 04.77.02 siti fatimah 1 4/18/94 27
39 04.77.10 vivin puji astutik 1 6/10/1992 29
40 04.77.17 anggi 1 07-03-2000 21 1
41 04.72.09 febi ayu dwi yanti 1 02-07-2005 17 1
42 04.73.86 fika krisna andani 1 4/16/2006 15 1
43 04.39.92 sandra diana 1 11/8/1996 25
44 04.77.56 rifah 1 11/5/1982 39
45 04.75.66 sri setyowati 1 7/18/81 40
46 03.18.43 eka mauliddia 1 5/18/2002 19 1
47 02.45.65 siti romlah 1 8/9/1989 32 1
48 02.86.14 tutik wulansari 1 9/3/1998 24 1
49 04.77.75 anggun putri tio b. 1 11/23/2000 21
50 04.73.85 fatimatus jahro 1 1/13/88 34
51 02.62.83 yuliatri wulandari 1 7/28/2007 14 1
52 04.77.89 rania putri arisna 1 3/31/2002 22 1
53 04.77.97 siti mila hanifah 1 8/17/2000 21 1
54 03.87.58 fitri ratnawati 1 4/3/1995 27 1
55 04.78.00 siti mas'ula 1 7/27/96 25
56 04.78.05 devi kristina 1 1/29/95 27
57 04.72.15 sumiati 1 12/15/84 37 1
58 04.71.78 umi kulsum 1 5/15/89 32
59 04.65.17 isabela 1 5/5/1992 29
60 04.06.26 ririn haswotini 1 3/24/2000 22 1
61 01.46.41 ajeng pujayanti 1 04-01-2000 22 1
62 04.50.47 aris mikail mia 1 8/14/92 29 1
63 04.78.59 ernawati 1 4/19/89 33 1
64 04.67.43 erniasih 1 02-08-2002 20 1
65 02.98.11 vera ani susanti 1 7/12/1993 28 1
66 04.78.37 kiki oktaviani 1 8/10/1991 30 1
67 04.78.60 siti ainun jariyah 1 6/30/95 26
68 04.78.41 raudah 1 10/4/1985 37
69 04.59.22 eni susiyanti 1 1/20/85 37
70 04.78.78 sumiati ningsih 1 7/10/1985 36
71 04.76.93 norma vita indrianti 1 11/17/2000 21 1
72 04.54.09 diah ayu lestari 1 12/28/2002 19 1
73 04.79.11 husny fadhilatur rohman 1 2/13/97 24
74 04.79.21 ngatiyam 1 3/29/58 64 1
75 03.03.36 dwi sari ratna ningrum 1 2/23/96 26
76 03.67.09 megawati 1 9/2/1998 24
77 04.79.61 nur hasanah 1 11/21/93 28
78 04.35.07 sela putri oktavia 1 10/19/98 23 1
79 01.42.57 nina lailatul munawaroh 1 3/21/95 27 1
80 04.79.77 dia widuriati 1 11/1/1994 28
81 04.79.88 siti amilatus solikhah 1 4/30/2000 21
30 2 3 1 1
1 31 1 1 1 1
1 30 1 2 1 1
30 1 2 1 1
31 2 2 1 1
1 2 1 1 1
1 1 2 1 1 1
1 2 1 1 1
1 4 3 1 1
1 3 2 1 1
2 4 2 1 1
3 4 1 1 1
3 4 1 1 1
3 5 2 1 1
3 5 2 1 1
3 5 2 1 1
1 4 5 1 1 1
4 6 2 1 1
4 6 2 1 1
4 6 2 1 1
5 6 1 1 1
1 5 6 1 1 1
1 7 7 1 1 1
6 7 1 1 1
7 8 1 1 1
7 9 2 1 1
1 7 8 1 1 1
1 8 9 1 1 1
8 10 2 1 1
9 11 2 1 1
10 11 1 1 1
10 11 1 1 1
1 10 11 1 1 1
10 12 2 1 1
11 12 1 1 1
11 13 2 1 1
11 13 2 1 1
1 11 15 4 1 1
1 11 13 1 1 1
11 12 1 1 1
12 14 2 1 1
12 14 2 1 1
1 12 13 1 1 1
1 14 15 1 1 1
1 14 15 1 1 1
14 15 1 1 1
14 15 1 1 1
14 16 2 1 1
1 15 16 1 1 1
1 15 16 1 1 1
16 17 1 1 1
16 17 1 1 1
16 19 2 1 1
17 18 1 1 1
1 17 18 1 1 1
1 17 18 1 1 1
17 19 2 1 1
1 18 20 2 1 1
1 18 19 1 1 1
18 20 2 1 1
18 19 1 1 1
18 20 2 1 1
19 21 2 1 1
19 20 1 1 1
19 21 2 1 1
19 21 2 1 1
1 19 20 1 1 1
1 19 21 2 1 1
1 20 21 1 1 1
1 20 22 2 1 1
20 22 2 1 1
21 23 2 1 1
1 22 23 1 1 1
22 23 1 1 1
1 23 25 2 1 1
1 25 27 2 1 1
1 25 27 2 1 1
25 27 2 1 1
25 27 2 1 1
1 26 28 2 1 1
1 26 27 1 1 1
pasirian post sc 2 jam sc
jarit post sc 2 jam sc
tumpeng post sc 3 jam sc
jarit post sc 2 jam sc
tegalrejo post partum 6 jam spt od
kalibendo post partum 6 jam spt od
sumbermujur post sc 1 jam sc
nguter post curetage curetage
kunir heg
sumbermujur post sc 1 jam sc
candipuro hamil dg kpd
candipuro post sc 2 jam sc
sumberwuluh post sc 4 jam sc
jarit post sc 2 jam sc
bades post curetage curetage
selokanyar hamil dg kpd
bago post partum 6 jam spt b
tempursari post sc 1 jam sc
candipuro post partum 6 jam spt od
nguter post sc 2 jam sc
lempeni post curetage curetage
jarit post partum 6 jam spt induksi
selokawar post partum 6 jam spt od
selokawar post partum 6 jam spt od
tambahrejo post sc 2 jam sc
pulo post sc 3 jam sc
pasirian post partum 6 jam spt od
jarit post partum 6 jam spt induksi
jarit post sc 2 jam sc
candipuro pua
madurejo menstrual bleeding
selokanyar post partum 6 jam spt od
gondoruso post partum 6 jam spt od
condro ppi+ kpd
selokawar post partum 6 jam spt induksi
besuk hamil dg kista ovarium cystectomy
oroombo post partum 6 jam spt od mati
sumberejo post sc 1.5 jam sc
jokarto post sc 2 jam sc
lempeni hiperplasi endometrium
nguter post sc 1 jam sc
jarit post sc 2 jam sc
jarit post partum 4 jam spt b
oroombo post sc 4 jam sc
kloposawit post partum 6 jam spt od
bago post sc 2 jam sc
bago post sc 2 jam sc
sememu post sc 3 jam sc
jokarto post sc 3 jam sc
pasirian post partum 6 jam spontan br
bades post sc 1 jam sc
selokawar post sc 1 jam sc
sumberwuluh g1 p0-0 uk 33-34mg dg kpd+ gawat jasc
madurejo post sc 1 jam sc
madurejo post sc 2 jam sc
candipuro post sc 3 jam sc
selokanyar post sc 3 jam sc
pronojiwo post sc 3 jam sc
nguter post partum 6 jam spt od
candipuro post sc 4 jam SC
condro post partum 6 jam spt induksi
pasirian post partum 6 jam spt od
sumberwuluh post sc 3 jam sc+ mow
lkalibendo post partum 6 jam spt od
selokawar post sc 2 jam sc
sumberejo g2 p1-1 uk 28-29mg th preskep dg ppi
jugosari post partum 6 jam spt od
bades post sc 5 jam sc
gondoruso post partum 6 jam spt b
selokawar post sc 1/2 jam sc
condro post sc 1 jam sc
madurejo heavy menstrual bleeding
candipuro post sc 2 jam sc
sumberwuluh pua a/I ca cx
nguter post sc 3 jam sc
selokawar post sc 8 jam sc
jugosari post sc 8 jam sc
nguter post sc 8 jam sc
jarit heg
tamanayu post sc 4 jam SC
tamanayu post partum 6 jam spt b
Ruangan permata
Jumlah TT 10

JK Um Cara bayar
No. NO RM NAMA TGL LAHIR ur
L P Umum BPJS SKTM Jampersal JR BPJS TK

1 04.80.56 nur hamidah 1 10/26/83 38 1


2 04.80.52 siti rofiah 1 5/9/1985 36
3 04.80.06 mujiati 1 4/27/88 34 1
4 04.80.68 endang setyaningsih 1 1/4/1982 40
5 04.60.84 muntri filya 1 4/6/1990 31
6 04.80.80 yeni hermawan 1 6/22/95 26 1
7 04.80.81 sofia 1 05-01-2003 19 1
8 04.54.09 diah ayu lestari 1 12/28/2002 19 1
9 04.81.11 faridatul tamama 1 9/25/99 22 1
10 04.81.12 siti munaifah 1 01-02-2002 20 1
11 04.81.17 ayu fernanda 1 5/10/2004 17 1
12 04.73.35 khotimah 1 8/11/1989 32
13 04.81.49 cicik agustiningrum 1 8/27/74 47 1
14 04.81.62 siti muktiatun nikmah 1 07-09-2000 21 1
15 00.71.49 eris susanti 1 10/24/94 27 1
16 01.56.81 suken sri 1 3/16/78 43 1
17 04.81.66 putri malida 1 3/18/2003 19 1
18 04.81.69 towila 1 4/7/1992 29
19 04.81.81 meirani chriti 1 3/5/1987 35 1
20 04.81.80 sundia rusmawati 1 2/22/95 27
21 04.50.99 surti 1 1/7/1960 61 1
22 04.73.15 filiyanti 1 12/25/2001 20 1
23 04.82.04 senimah 1 5/11/1978 43 1
24 04.82.15 farida 1 11/1/1996 26 1
25 04.82.35 reni novitasari 1 12/12/1999 22
26 04.82.24 wulandari 1 04-01-2001 21
27 04.82.17 rusmaidah 1 4/5/1997 25
28 04.48.01 titin kusumawati 1 3/13/83 39 1
29 04.82.67 devi ayu ratnasari 1 3/10/1991 30 1
30 04.82.95 rindi setia ningrum 1 5/20/2003 18 1
31 04.82.93 risma sisilia 1 3/26/2004 18 1
32 04.82.72 lailatul badriyah 1 12/15/94 27
33 04.82.87 beby ayu lestari 1 08-10-2002 19
34 04.71.84 fina nurjanah 1 8/26/2003 18
35 04.83.05 sri wahyuni 1 5/5/1979 93 1
36 02.06.16 khusnul khotimah 1 2/9/1994 27 1
37 04.70.46 enis andini 1 5/29/92 29
38 00.51.63 dahlia 1 12/15/86 35
39 01.99.76 flaviana wahyu n. 1 8/29/98 23
40 04.77.66 nur laili rizqiyah 1 2/10/1991 30 1
41 02.72.26 mia murni bandawati 1 3/28/2002 20 1
42 02.61.19 fitria ningsih 1 1/29/98 24 1
43 03.82.29 misni 1 6/18/83 38 1
44 04.72.37 mita anggraini 1 11-11-2002 19 1
45 04.11.92 nafiatul jumaroh 1 7/26/2001 20 1
46 04.83.55 eka aktafiyah 1 6/1/1989 33 1
47 04.83.70 hesti rokhaniyah 1 11/27/99 22 1
48 00.94.77 wahida prasetyowati 1 1/18/88 34 1
49 04.84.10 lusin karianti 1 5/13/89 38 1
50 04.84.05 devita regar 1 6/1/1997 25
51 00.43.81 siti rochania 1 1/12/1988 33 1
52 04.81.81 meirani chriti 1 5/1/878 35 1
53 04.84.07 kiki indra sari 1 5/16/91 30 1
54 04.84.35 yesi eka retno 1 6/1/1997 25 1
55 04.68.78 nur hamidah 1 9/17/96 25
56 04.84.31 ninik munfariha 1 6/18/93 28
57 04.65.18 olivia naftaria sari 1 07-03-2002 19
58 04.84.40 khismatin 1 11-12-2000 21
59 04.84.58 devi dwi arofah 1 1/7/1989 32
60 04.84.30 syarifatul qomariyah 1 9/8/1984 37 1
61 04.84.57 riska indahwati 1 3/17/94 28 1
62 04.81.81 meirani chriti 1 1/5/1987 35 1
63 04.84.66 nurul pinkky aurela 1 01-03-2003 19 1
64 04.76.26 siti nur syamsiyeh 1 4/28/93 29 1
65 04.85.08 haris fitria 1 11/23/2005 16
66 04.44.19 siti julaikha 1 1/7/1986 35
67 04.85.12 suminah 1 3/1/1989 33
68 04.77.23 vizayanti ali akhbar 1 10/12/1999 22
69 04.84.87 rismawati 1 08-11-2002 19 1
70 04.85.38 nurfadilah ilmiyah 1 06-02-2001 20 1
71 04.85.55 sumarni 1 5/12/1993 28 1
72 04.85.80 siti hajar dewantoro 1 3/26/89 33 1
73 04.85.79 suyati 1 9/18/45 76 1
74 04.85.78 iin indah dwi lestari 1 6/3/1999 23 1
75 04.85.68 meri anggraeni 1 8/4/1997 25 1
76 04.85.91 siti aminah 1 4/7/1986 35 1
77 04.85.92 intan kristiani 1 8/30/2002 19 1
78 04.85.38 nurfadilah ilmiyah 1 06-02-2001 20 1
79 04.85.93 wardatul mukarromah 1 6/19/95 26
80 02.77.09 jesika levirana 1 12/30/2005 16
81 04.86.62 lilik yuliani 1 12/9/1985 36 1
82 02.28.07 tri rizqi muharoma 1 7/14/93 28 1
83 03.89.89 miftahul fitria hasanah 1 1/9/1997 24 1
84 04.86.26 tuminem 1 6/30/47 74 1
85 04.86.67 ani wahyuni 1 7/7/1999 22
86 04.42.10 indah tri utami 1 1/10/1990 31
87 04.86.78 eva fera suryani 1 8/17/2003 18
88 04.78.15 mujiati 1 6/8/1976 45 1
89 04.35.02 nurhayati 1 2/28/95 26 1
90 04.86.97 sri wahyuni 1 1/8/1995 26 1
91 04.87.12 nanik yuningsih 1 12/19/92 29
92 02.45.80 lina puspita devi 1 03-12-2002 20
93 04.87.07 siti fatimah bakri 1 09-04-2003 18 1
94 04.87.18 alib sofia hidayat 1 1/1/1998 23
95 01.05.42 khusnul rosyidah 1 2/8/1992 29
96 04.87.37 muflihah 1 7/5/1977 45 1
97 04.73.74 hetty rosaline 0 1 4/16/2000 22 1
98 04.87.50 nur hasanah 1 7/18/88 33 1
99 04.63.40 siti nurikhah camila 1 3/16/2000 22
100 04.08.11 siti nur indah sari 1 7/14/92 29
101 04.87.80 umi latifah 1 8/8/1996 25 1
102 04.10.86 marfungatul soliah 1 3/29/2001 21 1
103 00.58.11 ajeng eka safitri 1 7/15/93 28 1
104 04.86.99 dewi sri sejati 1 7/16/68 53 1
105 04.88.03 puji astutik 1 2/10/1990 31
106
107
108
109
110
JUMLAH 0 105 9 59 0 0 0 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
ara bayar Tanggal Lama BRM
dirawat kembali Hidup Mati Pindah
Sembuh APS Rujuk
PG JKN RG Kemkes Lain MRS KRS < 48 > 48 < 48 > 48 Ruang

30 1 1 1 1
1 29 1 2 1 1
30 1 1 1 1
1 30 2 2 1 1
1 30 2 2 1 1
2 3 1 1 1
2 3 1 1 1
2 4 2 1 1
3 5 2 1 1
3 4 1 1 1
4 5 1 1 1
1 4 5 1 1 1
5 6 1 1 1
6 8 2 1 1
6 7 1 1 1
4 5 1 1 1
6 7 1 1 1
1 6 8 2 1 1
6 8 2 1 1
1 6 9 3 1 1
8 10 2 1 1
8 10 2 1 1
9 12 3 1 1
9 10 1 1 1
1 9 10 1 1 1
1 9 10 1 1 1
1 9 10 1 1 1
9 11 2 1 1
9 11 2 1 1
10 11 1 1 1
10 11 1 1 1
1 10 11 1 1 1
1 10 11 1 1 1
1 10 11 1 1 1
10 18 8 1 saphire
11 12 2 1 1
1 11 12 2 1 1
1 11 12 2 1 1
1 11 12 2 1 1
11 12 2 1 1
11 12 2 1 1
12 14 2 1 1
12 14 2 1 1
12 14 2 1 1
12 14 2 1 1
12 14 2 1 1
12 13 1 1 1
12 13 1 1 1
13 14 1 1 1
1 13 14 1 1 1
13 14 1 1 1
13 15 2 1 1
13 15 2 1 1
14 15 1 1 1
1 14 15 1 1 1
1 14 15 1 1 1
1 14 16 2 1 1
1 15 16 1 1 1
1 16 17 1 1 1
14 17 3 1 1
16 18 2 1 1
16 18 2 1 1
16 17 1 1 1
16 18 2 1 1
1 17 18 1 1 1
1 18 18 1 1 1
1 17 18 1 1 1
1 17 19 2 1 1
17 19 2 1 1
19 20 1 1 1
19 21 2 1 1
20 21 1 1 berlian
20 20 1 1 hcu
20 21 1 1 1
20 22 2 1 1
21 22 1 1 1
21 22 1 1 1
21 22 1 1 1
1 21 22 1 1 1
1 23 25 2 1 1
23 26 3 1 1
23 25 2 1 1
23 26 3 1 1
23 25 2 1 1
1 23 24 1 1 1
1 23 25 2 1 1
1 24 26 2 1 1
24 26 2 1 1
24 26 2 1 1
25 26 1 1 1
1 25 26 1 1 1
1 25 27 2 1 1
25 27 2 1 1
1 25 27 2 1 1
1 26 27 1 1 1
26 27 1 1 1
27 28 1 1 1
27 29 2 1 1
1 28 29 1 1 1
1 29 30 1 1 1
29 30 1 1 1
30 30 1 1 1
28 30 2 1 1
30 31 1 1 1
1 30 31 1 1 1

37 0 0 0 273 198 45 0 29 0 0 29 0 0

AH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)


Diagnosa Tindakan
Alamat (Desa) Primer ICD (Operasi) Pelayanan

nguter pp diluar dg hpp obgyn


bago post partum 6 jam spt b obgyn
jatisari post sc 3 jam sc obgyn
candipuro post sc 3 jam sc obgyn
pasirian post sc 2 jam sc obgyn
banyuwangi post sc 6 jam sc obgyn
tempeh post sc 6 jam sc obgyn
madurejo pua- ovulatori + anemia gynec
tumpeng post sc 3 jam sc obgyn
jatisari post partum 6 jam spt b obgyn
selokawar post sc 3 jam sc obgyn
kalibendo post sc 2 jam sc obgyn
pasirian post curetage biopsi obgyn
jarit post partum diluar +curetage obgyn
bades post curetage curetage obgyn
banyuwangi ca cervic gynec
selokanyar post partum 6 jam spt od obgyn
selokanyar post sc 4 jam sc obgyn
jugosari ppi obgyn
condro post sc 1 jam sc obgyn
lempeni ca cervic gynec
selokawar post sc 2 jam sc obgyn
orooroombo post op kista + apendi cystectomy
gynec
bondowoso post partum 6 jam spt od obgyn
jatisari post sc 1.5 jam sc obgyn
besuk post partum 6 jam spt od obgyn
pasrujambe post partum 6 jam spt induksiobgyn
jarit hamil dg apb ( plasenta previa obgyn
pasirian post sc 3 jam sc obgyn
karanganom post sc 2 jam sc obgyn
gesang post partum 6 jam spt b obgyn
kalibendo post partum 6 jam spt induksiobgyn
tumpeng post partum 6 jam spt b obgyn
selokawar post partum 6 jam spt b obgyn
besuk pua gynec
sememu post sc 4 jam sc obgyn
tempursari post sc 2 jam sc obgyn
pasirian post sc 4 jam sc obgyn
nguter post partum 6 jam spt od obgyn
bades post partum 6 jam spt od obgyn
pasirian post partum 6 jam spt od obgyn
jarit post sc 1 jam sc obgyn
sumbersuko post sc 1 jam sc obgyn
selokawar post sc 3 jam sc obgyn
jarit post sc 1 jam sc obgyn
kertosari post sc 2 jam sc obgyn
jarit post partum 6 jam spt b obgyn
pasirian hamil dg presbo+ plasenta pre obgyn
tegir post curetage curetage obgyn
nguter post partum 6 jam spt od obgyn
sememu post partum 6 jam spt od obgyn
jugosari post sc 2 jam sc obgyn
jugosari post sc 4 jam sc obgyn
selokawar post partum 6 jam spt b obgyn
selokanyar post partum 6 jam spt b obgyn
sumbersuko post partum 6 jam spt b obgyn
tempursari post sc 3 jam sc obgyn
kalibendo post sc 3 jam sc obgyn
penanggal post sc 3 jam sc obgyn
sememu post sc 2 jam sc obgyn
jugosari post sc 2 jam sc obgyn
jugosari post sc dg diare obgyn
selokawar post partum 6 jam spt b obgyn
selokanyar post sc 1 jam sc obgyn
jarit post sc 1 jam sc obgyn
pasirian post partum 6 jam spt b obgyn
jugosari post partum 6 jam spt b obgyn
bago post sc 3 jam sc obgyn
sumberwuluh post sc 3 jam sc obgyn
sumberwuluh hamil dg pe obgyn
penanggal hamil dg bsc+ plasenta previa obgyn
candipuro hamil dg tb paru obgyn
orooroombo prolaps uteri+ syock cardioge gynec
gondoruso post partum 6 jam spt induksiobgyn
jarit post sc 2 jam sc obgyn
supiturang post partum 6 jam spt b obgyn
gondoruso post partum 6 jam spt b obgyn
sumberwuluh post sc 1 jam sc obgyn
sumberurip post sc 4 jam sc obgyn
tempursari post ve 6 jam ve obgyn
pronojiwo post curetage curetage obgyn
pasirian post sc 8 jam sc obgyn
candipuro post sc 8 jam sc obgyn
tegalrejo pua gynec
nguter post sc 8 jam sc obgyn
tumpeng post sc 8 jam sc obgyn
besuk post sc 2 jam sc obgyn
tempursari post sc 2 jam sc obgyn
gondoruso post sc 2 jam sc obgyn
kalibendo post sc 2 jam sc obgyn
jugosari post sc 1.5 jam sc obgyn
bades post sc 12 jam sc obgyn
penanggal post sc 8 jam sc obgyn
bago post sc 3 jam sc obgyn
kalibendo post sc 4 jam sc obgyn
sememu post partum diluar dg peb obgyn
selokawar post sc 2 jam sc obgyn
sumberurip hamil dg plasenta previa obgyn
kalibendo post sc 2 jam sc obgyn
gondoruso post sc 2 jam sc obgyn
lempeni heg obgyn
banjarnegara post partum 6 jam spt b obgyn
pasirian post sc 6 jam obgyn
pandanwangi post insisi bartholini gynec
tamanayu post partum 6 jam spt od obgyn
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM Jampersal

1 03.58.67 khoirul mutmainah 1 8/28/90 31 1


2 04.87.96 siti khusnul khotimah 1 12/2/1993 29 1
3 04.88.44 elizha rahma azhari 1 8/8/2001 20 1
4 00.94.50 ayu wandira 1 6/13/99 22 1
5 04.77.47 holidah 1 12/24/89 32 1
6 04.67.22 lailatul nikmah 1 10/26/2001 20 1
7 04.88.35 nikmatul ula 1 11/17/2002 19 1
8 00.00.80 siti avivatur rosyidatul 1 2/1/1998 24 1
9 04.88.45 renata windari 1 03-03-2002 20
10 04.88.18 solati handayani 1 3/6/1993 28
11 00.40.47 dewi imroa 1 5/16/96 26 1
12 04.20.97 yeriel yuwandari 1 6/1/1986 36 1
13 04.88.68 nelli arindi 1 11/22/2006 15
14 04.88.97 tati 1 12/25/78 43
15 03.99.58 nur fadilah 1 7/15/89 32 1
16 02.37.28 sri ngatini 1 1/4/1981 41 1
17 04.89.04 khoiril dwi pratiwi 1 01-09-2002 20
18 04.89.17 anik susanti 1 7/2/1986 36
19 04.89.23 hasanah 1 7/5/1978 44
20 04.77.06 nurul hidayah 1 2/14/85 37 1
21 01.93.35 krisna karyawati 1 1/23/97 25 1
22 01.11.89 lintang cahaya lidia 1 5/19/87 35 1
23 04.85.13 sumarni 1 5/4/1973 49 1
24 04.80.28 naning yuliana 1 1/7/1991 30 1
25 04.89.78 nining apriyani 1 6/4/1993 29
26 01.76.52 liawati 1 1/15/98 24
27 04.80.27 ulfa 1 2/20/90 32
28 04.57.10 nia dewi pratiwi 1 8/3/1998 24
29 04.90.06 nurisma handayani 1 5/9/1996 25 1
30 02.37.25 sri ngatini 1 1/4/1981 41 1
31 04.90.32 nur khofifah 1 03-04-2002 20
32 04.86.48 ika susasi 1 1/7/1986 35 1
33 04.90.45 bibit juniarti 1 6/22/2003 18 1
34 04.90.37 ilnawati 1 9/20/89 33 1
35 04.11.86 iin tri hendriana 1 4/12/1984 37 1
36 04.48.01 titin kusumawati 1 3/13/93 39
37 04.90.50 putri novisah 1 8/25/96 25 1
38 04.90.69 hanifatul isnaini 1 5/29/92 30
39 04.88.22 st nur afifah 1 01-09-2008 14 1
40 04.90.74 yuli purnama sari 1 12/7/2001 20 1
41 03.44.92 sri handayani 1 2/1/1990 32 1
42 04.90.81 ila khomariyah 1 12/16/92 29
43 04.92.92 laipah 1 6/20/54 67 1
44 04.90.95 ilda eko kusuma 1 06-12-2001 21 1
45 04.91.35 cindy aulia 1 2/24/2004 18 1
46 00.79.23 khusnul khotimah 1 12-11-2003 19 1
47 04.86.77 siti nur qoyum 1 4/15/99 23 1
48 03.92.42 altahtul fitria 1 12/22/2001 20 1
49 04.82.16 khoirun nisak 1 8/24/2002 19 1
50 01.02.98 iswatun hasanah 1 6/15/94 28 1
51 04.91.46 saskia fitri 1 3/12/1997 24 1
52 03.59.41 zahrotul jannah 1 2/14/93 29
53 04.91.59 sutatik 1 3/12/1985 36
54 04.91.51 sri indayani 1 6/15/83 39
55 01.98.90 yuli astutik 1 7/29/89 32 1
56 03.25.01 siti hotimah 1 4/2/1985 37 1
57 04.89.84 renata fitriyanti 1 12/24/90 31 1
58 00.67.36 khuswatun khasanah 1 6/20/94 27 1
59 02.87.23 ahyun siti nurhasanah 1 10/28/97 24 1
60 04.73.55 maimunah 1 8/28/87 34 1
61 04.78.37 kiki oktaviani 1 8/10/1991 30 1
62 04.91.97 musammatun 1 5/8/1997 24 1
63 02.75.50 naning widianto 1 11/2/1980 42 1
64 04.91.86 amsemi 1 4/2/1999 23
65 04.92.06 anggarizza listiatul fitria 1 8/24/2000 21 1
66 04.92.08 rizkiana fauziah 1 1/2/1997 25 1
67 04.92.11 dwi septia akiria 1 9/30/2005 16
68 04.92.17 enik 1 1/7/1990 31 1
69 04.85.23 yuliani 1 7/5/1980 42
70 04.73.39 qurrotul uyun 1 1/26/2001 21
71 04.92.36 santi setya ningrum 1 3/12/1993 28
72 04.92.28 marta dewi aprillia 1 3/31/94 28
73 04.76.51 wiwik dwi wijayanti 1 12/30/2000 21 1
74 04.91.05 rasumi 1 4/22/71 51 1
75 00.72.14 nanik wagiati 1 2/13/90 32
76 03.12.59 nias faiqoh 1 10/6/1993 29
77 04.92.59 safa atin ridho 1 6/1/1996 26
78 04.92.42 ica novsintya 1 11/11/1993 28
79 00.36.10 tri wulandari 1 4/11/1996 25 1
80 04.58.37 ima sari 1 5/28/2000 22 1
81 04.92.76 kalimah 1 12/17/76 45 1
82 04.92.73 tri wagini 1 1/30/77 45
83 04.92.97 aisyah sukmawati 1 10/17/2002 19
84 04.93.03 avinda ramadani 1 10/20/2006 16 1
85 02.09.95 anggi dea falentya 1 6/20/99 23 1
86 04.93.15 devi helmalia 1 8/5/2003 19 1
87 04.62.87 windi antika 1 2/23/2002 20 1
88 04.56.76 kalima dila setyanda 1 9/23/97 24 1
89 04.93.14 waginem 1 11/6/1983 39 1
90 04.17.19 siti mutmainah 1 4/27/2001 21 1
91 04.92.52 putikah 1 10/18/94 27 1
92 04.93.37 novita setya sari 1 11/5/1993 29
93 04.93.56 riza syafaatul 1 66/12/2002 20 1
94 03.99.87 etik 1 3/15/2001 21 1
95 04.92.28 marta dewi aprillia 1 3/31/94 28
96 04.93.64 dian saputri 1 11/25/2001 20 1
97 04.78.99 miftahul khoiriyah 1 9/16/98 23
98 00.98.81 yeni ananda putri 1 6/25/98 24 1
99 04.93.94 siti roudotul maimuna 1 02-08-2008 14 1
100 02.52.68 nike ani nur rohmah 1 4/27/95 27 1
101 04.70.66 huda sakdiyah 1 8/20/99 23 1
102 04.94.24 yuni anita 1 6/22/2001 21 1
103 04.94.28 desita anggraeny d.s 1 12/15/97 24 1
104 04.49.75 wiwin indrawati 1 2/17/82 40 1
105
106
107
108
109
110
111
JUMLAH 0 104 10 61 0 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
Cara bayar Tanggal Lama BRM
dirawat kembali Hidup Mati
Sembuh APS Rujuk
JR BPJS TK PG JKN RG Kemkes Lain MRS KRS < 48 > 48 < 48 > 48

30 1 2 1 1
30 1 2 1 1
31 1 1 1 1
31 1 1 1 1
31 1 1 1 1
31 1 1 1 1
31 2 2 1 1
31 2 2 1 1
1 31 2 2 1 1
1 1 1 1 1 1
1 1 1 1 1
2 3 1 1 1
1 2 3 1 1 1
1 2 3 1 1 1
2 4 2 1 1
2 3 1 1 1
1 2 3 1 1 1
1 3 4 1 1 1
1 3 4 1 1 1
3 4 1 1 1
3 5 2 1 1
5 6 1 1 1
4 7 3 1 1
6 7 1 1 1
1 6 7 1 1
1 7 9 2 1 1
1 8 9 1 1 1
1 8 9 1 1 1
8 9 1 1 1
8 9 1 1 1
1 8 10 2 1 1
9 10 1 1 1
9 10 1 1 1
9 10 1 1 1
9 11 2 1 1
1 9 11 2 1 1
9 11 2 1 1
1 10 12 2 1 1
11 12 1 1 1
11 12 1 1 1
11 13 2 1 1
1 11 14 3 1 1
12 14 2 1 1
12 13 1 1 1
14 16 2 1 1
14 15 1 1 1
14 15 1 1 1
14 17 3 1 1
15 16 1 1 1
15 17 2 1 1
15 16 1 1 1
1 15 16 1 1 1
1 15 17 2 1 1
1 16 18 2 1 1
16 18 2 1 1
16 17 1 1 1
16 17 1 1 1
16 17 1 1 1
16 17 1 1 1
16 17 1 1 1
16 17 1 1 1
17 18 1 1 1
17 19 2 1 1
1 17 18 1 1 1
18 21 3 1 1
18 19 1 1 1
1 18 19 1 1 1
19 20 1 1 1
1 19 20 1 1 1
1 19 22 3 1 1
1 20 21 1 1 1
1 20 21 1 1 1
20 21 1 1 1
20 21 1 1 1
1 20 21 1 1 1
1 20 21 1 1 1
1 20 22 2 1 1
1 20 21 2 1 1
20 21 2 1 1
21 22 1 1 1
21 22 1 1 1
1 21 23 2 1 1
1 22 22 1 1 1
22 24 2 1 1
22 23 1 1 1
22 23 1 1 1
22 23 1 1 1
22 23 1 1 1
22 24 2 1 1
22 24 2 1 1
23 25 2 1 1
1 23 24 1 1 1
24 28 4 1 1
24 25 1 1 1
1 24 25 1 1 1
25 26 1 1 1
1 25 29 4 1 1
25 27 2 1 1
27 28 1 1 1
26 27 1 1 1
27 29 2 1 1
28 29 1 1 1
28 29 1 1 1
29 30 1 1 1

0 0 33 0 0 0 1701 1568 151 0 29 0 0 29 0 0

WAH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)

RNA MERAH
atus Pulang
Tindakan
Pindah Alamat (Desa) Diagnosa Primer ICD (Operasi) Pelayanan
Ruang

madurejo post sc 5 jam sc obgyn


tumpeng post curetage curetage obgyn
candipuro hamil dg febris obgyn
bades post sc 1 jam sc obgyn
supiturang post sc 30 menit sc obgyn
pasrujambe post partum 6 jam spt od obgyn
selokanyar\ post curetage curetage obgyn
condro post sc 2 jam sc obgyn
selokawar post sc 1 jam sc obgyn
nguter post sc hari ke 1 sc obgyn
kalibendo post partum 6 jam spt b obgyn
pasirian post partum diluar 6 jam obgyn
nguter post partum 6 jam spt b obgyn
kaliuling post sc 1.5 jam sc obgyn
jarit abortus imminent obgyn
madurejo abortus imminent obgyn
bago post partum 6 jam spt b obgyn
tamanayu post sc 3 jam sc obgyn
oro" ombo post sc 4 jam sc obgyn
candipuro post sc 4 jam sc obgyn
kloposawit menometroragia gynec
pasirian post curetage curetage obgyn
candipuro mioma uteri histerekto gynec
jarit post ve 6 jam ve obgyn
kalibendo post partum 6 jam spt od obgyn
bades post sc 1 jam sc obgyn
selokanyar post sc hari ke 2 sc obgyn
jarit post sc 2 jam sc obgyn
jarit post sc 2 jam sc obgyn
madurejo post curetage curetage obgyn
kalibendo post sc 4 jam sc obgyn
selokawar post partum 6 jam spt b obgyn
candipuro post partum 6 jam spt od obgyn
jokarto post sc 2 jam sc obgyn
gondoruso post sc 1 jam sc obgyn
jarit post sc 3 jam sc obgyn
selokawar ppi obgyn
tamanayu post sc 1 jam sc obgyn
bades post sc 1 jam sc obgyn
kalibendo post partum 6 jam spt od obgyn
sememu post sc 2 jam sc obgyn
jarit post sc 1 jam sc obgyn
jarit ca cervic gynec
pasrujambe susp endometrial hiperplasi gynec
nguter heg obgyn
sumbermujur post sc 2 jam sc obgyn
tumpeng post sc 2 jam sc obgyn
selokawar post sc 4 jam sc obgyn
selokanyar post sc 1 jam sc obgyn
selokanyar hamil dg plasenta previa obgyn
candipuro post partum 6 jam ekstraksi toobgyn
pasirian post partum 2 jam spt brach obgyn
supiturang post sc 1 jam sc obgyn
selokawar post sc hari ke 1 sc obgyn
selokawar hamil dg asma broncial obgyn
sumberwuluh hamil dg ht gestasional obgyn
selokawar post sc 1 jam sc obgyn
sememu post sc 3 jam sc obgyn
selokawar post sc 2 jam sc obgyn
jarit post partum 6 jam spt b obgyn
sumberejo post partum 6 jam spt b obgyn
sumberejo post partum 6 jam spt b obgyn
pasirian missed abortion curetage obgyn
pasirian post sc 4 jam sc obgyn
kaliuling iufd curetage obgyn
pasirian post partum 6 jam spt od obgyn
tempursari post partum 6 jam spt od obgyn
madurejo post partum diluar obgyn
pasirian post sc 30 menit sc obgyn
bago post sc 1 jam sc obgyn
tumpeng post partum 6 jam spt induksiobgyn
kloposawit post sc hari ke 1 sc obgyn
jarit post partum 6 jam spt od obgyn
selokanyar post curetage curet biopsgynec
jarit post sc 6 jam sc obgyn
pasirian post sc 3 jam sc obgyn
sumberwuluh post sc 3 jam sc obgyn
candipuro post sc 1 jam sc obgyn
pasirian heg obgyn
tumpeng post partum 6 jam spt od obgyn
tumpeng pua gynec
penanggal post partum 6 jam spt b obgyn
jarit post partum 6 jam spt b obgyn
pronojiwo post sc 3 jam sc obgyn
bades post partum 6 jam spt od obgyn
selokanyar post partum 6 jam spt od obgyn
sememu post partum 6 jam spt od obgyn
sirenggo post partum 6 jam spt od obgyn
bades post sc 4 jam sc + mow obgyn
bades pua gynec
sumberwuluh post sc 3 jam sc obgyn
penanggal post sc 1 jam sc obgyn
karanganom abortus incomplit curetage obgyn
madurejo post partum 6 jam spt b obgyn
kloposawit post sc hari ke 5 obgyn
selokawar post partum 6 jam spt b obgyn
oro" ombo post sc 3 jam sc obgyn
jugosari hamil dg kpd obgyn
condro hamil dg kpd obgyn
selokawar post partum 6 jam spt b obgyn
supiturang heg obgyn
selokawar post partum 6 jam spt b obgyn
probolinggo post sc 3 jam sc obgyn
selokanyar post sc 2 jam sc obgyn
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum
BPJSSKTM jps JR BPJS TK PGJKN RGkmk Lain

1 05.37.73 ismatillah 1 12-11-2000 22 1


2 05.30.79 eka fitri wulandari 1 01-01-2001 21 1
3 05.07.24 husnul khotimah 1 10/13/89 33 1
4 05.39.54 yualimah 1 2/16/80 42 1
5 02.43.78 putri permata darma 1 2/12/1995 27 1
6 05.34.02 triya sakki januari 1 1/27/90 32 1
7 05.39.98 ayulistia zahra nadhifa 1 08-05-2001 21 1
7 05.09.38 nuris agustian ningsih 1 7/8/1996 26 1
8 05.40.02 munhidlotul ummah 1 2/23/89 33 1
9 05.40.06 yunia ratna dewi 1 6/20/97 25 1
10 05.40.08 siti nurkotimah 1 08-11-2000 22 1
11 04.45.79 tavia septiayansah 1 4/9/1999 23 1
12 05.37.41 khusnul chotimah 1 4/27/93 29 1
13 05.40.24 elvi sukaesih 1 1/2/94 29 1
14 05.40.46 ike sumiati 1 12/25/98 24 1
15 05.40.42 yuliatin 1 7/21/86 36 1
16 05.40.43 siti nur jadidah 1 9/27/86 36 1
17 03.50.58 rohmatul jamilah 1 6/16/82 40 1
18 02.23.42 mamluatul rofiah 1 11/20/2003 19 1
19 05.40.59 hamse inan f 1 2/3/1984 38 1
20 05.40.69 maratus soleh 1 10-04-2000 22 1
21 05.41.01 anita silfia 1 04-06-2000 22 1
22 02.48.07 chusnul siti chotijah 1 1/21/96 26 1
23 05.41.10 siti nuriya 1 4/11/1999 23 1
24 05.41.09 tutik indrawati 1 5/27/68 54 1
25 05.41.16 vika kusuma etis 1 5/13/95 27 1
26 05.41.17 lailatul afifa 1 1/3/1997 25 1
27 05.41.21 misnati 1 8/18/94 28 1
28 05.38.58 siti holifah 1 6/13/2002 20 1
29 05.41.40 riatik dwi ayu 1 7/10/1996 26 1
30 05.41.43 siti nike ardillah 1 6/12/1998 24 1
31 05.34.35 santi agustinawati 1 8/18/94 28 1
32 04.87.90 levia ayu lestari 1 11/20/99 23 1
33 02.99.75 kholifah sufristi 1 9/11/1990 32 1
34 05.41.60 jumaliyah 1 6/9/1988 34 1
35 05.41.57 kiki amelia 1 8/29/2007 15 1
36 05.41.46 dina mariana 1 12/15/97 25 1
37 05.41.55 riska prastiningsih 1 6/26/2001 21 1
38 05.41.58 dewi sofiyah 1 4/29/97 25 1
39 05.41.73 siti firdausiah 1 9/19/2000 22 1
40 05.41.87 sintia utami 1 8/26/2006 16 1
41 05.41.91 yuniar okky elviandini 1 5/6/1997 25 1
42 03.01.38 mukimah 1 7/15/90 32 1
43 05.42.06 bawon tri utami 1 3/28/98 24 1
44 05.42.15 wahyu arum ratnasari 1 1/7/1996 26 1
45 05.42.26 nur azizah 1 4/8/1993 29 1
46 05.42.20 nanda septian permatasa1 9/21/95 27 1
47 01.93.67 sintya tri wulandari 1 5/3/1999 23 1
48 05.38.24 wiwik 1 1/20/89 33 1
49 01.67.12 putri regina prasasti 1 4/29/2002 20 1
50 04.52.72 binti sulis khasanah 1 4/10/1995 27 1
51 05.42.47 milur rohmah 1 02-02-2001 21 1
52 05.41.73 siti firdausiah 1 9/19/2000 22 1
53 05.42.45 rina hamala 1 1/15/93 30 1
54 05.40.54 martiningsih 1 3/19/86 36 1
55 05.42.73 wiwik setyowati 1 4/25/83 39 1
56 05.42.72 sumiah 1 8/18/85 37 1
57 05.42.88 yuyun lestari 1 1/4/1989 33 1
58 01.27.23 marifatul hidayah 1 12-08-2001 21 1
59 05.42.84 dillah prima kusweni 1 4/13/86 36 1
60 05.35.79 desi yuniawati 1 12/23/95 27 1
61 05.43.05 ratna juwita 1 9/30/2001 21 1
62 05.43.06 suniati 1 4/25/90 32 1
62 05.43.14 muinah 1 7/4/1991 31 1
63 00.63.44 fihullatil lutfi 1 6/25/99 23 1
64 05.43.29 luluk rahmawati 1 10/24/95 27 1 1
65 02.45.47 urifah 1 3/14/78 44 1
66 05.43.36 hermin 1 8/28/90 32 1
67 05.36.26 uswatun hasanah 1 6/17/86 36 1
68 05.43.34 khusnul hotimah 1 04-10-2004 18 1
69 05.43.45 siti maisaroh 1 2/23/96 26 1
70 05.34.04 yuninimatul rohmaniya 1 6/20/2004 18 1
71 05.43.10 daniatuz zahro 1 05-07-2001 21 1
72 05.43.10 daniatuz zahro 1 05-07-2001 21 1
73 05.37.37 nuryati 1 11/10/1989 33 1
74 04.89.56 wiwin dwi lestari 1 1/1/1982 41 1
75 05.43.47 mufarida 1 4/18/99 23 1
76 05.43.60 aidah fadhilah 1 2/14/97 25 1
77 05.43.71 velysia surya dewi 1 9/2/1996 26 1
78 04.52.72 binti sulis khasanah 1 4/10/1995 27 1
79 02.33.58 novita isabela 1 6/25/2000 22 1
80 05.43.95 eva rahmawati 1 11/13/2001 21 1
81 05.44.02 lilik amindari 1 12/23/85 37 1
82 05.44.03 yuliatun hasanah 1 7/9/1999 23 1
83 02.79.99 elisa indrawati 1 04-04-2006 16 1
84 05.44.08 yuninimatul rohmaniya 1 6/20/2004 18 1
85 02.39.46 kasiani mu'azizah 1 8/20/89 33 1
86 05.26.42 anisa 1 6/10/1984 38 1
87 00.03.38 redina nur emylia 1 5/14/2001 21 1
88 05.44.59 diah oktavia 1 04-05-2003 19 1
88 05.42.08 paradina agnes l.w 1 12/8/1991 31 1
89 05.44.69 siti khoiriyah 1 10/20/99 23 1
90 03.09.17 sri wahyuni 1 6/5/1991 31 1
91 05.44.65 muallifah 1 05-05-2000 22 1
92 05.44.58 suntrik 1 7/13/86 36 1
93 05.44.71 siti nur aeni 1 5/6/1996 26 1
94 05.44.76 indartiningsih 1 7/6/1992 30 1
95 05.44.88 iis eka safitri 1 7/20/91 31 1
96 03.96.57 putri wulandari 1 11/3/1999 23 1
97 05.45.18 laili ida nuraini 1 11/20/88 34 1
98 05.45.20 sri wahyuni 1 5/25/87 35 1
99 05.45.21 lailatuz zahro 1 1/28/99 23 1
100 02.81.09 arum krisdayanti 1 10/25/98 24 1
101 01.49.33 indana zulfa 1 1/10/1998 24 1
102 05.45.52 suci prasetyo 1 4/28/88 34 1
103 05.45.61 noviatul nadira 1 2/11/1995 27 1
104 05.45.49 siti maria ulfa 1 5/17/94 28 1
105 05.45.60 anggi eka pratiwi 1 4/18/2007 15 1
106 01.65.72 nurul fitria 1 1/28/98 25 1
107 05.45.77 ida komala sari 1 1/1/1997 26 1
108 05.44.45 latifatul khairoh 1 3/27/96 26 1
109
110
111
112
113
114
115
110
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
JUMLAH 0 111 11 52 1 0 0 0 48 0 0 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
Tanggal Lama BRM Alamat Diagnosa
Hidup Mati ICD
dirawat kembali Sembuh APS Rujuk Pindah (Desa) Primer
MRS KRS < 48 > 48 < 48 > 48 Ruang

30 1 2 1 1 selokanyar post sc 4 jam


30 1 2 1 1 jarit post sc 4 jam
31 1 1 1 1 sumberwulupost partum 6 jam
1 2 1 1 1 sumberwulupost sc 3 jam
2 3 1 1 1 pasirian post partum 6 jam
2 4 2 1 1 tumpeng post partum 6 jam
3 4 1 1 1 pasirian post sc 2 jam
3 5 2 1 1 nguter hamil dg anemia + diare+ stomati
3 5 2 1 1 bades hamil dg letsu + plasenta previa
3 4 1 1 1 jarit post partum 6 jam
3 5 2 1 1 kloposawit post sc 2 jam
3 5 2 1 1 pasirian post sc 2 jam
4 6 2 1 1 madurejo post sc 2 jam
4 6 2 1 1 selokanyar post sc 2 jam
5 6 1 1 1 jarit post sc 4 jam
5 6 1 1 1 sumberejo post sc 3 jam
5 7 2 1 1 penanggal post sc 1 jam
5 7 2 1 1 condro post curetage
6 7 1 1 1 lempeni post sc 3 jam
6 7 1 1 1 tamanayu post sc 3 jam
6 8 2 1 1 gumukmas hamil dg b20
9 10 1 1 1 kloposawit post sc 2 jam
9 12 3 1 1 jarit heg
9 10 1 1 1 sememu jtm
9 12 3 1 1 lempeni kista ovarium
9 11 2 1 1 jugosari post sc 2 jam
9 11 2 1 1 tumpeng post partum 6 jam
10 11 1 1 1 selokanyar post sc 4 jam
10 12 2 1 1 selokawar post partum 6 jam
10 12 2 1 1 tambahrejo post partum 6 jam
10 11 1 1 1 jarit jtm
10 12 2 1 1 bades post sc 4 jam
10 13 3 1 1 nguter post sc 3 jam
11 12 1 1 1 selokawar post partum 6 jam
11 12 1 1 1 sumberejo post sc 1 jam
11 12 1 1 1 sumberwulupost sc 2 jam
11 11 1 1 1 candipuro bo
11 12 1 1 1 jokarto post partum 6 jam
11 13 2 1 1 jarit post sc 4 jam
12 12 1 1 hcu supiturang post sc
12 13 1 1 1 candipuro post sc 2 jam
12 14 2 1 1 sumberwuluhamil dg amc back pain
12 14 2 1 1 jugosari late hpp + anemia
13 14 1 1 1 nguter post partum 6 jam
13 14 1 1 1 pronojiwo post partum 6 jam
13 14 1 1 1 jember post partum 6 jam
13 16 3 1 1 jarit post sc 3 jam
13 16 3 1 1 selokawar post sc 2 jam
14 16 2 1 1 sumbermujupost sc 3 jam
15 16 1 1 1 selokawar post partum 6 jam
15 16 1 1 1 nguter post ve 6 jam
15 16 1 1 1 selokanyar post partum 6 jam
15 16 1 1 1 supiturang post sc hari ke 3
15 16 1 1 1 sumberwuluretensio plasenta
15 18 3 1 1 pasirian mioma uteri
16 17 1 1 1 tamanayu post sc 2 jam
16 17 1 1 1 pronojiwo post partum 6 jam
17 18 1 1 1 sumberurip post sc 1.5 jam
17 18 1 1 1 sumberurip post sc 2 jam
17 18 1 1 1 condro hamil dg susp KP
17 19 2 1 1 kalibendo post sc 3 jam
17 19 2 1 1 sumberwulupost histerotomy
17 20 2 1 1 tempursari post sc 1 jam
18 20 1 1 1 kalibendo post sc 2 jam
18 19 1 1 1 pasirian post curetage
18 20 2 1 1 nguter post sc 4 jam
18 20 2 1 1 kalibendo peb
19 20 1 1 1 pulo post sc 4 jam
19 20 1 1 1 kalibendo post sc 3 jam
19 20 1 1 1 madurejo post partum 3 jam
19 21 2 1 1 pasrujambepost sc 2 jam
19 21 2 1 1 jarit gemeli+ ppi
17 18 1 1 hcu pronojiwo post partum 6 jam
19 20 1 1 1 pronojiwo post partum + cureta
19 21 2 1 1 selokawar post sc 2 jam
19 20 1 1 1 pasirian post curetage
19 20 1 1 1 malang post sc 3 jam
20 21 1 1 1 bago post partum 6 jam
20 21 1 1 1 pulo menometroragia
21 22 1 1 1 nguter wound hisen periniu
22 23 1 1 1 selokawar post partum 6 jam
23 24 1 1 1 kertosari post partum 6 jam
23 27 4 1 1 mojosari pua a/I mioma uteri+
23 26 3 1 1 madurejo kpd
24 25 1 1 1 selokawar post partum 6 jam
24 25 1 1 1 jarit post sc 3 jam
25 26 1 1 1 jarit plasenta previa
25 25 1 1 1 bades post partum 6 jam
24 26 2 1 1 jarit post partum 6 jam
25 26 1 1 1 burno post partum 6 jam
25 26 1 1 1 tamanayu post sc 2 jam
25 27 2 1 1 padang post sc 2 jam
25 26 1 1 1 gesang post sc 1 jam
25 27 2 1 1 bago post sc 4 jam
25 27 2 1 1 jarit post sc 2 jam
25 27 2 1 1 jarit post sc 2 jam
26 27 1 1 1 bago post sc 6 jam
26 27 1 1 1 supiturang post sc 1 jam
27 28 1 1 1 tambahrejo abortus complite
28 29 1 1 1 kalibendo post sc 2 jam
28 29 1 1 1 selokanyar post partum 6 jam
28 29 1 1 1 penanggal post partum 6 jam
27 30 3 1 1 jugosari post sc 2 jam
28 30 2 1 1 pasirian post ve 6 jam
29 30 1 1 1 kaliuling post partum 6 jam
30 30 1 1 1 kloposawit post partum 6 jam
29 31 2 1 1 condro post sc 3 jam
29 31 2 1 1 sememu ppi
30 31 1 1 1 selokawar post sc 3 jam
30 31 1 1 1 jember post sc 3 jam
30 31 1 1 1 bago post sc 3 jam
### ### 167 0 110 0 0 108 0 0

mutiara c19

WAH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)


Tindakan
(Operasi) Pelayanan

sc obgyn
sc obgyn
spt od obgyn
sc obgyn
spt od obgyn
spt od obgyn
sc obgyn
anemia + diare+ stomatiobgyn
etsu + plasenta previa obgyn
spt b obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
curetage obgyn
sc obgyn
sc obgyn
obgyn
sc obgyn
obgyn
curetage obgyn
salpingekto gynec
sc obgyn
spt od obgyn
sc obgyn
spt b obgyn
spt b obgyn
curetage obgyn
sc obgyn
sc obgyn
spt b obgyn
sc obgyn
sc obgyn
obgyn
spt b obgyn
sc obgyn
sc obgyn
sc obgyn
amc back pain obgyn
obgyn
spt b obgyn
spt od obgyn
spt b obgyn
sc obgyn
sc obgyn
sc obgyn
spt od obgyn
ve obgyn
spt od obgyn
obgyn
obgyn
miomekto gynec
sc obgyn
spt od obgyn
sc obgyn
sc obgyn
obgyn
sc obgyn
histerotomyobgyn
sc obgyn
sc obgyn
curetage obgyn
sc + kistekt obgyn
obgyn
sc obgyn
sc obgyn
spt b obgyn
sc obgyn
obgyn
spt od obgyn
curetage obgyn
sc obgyn
curet biopsobgyn
sc obgyn
spt od obgyn
gynec
repair per obgyn
spt b obgyn
spt b obgyn
miomektomgynec
sc obgyn
ekstraksi toobgyn
sc obgyn
obgyn
spt b obgyn
spt od obgyn
spt b obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
obgyn
sc obgyn
spt b obgyn
spt od obgyn
sc obgyn
ve obgyn
spt b obgyn
spt b obgyn
sc obgyn
obgyn
sc obgyn
sc obgyn
sc obgyn
Ruangan permata
Jumlah TT 10

JK Um Cara bayar
No. NO RM NAMA TGL LAHIR ur
L P Umum BPJS SKTM jps JR BPJS TK PG JKN RG kmk

1 04.37.00 dewi susanti 1 07-06-2000 22 1


2 03.63.53 danny musrifah 1 3/3/1979 43 1
3 05.46.22 rutik 1 8/8/1990 32 1
4 05.46.23 milawati 1 5/26/88 34 1
5 05.46.21 sri wahyuni 1 1/26/93 30 1
6 03.22.42 yuninis 1 4/11/2002 20 1
7 05.46.44 nur padillah 1 12/8/1993 29 1
7 05.46.50 silfia afkarina 1 8/13/99 23 1
8 05.40.14 syahrin tri andila 1 12/19/97 25 1
9 05.46.53 puji rahayu 1 04-03-2003 19 1
10 05.42.70 tumi 1 6/15/82 40 1
11 05.26.40 rika arista 1 1/28/97 26 1
12 05.17.19 yusi 1 6/17/94 28 1
13 05.40.15 luluk lita sari 1 8/21/97 25 1
14 02.51.16 wiwit agustin 1 8/20/88 34 1
15 04.79.29 sri wahyuni 1 9/23/91 31 1
16 00.56.94 sonik mafiyanti 1 3/25/94 28 1
17 05.46.89 ida kurniawati 1 5/4/1986 36 1
18 05.46.83 dewi maullinda 1 11/27/200121 1
19 01.17.42 mariam agustin 1 08-10-2002 20 1
20 05.46.96 aurilia nursalsabila 1 4/26/2017 5 1
21 02.39.46 kasiani muazizah 1 8/20/89 33 1
22 01.55.32 lina andiyanti 1 7/10/1987 35 1
23 05.47.14 lauri rismaan 1 12/26/200616 1
24 04.48.43 nurul fitria 1 9/6/1986 36 1
25 05.47.26 nurul anik oktafia 1 11/15/93 29 1
26 05.47.33 erna 1 10/6/1987 35 1
27 05.47.29 avi wulansari 1 04-12-2001 21 1
28 05.09.38 nuris agustian ningsih 1 7/8/1996 26 1
29 05.47.49 nisa faiqotul nimah 1 3/23/98 24 1
30 05.47.42 indrawati 1 12/7/1987 35 1
31 05.47.57 iis rumaiyah 1 7/17/86 36 1
32 05.47.44 siti amina 1 6/26/84 38 1
33 03.70.28 nehayatus zainia 1 9/30/2002 20 1
34 05.47.45 yayuk indahyani 1 10/29/93 29 1
35 02.51.45 roudhotus solicha 1 3/19/2003 19 1
36 05.47.70 april lina 1 4/16/2004 18 1
37 05.47.77 masila 1 1/1/1998 25 1
38 00.86.35 desi anggraeni 1 4/2/1998 25 1
39 05.40.02 munhidlotul ummah 1 2/23/89 33 1
40 05.46.03 siti julaikha 1 5/1/1996 27 1
41 05.47.91 yulia 1 6/7/1990 32 1
42 04.84.26 nurfiyati 1 6/17/82 40 1
43 03.15.12 virly aan dini putri 1 9/27/99 23 1
44 05.48.09 eka ratna furi 1 3/21/90 32 1
45 05.48.13 khoirotul afifah 1 2/25/2000 22 1
46 05.48.36 siti aisa 1 12/30/200715 1
47 03.92.66 ani indayani 1 6/8/1991 31 1
48 05.16.95 nasya jawada mindasa f. 1 8/18/2006 16 1
49 05.48.31 leginem 1 5/1/1989 34 1
50 05.48.37 maratus sholikah 1 7/15/2000 22 1
51 05.48.42 riska novebiana 1 11/28/200220 1
52 05.48.44 mariyem 1 8/12/1988 34 1
53 04.23.99 siti faidatur 1 10/5/1992 30 1
54 05.48.40 taslimah 1 2/13/2000 23 1
55 05.48.48 dalila safitri 1 9/6/1997 25 1
56 05.48.49 irfa mafiroh 1 2/28/2005 17 1
57 05.48.65 dian febicha 1 02-08-2003 20 1
58 05.48.68 ayu ritmawati 1 10/19/96 26 1
59 05.48.73 imroatul latifah 1 9/9/1992 30 1
60 05.31.14 nurul fahana 1 2/19/2002 20 1
61 05.48.87 ela ratnasari 1 10/17/200121 1
62 01.44.13 ani nindia puspita 1 9/28/85 37 1
62 05.48.91 hamimah 1 1/8/1996 26 1
63 03.68.59 nemi fidia 1 8/15/73 49 1
64 05.48.84 fitriyah 1 12/14/200220 1
65 04.53.23 enik febriyanti 1 6/2/1990 33 1
66 05.49.28 nurul siswi f. 1 12/16/97 25 1
67 00.33.13 hanifah 1 7/29/92 30 1
68 05.41.96 dwi mariyani 1 3/19/89 33 1
69 05.49.41 salmawati 1 3/20/96 26 1
70 05.23.64 eka setyawati 1 9/24/86 36 1
71 05.49.48 ernawati 1 5/7/1989 33 1
72 02.39.46 kasiani muazizah 1 8/20/89 33 1
73 05.49.71 maftuhah 1 1/14/88 35 1
74 05.49.86 pipit putri wulandari 1 3/9/1993 29 1
75 05.11.35 vidia afrilia 1 4/17/93 29 1
76 05.49.88 lailatul magfiroh 1 1/15/2008 15 1
77 01.65.03 devi ekawati 1 ### 35 1
78 05.50.02 mega wati 1 5/2/1992 31 1
79 05.50.01 riza putri wardani 1 7/19/94 28 1
80 00.65.53 iis indrayani 1 11/4/1998 24 1
81 05.50.19 diah ayu regita 1 01-01-'200320 1
82 05.50.18 paisri 1 11/7/1990 32 1
83 05.50.11 fitriani 1 12-05-2003 19 1
84 05.49.79 sinta nuria 1 2/6/1999 23 1
85 05.09.01 amandha cherly vania 1 09-12-2001 21 1
86 05.40.69 maratus sholikah 1 10-04-2000 22 1
87 05.40.69 maratus sholikah 1 10-04-2000 22 1
88 05.46.18 dian puji rahayu 1 12/30/93 29 1
88 05.49.11 fadilah ayu afifa 1 12/20/200121 1
89 03.02.70 dewi komariyah 1 11-07-2002 20 1
90 05.50.52 siti alfiyah 1 8/13/83 39 1
91 00.72.00 siti komariyah 1 4/13/89 33 1
92 05.49.86 pipit putri wulandari 1 3/9/1993 29 1
93 05.50.68 leni kristiana 1 1/20/2001 22 1
94 00.33.13 hanifah 1 7/29/92 30 1
95 05.50.72 zianatul miliah 1 3/15/2002 20 1
96 05.51.01 titik sundari 1 11/30/89 33 1
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
110
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
JUMLAH 0 99 8 56 2 0 0 0 33 0 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
Tanggal Lama BRM Alamat Diagnosa
Hidup Mati ICD
dirawat kembali Sembuh APS Rujuk Pindah (Desa) Primer
Lain MRS KRS < 48 > 48 < 48 > 48 Ruang

30 1 2 1 1 sumberwul post sc 6 jam


1 2 1 1 1 selokawar kista bartolinitis
1 2 1 1 1 supiturang post sc 2 jam
1 2 1 1 1 pulo post partum 6 jam
1 2 1 1 1 penanggal post partum 6 jam
1 2 1 1 1 penanggal post partum 6 jam
2 3 1 1 1 sumberwul post sc 2 jam
2 3 1 1 1 selokanyar post partum 6 jam
2 4 2 1 1 pronojiwo post sc 3 jam
3 4 1 1 1 candipuro post sc 3 jam
3 4 1 1 1 pasirian post sc 2 jam
3 4 1 1 1 candipuro post sc 2 jam
3 4 1 1 1 bades post sc 2 jam
3 4 1 1 1 selokawar post sc 2 jam
3 4 1 1 1 bades post partum 6 jam
3 5 2 1 1 selokanyar post sc 2 jam
3 5 2 1 1 gondoruso post sc 2 jam
4 6 2 1 1 gondoruso post sc 3 jam
4 6 2 1 1 sumberurippost sc 1 jam
4 6 2 1 1 kloposawit menometroragia + anemia
5 6 1 1 1 tempeh rupture perinium
6 7 1 1 1 jarit hamil dg plasenta previa marg
6 8 2 1 1 jatisari post sc 2 jam
6 8 2 1 1 sumbermujpost sc 1 jam
7 8 1 1 1 sumberwul missed abortion
7 8 1 1 1 jarit post sc 2 jam
8 9 1 1 1 pasirian post sc 3 jam
7 9 1 1 1 candipuro post sc 3 jam
8 8 1 1 hcu nguter hamil dg dm+ anemia+ hipert
8 9 1 1 1 jokarto post partum 6 jam
8 9 2 1 1 jarit post partum 6 jam
8 10 2 1 1 gondoruso post sc 3 jam
8 10 2 1 1 orooro ombpost sc 3 jam
8 10 2 1 1 sumberwul post sc 2 jam
8 10 2 1 1 pasirian bo
8 10 2 1 1 kalibendo hamil dg kpd
9 11 2 1 1 pronojiwo post sc 2 jam
9 11 2 1 1 tumpeng post sc 2 jam
10 11 1 1 1 sumberwul post sc 2 jam
11 12 1 1 1 bades post sc 2 jam
11 12 1 1 1 sememu post sc 2 jam
10 13 2 1 1 pulo post sc 6 jam
11 12 1 1 1 sumberwul post sc 2 jam
11 12 1 1 1 jarit post sc 1 jam
11 13 2 1 1 jarit post sc 6 jam
12 13 1 1 1 kalibendo post sc 3 jam
13 14 1 1 1 sumberwul post partum 6 jam
13 15 2 1 1 selokawar post sc 2 jam
13 14 1 1 1 candipuro post sc 2 jam
13 14 1 1 1 penanggal post sc 3 jam
13 14 1 1 1 jatisari post partum 6 jam
13 14 1 1 1 sumberwul post sc 2 jam
13 14 1 1 1 orooro ombpost partum 6 jam
13 14 1 1 1 bades post partum 6 jam
13 15 2 1 1 sumberwul heg
13 15 2 1 1 selokawar post partum 6 jam
14 15 1 1 1 selokawar post sc 2 jam
14 15 1 1 1 candipuro post partum 6 jam
14 15 1 1 1 bades post partum 6 jam
15 16 1 1 1 penanggal post partum 6 jam
14 16 2 1 1 bades post sc 2 jam
15 16 1 1 1 jarit post sc 3 jam
15 16 1 1 1 penanggal post sc 2 jam
15 16 1 1 1 pronojiwo post sc 2 jam
15 16 1 1 1 sememu pua a/I myoma uteri+ anemia
15 17 2 1 1 sumberwul post sc 2 jam
15 17 2 1 1 jarit post sc 2 jam
17 22 5 1 1 bandung heg + febris
17 18 1 1 1 sumberwul heg
17 18 1 1 1 pasirian post op ket
17 19 2 1 1 sumba barapost partum 6 jam
18 19 1 1 1 penanggal post sc 2 jam
18 19 1 1 1 tumpeng post partum 6 jam
20 21 1 1 1 jarit post sc 2 jam
20 21 1 1 1 pronojiwo post partum 6 jam
20 21 1 1 1 bades post partum 6 jam
20 22 2 1 1 sumbersuk post partum 6 jam
20 22 2 1 1 tumpeng post sc 2 jam
21 22 1 1 1 sumbermujpost sc 1 jam
21 22 1 1 1 kalibendo post partum 6 jam
21 22 1 1 1 pulo post partum 6 jam
22 23 1 1 1 selokawar post sc 2 jam
22 23 1 1 1 selokanyar post sc 2 jam
22 23 1 1 1 jarit post sc 2 jam
22 24 2 1 1 sumberwul post sc 2 jam
23 24 1 1 1 jarit post sc 2 jam
22 24 2 1 1 candipuro post partum 6 jam
23 23 1 1 hcu jember post sc hari ke 5 dg b20+ su
24 27 3 1 rsdh jember post sc hari ke 6 dg b20+ su
24 25 1 1 1 sumbermujpost partum 6 jam
24 25 1 1 1 sumberjati post partum 6 jam
24 26 2 1 1 sumberwul hamil 33-34mg belum inpartu
25 26 1 1 1 pulo post sc 2 jam
25 26 1 1 1 selokawar post partum 6 jam
26 27 1 1 1 bades post partum dg haemoroid
26 28 2 1 1 nguter post partum 6 jam
27 28 1 1 1 sumberwul heg
27 28 1 1 1 selokawar post partum 6 jam
27 28 1 1 1 sumberejo post partum 6 jam
0 ### ### 137 0 31 0 0 31 0 0

mutiara c19

H 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)


Tindak
an
(Opera Pelayanan
si)

sc obgyn
marsupia gynec
sc obgyn
spt od obgyn
spt induobgyn
spt induobgyn
sc obgyn
spt b obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
spt b obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
roragia + anemia gynec
repair p gynec
plasenta previa margobgyn
sc obgyn
sc obgyn
curetageobgyn
sc obgyn
sc obgyn
sc obgyn
dm+ anemia+ hipertobgyn
spt b obgyn
spt b obgyn
sc obgyn
sc obgyn
sc obgyn
curetageobgyn
obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
spt b obgyn
sc obgyn
sc obgyn
sc obgyn
spt od obgyn
sc obgyn
spt b obgyn
spt induobgyn
obgyn
spt od obgyn
sc obgyn
spt b obgyn
spt b obgyn
spt b obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
yoma uteri+ anemiagynec
sc obgyn
sc obgyn
obgyn
obgyn
salpinge obgyn
spt b obgyn
sc obgyn
spt b obgyn
sc obgyn
spt induobgyn
spt induobgyn
spt od obgyn
sc obgyn
sc obgyn
spt b obgyn
spt b obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
sc obgyn
spt od obgyn
ri ke 5 dg b20+ su obgyn
ri ke 6 dg b20+ su obgyn
spt od obgyn
spt od obgyn
34mg belum inpartuobgyn
sc obgyn
spt b obgyn
um dg haemoroid obgyn
spt od obgyn
obgyn
spt b obgyn
spt od obgyn
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM Jampersal JR BPJS TK

1 05.45.04 sumini 1 6/7/1978 44 1


2 04.16.66 hariani 1 5/17/85 37 1
3 00.66.67 sri wahyuni 1 3/17/89 33 1
4 05.51.14 nurul aeni 1 01-06-2005 18 1
5 02.85.74 lilis indayani 1 2/1/1988 35 1
6 05.49.91 nuraini 1 09-04-2000 22 1
7 02.07.32 venty yolanda 1 7/21/98 24 1
8 05.51.36 devita anggraeni 1 4/27/93 29 1
9 05.51.44 ida ning rahayu 1 8/16/93 29
10 05.51.42 halimatus sakdiyah 1 1/14/2001 22 1
11 05.51.56 harita 1 8/3/1977 45
12 05.46.26 marshanda nurwati 1 3/13/2006 16
13 05.51.72 saodah isnaeni 1 5/14/90 32 1
14 05.51.64 sholiha indriani 1 ### 33 1
15 05.51.63 tantri wahyuni 1 1/1/1992 31
16 05.47.79 siti aisyah 1 10/4/1996 26
17 05.51.80 tutin lestari 1 1/9/1987 35
18 05.51.68 putri asparaga 1 02-02-2000 23
19 02.51.45 roudhotus solicha 1 3/19/2003 19
20 05.51.89 fera andriani 1 6/28/86 36 1
21 05.45.60 anggi eka pratiwi 1 1/18/2007 15 1
22 01.97.60 imas lia fridayanti 1 8/13/99 23 1
23 05.51.92 ilmiatul hidayah 1 8/19/2003 19
24 05.52.05 alfia krisnawati 1 5/24/2001 21 1
25 05.23.67 neni megawati 1 12/3/1989 33 1
26 05.52.71 nunuk sholehah 1 6/16/81 41 1
27 05.52.14 nurlisa 1 1/9/1993 29 1
28 02.49.69 jeane wahyu kartikasari 1 8/1/1997 26
29 05.52.19 sami sanum 1 7/19/54 68 1
30 05.52.33 fitria nandayani 1 3/12/93 29
31 05.52.44 eva meilani 1 05-05-2003 19 1
32 05.52.62 khoirutul hasanah 1 12/25/200022 1
33 05.19.38 reni dwi milasari 1 7/22/2000 22 1
34 02.07.32 venty yolanda 1 7/21/98 24 1
35 05.52.51 devi vila nurvia 1 8/30/89 33 1
36 05.52.61 siti anisa 1 1/4/1997 25 1
37 04.74.64 siti nur hasanah 1 8/9/1995 27 1
38 05.52.84 destrianti swardhani 1 12/28/97 25 1
39 01.76.15 ristiana 1 1/2/1996 27 1
40 05.15.99 sumaida 1 6/27/90 32
41 05.52.78 aida nurhasanah 1 2/19/2004 19
42 05.52.89 erni 1 1/12/1980 42 1
43 05.51.10 nurul eriska 1 03-02-2001 22 1
44 05.52.97 entik kurniawati 1 1/1/1985 38 1
45 05.52.98 estin febriana 1 2/27/92 31 1
46 05.53.06 ersi ernawati 1 4/3/1993 30 1
47 01.94.53 eka dwi astutik 1 ### 24 1
48 03.37.90 putri agustin ningtyas 1 8/17/2000 22 1
49 05.27.45 lilis wulandari 1 8/3/1998 25
50 00.68.12 dwi jayanti 1 2/22/99 24 1
51 03.74.20 luluk sarimatud d. 1 11-10-2001 21 1
52 05.37.20 nanik shofiyah 1 2/19/81 42 1
53 05.53.25 sumarni 1 9/10/1969 53 1
54 05.53.34 ayu soraya 1 9/7/1999 28 1
55 05..53.31 sri tuweni 1 8/4/1987 35 1
56 00.66.67 sri wahyuni 1 3/17/89 33 1
57 05.53.69 ina maya kurnia 1 5/18/89 33
58 02.97.74 indah tri kasari 1 09-08-2001 21 1
59 04.27.04 nilam sentika dewi n.s 1 6/11/1989 33 1
60 01.31.40 dian eka pratiwi 1 10/9/1998 24 1
61 05.19.38 reni dwi milasari 1 7/22/2000 22 1
62 05.53.91 puput wulandari 1 5/1/1992 31 1
63 05.53.97 melyta khoirun nisa 1 5/20/89 33 1
64 05.53.57 yusrolana 1 10/18/200319 1
65 05.54.05 kristinah 1 5/11/1995 27 1
66 05.54.10 siti fahimatus 1 1/18/96 27
67 00.80.72 fiki anjani 1 9/9/1999 23 1
68 05.51.08 devy dwi rohmawati 1 12/28/96 26 1
69 05.54.23 denik wulandari 1 7/25/89 33 1
70 05.54.30 amelia chandra dewi 1 11-10-2009 13 1
71 05.53.41 findi safitri 1 3/8/1993 29 1
72 05.54.53 dwi sagita mawarni 1 ### 24 1
73 05.54.38 erma sukowulan 1 9/16/90 32
74 05.46.60 evy kristianti 1 5/24/88 34
75 02.08.57 fitria udianingsih 1 6/26/94 28 1
76 03.51.26 ida sanjaya 1 6/7/1994 28 1
77 05.48.30 qoyyimah 1 12/29/73 49 1
78 01.51.91 dewi idayati 1 5/16/99 23 1
79 05.53.81 widi astutik 1 1/2/1992 31 1
80 05.54.63 rosyidatul faizah 1 3/13/99 24
81 05.19.38 reni dwi milasari 1 7/22/2000 22 1
82 05.54.77 nurul aini 1 2/8/1982 40
83 01.60.66 rohmawati 1 3/20/2000 22
84 01.02.23 vely septiana saro 1 09-05-2004 18 1
85 05.54.85 aprilia sintia dewi 1 5/4/1996 26 1
86 04.66.54 nur latifah 1 3/18/90 32
87 05.55.04 nabila 1 01-01-2002 21 1
88 05.55.18 mariyati 1 12/1/1998 25 1
89 05.55.07 istiyani 1 8/20/90 32
90 05.04.11 evi awindha 1 4/20/90 32
91 05.55.15 lilik handayani 1 1/2/1987 36
92 05.51.94 siti muhajah sholih 1 7/23/2002 20 1
93 05.55.23 tutik wijayanti 1 5/9/1993 29 1
94 05.55.30 rini rofiani 1 11/4/1996 26
95 05.55.33 putri endah sari 1 10-02-2000 22 1
96 05.44.58 suntrik 1 7/13/86 36 1
97 05.22.30 husnul siti maisaroh 1 5/7/1990 32 1
98 05.55.58 oktavia 1 6/16/95 27 1
99 05.55.60 novita sari 1 11-03-2000 22 1
100 05.55.63 lailatul khikmah 1 5/16/96 26
101 05.55.56 novi irawati 1 1/6/1993 29
102 05.55.61 ainur rohimah 1 10/20/200319
103 05.23.73 wega dwi maysilia 1 5/20/2003 19 1
104 05.55.81 putri andaningsih 1 11-11-2004 18 1
105 05.55.77 mutmainah 1 12/13/73 49 1
106 05.06.95 amalia mu mila 1 8/27/98 24 1
107 01.98.50 uliyanah 1 4/22/88 34 1
108 05.55.93 eva ambar kirey 1 6/20/98 24
109 05.44.58 suntrik 1 7/13/86 36 1
110 05.56.04 devi anggraeni 1 6/30/81 41
111 03.02.70 dewi komaria r. 1 11-07-2002 20
112 05.56.05 susanti 1 10/21/96 26 1
113 02.52.20 reni setiowati 1 9/9/1991 31 1
114 05.56.10 afriska putri 1 4/1/1996 27 1
115 05.56.11 siti robiatun farkhah 1 7/15/98 24 1
116 05.56.19 desi maulina fitriani 1 7/12/2005 17 1
117 05.56.21 yeni kurniasari 1 7/20/2001 21 1
118 03.26.36 fitri risky n.a 1 1/25/2001 22
119 05.56.33 anggeh tri meykawati 1 2/5/1985 37 1
120 05.56.34 yunarni 1 3/28/99 23 1
121 05.56.46 susiani 1 12/27/98 24 1
122 05.56.48 nurani 1 1/7/1995 27
123 04.64.70 nur hayati 1 ### 29
124 05.44.58 suntrik 1 7/13/86 36 1
125 05.56.56 ponitri 1 6/19/81 41 1
126 05.56.64 ida ratnawati 1 12/27/88 34 1
127 04.53.65 putri aningsih 1 7/28/2004 18 1
128 05.56.76 indrawati 1 6/9/1994 28
129 00.02.65 yuni sanjata a.p 1 6/26/2002 20
130 04.43.66 hariati 1 5/17/85 37 1
131 05.54.21 umi choiriyah 1 5/6/1976 46 1
132 00.00.01 siti nur nilam sari 1 02-02-2001 22 1
133 05.56.92 mariatul kiftia 1 10-12-2000 22 1
134 03.95.17 anik minarti 1 5/6/1977 45 1
135 00.86.92 warosatul ambiyak 1 9/18/2001 21 1
136 05.13.66 dwiana kusumagustin 1 8/31/94 28
137 05.56.97 sodakhol ida 1 1/10/1987 35 1
138 05.56.98 siti nurul ainun hidayah 1 10/19/200121 1
139 01.21.47 yuliani 1 5/24/85 37 1
140 05.57.06 selviatul khasana 1 9/24/93 29 1
141 02.60.97 misulis 1 4/9/1980 42 1
142 05.57.11 nurul ilmiyah 1 4/8/1995 27 1
143 02.89.26 supratiningsih 1 10/13/87 35 1
144 05.57.16 santi inda dewi 1 12/23/86 36
145 03.71.55 marmi ningsih 1 6/26/82 40
146 05.26.72 sunarsih 1 3/1/1980 43
147 05.53..41 findi safitri 1 3/8/1993 29 1
148 02.40.26 heni permatasari 1 5/25/2003 19 1
149 05.57.49 nuro fadia rohmah 1 08-07-2002 20 1
150 05.57.46 fatimatuz zahro 1 7/29/83 39
151 05.50.68 leni kristiana 1 22 1
0 151 15 91 3 0 0 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN = 5 B
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
a bayar Tanggal Lama BRM
Hidup Mati
dirawat kembali Sembuh APS Rujuk Pindah
PG JKN RGKemkesLain MRS KRS < 48 > 48 < 48 > 48 Ruang

27 1 2 1 1
27 1 2 1 1
28 1 1 1 1
28 2 2 1 1
28 2 2 1 1
28 2 2 1 1
28 2 2 1 1
28 2 2 1 1
1 1 3 2 1 1
1 2 1 1 1
1 1 3 2 1 1
1 1 3 2 1 1
2 3 1 1 1
3 4 1 1 1
1 2 4 2 1 1
1 2 4 2 1 1
1 2 3 1 1 1
1 2 4 2 1 1
1 2 4 2 1 1
2 3 1 1 1
3 4 1 1 1
3 4 1 1 1
1 3 4 1 1 1
3 4 1 1 1
4 5 1 1 1
4 5 1 1 1
4 5 1 1 1
1 4 5 1 1 1
4 6 2 1 1
1 6 7 1 1 1
6 7 1 1 1
6 7 1 1 1
6 8 2 1 1
6 7 1 1 1
6 8 2 1 1
6 8 2 1 1
7 8 2 1 1
7 8 1 1 1
7 8 1 1 1
1 7 8 1 1 1
1 7 9 2 1 1
8 9 1 1 1
8 9 1 1 1
8 9 1 1 1
8 9 1 1 1
8 9 1 1 1
8 9 1 1 1
8 9 1 1 1
1 8 9 1 1 1
8 9 1 1 1
9 9 1 1 1
9 10 1 1 1
9 12 3 1 1
10 11 1 1 1
10 12 2 1 1
10 13 3 1 1
1 12 13 1 1 1
12 13 1 1 1
12 14 2 1 1
13 14 1 1 1
13 14 1 1 hcu
13 14 1 1 1
13 15 2 1 1
11 12 1 1 1
13 15 2 1 1
1 13 14 1 1 1
13 14 1 1 1
14 17 3 1 1
14 16 2 1 1
14 16 2 1 1
14 15 1 1 1
15 16 1 1 1
1 15 15 1 1 1
1 15 16 1 1 1
15 16 1 1 1
15 16 1 1 1
15 18 3 1 1
15 17 2 1 1
15 17 2 1 1
1 16 17 2 1 1
15 16 1 1 1
1 16 18 2 1 1
1 17 18 1 1 1
17 18 1 1 1
17 18 1 1 1
1 17 19 2 1 1
18 19 1 1 1
19 20 1 1 1
1 18 20 2 1 1
1 19 21 2 1 1
1 19 20 1 1 1
20 21 1 1 1
20 20 1 1 rsdh
1 20 22 2 1 1
20 21 1 1 1
20 21 1 1 1 hcu
20 23 2 1 1
21 22 1 1 1
21 22 1 1 1
1 21 22 1 1 1
1 21 22 1 1 1
1 21 23 2 1 1
21 23 2 1 1
22 23 1 1 1
21 23 2 1 1
22 24 2 1 1
22 23 1 1 1
1 22 23 1 1 1
23 24 1 1 hcu
1 23 24 1 1 1
1 24 25 1 1 1
23 24 1 1 1
23 24 1 1 1
24 25 1 1 1
24 25 1 1 1
24 26 2 1 1
24 25 1 1 1
1 24 25 1 1 1
24 26 2 1 1
25 26 1 1 1
25 27 2 1 1
1 25 26 1 1 1
1 25 26 1 1 1
25 26 1 1 1
26 27 1 1 1
26 28 2 1 1
27 28 1 1 1
1 27 28 1 1 1
1 27 28 1 1 1
27 30 3 1 1
27 30 3 1 1
27 29 2 1 1
27 28 1 1 1
27 30 3 1 1
27 28 1 1 1
1 28 30 2 1 1
28 29 1 1 1
28 29 1 1 1
28 29 1 1 1
28 29 1 1 1
28 29 1 1 1
28 29 1 1 1
29 30 1 1 1
1 28 30 2 1 1
1 30 31 1 1 1
1 29 30 1 1 hcu
29 31 2 1 1
29 31 2 1 1
30 31 1 1 1
1 30 31 1 1 1
7 7 7 1 1
42 0 0 0 2475 2459 219 0 150 0 0 146 0 0

TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)


Diagnosa Tindakan
Alamat (Desa) Primer ICD (Operasi) Pelayanan

madurejo post sc 2 jam sc obgyn


jarit pua s/I mioma utcuretage +gynec
sumberwuluh post partum dg hypertiroidobgyn
selokawar hamil dg kpd obgyn
jokarto post sc 2 jam sc obgyn
selokanyar post sc 2 jam sc obgyn
pasirian post sc 1 jam sc obgyn
pasirian ppi obgyn
purorejo post sc 2 jam sc obgyn
sumberwuluh ppi obgyn
sumbermujur post sc 5 jam sc obgyn
condro post sc 3 jam sc obgyn
selokawar post partum 6 j spt b obgyn
bades post sc hari ke 1 obgyn
bago post sc + ht 4 ja sc obgyn
pronojiwo post sc 2 jam sc obgyn
penanggal post sc 3 jam sc obgyn
tempeh post sc 2 jam sc obgyn
kalibendo post sc 4 jam sc obgyn
bago hamil 12 jtm curetage obgyn
sememu post partum 6 j spt b obgyn
candipuro post sc 3 jam sc obgyn
pronojiwo post partum 6 j spt od obgyn
jarit abortus incomplicuretage obgyn
jarit post sc 2 jam sc obgyn
jarit post sc 1.5 jam sc obgyn
selokawar hamil dg trauma abdomen obgyn
candipuro retensio plasenthisterotomobgyn
pandanarum pua a/I ca cx +{ anemia gynec
madurejo post sc 2 jam sc obgyn
pasrujambe post sc 1.5 jam sc obgyn
sumberejo post partum 6 j spt b obgyn
tompokersan kpd obgyn
pasirian post sc hari ke 6 dg colic obgyn
sumberejo post curetage curetage obgyn
nguter post sc 3 jam sc obgyn
sememu rupture perinium derajat 4 obgyn
tempeh dismenorea gynec
lempeni post curetage curetage obgyn
selokawar post sc 3 jam sc obgyn
tambahrejo post sc 1.5 jam sc obgyn
madurejo peb obgyn
sidomulyo post sc 5 jam sc obgyn
bades post sc 5 jam sc obgyn
jarit post sc 6 jam sc obgyn
candipuro post sc 8 jam sc obgyn
selokawar post sc 5 jam sc obgyn
jarit post sc 3 jam sc obgyn
tumpeng post sc 4 jam sc obgyn
candipuro post curetage curetage obgyn
sememu abortus incomplicuretage obgyn
bades post sc 2 jam sc obgyn
pasirian prolaps uteri histerotomgynec
sememu post sc 1 jam sc obgyn
jarit post sc 3 jam sc obgyn
sumberwuluh post partum hari ke 10+ OF+gynec
bades post sc 3 jam sc obgyn
sumberwuluh early hpp a/I sis curetage obgyn
jombang post sc 12 jam sc obgyn
pasirian post sc 2 jam sc obgyn
tompokersan peb+ kpd sc obgyn
sememu post partum 6 j spt induksiobgyn
pasirian hamil dg jtm+ prsc obgyn
selokanyar post partum 6 j spt b obgyn
sumberwuluh post sc 2 jam sc obgyn
kunir post partum 6 j spt b obgyn
sememu hamil 8 mg dg j curetage obgyn
purorejo hamil dg gemeli sc obgyn
selokawar post sc 2 jam sc obgyn
pasirian menometroragia gynec
madurejo heg obgyn
pasirian jtm curetage obgyn
madurejo post partum 6 j spt od obgyn
tamanayu post sc 3 jam sc obgyn
pasirian post sc 4 jam sc obgyn
orooroombo post sc 4 jam sc obgyn
selokanyar mioma uteri myomektomgynec
nguter post sc 5 jam sc obgyn
madurejo post sc 5 jam sc obgyn
bades post sc 5 jam sc obgyn
tompokersan post sc hari ke 1 obgyn
jarit post sc 2 jam sc obgyn
bago post sc 2 jam sc obgyn
jugosari post sc 2 jam sc obgyn
tamanayu post sc 3 jam sc obgyn
kalibendo post sc 2 jam sc obgyn
pandanarum post partum 6 j spt od obgyn
gondoruso bartholini gynec
jugosari post sc 1 jam sc obgyn
bades post sc 6 jam sc obgyn
gondoruso post partum 6 j spt b obgyn
pundungsari post sc 6 jam sc obgyn
orooroombo hamil 21 mg dg anemia obgyn
tempeh post sc 4 jam sc obgyn
bades post sc 6 jam sc obgyn
jarit hamil uk 28-29mg dg peb obgyn
bades kista ovarium gynec
penanggal post sc 2 jam sc obgyn
pulo post sc 3 jam sc obgyn
pulo post sc 2 jam sc obgyn
gondoruso post sc 3 jam sc obgyn
jugosari post sc 4 jam sc obgyn
tempeh post sc 3 jam sc obgyn
supiturang post sc 4 jam sc obgyn
sumberwuluh abortus incomplicuretage obgyn
sememu post sc 2 jam sc obgyn
pasirian post partum 4 j spt b obgyn
tempursari post partum 6 j spt induksiobgyn
jarit hamil uk 28-29mgspt b obgyn
kalibendo post partum 6 j spt od obgyn
sumberwuluh post sc 2 jam sc obgyn
supiturang post partum 6 j ekstraksi t obgyn
sememu bo curetage obgyn
padang post curetage curetage obgyn
kalibendo post curetage curetage obgyn
condro post sc 2 jam sc obgyn
penanggal post sc 2 jam sc obgyn
pundungsari post sc 2 jam sc obgyn
bades post sc 1 jam sc obgyn
sumbermujur post sc 1 jam sc obgyn
pasirian kpd obgyn
sumberwuluh post partum 6 j spt b obgyn
pasrujambe post partum 6 j spt b obgyn
jarit post sc hari ke 1 obgyn
sumberwuluh post sc + mow sc+ mow obgyn
aceh post sc 3 jam sc obgyn
penanggal post sc 3 jam sc obgyn
siupiturang post sc 6 jam sc obgyn
kalibendo post partum 6 j spt od obgyn
jarit mioma uteri + anemia gynec
jarit ca cx + anemia gynec
candipuro post sc 3 jam sc obgyn
kalibendo post sc 2 jam sc obgyn
pasirian mioma uteri histerekto gynec
bades heg obgyn
jugosari post sc hari ke 1 obgyn
bago post partum 6 j ekstraksi t obgyn
sememu post sc 4 jam sc obgyn
condro post sc 5 jam sc obgyn
besuk post sc 7 jam sc obgyn
gondoruso post sc 6 jam sc obgyn
supiturang post sc 3 jam sc obgyn
pulo post partum 6 j spt induksiobgyn
kalibendo post sc 3 jam sc obgyn
supiturang post sc 1 jam sc obgyn
jarit peb sc obgyn
madurejo hamil dg post jatuh obgyn
pasirian post sc 1.5 jam sc obgyn
selokawar post sc 6 jam sc obgyn
sumberurip post sc 4 jam sc obgyn
nguter rupture periniu repair per obgyn
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM jps JR BPJS TKPG

1 05.26.72 sunarsih 1 3/1/1980 43 1


2 04.43.76 fatchiyatul azizah 1 02-10-2002 21 1
3 05.57.55 nur hidayatur rohmah 1 10/18/94 28 1
4 05.57.61 nurul umayatul 1 9/12/1991 31 1
5 03.45.91 alfiah nur aini 1 1/28/88 35 1
6 04.34.35 mujiati 1 7/12/1986 36 1
7 05.57.64 wahyu aprilia 1 4/24/89 33 1
8 05.57.76 uswatun hasnaah 1 3/16/86 37 1
9 02.69.84 anisia asri wulandari 1 5/3/1998 25 1
10 05.57.72 risa prastika 1 7/3/1993 30 1
11 05.57.90 lailatul fitria 1 5/7/1990 32 1
12 02.32.22 yuliaten 1 9/4/1997 25 1
13 05.57.98 silfi hofifah 1 11/15/200121 1
14 05.56.49 linda kumalasari 1 3/25/2002 21 1
15 05.58.19 rizma wakhyuni 1 9/21/2002 20 1
16 00.10.66 tantin umu khasanah 1 ### 57 1
17 05.54.15 alfia 1 ### 36 1
18 05.58.28 sania 1 1/30/2001 22 1
19 05.58.47 yulina 1 10/18/90 26 1
20 01.23.84 nur halimah 1 5/15/88 34 1
21 00.44.73 rima melati 1 5/3/1999 24 1
22 04.07.87 hesty pramitasari 1 9/6/1995 27 1
23 05.58.90 putri ratnasari 1 7/23/2000 22 1
24 05.58.72 sindy pratiwi putri 1 06-08-2003 19 1
25 05.58.84 vela safitri 1 1/29/2000 23 1
26 05.58.70 aida kurniawati 1 11/21/88 34 1
27 04.07.87 hesty pramitasari 1 9/6/1995 27 1
28 05.58.72 sindy pratiwi putri 1 8/6/2003 19 1
29 05.04.45 elisa 1 02-10-2001 21 1
30 03.21.77 emilda zuhria 1 2/4/1999 24 1
31 05.15.50 sahyani 1 7/6/1966 56 1
32 03.66.15 aris kristiana dewi 1 10/5/1992 30 1
33 05.59.11 dwi zuarningtyas 1 1/6/1984 38 1
34 05.59.14 elen agustin lestari n. 1 05-08-2003 19 1
35 05.59.34 dessy nataliasari 1 12/25/97 25 1
36 05.59.31 nur hayati 1 9/8/1993 29 1
37 05.59.24 masamah 1 6/30/72 50 1
38 02.53.48 theresia ari aquirista 1 1/27/92 31 1
39 04.52.42 hesti candra w. 1 9/27/90 32 1
40 05.59.55 wilujeng tri rahayu 1 9/8/1990 32 1
41 05.59.57 muthfatul khoiroh 1 7/21/95 27 1
42 05.59.59 sucik irawati 1 04-05-2001 22 1
43 05.52.68 novia dwi ramadani 1 11/28/200022 1
44 04.79.20 fita fatimah 1 9/15/92 30 1
45 05.59.96 sofia 1 7/7/1998 24 1
46 05.59.93 minut 1 10/6/1957 65 1
47 05.60.03 rotifah aini 1 10/6/1997 25 1
48 05.59.80 uswatun hasnaah 1 5/8/1990 32 1
49 02.62.76 risma valayati 1 3/26/90 32 1
50 05.51.36 devita anggraeni 1 4/27/93 29 1
51 05.60.10 sumi ullilawati 1 03-01-2003 20 1
52 05.60.26 hamidah 1 3/20/82 41 1
53 05.57.24 kurnia siwi kinasih 1 ### 24 1
54 02.18.75 intan wijayanti 1 02-02-2001 22 1
55 00.21.72 aulia arief kurniawati 1 9/21/93 29 1
56 05.60.39 relyta dwi andini 1 01-05-2002 21 1
57 05.60.41 iriyani 1 05-04-2002 20 1
58 03.87.66 yulian dwi hidayatul h. 1 5/7/1996 26 1
59 05.50.88 siti romlah 1 2/2/1983 40 1
60 05.60.61 supiati 1 8/17/84 38 1
61 05.60.59 zahro 1 5/11/1997 25 1
62 05.55.21 siti wulandari 1 4/24/92 30 1
63 05.20.12 arifah 1 7/29/91 31 1
64 01.35.27 devia fahira r. 1 12/30/98 24 1
65 04.52.42 hesti candra w. 1 9/27/90 32 1
66 05.60.67 sami 1 ### 36 1
67 05.56.46 susiani 1 12/27/98 24 1
68 05.34.07 siti fatimah 1 5/20/85 37 1
69 05.60.80 uswatun hasnaah 1 01-01-2000 23 1
70 02.37.25 sri ngatini 1 1/4/1981 42 1
71 05.61.01 vivi indah k. 1 2/17/98 25 1
72 05.60.98 maresta sarwo indah 1 3/16/89 34 1
73 05.61.08 arik wijayanti 1 5/17/2002 20 1
74 05.61.27 enis susiantini 1 6/26/98 24 1
75 05.61.28 choiril maulida 1 7/20/97 25 1
76 00.74.84 mulianik 1 5/6/1986 36 1
77 04.16.66 hariani 1 5/17/85 37 1
78 05.61.46 mey munawaroh 1 5/21/99 23 1
79 02.67.67 suliati muna 1 12/15/80 42 1
80 05.61.30 siti maimunah 1 10/6/1982 40 1
81 05.61.43 siti fatimah 1 07-12-2000 22 1
82 05.61.33 yuni anisa 1 2/20/99 24 1
83 05.61.50 dina rianti 1 5/19/87 35 1
84 02.18.75 intan wijayanti 1 02-02-2001 22 1
85 05.61.48 luluk putri mashuda 1 07-01-2004 18 1
86 05.61.56 rani maria putri 1 3/17/95 28 1
87 02.85.26 tilawatil hasanah 1 7/14/98 24 1
88 04.73.46 myra leetyanzi 1 12/18/97 25 1
89 05.61.61 choiriyah 1 3/12/1983 39 1
90 05.61.78 maiya afriliya 1 4/14/2008 15 1
91 05.61.45 siti halimah 1 10/6/1981 41 1
92 05.61.59 iis ariska 1 08-04-2001 21 1
93 05.61.70 ngatminah 1 1/1/1994 29 1
94 05.61.73 defi anggraeni 1 4/4/1999 24 1
95 05.62.01 riska kholifah 1 2/27/2000 23 1
96 03.64.81 nur fatima 1 10/27/93 29 1
97 05.62.06 yanis dharma s. 1 2/22/97 26 1
98 05.62.17 desi natalia sari 1 12/27/93 29 1
99 05.62.28 siti susilowati 1 4/13/99 24 1
100 05.62.33 putri dwitasari 1 8/22/2002 20 1
101 02.24.99 nujum sahroh 1 2/3/1997 28 1
102 05.62.41 putri laili maulidiyah 1 5/18/2002 20 1
103 05.62.64 evi nurul hikmah 1 9/5/1998 24 1
104 05.62.70 chusnah 1 12/24/72 50 1
105 05.62.73 dian eka erfaniar s. 1 6/9/1993 29 1
106 05.63.17 anggraeni lestari 1 4/9/1992 30 1
107 05.63.32 muzzayanah 1 12/4/1998 25 1
108 05.63.26 rodhiyah 1 9/29/86 26 1
109 05.61.50 dina rianti 1 5/19/87 35 1
110 00.41.40 putri kusuma dewi 1 7/29/92 30 1
111 05.63.48 wiwin endang l. 1 2/5/1997 25 1
112 05.63.52 ika yuli martasari 1 4/14/88 35 1
113 02.39.78 sintya wahyu ningsih 1 5/21/2005 17 1
114 05.63.78 mega andriati 1 6/4/1998 25 1
115 05.63.82 dela pratiwi 1 05-06-2002 20 1
116 05.63.84 fitria amanda sari 1 7/12/1999 23 1
117 05.53.41 findi safitri 1 3/8/1993 29 1
118 05.63.89 faiqotul himmah 1 4/15/91 32 1
119 05.42.71 intan ditya permatasari 1 10/4/1984 39 1
120 05.64.10 yesi setiawati 1 4/29/2004 19 1
121 05.64.14 aina u. khudriyah 1 10/5/1989 33 1
122
123
124
125
JUMLAH 0 121 8 74 1 0 0 0 38
1 KOLOM WARNA UNGU TIDAK USAH DIISI
2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
yar Tanggal Lama BRM Alamat Diagnosa
Hidup Mati
dirawat kembali Sembuh APS Rujuk Pindah (Desa) Primer
JKN RGkmk Lain MRS KRS < 48 > 48 < 48 > 48 Ruang

31 1 1 1 1 jarit post sc hari ke 1


30 1 2 1 1 candipuro post sc 3 jam
30 1 2 1 1 sememu post sc 3 jam
31 1 1 1 1 jarit post sc 2 jam
31 2 2 1 1 selokawar post sc 3 jam
31 2 2 1 1 penanggal post sc 2 jam
31 1 1 1 1 besuk post partum 6 jam
1 2 1 1 1 candipuro post sc 2 jam
31 2 2 1 1 nguter post sc 2 jam
31 1 1 1 1 penanggal heg
1 3 2 1 1 sumberwulupost sc 2 jam
2 3 1 1 1 gondoruso post sc 6 jam
2 5 3 1 1 pasrujambepost curetage
3 5 2 1 1 candipuro post curetage
3 5 2 1 1 sememu post sc 3 jam
4 7 3 1 1 jarit mioma uteri
4 5 1 1 1 penanggal post sc 2 jam
4 6 2 1 1 jugosari post sc 4 jam
5 6 1 1 1 sememu post sc 4 jam
5 6 1 1 1 jugosari post sc 1 jam
5 7 2 1 1 sememu post sc 3 jam
5 6 1 1 hcu jatirejo post sc
6 7 1 1 1 sumberrejo post partum 3 jam
6 6 1 1 hcu penanggal post sc
6 7 1 1 1 kertosaripost partum 6 jam
6 8 2 1 1 tempeh post sc 4 jam
7 8 1 1 1 jatirejo post sc
7 8 1 1 1 penanggal post sc
7 10 3 1 saphire candipuro ileus obstruktif
7 8 1 1 1 pasirian menometroragia
7 10 3 1 1 penanggal pua
7 9 2 1 1 nguter post sc 2 jam
8 9 1 1 1 pasirian post sc 6 jam
8 10 2 1 1 tumpeng abortus complite
9 10 1 1 1 tambahrejo post partum 6 jam
9 11 2 1 1 supiturang post partum 6 jam
9 11 2 1 1 tamanayu pua
10 12 2 1 1 tempursari post sc 2 jam
10 12 2 1 hcu pasirian post sc 4 jam
10 12 2 1 1 pasirian heg
10 11 1 1 1 bades post partum 6 jam
10 11 1 1 1 nguter post partum 6 jam
11 12 1 1 1 bades post sc 3 jam
11 12 1 1 1 pundungsarpost sc 2 jam
11 12 1 1 1 orooroomb kpd
11 12 1 1 1 nguter bakterial vaginasis + isk
11 13 2 1 1 orooroomb hamil dg plas previa marg
11 13 2 1 1 jugosari missed abortion
12 13 1 1 1 pasirian post sc 3 jam
12 13 1 1 1 pasirian post sc 4 jam
12 13 1 1 1 tempursari post sc 2 jam
12 14 2 1 1 sidomulyo post sc 4 jam
12 13 1 1 1 bago post partum 6 jam
12 14 2 1 1 sumberwuluheg
13 14 1 1 1 condro post sc 4 jam
13 14 1 1 1 tempursari post sc 1 jam
13 14 1 1 1 pulo post sc 1 jam
13 17 4 1 1 sememu heg
13 15 2 1 1 bulurejo post sc 4 jam
14 15 1 1 1 purorejo post sc 2 jam
14 15 1 1 1 bago post sc 3 jam
14 15 1 1 1 nguter post sc 5 jam
14 15 1 1 1 mojorejo post sc 7 jam
14 15 1 1 1 bago hamil dg isk
13 15 2 1 1 pasirian post sc
14 15 1 1 1 pronojiwo post sc 3 jam
14 15 1 1 1 pasirian post partum 6 jam
15 16 1 1 1 bades post sc hari ke 1
14 16 2 1 1 madurejo post sc 2 jam
14 16 2 1 1 madurejo post sc 2 jam
15 17 2 1 1 sememu post sc 4 jam
15 17 2 1 1 tumpeng post sc 2 jam
16 17 1 1 1 penanggal post sc 2 jam
16 18 2 1 1 malang abortus incomplite
16 18 2 1 1 bago post sc 3 jam
17 18 1 1 1 tumpeng post sc 3 jam
17 20 3 1 1 jarit mioma uteri
17 19 2 1 1 tegalrejo post sc 1.5 jam
17 18 1 1 1 sumberwulupost sc 2 jam
17 19 2 1 1 sumberurip post sc 2 jam
17 19 2 1 1 nguter post sc 3.5 jam
17 19 2 1 1 tegalrejo post sc 2 jam
17 19 2 1 1 sememu hamil dg oligo+ presbo
18 19 1 1 1 sumberwuluheg
18 19 1 1 1 tekung post sc 2 jam
18 19 1 1 1 candipuro post partum 6 jam
18 19 1 1 1 bago post sc 3 jam
18 19 1 1 1 sememu post sc 3 jam
18 19 1 1 1 kaliuling post sc 4 jam
18 21 3 1 1 sumbermujugawat janin+ gagal ko
18 19 1 1 1 tamanayu post sc hari ke 2
18 19 1 1 1 krasak post partum 6 jam
18 20 2 1 1 sumberwulupost sc 2 jam
18 20 2 1 1 tempurejo post sc 1 jam
20 21 1 1 1 bades post sc 2 jam
20 20 1 1 1 selokanyar post partum 6 jam
20 21 1 1 1 bades post sc 6 jam
20 21 1 1 1 nguter post sc 2 jam
20 21 1 1 1 sememu post partum 6 jam
21 22 1 1 1 bades post partum 6 jam
21 22 1 1 1 candipuro post partum 6 jam
21 23 1 1 1 sememu post partum 6 jam
22 23 1 1 1 sumberwuluheg
23 24 2 1 1 sememu pua + anemia
23 24 2 1 1 kalibendo post partum 6 jam
25 26 1 1 1 pasirian post partum 6 jam
26 26 1 1 1 selokawar abortus incomplite
25 27 2 1 1 nguter post sc 2 jam
26 28 2 1 1 sememu post sc 2 jam
26 29 3 1 1 pasirian heg
26 27 1 1 1 pasrujambepost partum 6 jam
27 28 1 1 1 nguter post sc 2.5 jam
27 29 2 1 1 tempeh kpd
27 29 2 1 1 kutai timur post sc 5 jam
28 29 1 1 1 gondoruso post sc 6 jam
28 29 1 1 1 pronojiwo post sc 3 jam
28 29 1 1 1 madurejo heg
28 30 2 1 1 bades ppi
29 30 1 1 1 condro post sc hari ke 1
29 30 1 1 1 karangbendrupture vulva
29 30 1 1 1 bades post partum 6 jam

0 0 0 1914 1813 182 0 120 0 0 115 1 0


mutiara c19

AH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)


Tindakan
ICD (Operasi) Pelayanan

post sc hari ke 1 obgyn


post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt od obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
obgyn
post sc 2 jam sc obgyn
post sc 6 jam sc obgyn
post curetage curetage obgyn
post curetage curetage obgyn
post sc 3 jam sc obgyn
mioma uteri gynec
post sc 2 jam sc obgyn
post sc 4 jam sc obgyn
post sc 4 jam sc obgyn
post sc 1 jam sc obgyn
post sc 3 jam sc obgyn
sc obgyn
post partum 3 jam spt b obgyn
sc obgyn
post partum 6 jam spt od obgyn
post sc 4 jam sc obgyn
obgyn
sc obgyn
ileus obstruktif obgyn
menometroragia gynec
gynec
post sc 2 jam sc obgyn
post sc 6 jam sc obgyn
abortus complite obgyn
post partum 6 jam spt od obgyn
post partum 6 jam spt od obgyn
gynec
post sc 2 jam sc obgyn
post sc 4 jam sc obgyn
obgyn
post partum 6 jam spt od obgyn
post partum 6 jam spt b obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
obgyn
bakterial vaginasis + isk gynec
hamil dg plas previa marginalis obgyn
missed abortion curetage obgyn
post sc 3 jam sc obgyn
post sc 4 jam sc obgyn
post sc 2 jam sc obgyn
post sc 4 jam sc obgyn
post partum 6 jam spt od obgyn
obgyn
post sc 4 jam sc obgyn
post sc 1 jam sc obgyn
post sc 1 jam sc obgyn
obgyn
post sc 4 jam sc obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 5 jam sc obgyn
post sc 7 jam sc obgyn
hamil dg isk obgyn
obgyn
post sc 3 jam sc obgyn
post partum 6 jam spt b obgyn
post sc hari ke 1 sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 4 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
abortus incomplite curetage obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
mioma uteri histerekto gynec
post sc 1.5 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 3.5 jam sc obgyn
post sc 2 jam sc obgyn
hamil dg oligo+ presbo obgyn
obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt od obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 4 jam sc obgyn
gawat janin+ gagal kosc obgyn
post sc hari ke 2 obgyn
post partum 6 jam spt od obgyn
post sc 2 jam sc obgyn
post sc 1 jam sc obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt b obgyn
post sc 6 jam sc obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt od obgyn
post partum 6 jam spt od obgyn
post partum 6 jam spt b obgyn
post partum 6 jam spt od obgyn
obgyn
pua + anemia gynec
post partum 6 jam spt b obgyn
post partum 6 jam spt od obgyn
abortus incomplite obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
obgyn
post partum 6 jam spt od obgyn
post sc 2.5 jam sc obgyn
obgyn
post sc 5 jam sc obgyn
post sc 6 jam sc obgyn
post sc 3 jam sc obgyn
obgyn
obgyn
post sc hari ke 1 sc obgyn
rupture vulva repair vulvagynec
post partum 6 jam spt b obgyn
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM jps JR BPJS TK PG

1 05.54.21 umi choiriyah 1 5/6/1976 46 1


2 05.64.27 siti ulfaizzah 1 2/12/1997 25 1
3 00.39.67 devi anjar f. 1 4/26/94 29 1
4 02.81.53 nanik indrawati 1 4/2/1990 33 1
5 05.64.82 umi kulsum 1 6/.20/81 41 1
6 05.07.80 hikmatul khoirunnisa 1 5/23/20002 20 1
7 04.55.35 madamilatul hasanah 1 10/3/1998 25 1
8 05.65.29 arisatul aini 1 2/4/2001 22 1
9 05.65.32 puji astutik 1 5/5/1993 29 1
10 04.44.23 ifa ouji astutik 1 11/5/1998 24 1
11 05.65.34 miselah 1 6/26/80 42 1
12 05.65.45 siti zainab 1 10/14/91 31 1
13 05.65.46 sri wahyuni 1 2/1/1986 37 1
14 05.65.67 khoirunnisa masbul 1 9/15/80 42 1
15 05.65.65 diana nuroktafiani 1 10/14/2000 22 1
16 05.65.75 nora safira 1 7/25/99 23 1
17 05.65.72 ulil maghfiroh 1 9/30/2001 21 1
18 00.53.59 dasri kurniawati 1 10/3/1995 28 1
19 05.58.26 bibit pujianti 1 9/7/1984 38 1
20 05.65.96 devi mayasari 1 2/2/1990 33 1
21 05.66.07 siti lutfiah 1 4/2/1995 28 1
22 05.66.15 susiati 1 5/25/95 27 1
23 05.66.11 riyati 1 7/2/1984 39 1
24 05.66.23 linda pratiwi 1 12/8/1999 23 1
25 05.66.00 husnul khotimah 1 5/24/91 32 1
26 05.66.22 veleria silvester 1 5/11/1997 25 1
27 05.66.44 rumani 1 8/20/80 42 1
28 05.66.83 khusyaimah 1 8/8/1988 34 1
29 05.66.80 nova putri sari 1 2/24/2002 23 1
30 05.66.93 kurniasih yunita 1 11/6/1989 33 1
31 05.66.97 khusnul hotimah 1 4/11/1992 30 1
32 05.66.94 nur hasiseh 1 6/15/2000 22 1
33 05.66.95 ratna dewwi saadah 1 6/15/96 26 1
34 05.67.00 etik retnowati 1 9/3/1987 36 1
35 05.67.04 gabela sari kusumawati 1 5/31/91 31 1
36 05.67.31 endang sari 1 9/5/1993 30 1
37 05.65.76 nabila dhenis naura 1 03-09-2006 17 1
38 05.67.17 eni ajeng alisa 1 3/3/1997 26 1
39 05.67.21 siska maisaroh 1 2/10/2002 20 1
40 05.67.09 nur latifah 1 4/1/1999 24 1
41 05.67.52 enny widiyawati 1 10/13/90 32 1
42 05.64.84 imeliya firanda 1 01-07-2005 18 1
43 05.67.38 yuni indah sari 1 05-08-2000 23 1
44 05.67.41 rohilah 1 4/6/1991 31 1
45 05.67.43 susilowati 1 8/3/1992 31 1
46 02.20.28 khotima 1 4/7/1987 35 1
47 05.67.62 berliana kralista shafaa 1 05-06-2006 15 1
48 04.23.13 fiwinarsih 1 1/7/1983 39 1
49 05.67.66 saifun nisa 1 10/10/1990 32 1
50 05.67.38 yuni indah sari 1 05-08-2000 23 1
51 05.67.72 sukimi 1 5/11/1986 36 1
52 05.67.77 ika nur t. 1 5/14/88 34 1
53 05.67.37 khalimah 1 7/27/76 46 1
54 02.87.32 sugiarti 1 05-08-2001 22 1
55 05.68.00 nimatul habibah 1 10/26/86 36 1
56 02.93.02 ika retno sulistiowati 1 3/18/86 37 1
57 05.68.03 renina agustin 1 5/3/1989 34 1
58 02.39.21 juan kartika susanti 1 12/21/83 39 1
59 05.68.15 efi sundari 1 7/16/90 32 1
60 05.68.31 emiliyah nur hasanah 1 03-02-2002 21 1
61 05.66.11 riyati 1 7/2/1984 39 1
62 05.68.35 dhulami 1 3/4/1966 57 1
63 04.23.13 fiwinarsih 1 1/7/1983 39 1
64 05.68.07 wati 1 3/31/93 30 1
65 01.46.80 yusi mela rulita 1 12/29/97 25 1
66 05.68.56 eka vidiyanti 1 7/16/99 23 1
67 05.68.60 yunita aprilia 1 04-05-2003 20 1
68 05.68.66 ilung ramadhanti 1 9/1/1998 25 1
69 05.68.67 irya sinta susi 1 5/28/84 38 1
70 05.34.16 yuli pramita dewi 1 7/16/91 31 1
71 05.68.48 sih dwi astutik 1 7/31/88 34 1
72 05.68.69 linda ayu kumala sari 1 5/14/2008 15 1
73 05.68.92 nurul aisyah 1 02-02-2002 21 1
74 02.74.33 vania sella fitri 1 11-09-2005 17 1
75 05.69.11 siti rochmana 1 1/20/2001 22 1
76 01.13.87 santi dela mahardika 1 8/8/1986 36 1
77 05.69.17 siti faizah 1 7/27/80 42 1
78 05.69.29 siti asiyah 1 5/16/98 25 1
79 01.22.47 ida royani 1 7/5/1995 28 1
80 05.66.73 miftakhul rachmah 1 8/8/1988 35 1
81 05.69.42 rusmiati 1 3/27/79 44 1
82 05.69.44 ari kusbianti 1 2/2/1996 27 1
83 05.69.46 agnes oktavianoly 1 10-09-2000 22 1
84 05.69.30 lailatul zahro 1 3/20/96 27 1
85 05.68.67 irya sinta susi 1 5/28/84 38 1
86 05.67.09 nur latifah 1 4/1/1999 24 1
87 05.69.59 ambarsari 1 4/26/99 24 1
88 05.69.57 farida 1 1/20/87 36 1
89 01.05.87 rina candra sari 1 1/8/1991 31 1
90 05.69.56 walafhotul isnaini 1 12/6/1985 37 1
91 05.69.83 yuliatin 1 2/19/96 27 1
92 05.69.88 siti fatimah 1 4/29/97 26 1
93 05.69.89 novarinda ramandina 1 11-12-2002 20 1
94 05.69.98 marsini 1 5/12/1991 31 1
95 05.70.16 uut utari 1 6/27/95 27 1
96 05.70.06 eka yuniar safitri 1 1/31/98 25 1
97 05.68.83 yunitasari 1 06-01-2002 20 1
98 05.70.28 ristiyah 1 5/20/2005 18 1
99 05.63.89 faiqotul himmah 1 4/15/91 32 1
100 05.70.42 diana puspitasari 1 8/25/2001 21 1
101 05.70.37 siti holisa 1 2/14/91 32 1
102 05.60.03 rotifah' aini 1 10/6/1997 25 1
103 04.60.95 dewi nur faizah 1 8/10/1999 23 1
104 05.68.80 lella eka hariyanti 1 03-10-2003 20 1
105 05.70.72 dewi ayu anisa 1 4/27/98 25 1
106 05.70.54 ririn rosida 1 1/7/1991 31 1
107 02.39.78 sintya wahyu ningsih 1 5/21/2005 18 1
108 05.70.96 faiqotul himma 1 9/20/99 23 1
109 05.71.03 devi novitasari 1 07-01-2004 18 1
110 05.69.30 lailatul zahro 1 3/20/96 27 1
111 03.93.54 ayla zania iganing 1 5/18/98 25 1
112 05.71.14 chotifah 1 3/10/1989 33 1
113 05.71.24 rosalinda putri 1 03-01-2006 17 1
114 05.71.20 fitri wulandari 1 2/13/98 25 1
115 05.67.84 siti khoiroh amaliah 1 11/12/1993 29 1
110 04.25.78 nining purwanti 1 3/18/96 27 1
116 05.71.48 Friday maharani 1 7/17/99 23 1
117 05.71.60 ernawati 1 9/20/2002 20 1
118 05.71.68 muani 1 4/27/81 42 1
119 05.71.67 nuri suhartini 1 4/15/83 40 1
120 05.71.87 cindy yanuar f. 1 1/27/98 25 1
121 05.71.78 entiningsih 1 5/7/1977 45 1
122 05.71.77 henik mahmudah 1 10/26/85 37 1
123 05.71.97 uswatun hasanah 1 5/14/98 25 1
124 05.71.69 febriana dwi wijayanti 1 2/23/2005 18 1
125 04.48.41 lati supiani 1 3/19/83 40 1
126 05.72.05 novita ramadani 1 11-04-2005 17 1
127 05.72.28 miranti arindani 1 3/2/1993 30 1
128 02.86.58 siti khumaiyah 1 11/22/90 32 1
129 05.06.77 sukartin 1 8/8/1957 65 1
130 01.01.78 dika andini suliyandari 1 01-11-2002 21 1
131 05.72.28 miranti arindani 1 3/2/1993 30 1
132 05.42.69 dela alvira damayanti 1 12/28/2003 19 1
133 00.69.08 rismawati 1 11/4/1992 31 1
134 04.88.35 nikmatul ula 1 11/17/2002 20 1
135 05.72.69 sarmilah 1 09-12-2005 17 1
136 05.72.89 fitri roziyah 1 7/21/82 40 1
137 05.72.72 mei fiani nur saputri 1 05-05-2002 21 1
138 05.72.68 eka nur lailah 1 1/17/2004 19 1
139 00.31.93 ita anggraeni 1 8/22/96 26 1
140 05.18.56 akhadiyah 1 7/16/83 39 1
141 05.73.00 umiati 1 7/9/1987 35 1
142 05.73.06 eka chindi lestari 1 9/14/98 24 1
143 05.73.15 rita megawati 1 5/10/1995 27 1
144 05.65.94 simah 1 1/26/1900 56 1
145 05.73.23 yulinda 1 1/7/1980 42 1
146 01.01.78 dika andini suliyandari 1 01-11-2002 21 1
147
148
149
150
151
152
153
154
155
156
JUMLAH 0 147 14 77 1 0 0 0 55

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN = 5 B,
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Lam Kondisi Keluar Status Pulang
ayar a BRM
Tanggal Alamat Diagnosa
dira kemba
li
Hidup Mati
Sembuh APS Rujuk Pindah (Desa) Primer
JKN RG kmk Lain MRS KRS wat < 48 > 48< 48> 48 Ruang

30 4 4 1 1 jarit ca cervic + anemia


1 2 1 1 1 gondoruso post partum 6 jam
1 2 1 1 1 pakuniran post partum 6 jam
2 3 1 1 1 sememu post sc 5 jam
3 3 1 1 1 sumberwulupost sc
3 5 2 1 1 bades kpd
3 5 2 1 1 sumberwulupost sc 2 jam
3 4 1 1 1 nguter post sc 2 jam
3 4 1 1 1 madurejo post sc 2 jam
3 4 1 1 1 tumpeng post sc 2 jam
3 4 1 1 1 nguter post sc 2 jam
3 5 2 1 1 randuangunpost sc 6 jam
3 5 2 1 1 bago post sc 1 jam
4 5 1 1 1 sidomulyo post sc 5 jam
4 5 1 1 1 penanggal post sc 3 jam
4 5 1 1 1 sumberejo post sc 2 jam
4 5 1 1 1 sumberwulupost sc 4 jam
4 5 1 1 1 pronojiwo post partum 6 jam
4 6 2 1 1 tempursari post sc 2 jam
5 6 1 1 1 gorontalo post sc 2 jam
5 6 1 1 1 gondoruso post sc 2 jam
5 6 1 1 1 pandanwangpost partum dg febris
5 6 1 1 1 gondoruso abortus imminent
5 6 1 1 1 sumbermujupost partum 6 jam
6 7 1 1 1 pronojiwo post sc hari ke 1
5 7 2 1 1 puger post sc 3 jam
7 8 1 1 1 sumberejo post sc 2 jam
8 9 1 1 1 orooroomb post sc 2 jam
8 9 1 1 1 sememu post partum 6 jam
8 9 1 1 1 tumpeng post partum 6 jam
8 10 2 1 1 lempeni hamil dg gea + tpha reaktif
8 10 2 1 1 sumberwulupost sc 2 jam
8 10 2 1 1 greik post sc 3 jam
9 10 1 1 1 madurejo post sc 1 jam
9 10 1 1 1 kalibendo post curetage
9 10 1 1 1 bago post sc 3 jam
9 10 1 1 1 jokarto post sc 3 jam
9 11 2 1 1 mojosari post sc 3 jam
9 10 1 1 1 supiturang post partum 6 jam
9 11 2 1 1 orooroomb kpd
9 11 2 1 1 gesang post partum 6 jam
9 11 2 1 1 jugosari post sc 2 jam
9 10 1 1 hcu madurejo post sc
9 10 1 1 1 supiturang heg
9 11 2 1 1 sumberjati febris
10 12 2 1 1 kalibendo ppi
10 11 1 1 1 pronojiwo pua-o
10 12 2 1 hcu sumbermujuket + anemia
10 11 1 1 1 nguter post partum 6 jam
11 11 1 1 1 madurejo post sc
11 12 1 1 1 tamanayu plasenta akreta + ane
11 13 2 1 1 candipuro hamil dg plasenta previa
11 13 2 1 1 sumberwulutoa
11 12 1 1 1 sumberejo post sc 4 jam
11 12 1 1 1 bades post partum 6 jam
12 13 1 1 1 gondoruso post sc 3 jam
12 13 1 1 1 tambahrejo post sc 4 jam
12 13 1 1 1 pasirian post sc 3 jam
12 13 1 1 1 tempurejo post sc 6 jam
12 15 3 1 1 jarit post partum 6 jam
13 15 2 1 1 gondoruso abortus imminent
13 13 1 1 hcu jatimulyo pua a/I ca cx+ anemia
13 15 2 1 1 sumbermujuket + anemia + syok hipovolem
13 15 2 1 1 sumberwuluket + anemia + syok h
13 16 3 1 1 sumberejo post sc 3 jam
14 15 1 1 1 condro post curetage
14 15 1 1 1 tumpeng post sc 3 jam
14 16 2 1 1 pasirian post partum 6 jam
14 15 1 1 hcu jarit post sc
14 15 1 1 1 bades post partum 6 jam
13 15 2 1 1 purorejo post sc 1 jam
15 15 1 1 1 bago abortus incomplite
15 16 1 1 1 jugosari post sc 3 jam
15 16 1 1 1 madurejo post partum 6 jam
15 17 2 1 1 bades post sc 3 jam
15 16 1 1 1 gesang jtm
16 18 2 1 1 gondoruso mioma uteri
16 17 1 1 1 sidomulyo post sc 3 jam
16 18 2 1 1 sememu post sc 3 jam
16 18 2 1 1 bago post sc 6 jam
16 18 2 1 1 kalibendo post sc 6 jam
16 18 2 1 1 jarit post sc hari ke 1
16 18 2 1 1 madurejo post sc 3 jam
17 18 2 1 1 bago post sc hari ke 1
17 18 1 1 1 jarit post sc hari ke 1
17 18 1 1 1 orooroomb post sc 3 jam
17 18 1 1 1 jarit post sc 4 jam
17 18 1 1 1 bago post sc 3 jam
17 18 1 1 1 orooroomb post sc 5 jam
17 18 1 1 1 sumberejo post sc 2 jam
17 18 1 1 1 tumpeng post partum 6 jam
18 19 1 1 1 jarit post sc 3 jam
18 20 2 1 1 sumberwulupost sc 3 jam
18 20 2 1 1 selokawar hamil dg obs dypsneu + hbsag r
19 22 3 1 1 gondoruso ppi
19 20 1 1 1 selokawar post sc 3 jam
19 21 2 1 1 pronojiwo post sc 3 jam
20 20 1 1 1 bago post partum 6 jam
20 22 2 1 1 bades post sc 2 jam
20 22 2 1 1 tambahrejo post sc 3 jam
21 22 1 1 1 sumberejo post sc hari ke 1
21 23 2 1 1 orooroomb post sc 3 jam
22 24 2 1 1 penanggal post sc 3 jam
22 23 1 1 1 madurejo post sc 3 jam
22 23 1 1 1 pekanbaru post curetage
22 23 1 1 1 selokawar post sc hari ke 1
22 23 1 1 1 tempeh post partum 6 jam
22 23 1 1 1 sumberwulupost partum 6 jam
22 23 1 1 1 penanggal post sc 1 jam
23 24 1 1 1 bago post sc hari ke 7 dg dyspepsia
23 24 1 1 1 jarit post sc 4 jam
23 24 1 1 1 jugosari post sc 2 jam
23 24 1 1 1 sumberwulupost sc 3 jam
23 25 2 1 1 condro post sc 3 jam
23 24 1 1 1 jatisari bo
23 25 2 1 1 bago post sc 2 jam
23 25 2 1 1 bago post sc 2 jam
24 26 2 1 1 pandanaru post partum 6 jam
24 26 2 1 1 sidomulyo post sc 1 jam
24 26 2 1 1 candipuro peb
25 26 1 1 1 pasirian post partum 6 jam
25 26 1 1 1 tempursari post sc 2 jam
25 26 1 1 1 jarit post sc 2 jam
25 27 2 1 1 sumberwuluhamil asma bronciale
26 27 1 1 1 jarit hamil dg febris
25 27 2 1 1 bulurejo post sc 2 jam
26 27 1 1 1 nguter post sc 2 jam
27 27 1 1 hcu condro post sc
27 29 2 1 1 sememu hamil dg kpd
27 28 1 1 1 gondoruso ca cervix
27 29 2 1 1 bades ppi
28 29 1 1 1 condro post sc hari ke 1
27 29 2 1 1 tumpeng post sc 1 jam
27 29 2 1 1 madurejo presbo
28 30 2 1 1 selokanyar post sc 1 jam
29 31 2 1 1 nguter bartolini
29 31 2 1 1 tegalrejo post sc 6 jam
29 31 2 1 1 penanggal post sc 3 jam
29 31 2 1 1 jugosari post sc 3 jam
29 30 1 1 1 kalibendo post sc 2 jam
29 30 1 1 1 sememu kpd
30 30 1 1 1 supiturang post partum 6 jam
30 31 1 1 1 kebonsari post sc 2 jam
30 31 1 1 1 selokawar post partum 6 jam
30 31 1 1 1 selokawar pua
30 31 1 1 hcu sumberejo post sc
31 31 1 1 1 bades post partum 2 jam

0 0 0 2294 2466 211 0 146 0 0 140 0 0

mutiara c19

WAH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)

NA MERAH
Tindakan
ICD (Operasi) Pelayanan

ca cervic + anemia gynec


post partum 6 jam spt od obgyn
post partum 6 jam spt od obgyn
post sc 5 jam sc obgyn
obgyn
obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 6 jam sc obgyn
post sc 1 jam sc obgyn
post sc 5 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 4 jam sc obgyn
post partum 6 jam spt od obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post partum dg febris obgyn
abortus imminent obgyn
post partum 6 jam spt od obgyn
post sc hari ke 1 sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt od obgyn
post partum 6 jam spt od obgyn
hamil dg gea + tpha reaktif obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 1 jam sc obgyn
post curetage curetage obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post partum 6 jam spt od obgyn
obgyn
post partum 6 jam spt b obgyn
post sc 2 jam sc obgyn
sc obgyn
obgyn
obgyn
obgyn
gynec
ket + anemia salpingekt obgyn'
post partum 6 jam spt od obgyn
obgyn
plasenta akreta + anehisterotomobgyn
hamil dg plasenta previa obgyn
gynec
post sc 4 jam sc obgyn
post partum 6 jam spt b obgyn
post sc 3 jam sc obgyn
post sc 4 jam sc obgyn
post sc 3 jam sc obgyn
post sc 6 jam sc obgyn
post partum 6 jam spt od obgyn
abortus imminent obgyn
pua a/I ca cx+ anemia gynec
ket + anemia + syok hipovolemikobgyn'
ket + anemia + syok hsos obgyn
post sc 3 jam sc obgyn
post curetage curetage obgyn
post sc 3 jam sc obgyn
post partum 6 jam spt od obgyn
sc obgyn
post partum 6 jam spt b obgyn
post sc 1 jam sc obgyn
abortus incomplite curetage obgyn
post sc 3 jam sc obgyn
post partum 6 jam spt od obgyn
post sc 3 jam sc obgyn
curetage obgyn
mioma uteri histerotomygynec
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 6 jam sc obgyn
post sc 6 jam sc obgyn
post sc hari ke 1 sc obgyn
post sc 3 jam sc obgyn
post sc hari ke 1 sc obgyn
post sc hari ke 1 obgyn
post sc 3 jam sc obgyn
post sc 4 jam sc obgyn
post sc 3 jam sc obgyn
post sc 5 jam sc obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt b obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
hamil dg obs dypsneu + hbsag reobgyn
obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post partum 6 jam spt od obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc hari ke 1 sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post curetage curetage obgyn
post sc hari ke 1 sc obgyn
post partum 6 jam spt od obgyn
post partum 6 jam spt od obgyn
post sc 1 jam sc obgyn
post sc hari ke 7 dg dyspepsia obgyn
post sc 4 jam sc obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
curetage obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt od obgyn
post sc 1 jam sc obgyn
obgyn
post partum 6 jam spt induksiobgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
hamil asma bronciale obgyn
hamil dg febris obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
sc obgyn
hamil dg kpd obgyn
gynec
obgyn
post sc hari ke 1 obgyn
post sc 1 jam sc obgyn
obgyn
post sc 1 jam sc obgyn
insisi gynec
post sc 6 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
obgyn
post partum 6 jam spt b obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt od obgyn
curetage biogynec
sc obgyn
post partum 2 jam spt b obgyn
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM jps JR BPJS TK PG

1 05.73.16 dwi rahayu ratnawati 1 9/3/1996 27 1


2 02.42.33 siti nurlia dwi f. 1 2/18/95 28 1
3 05.51.71 ferra ernawaty 1 1/17/95 28 1
4 05.73.23 yulinda 1 1/7/1980 42 1
5 03.79.77 yulia trisnawati 1 7/24/99 23 1
6 04.46.03 siti anisa 1 7/25/91 31 1
7 05.73.44 sulami 1 8/5/1967 56 1
7 04.72.61 siti fatimah 1 8/20/2001 21 1
8 03.36.38 kiki indrayanti 1 3/6/1989 33 1
9 05.73.35 muslimah 1 5/16/84 39 1
10 05.73.48 eni astutik 1 01-08-2003 20 1
11 05.73.38 dian novita 1 10/1/1993 30 1
12 05.00.62 novianingsih 1 11/13/200220 1
13 05.59.20 rofiatul agustin 1 1/7/1998 24 1
14 01.29.59 zumrotul djazilatul 1 11/5/1989 34 1
15 05.73.79 putri muamalah 1 10/25/200220 1
16 05.73.76 nur hayati 1 4/8/1993 29 1
17 05.73.85 eva yanti 1 07-06-2001 21 1
18 05.73.59 indah nursetyowiratih 1 3/19/92 31 1
19 05.32.16 juwariyah 1 12/6/1988 34 1
20 05.72.71 suwarni 1 4/25/85 38 1
21 05.73.96 patricia restanancy 1 11/24/93 29 1
22 00.43.89 luluk kustiarimami 1 1/19/85 38 1
23 00.43.89 luluk kustiarimami 1 1/19/85 38 1
24 05.25.18 ika agustin 1 2/8/1996 26 1
25 02.19.36 latifatul khasanah 1 12-06-2001 21 1
26 00.57.44 jumaida suprapti 1 11/1/1991 31 1
27 05.74.19 maylatul yessita 1 3/26/95 28 1
28 05.74.29 yana zain 1 3/7/1984 38 1
29 04.63.26 lutfi maulidiyah 1 5/5/1999 24 1
30 05.71.67 nuri suhartini 1 4/15/83 40 1
31 03.36.90 melista sugesti 1 5/14/95 28 1
32 05.74.62 wahyu indes saputri 1 12/20/96 26 1
33 05.74.47 erna nova siahaan 1 4/13/93 30 1
34 05.74.41 alfrista reftitania 1 9/15/90 32 1
35 05.00.62 novianingsih 1 11/13/200220 1
36 04.68.78 nur hamidah 1 9/17/96 26 1
37 04.68.78 nur hamidah 1 9/17/96 26 1
38 05.74.85 mela dwi anggraeni 1 5/31/97 26 1
39 05.75.05 wasiah 1 5/19/95 28 1
40 05.74.89 khurida wahyuni 1 9/18/99 23 1
41 05.75.08 siti nur khasanah 1 3/26/86 37 1
42 05.75.18 nilam anggraeni devi 1 1/28/96 27 1
43 05.74.99 khusnul khotimah 1 8/19/2000 22 1
44 00.40.64 yudia nurma 1 4/24/84 39 1
45 05.75.34 yuliani ismawati 1 7/19/96 26 1
46 05.75.26 elva juliati 1 10/8/1984 38 1
47 05.75.25 novi dwi yulianti 1 10/31/200220 1
48 05.30.51 isnayatun 1 7/26/87 35 1
49 05.75.44 malva devin naira 1 4/12/2012 10 1
50 05.75.21 titin eka ariyanti 1 5/15/92 31 1
51 05.75.24 elmiati 1 4/20/90 33 1
52 04.89.56 wiwin dwi lestari 1 1/1/1982 41 1
53 03.61.60 khimah fitrianis 1 01-12-2000 23 1
54 04.08.98 sinta putri nanda 1 05-06-2004 19 1
55 05.74.59 nuning purwanti 1 2/2/1982 41 1
56 05.75.76 siti iswanti 1 10-03-2003 19 1
57 05.75.80 eni purwati 1 6/26/2003 19 1
58 05.75.91 faiqotuz zahro 1 4/3/2002 21 1
59 05.76.02 siama 1 7/5/1950 73 1
60 05.76.04 ernawati 1 12/2/1992 31 1
61 05.69.22 sumiati 1 2/26/83 40 1
62 05.76.33 lilik astutik 1 10/15/63 59 1
63 03.42.57 maya paurita 1 6/5/1998 25 1
64 05.76.26 sindi tria ayu natalia 1 04-03-2003 20 1
65 02.28.08 fitrianingsih 1 4/22/89 34 1
66 02.32.62 nova kharisma 1 03-12-2002 21 1
67 05.76.47 fitria atmasari 1 12/22/200022 1
68 05.76.45 buyati 1 10/28/80 42 1
69 05.73.09 ayu agustina 1 8/26/2000 22 1
70 05.53.41 findi safitri 1 3/8/1993 39 1
71 05.63.01 minda sukma larasati 1 7/31/99 23 1
72 02.14.42 ernawati 1 8/4/1985 38 1
73 05.76.81 yuli anggraeni 1 7/7/1997 25 1
74 05.76.85 siti nur hasanah 1 11/28/93 29 1
75 05.76.85 siti nur hasanah 1 11/28/93 29 1
76 05.76.92 oktaviana ika p. 1 10/19/94 28 1
77 05.71.56 ferrina eky p. 1 2/14/98 25 1
78 02.20.28 khotima 1 4/7/1987 35 1
79 05.77.31 kholifatul isnayni 1 3/25/2003 20 1
80 05.75.52 wiwin andriyani 1 5/3/1985 38 1
81 02.86.58 siti khumaiyah 1 11/22/90 32 1
82 05.77.35 azizah nita wardani 1 12-01-2001 21 1
83 05.77.41 kusriati 1 6/7/1982 40 1
84 05.69.98 marsini 1 5/12/1991 31 1
85 05.77.48 monica linda permatasari 1 8/19/96 26 1
86 05.75.34 yuliani ismawati 1 7/19/96 26 1
87 00.94.70 septi dwi cahyani 1 9/22/92 30 1
88 05.77.58 siti nur farida 1 10/29/92 30 1
89 01.95.05 isa winingsih 1 6/16/95 27 1
90 05.77.61 risa umami 1 8/28/93 29 1
91 05.53.85 fira fatmasari 1 10/22/99 23 1
92 05.77.60 okte rina jayanti 1 10/13/98 24 1
93 05.77.66 menis suryani 1 1/1/1984 39 1
94 05.77.67 li ani 1 9/12/83 39 1
95 05.77.78 kokoh fifi lestari 1 12/1/1997 26 1
96 05.18.56 akhadiyah 1 7/16/83 39 1
97 05.78.09 selvilia eka tri w. 1 9/14/96 26 1
98 05.77.97 siti nur kholilah 1 12/24/97 25 1
99 05.75.34 yuliani ismawati 1 7/19/96 26 1
100 05.78.19 zubaidah 1 3/19/86 37 1
101 05.69.65 lilik choriyana 1 10/18/90 32 1
102 05.78.38 widiyawati 1 06-10-2001 22 1
103 05.78.29 nisvi febri ayu n. 1 2/24/98 25 1
104 01.92.56 tri wulandari 1 4/8/1987 35 1
105 05.78.27 fifi magfiroh 1 4/14/2003 20 1
106 03.18.43 eka mauliddia 1 5/18/2002 21 1
107 05.49.28 nurul siswi faizaatun n. 1 12/16/97 25 1
108 05.74.98 siti zulaicha 1 8/12/1993 29 1
109 05.78.70 hesti ratnasari 1 ### 28 1
110 02.79.06 risalatul ainiyah 1 1/20/88 35 1
111 05.78.88 sri rejeki 1 8/9/1990 32 1
112 05.78.83 qoyyimah 1 5/8/1999 23 1
113 05.78.77 sutiah 1 6/13/86 37 1
114 05.78.78 fresti vaula putri 1 04-10-2003 20 1
115 05.78.94 yuliatin 1 11/3/1990 33 1
116 05.79.05 nike kristian 1 5/13/99 24 1
117 05.78.99 yanik alfiati 1 9/24/91 31 1
118 05.52.14 nurlisa 1 1/7/1993 29 1
119 05.78.85 diana 1 6/27/91 31 1
120 05.79.17 ika emilia iravanti 1 05-01-2001 22 1
121 05.79.43 sutaya 1 6/16/71 52 1
122 05.78.51 ririn astutin 1 11/19/87 35 1
123 05.78.03 siti nur asiah 1 1/2/1992 31 1
124 05.79.63 ika andriani 1 6/17/93 30 1
125 05.29.69 alvi wulandari 1 7/25/96 26 1
126 05.71.56 ferrina eky p. 1 2/14/98 25 1
127 05.79.78 wulandari 1 7/20/94 28 1
128 05.78.51 ririn astutin 1 11/19/87 35 1
129 05.80.03 rizka 1 04-05-2002 20 1
130 03.94.31 siti nurjanah 1 2/11/1991 31 1
131 05.79.85 aprilia dwi lestari 1 4/13/96 27 1
132 05.80.09 siti aisyah 1 11-12-2003 19 1
133 02.79.06 risalatul ainiyah 1 1/20/88 35 1
134 05.80.20 yayang ariyanti deswita 1 06-10-2001 22 1
135 00.44.08 erna wijayanti 1 9/12/1998 24 1
136 05.80.30 devi nurfadila 1 3/12/1997 25 1
137 05.80.42 sri djaya lokawati 1 6/18/60 63 1
138 05.60.46 anisa 1 6/15/99 24 1
139 00.57.55 rohmah 1 7/5/1982 41 1
140 05.79.88 hartati 1 6/5/1981 42 1
141
142
143
144
145
146
JUMLAH 0 141 17 76 1 0 0 0 47

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
bayar Tanggal Lama BRM Alamat
dirawat kembali Hidup Mati Pindah (Desa)
Sembuh APS Rujuk
JKN RG kmk Lain MRS KRS < 48 > 48 < 48 > 48 Ruang

30 1 2 1 1 orooroombo
30 1 2 1 1 madurejo
30 1 2 1 1 jarit
1 2 1 1 1 sumberejo
30 1 2 1 1 bades
31 1 1 1 1 sememu
31 1 1 1 1 karanganom
31 1 1 1 1 orooroombo
31 1 1 1 1 selokawar
31 1 1 1 1 orooroombo
31 2 2 1 1 besuk
31 2 2 1 1 bades
31 2 2 1 1 sememu
31 2 2 1 1 bades
1 2 1 1 1 kalibendo
1 2 1 1 1 bulurejo
1 2 1 1 1 tanggul
1 2 1 1 1 selokawar
1 2 1 1 1 candipuro
2 3 1 1 1 tamanayu
3 4 1 1 1 penanggal
3 4 1 1 1 penanggal
2 2 1 1 hcu pasirian
3 4 1 1 1 pasirian
3 3 1 1 1 condro
4 5 1 1 1 kalibendo
4 6 2 1 1 selokawar
3 6 2 1 1 pasirian
4 6 2 1 1 bades
3 5 2 1 1 sumberejo
5 6 1 1 1 candipuro
5 6 1 1 1 tempurejo
5 6 1 1 1 candipuro
5 6 1 1 1 tegalrejo
5 6 1 1 1 sumberejo
5 7 2 1 1 sememu
5 5 1 1 hcu selokanyar
6 7 1 1 1 selokanyar
6 8 2 1 1 pasirian
7 8 1 1 1 kalibendo
6 7 1 1 1 bago
7 8 1 1 1 pasirian
8 8 1 1 1 nguter
7 9 2 1 1 jarit
7 9 2 1 1 kalibendo
8 9 1 1 1 pasirian
8 9 1 1 1 besuk
8 9 1 1 1 pronojiwo
8 9 1 1 1 bades
8 9 1 1 1 bades
8 9 1 1 1 sumberbaru
8 10 2 1 1 sumbermujur
8 11 3 1 1 pasirian
8 10 2 1 1 condro
9 9 1 1 1 selokawar
9 11 2 1 1 orooroombo
10 11 1 1 1 bago
10 12 2 1 1 tempursari
10 12 2 1 1 bades
11 12 1 1 1 pasirian
11 12 1 1 1 lempeni
12 13 1 1 1 tamanayu
13 14 1 1 1 kalibendo
12 13 1 1 1 nguter
12 14 2 1 1 kaliuling
13 14 1 1 1 pronojiwo
13 14 1 1 1 bago
13 14 1 1 1 bades
13 14 1 1 1 supiturang
13 15 2 1 1 sememu
13 15 2 1 1 madurejo
14 15 1 1 1 sumberwuluh
14 15 1 1 1 sumberwuluh
14 16 2 1 1 kalibendo
15 15 1 1 hcu sukorejo
16 17 1 1 1 sukorejo
15 17 2 1 1 pronojiwo
15 16 1 1 1 pasirian
15 17 2 1 1 kalibendo
16 17 1 1 1 pasirian
16 17 1 1 1 kloposawit
16 18 2 1 1 sememu
16 17 1 1 1 jarit
16 18 2 1 1 sumbermujur
17 18 1 1 1 selokawar
17 18 1 1 1 kepuharjo
17 18 1 1 hcu pasirian
17 17 1 1 1 pasirian
17 18 1 1 1 sememu
18 20 2 1 1 tempursari
18 19 1 1 1 sumberwuluh
18 19 1 1 1 bades
18 19 1 1 1 sumberwuluh
18 19 1 1 1 gondoruso
18 21 3 1 1 pronojiwo
18 20 2 1 1 nguter
19 20 1 1 1 sememu
19 20 1 1 1 selokanyar
19 20 1 1 1 jarit
19 20 1 1 1 pasirian
19 21 2 1 1 kalibendo
20 21 1 1 1 bago
20 21 1 1 1 supiturang
20 21 1 1 1 jatisari
20 21 1 1 1 selokawar
20 22 2 1 1 pasirian
20 22 2 1 1 bago
21 22 1 1 1 bandung
21 23 2 1 1 condro
21 23 2 1 1 condro
21 24 3 1 1 sememu
22 23 1 1 1 pasirian
22 23 1 1 1 sumberwuluh
22 23 1 1 1 pungdungsari
22 23 1 1 1 tegalrejo
22 23 1 1 1 jarit
23 24 1 1 1 nguter
22 23 1 1 1 sememu
22 24 2 1 1 selokawar
23 24 1 1 1 penanggal
23 24 1 1 1 pasirian
25 28 3 1 1 sumberejo
26 26 1 1 hcu penanggal
26 27 1 1 1 nguter
26 28 2 1 1 bulurejo
26 28 2 1 1 jarit
26 27 1 1 1 pasirian
26 29 3 1 1 kalibendo
27 27 1 1 1 penanggal
27 28 1 1 1 selokanyar
27 28 1 1 1 tempursari
27 28 1 1 1 orooroombo
27 29 2 1 1 kalibendo
28 28 1 1 1 sememu
28 29 1 1 1 pasirian
28 29 1 1 1 sumberwuluh
29 30 1 1 1 sumberejo
29 29 1 1 1 pasirian
29 30 1 1 1 kloposawit
29 30 1 1 1 sememu
29 30 1 1 1 selokanyar

0 0 0 2273 2051 191 0 140 0 0 132 2 0

mutiara c19

WAH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)

RNA MERAH
Diagnosa Tindakan
Primer ICD (Operasi) Pelayanan

post sc 5 jam sc obgyn


post sc 5 jam sc obgyn
post sc 2 jam sc obgyn
post sc hari ke 1 obgyn
hamil dg takikardy obgyn
bo curetage obgyn
pua a/I ca cx curetage obgyn
abortus incomplite curetage obgyn
post sc 3 jam sc obgyn
post sc 5 jam sc obgyn
post sc 4 jam sc obgyn
post sc 4 jam sc obgyn
post sc 1 jam sc obgyn
post sc 1.5 jam sc obgyn
post sc 2 jam sc obgyn
abortus incomplite curetage obgyn
post partum 6 jam spt od obgyn
post sc 2 jam sc obgyn
heg obgyn
post partum 6 jam spt induksiobgyn
post partum 2 jam spt b obgyn
ket + anemia+ syok h salpingekto obgyn
post sc sc obgyn
post sc hari ke 1 obgyn
retensio plasenta curetage obgyn
post partum 6 jam spt b obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 1 jam sc obgyn
missed abortion curetage obgyn
post partum 6 jam spt b obgyn
post partum 6 jam spt induksiobgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc hari ke 5 dg chepalgia + gynec
post sc sc obgyn
post sc hari ke 1 obgyn
post sc 4 jam sc obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt induksiobgyn
post sc 3 jam sc obgyn
post partum 6 jam spt b obgyn
missed abortion curetage obgyn
post sc 8 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
laserasi perinium gynec
post sc 6 jam sc obgyn
post sc 2 jam sc obgyn
mioma uteri histerektomobgyn
hamil dg kpd+ b20 obgyn
hamil dg asma obgyn
post sc 4 jam sc + mow obgyn
post partum 6 jam spt b obgyn
ppi obgyn
post partum 6 jam spt od obgyn
prolaps uteri + anemia gynec
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
pua a/I ca cx curetage + bgynec
bo curetage obgyn
post partum 6 jam spt od obgyn
post sc 6 jam sc obgyn
post partum 6 jam spt od obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 4 jam sc obgyn
post partum 6 jam spt b obgyn
post partum 6 jam spt od obgyn
hamil dg asma obgyn
hamil dg kpd obgyn
post sc sc obgyn
post sc hari ke 1 obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt od obgyn
post sc 1 jam sc obgyn
post partum 6 jam spt od obgyn
pua a/I he curetage gynec
post sc 1 jam sc obgyn
post partum 6 jam spt od obgyn
post sc 2 jam sc obgyn
post sc 1 jam sc obgyn
post partum 6 jam spt od obgyn
late hpp + anemia b-lynch + ligobgyn
post sc diluar dg gea obgyn
bo curetage obgyn
post sc hari ke 2 sc+ ht subtoobgyn
post partum 6 jam spt b obgyn
post sc 4 jam sc obgyn
post sc 4 jam sc obgyn
post partum 6 jam spt b obgyn
hamil dg kpd+ bothorax pain d. obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
late hpp + anemia obgyn
post sc 4 jam sc obgyn
post sc hari ke 2 sc obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 6 jam sc obgyn
post sc 6 jam sc obgyn
menometroragia gynec
post partum 6 jam spt od obgyn
post sc 6 jam sc obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post partum 6 jam spt induksiobgyn
post partum 6 jam spt od obgyn
bo curetage obgyn
post sc 4 jam sc obgyn
post sc 1 jam sc obgyn
ppi obgyn
ca cx + anemia gynec
post sc sc obgyn
post partum 6 jam spt od obgyn
post sc 6 jam sc obgyn
post partum 6 jam spt b obgyn
post curetage biopsi curetage + bobgyn
hamil dg kpd sc obgyn
post sc hari ke 1 obgyn
post partum 6 jam spt b obgyn
post sc 2 jam sc obgyn
post sc 4 jam sc obgyn
post sc 1 jam sc obgyn
menometroragia gynec
post sc 3 jam sc obgyn
post sc 1 jam sc obgyn
hamil dg vomiting+ gea gynec
myoma uteri + susp illeus + isk gynec
post partum 6 jam spt b obgyn
hiperplasi endometrium gynec
post sc 2 jam sc obgyn
Ruangan permata
Jumlah TT 10

JK Umu Cara bayar


No. NO RM NAMA TGL LAHIR r
L P Umum BPJS SKTM jps JR BPJS TK PG JKN RG

1 02.80.36 ayu dwi novitasari 1 11/17/98 24 1


2 05.80.50 nabillatul jannah 1 10/30/200319 1
3 05.80.51 rita setyaningrum 1 3/19/96 27 1
4 05.50.82 junaidatul arifah 1 12/17/86 36 1
5 02.31.82 meilinda ratna 1 1/5/1993 30 1
6 05.80.65 kurniawati 1 3/21/95 28 1
7 05.80.77 ema utami 1 3/31/2000 23 1
7 05.80.90 siti umiarsih 1 10/5/1993 30 1
8 00.26.96 yulaikha 1 8/7/1984 38 1
9 05.80.84 islam purwati 1 6/23/78 45 1
10 05.36.96 yulia kusmita sari 1 7/7/1999 23 1
11 05.27.23 holilah putri lestari 1 5/22/99 24 1
12 05.70.04 diana pungky 1 10/16/200022 1
13 03.61.60 khimah fitrianis sholehah 1 01-12-2000 23 1
14 05.81.18 ulfatul hasanah 1 ### 24 1
15 05.80.77 ema utami 1 3/31/2000 23 1
16 05.81.39 bella ika kurniawati 1 3/16/98 25 1
17 05.65.28 lailatul khomisah 1 10/19/91 31 1
18 05.81.48 anita 1 11/9/1999 23 1
19 05.81.61 hoirotun nikmah 1 05-01-2002 21 1
20 05.81.68 istiyorini 1 1/7/1991 31 1
21 05.71.26 lailatul hikmah 1 8/21/94 28 1
22 05.81.75 titik yulika murni 1 10/7/1991 31 1
23 05.81.68 istiyorini 1 1/7/1991 31 1
24 05.81.21 martin handayani 1 6/6/1981 42 1
25 05.82.04 nofitasari 1 3/19/2003 20 1
26 05.82.05 suliani 1 03-12-2004 19 1
27 05.82.37 hika wahyuwidi u. 1 10/9/1995 27 1
28 05.82.41 sukarsih lianasari 1 5/20/97 26 1
29 05.82.47 ratnasari 1 5/5/1997 26 1
30 04.08.98 sinta putri nanda 1 05-06-2004 19 1
31 05.82.52 irka noviandari 1 6/12/1991 31 1
32 05.82.30 nurul misiyati 1 1/23/87 36 1
33 05.82.62 yulaida 1 7/1/1987 36 1
34 05.82.59 lailatul hikmah 1 7/22/2001 22 1
35 05.82.82 ayun monera sari 1 3/10/1996 26 1
36 05.82.86 silvi myamelinda 1 5/31/2002 21 1
37 05.83.03 mayasaroh 1 12/21/200418 1
38 05.48.40 taslimah 1 2/13/2000 23 1
39 05.76.63 sri bawon 1 10/4/1996 27 1
40 05.74.83 ratnawati 1 12/3/1991 32 1
41 03.61.53 inra yani sari tua p. 1 7/23/96 26 1
42 05.83.35 eva widya wati 1 1/9/1990 32 1
43 05.83.36 vicky nuriyawati 1 5/6/1996 27 1
44 05.08.42 nining elva lestari 1 10/20/200022 1
45 05.82.30 nurul misiyati 1 1/23/87 36 1
46 05.79.66 vina nur eliza 1 2/18/98 25 1
47 05.83.57 wiwin 1 10/1383 39 1
48 05.81.02 sumatri 1 1/6/1972 51 1
49 05.83.78 poniyah 1 9/18/89 33 1
50 05.82.30 nurul misiyati 1 1/23/87 36 1
51 05.83.97 risma zumroatus s. 1 5/6/1989 34 1
52 05.83.86 santika 1 8/3/1985 38 1
53 05.84.05 purnamasari 1 5/10/1993 29 1
54 05.84.06 alifyanti fitrianda 1 3/6/1994 29 1
55 05.67.93 mentik riana 1 2/5/1984 39 1
56 05.84.09 ana mudrika salim 1 7/27/97 25 1
57 02.45.21 yulindra nur alieva 1 7/23/2002 20 1
58 01.18.36 dian lupi indrawati 1 12/29/89 33 1
59 05.84.23 ngatrimin 1 6/3/1991 32 1
60 05.83.82 umi badriyah 1 07-07-2001 22 1
61 05.84.30 dini hermawati 1 6/2/1990 33 1
62 05.11.30 luluk mukarromah 1 07-04-2002 21 1
63 05.82.59 lailatul hikmah 1 4/22/2001 22 1
64 05.84.54 safitri 1 12-07-2002 20 1
65 02.83.13 dewi lasmi anggraeni diah 1 2/29/2000 23 1
66 05.83.35 eva widya wati 1 1/9/1990 32 1
67 05.84.99 ernawati 1 1/8/1988 34 1
68 05.65.28 lailatul khomisah 1 10/19/91 31 1
69 05.79.17 ika emolia irawanti 1 05-01-2001 22 1
70 05.83.95 henik nur afifa 1 7/13/93 30 1
71 00.10.03 siti mutmainah 1 08-04-2000 22 1
72 05.85.16 irawati 1 9/24/94 28 1
73 05.85.27 insiyeh 1 2/9/1994 28 1
74 05.65.28 lailatul khomisah 1 10/19/91 31 1
75 05.84.48 erniawati 1 2/11/1981 41 1
76 03.08.66 roudiatul jannah 1 3/8/1994 28 1
77 05.85.60 nurhayati 1 3/16/90 33 1
78 05.85.77 fitriyah 1 01-10-2000 23 1
79 05.85.99 popi safira 1 3/23/2000 23 1
80 05.85.84 tri yuni rosintan 1 6/24/94 29 1
81 02.13.87 fifi dewi sari 1 6/28/96 27 1
82 04.45.43 annisa safitri 1 12/23/99 23 1
83 05.85.83 ifah ririn utami 1 4/4/1985 38 1
84 05.86.07 ulfi indriani sari 1 11/23/97 25 1
85 05.83.86 santika 1 8/3/1985 38 1
86 00.12.52 afrida swastika diwi 1 7/26/97 25 1
87 04.50.05 eva putri salsabila 1 12/22/200517 1
88 05.86.54 indah dwi hartini 1 11/29/200616 1
89 05.86.65 mila amelita 1 5/19/94 29 1
90 05.86.97 desi ayu anggela 1 12/28/200220 1
91 05.86.75 alfiatul hasanah 1 7/24/99 24 1
92 05.86.96 irma yunita 1 1/1/1991 32 1
93 05.87.10 anita dewi 1 7/24/96 27 1
94 05.87.14 rafita dewi 1 9/1/2001 22 1
95 05.87.33 sumiati 1 6/2/1990 33 1
96 05.87.34 zulaikha 1 12/23/90 32 1
97 05.87.30 binti solikah 1 12/15/88 34 1
98 05.87.25 ririn setyawati 1 5/29/89 34 1
99 05.87.44 mayangsari tri 1 5/28/2000 23 1
100 05.85.80 siti nur hasanah 1 7/15/93 30 1
101 05.87.50 mei purwanti 1 5/5/1982 41 1
102 05.87.68 siti zubaedah 1 5/9/1990 32 1
103 00.23.18 hanna marsaleg 1 3/30/2001 22 1
104 05.87.81 yiyin dera kusumawati 1 ### 38 1
105 05.87.94 atik purwatiningsih 1 11/8/1987 35 1
106 00.23.18 hannah marsaleg 1 3/30/2001 22 1
107 02.48.07 chusnul siti chotijah 1 1/21/96 27 1
108 05.87.90 italia 1 6/6/1989 34 1
109 05.88.04 revalia putri 1 01-12-2006 17 1
110 05.88.23 habibah oktaviani 1 10/24/97 28 1
111 03.96.60 sri dewi 1 10/6/1996 27 1
112 05.87.99 rawati 1 6/10/1984 38 1
113 05.88.17 atina luluul aula m. 1 10/25/200121 1
114 05.88.31 atim jumaati 1 9/15/93 29 1
115 05.88.22 niken andrea sahputri 1 7/22/91 32 1
116 04.80.80 yeni hermawan 1 6/22/95 28 1
117 01.13.08 sasqia anggun 1 12/20/99 23 1
118 05.88.58 nuri fatmawati 1 3/20/2007 16 1
119 02.75.46 evi ferrina p. 1 7/6/1994 29 1
120 03.02.26 lovi pradinda 1 6/21/2006 17 1
121 05.88.75 marisatul khoiriyah 1 22-06-2003 20 1
122 05.88.76 sofiatul aeni 1 10/26/200319 1
123 05.86.54 indah dwi hartini 1 11/29/200616 1
124 05.89.11 sicilia davina 1 1/26/96 27 1
125 05.88.89 nur aini 1 5/7/1994 29 1
126 05.88.88 dewi ayu puspitasari 1 6/23/92 31 1
127 02.36.93 nur aini 1 5/2/1996 27 1
128 05.89.02 prida yuliatin 1 2/13/89 34 1
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
JUMLAH 0 ### 11 89 1 0 0 0 28 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Lam Kondisi Keluar Status Pulang
Tanggal a BRM Alamat Diagnosa
dira kemba
li
Hidup Mati
Sembuh APS Rujuk Pindah (Desa) Primer
kmk Lain MRS KRS wat < 48 > 48 < 48 > 48 Ruang

29 1 2 1 1 madurejo post curetage


30 1 1 1 1 malang pua
30 1 1 1 1 candipuro post sc 1 jam
30 1 1 1 1 sumberurip post sc 1 jam
30 1 1 1 1 selokawar post sc 1.5 jam
30 2 2 1 1 ampelgadin post sc 1 jam
1 2 1 1 1 sememu hamil dg gea
2 3 1 1 1 jugosari post partum 6 jam
2 3 1 1 1 condro post partum 6 jam
2 3 1 1 1 kloposawit post partum 6 jam
2 3 1 1 1 jarit abortus incomplite
2 3 1 1 1 nguter post sc 2.5 jam
2 3 1 1 1 tamanayu abortus imminent
3 4 1 1 1 bago post sc 2 jam
3 4 1 1 1 sidomulyo post sc 1 jam
3 5 2 1 1 sememu hamil dg gea
3 4 1 1 1 magetan post curetage
3 5 2 1 1 selokanyar peb+ bsc
4 5 1 1 1 tegalejo kpd
4 5 1 1 1 candipuro post sc 1 jam
4 4 1 1 hcu uranggantu post sc
5 6 1 1 1 selokanyar post sc 1 jam
5 6 1 1 1 candipuro post sc 0.5 jam
5 6 1 1 1 uranggantu post sc hari ke 1
6 6 1 1 1 jarit post partum 6 jam
5 7 2 1 1 pandanwangpost sc 4 jam
6 7 1 1 1 sumberwulupost sc 1 jam
6 9 3 1 1 jugosari post sc 2 jam
6 8 2 1 1 tamanayu post sc 1 jam
6 8 2 1 1 penanggal post sc 3 jam
7 8 1 1 1 selokawar post partum 6 jam
7 8 1 1 1 condro post sc 3 jam
6 8 2 1 1 condro peb+ kpd
7 8 1 1 1 sumbermujupost sc 4 jam
7 8 1 1 1 selokanyar post sc 4 jam
7 9 2 1 1 candipuro post sc 3 jam
8 9 1 1 1 pasrujambepost sc 2 jam
9 10 1 1 1 sumberwulupost sc 0.5 jam
10 11 1 1 1 sumberwulupost sc 2 jam
10 11 1 1 1 sememu post sc 2 jam
10 11 1 1 1 pasirian post sc 4 jam
10 13 2 1 1 kaliuling PPI
10 11 1 1 1 purorejo post partum 6 jam
10 12 2 1 1 kaliuling post sc 4 jam
11 12 1 1 1 gondoruso post sc 4 jam
11 11 1 1 hcu condro post partum 1 jam
11 12 1 1 1 madurejo post sc 2 jam
11 12 1 1 1 penanggal post sc 3 jam
11 14 3 1 1 pandanaru prolaps uteri
12 13 1 1 1 nguter post partum 6 jam
12 13 1 1 1 condro post curetage
12 13 1 1 1 sememu post sc 3 jam
12 14 2 1 1 gondoruso post sc 4 jam
12 14 2 1 1 pasirian post partum 6 jam
13 14 1 1 1 jogoyudan post sc 2 jam
13 14 1 1 1 condro post partum 6 jam
13 14 1 1 1 selokanyar heg
13 14 1 1 1 nguter post sc 2 jam
13 14 1 1 1 tempursari post sc 3 jam
13 14 1 1 1 jugosari post sc 2 jam
13 16 3 1 1 sukosari hamil dg gea
13 14 1 1 mutiara 5 tumpeng ca cx+ susp tb+ b20
14 15 1 1 1 selokanyar post sc 2 jam
14 18 4 1 1 selokanyar burst abdoment
15 15 1 1 1 jugosari post partum 6 jam
16 17 1 1 1 tambahrejo post sc 2 jam
16 20 4 1 1 purorejo rupture perinium
17 18 1 1 1 kloposawit post sc 3 jam
17 17 1 1 hcu selokanyar post sc
17 18 1 1 1 pasirian post sc 2 jam
17 18 1 1 1 selokanyar post sc 2 jam
17 19 2 1 1 candipuro kpd
17 19 2 1 1 sumbermujupeb
18 20 2 1 1 sumberurip post sc 1 jam
18 19 1 1 1 selokanyar post sc hari ke 1
18 19 1 1 1 pronojiwo post partum 6 jam
18 19 1 1 1 selokawar post curetage
19 21 1 1 1 sumberwulupost sc 2 jam
20 21 1 1 1 jatisari post sc 3 jam
20 22 2 1 1 jarit post sc 3 jam
20 21 1 1 1 pasirian pua-o+ anemia
20 21 1 1 1 bades post partum 6 jam
20 21 1 1 1 selokawar post partum 6 jam
20 22 2 1 1 tempurejo post sc 3 jam
21 22 1 1 1 gondoruso post partum 6 jam
21 26 5 1 1 gondoruso wound dehisensi post sc
21 25 4 1 1 jatiroto heg + hbsag reaktif+ bsc
22 24 2 1 1 sememu post sc 1 jam
22 24 2 1 1 jarit abortus imminent
23 24 1 1 1 jati makmurheg
24 25 1 1 1 sememu post partum 6 jam
24 25 1 1 1 orooroomb hamil dg varicella
24 27 3 1 1 gondoruso ket + anemia
24 26 2 1 1 sememu ppi + kpd
25 26 1 1 1 nguter post partum 6 jam
25 27 2 1 1 jugosari peb + kpd
25 27 2 1 1 tempeh kpd
25 27 2 1 1 jarit post sc 2 jam
25 26 1 1 1 sememu post sc 2 jam
25 27 2 1 1 sumberwulupost sc 2 jam
26 27 1 1 1 sememu post sc 3 jam
25 27 2 1 1 sumberejo post sc 2 jam
26 27 1 1 1 pulo post sc 2 jam
25 26 1 1 hcu jugosari post sc
26 28 2 1 1 tempursari post sc 3 jam
27 28 1 1 1 bago post sc 6 jam
27 28 1 1 1 jugosari post sc hari ke 1
27 28 1 1 1 jarit post sc 2 jam
27 29 2 1 1 kloposawit post sc 6 jam
27 28 1 1 1 tempeh heg
27 29 2 1 1 candipuro post sc 3 jam
27 28 1 1 1 bulurejo post sc 1 jam
27 28 1 1 1 pasirian post sc 1 jam
27 28 1 1 1 bades post sc 6 jam
28 30 2 1 1 bades post sc 2 jam
27 28 1 1 1 jarit abortus complite
28 29 1 1 1 candipuro post sc 4 jam
28 30 2 1 1 candipuro post sc 2 jam
28 29 1 1 1 nguter ppi
28 30 2 1 1 madurejo post sc + ht hari ke 1
29 30 1 1 1 candipuro post sc 2 jam
29 30 1 1 1 tumpeng post partum 6 jam
29 31 2 1 1 selokanyar heg
29 31 2 1 1 jarit heg
30 31 1 1 1 tumpeng post partum 6 jam
30 31 1 1 1 supiturang post sc 1 jam
30 31 1 1 1 pasirian post partum 6 jam
30 31 1 1 1 tumpeng post sc 1.5 jam
31 31 1 1 hcu bulurejo post sc

0 0 2175 2175 184 0 128 0 0 122 0 0

AH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)


Tindakan
ICD (Operasi) Pelayanan

post curetage curetage + robgyn


gynec
post sc 1 jam sc obgyn
post sc 1 jam sc obgyn
post sc 1.5 jam sc obgyn
post sc 1 jam sc obgyn
hamil dg gea obgyn
post partum 6 jam spt brach obgyn
post partum 6 jam spt b obgyn
post partum 6 jam ve obgyn
abortus incomplite curetage obgyn
post sc 2.5 jam sc obgyn
abortus imminent obgyn
post sc 2 jam sc obgyn
post sc 1 jam sc obgyn
hamil dg gea obgyn
post curetage curetage obgyn
obgyn
obgyn
post sc 1 jam sc obgyn
sc obgyn
post sc 1 jam sc + sod obgyn
post sc 0.5 jam sc obgyn
post sc hari ke 1 obgyn
post partum 6 jam spt b obgyn
post sc 4 jam sc obgyn
post sc 1 jam sc obgyn
post sc 2 jam sc obgyn
post sc 1 jam sc obgyn
post sc 3 jam sc obgyn
post partum 6 jam spt b obgyn
post sc 3 jam sc obgyn
obgyn
post sc 4 jam sc obgyn
post sc 4 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 0.5 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 4 jam sc obgyn
obgyn
post partum 6 jam spt induksiobgyn
post sc 4 jam sc obgyn
post sc 4 jam sc obgyn
post partum 1 jam spt b obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
prolaps uteri gynec
post partum 6 jam spt od obgyn
post curetage curetage obgyn
post sc 3 jam sc obgyn
post sc 4 jam sc obgyn
post partum 6 jam spt b + cur obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt b obgyn
obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
hamil dg gea obgyn
ca cx+ susp tb+ b20 gynec
post sc 2 jam sc obgyn
burst abdoment rawat luka obgyn
post partum 6 jam spt od obgyn
post sc 2 jam sc obgyn
rupture perinium heacting p obgyn
post sc 3 jam sc obgyn
sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
obgyn
obgyn
post sc 1 jam sc obgyn
post sc hari ke 1 obgyn
post partum 6 jam spt b obgyn
post curetage curetage obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
pua-o+ anemia gynec
post partum 6 jam spt b obgyn
post partum 6 jam spt induksiobgyn
post sc 3 jam sc obgyn
post partum 6 jam spt b obgyn
wound dehisensi post sc gynec
heg + hbsag reaktif+ bsc obgyn
post sc 1 jam sc obgyn
abortus imminent obgyn
obgyn
post partum 6 jam spt induksiobgyn
hamil dg varicella obgyn
ket + anemia laparatomy obgyn
obgyn
post partum 6 jam spt b obgyn
obgyn
obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
sc obgyn
post sc 3 jam sc obgyn
post sc 6 jam sc obgyn
post sc hari ke 1 obgyn
post sc 2 jam sc obgyn
post sc 6 jam sc obgyn
obgyn
post sc 3 jam sc obgyn
post sc 1 jam sc obgyn
post sc 1 jam sc obgyn
post sc 6 jam sc obgyn
post sc 2 jam sc obgyn
abortus complite obgyn
post sc 4 jam sc obgyn
post sc 2 jam sc obgyn
obgyn
post sc + ht hari ke 1 sc + hister obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt b obgyn
obgyn
obgyn
post partum 6 jam spt b obgyn
post sc 1 jam sc obgyn
post partum 6 jam spt od obgyn
post sc 1.5 jam sc obgyn
sc obgyn
Ruangan permata
Jumlah TT 10

JK Umu Cara bayar


No. NO RM NAMA TGL LAHIR r
L P Umum BPJS SKTM jps JR BPJS TK PG

1 05.88.92 hanifah anggun s. 1 9/8/1998 24 1


2 05.89.03 prida yuliatin 1 2/13/90 34 1
3 05.76.02 siama 1 7/5/1950 73 1
4 05.89.17 cikrak supami 1 12/7/1985 38 1
5 00.86.92 warosatul ambiyak 1 9/18/2001 21 1
6 05.89.32 putri khoirun nisa 1 01-03-2003 20 1
7 05.89.39 diajeng nuraini 1 4/30/2000 23 1
7 05.76.81 yuli anggraeni 1 7/7/1997 26 1
8 05.79.12 mistinah sudarwati 1 3/4/1988 35 1
9 01.75.80 indah permatasari 1 9/16/97 25 1
10 05.88.89 nur aini 1 5/7/1994 29 1
11 05.89.63 iswati 1 4/13/93 30 1
12 00.10.03 siti mutmainah 1 08-04-'200022 1
13 05.89.49 dewi mustikah 1 4/23/2000 23 1
14 05.88.53 ida yulaisa 1 7/7/1997 26 1
15 05.89.70 lilis anandha 1 ### 23 1
16 05.89.88 rizha yulinda salsabila 1 7/26/98 25 1
17 05.87.33 sumiati 1 6/2/1990 33 1
18 05.19.13 sri budi astutik 1 4/26/83 40 1
19 05.90.07 deva 1 12/20/200022 1
20 04.37.37 nur kholifah 1 5/11/1994 28 1
21 05.48.86 emillia 1 2/23/93 30 1
22 05.90.11 linda dewik trianti 1 2/17/96 27 1
23 05.76.81 yuli anggraeni 1 7/7/1997 26 1
24 05.90.26 arum kusuma wardani 1 6/19/92 31 1
25 02.88.83 devina jelita surya dewi 1 6/13/95 28 1
26 05.90.49 sri wulandari r. 1 3/19/92 31 1
27 05.90.38 linda sofia 1 7/17/2005 18 1
28 05.90.56 siti mukaromah 1 10/14/87 35 1
29 05.90.70 ilma harista 1 4/21/92 31 1
30 04.30.81 novita dwi kristanti 1 7/22/95 28 1
31 05.90.66 winarsih 1 12/31/92 30 1
32 05.90.72 siti nurainiyah 1 7/2/1990 33 1
33 05.84.36 indrawati 1 11/6/1983 40 1
34 05.85.76 FERA SINTANIA PUTRI 1 9/19/2000 22 1
35 03.47.16 PURWATI 1 4/10/1981 41 1
36 05.91.02 ARDILA PUTRI TRISNANING 1 8/26/92 30 1
37 05.88.58 nuri fatmawati 1 3/20/2007 16 1
38 05.91.33 hamidah 1 12-02-2000 22 1
39 05.91.34 sukarni 1 1/27/86 37 1
40 05.76.18 ida purwati 1 8/7/1988 35 1
41 03.61.86 lailatul choiriyah 1 5/16/2002 21 1
42 05.91.46 nala saidaturrohmah 1 03-04-2004 19 1
43 04.80.81 shofiyah 1 5/13/2003 21 1
44 05.81.55 rohanah 1 5/28/86 37 1
45 05.91.59 ngasini 1 2/23/67 56 1
46 05.91.69 iis shofiyatuz zulfa 1 9/17/82 40 1
47 02.21.21 risma sari 1 5/9/1997 25 1
48 05.91.75 nafisah fuadiyah 1 9/6/1998 25 1
49 01.27.98 kamilatuz zahroh 1 3/29/92 31 1
50 05.91.85 dian rachma pratiwi 1 1/17/2003 20 1
51 04.31.15 shalom mia a. 1 3/17/2003 20 1
52 05.91.77 aris jinitasari 1 12/6/1991 32 1
53 05.91.73 rosita dewi 1 ### 26 1
54 01.12.75 susilowati 1 7/9/1989 33 1
55 05.91.84 norma loise a. 1 8/22/98 24 1
56 05.91.12 eka lutfia islamiah 1 7/22/2002 21 1
57 01.35.27 devia fahira ramadhani 1 12/30/98 24 1
58 05.92.17 nurhayati 1 08-08-2000 23 1
59 04.95.12 rosi rofita 1 09-06-2002 20 1
60 05.92.14 vivi ratna sari 1 12/1/1995 28 1
61 05.92.33 ika dewi purnamasari 1 2/22/87 36 1
62 05.92.44 susiyawati 1 12/3/1967 56 1
63 05.92.65 siti maisaroh 1 9/23/89 33 1
64 05.92.76 yahning 1 7/19/85 38 1
65 05.92.77 fera kristianingsih 1 07-04-2002 21 1
66 00.23.18 hanna marsaleg 1 3/30/2001 22 1
67 05.92.96 fika mira yusidreni 1 6/11/1996 26 1
68 05.92.49 vivi rochmawati 1 7/11/1995 27 1
69 04.86.94 siti faidhatul nadiro 1 03-07-2005 18 1
70 05.93.27 endang 1 3/6/1988 35 1
71 05.93.00 rindy kasta wahyuni 1 7/23/2004 19 1
72 05.92.28 baidatul qhuril 1 8/21/2001 21 1
73 05.93.33 nurma yunita 1 8/27/88 34 1
74 05.93.43 siti hadiyatun zukmana 1 7/16/95 28 1
75 05.93.49 susiyati 1 8/15/90 33 1
76 05.60.49 wulan febrianti 1 10/2/1992 31 1
77 05.88.61 ega dwi wijayanti 1 8/30/99 23 1
78 05.93.20 anita farisa 1 8/15/88 34 1
79 05.93.07 toyibatur rochmah 1 12/2/1981 42 1
80 05.93.22 siti aminah 1 5/20/78 45 1
81 04.51.75 frety sinta r. 1 11/29/200220 1
82 00.97.64 emilda aisyah furi 1 2/20/2003 20 1
83 05.93.61 sekar cintana putri 1 10/4/2000220 1
84 05.93.62 novi fitria 1 1/4/1991 32 1
85 05.93.76 dwi maulia susanti 1 10/16/95 27 1
86 05.59.67 divani ardalia 1 11/21/200319 1
87 05.66.84 yuliana 1 8/26/86 36 1
88 05.85.28 dian agustin 1 1/8/1999 24 1
89 05.93.86 ninik irawati 1 11/19/84 38 1
90 05.94.11 nikmah nur annisa 1 9/28/2001 21 1
91 05.94.18 enik yulis anita 1 1/25/89 33 1
92 01.40.81 dyah ayulia annur 1 12-08-2002 20 1
93 04.50.02 hasanatun munawaroh 1 8/27/89 33 1
94 05.94.23 khusnul khotimah 1 02-02-2007 16 1
95 05.93.84 siti aminah 1 11/4/1982 41 1
96 02.54.12 parti 1 1/7/1994 29 1
97 05.94.38 fatmawati 1 8/9/1982 40 1
98 01.70.72 atika zahro milatul azizah 1 11/18/94 28 1
99 05.94.56 yulia audina 1 12/6/1996 27 1
100 05.94.61 anita 1 12/30/96 26 1
101 05.54.21 umi choiriyah 1 5/6/1976 47 1
102 05.94.68 nuraeni 1 12/8/1992 31 1
103 05.94.97 mutmaidah 1 6/30/82 41 1
104 05.94.86 alfat roifa 1 7/10/1990 32 1
105 05.84.22 oktanti suliandari 1 2/28/92 31 1
106 05.93.62 novi fitria 1 1/4/1991 32 1
107 03.02.90 rubaina 1 09-04-2002 20 1
108 05.95.20 nelly agustin 1 8/15/2007 16 1
109 05.93.61 sekar cintana putri 1 10-04-2002 20 1
110 03.42.57 maya faurita 1 6/5/1998 25 1
111 02.44.06 friska dwi andini 1 07-01-2001 22 1
112 05.95.25 miftakhur rohmi 1 3/19/97 26 1
113 05.95.26 citra agustin anggraeni 1 08-12-2002 21 1
114 01.68.31 yuliani 1 2/12/1992 30 1
115 05.95.28 titik dwi wijayanti 1 8/27/92 30 1
116 00.08.15 ania sera 1 4/20/99 24 1
117 03.38.54 ririn sunarmi 1 5/6/1982 41 1
118 05.95.43 imroatul muhar 1 9/30/97 25 1
119 04.16.22 sulihati 1 9/30/97 25 1
120 05.95.20 nelly agustin 1 8/15/2007 16 1
121 05.95.55 supiyatik 1 8/12/1982 40 1
122 05.93.89 priati 1 3/16/71 52 1
123 02.57.16 ratna indri astutik 1 05-08-2000 23 1
124 05.95.78 popy ayu sandi 1 10/2/1997 26 1
125 05.86.88 laili ikrimatus sania 1 02-01-2005 18 1
126 04.40.40 siti rokaini 1 5/3/1997 26 1
127 05.96.20 ida laila 1 2/6/1991 32 1
128 02.68.66 devi eka w. 1 12/20/99 23 1
129 05.95.81 nirta 1 4/5/1986 37 1
130 05.96.39 faridatul islamiyah 1 9/1/1994 29 1
131 02.96.58 jumiatun 1 7/11/1943 79 1
132 02.03.88 amilatul addawiyah 1 12/23/97 25 1
133 00.09.45 evi suciati 1 12/5/1996 27 1
134 05.96.70 ella indriani 1 7/5/1998 27 1
135 05.96.63 samiah 1 8/23/95 28 1
136 05.97.05 jumiah 1 2/8/1983 40 1
137 05.96.97 dwi wahyu wulandari 1 11/21/90 32 1
138 05.85.16 irawati 1 6/20/91 32 1
139 00.50.92 suhermin 1 5/2/1983 40 1
140 05.54.21 umi choiriyah 1 5/6/1976 47 1
141 05.96.94 wike aris mandasari 1 12/6/1987 36 1
142 02.02.64 khusnul khotimah 1 2/1/1989 34 1
143 05.97.11 zainul sofia 1 8/3/1997 26 1
144 05.86.65 mila amelita 1 5/19/94 29 1
145 05.97.20 sukristin yuliana 1 7/14/95 28 1
146 03.44.57 rimadhona syayyidah 1 1/17/97 20 1
147
JUMLAH 0 147 9 102 1 0 0 0 35

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
bayar Tanggal Lama BRM Alamat
Hidup Mati
dirawat kembali Sembuh APS Rujuk Pindah (Desa)
JKN RG kmk Lain MRS KRS < 48 > 48 < 48 > 48 Ruang

30 1 2 1 1 penanggal
1 2 1 1 1 bulurejo
31 2 2 1 1 pasirian
31 1 1 1 1 sumbermuju
31 1 1 1 1 bades
31 2 2 1 1 jarit
31 2 2 1 1 pasirian
1 1 1 1 1 kalibendo
31 1 1 1 1 besuk
31 1 1 1 1 gondoruso
1 1 1 1 1 supiturang
1 2 1 1 1 sumbermuju
1 2 1 1 1 candipuro
1 3 2 1 1 kedungoro
1 3 2 1 1 penanggal
1 3 2 1 1 gondoruso
2 2 1 1 1 candipuro
2 4 2 1 1 jugosari
2 5 3 1 1 condro
3 4 1 1 1 gondoruso
2 4 2 1 1 pronojiwo
2 4 2 1 1 jarit
3 4 1 1 1 nguter
3 4 1 1 1 klaibendo
3 4 1 1 1 tempursari
3 4 1 1 1 pundungsar
4 5 1 1 1 sidomulyo
3 5 2 1 1 madurejo
4 5 1 1 1 kalibendo
5 5 1 1 1 sememu
5 6 2 1 1 makasar
4 6 2 1 1 tempursari
5 6 1 1 1 kalibendo
5 6 1 1 1 nguter
6 7 1 1 1 tambahrejo
6 9 3 1 1 bades
7 8 1 1 1 sidomulyo
7 9 2 1 1 nguter
7 9 2 1 1 gondoruso
7 9 2 1 1 klaibendo
7 8 1 1 1 gondoruso
7 9 2 1 1 nguter
8 9 1 1 1 sumbermuju
8 9 1 1 1 pandanaru
8 9 1 1 1 sumberwulu
8 9 1 1 1 kalibendo
8 9 1 1 1 kaliuling
8 10 2 1 1 jarit
8 10 2 1 1 denok
8 10 2 1 1 jatisari
9 10 1 1 1 bago
9 10 1 1 1 bulurejo
8 10 2 1 1 pasirian
8 10 2 1 1 sumbermuju
9 10 1 1 1 pandanwang
9 10 1 1 1 tempursari
9 10 1 1 1 pronojiwo
10 11 1 1 1 bago
10 11 1 1 1 bades
9 11 2 1 1 jarit
9 11 2 1 1 tambahrejo
10 12 2 1 1 besuk
10 11 1 1 1 sememu
11 13 2 1 1 bago
12 13 1 1 1 tempursari
12 14 2 1 1 purorejo
12 16 4 1 1 jugosari
13 14 1 1 1 bago
13 14 1 1 1 tempeh
14 15 1 1 1 bades
14 15 1 1 1 nguter
14 15 1 1 1 bades
14 15 1 1 1 sumberurip
14 16 2 1 1 orooroomb
14 15 1 1 1 tambahrejo
15 16 1 1 1 selokawar
14 15 1 1 1 sumberwulu
14 15 1 1 1 jatisari
14 15 1 1 1 candipuro
14 15 1 1 1 pasirian
14 15 1 1 1 tempursari
15 18 3 1 1 tambahrejo
15 16 1 1 1 nguter
15 16 1 1 1 pulo
15 17 2 1 1 sememu
16 17 1 1 1 orooroomb
16 17 1 1 1 sidomulyo
16 18 2 1 1 tempursari
16 18 2 1 1 bades
16 18 2 1 1 bulurejo
17 18 1 1 1 purorejo
17 19 2 1 1 kloposawit
17 19 2 1 1 candipuro
17 19 2 1 1 sumberwulu
17 19 2 1 1 bago
17 19 2 1 1 pronojiwo
18 22 4 1 1 bago
18 20 2 1 1 sumberwulu
19 20 1 1 1 pasirian
19 20 1 1 1 tempursari
19 20 1 1 1 selokawar
19 22 3 1 1 jarit
20 22 2 1 1 selokanyar
21 23 2 1 1 sumberejo
21 22 1 1 1 bago
21 23 2 1 1 pronojiwo
21 24 3 1 1 sememu
22 23 1 1 1 bades
22 22 1 1 hcu jarit
22 23 1 1 1 pulo
22 24 2 1 1 nguter
22 24 2 1 1 tempeh
22 24 2 1 1 nguter
22 24 2 1 1 kaliuling
22 24 2 1 1 selokawar
22 24 2 1 1 sumbermuju
23 24 1 1 1 pasirian
23 24 1 1 1 sumberwulu
23 24 1 1 1 orooroomb
23 24 1 1 1 gondoruso
24 25 1 1 1 jarit
24 25 1 1 1 bades
24 27 3 1 1 kaliuling
24 26 2 1 1 pronojiwo
24 26 2 1 1 pulo
24 26 2 1 1 bades
25 26 1 1 1 sumbermuju
27 27 1 1 1 tambahrejo
26 27 1 1 1 bago
27 28 1 1 1 jarit
28 30 2 1 1 tempeh
28 30 2 1 1 pulo
28 30 2 1 1 pasirian
28 29 1 1 1 pasirian
28 29 1 1 1 kaliuling
28 29 1 1 1 selokanyar
29 31 1 1 1 pulo
29 30 1 1 1 klaibendo
29 30 1 1 1 sumbermuju
29 30 1 1 1 tempursari
29 31 1 1 1 jarit
29 31 1 1 1 kloposawit
29 31 1 1 1 kalibendo
30 31 1 1 1 jarit
30 31 1 1 1 bekasi
30 31 1 1 1 tempursari
30 31 1 1 1 bades

0 0 0 2282 ### 218 0 146 0 0 142 3 0

krs dr vk

H 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)


Diagnosa Tindakan
Primer ICD (Operasi) Pelayanan

post sc 1 jam sc obgyn


post sc hari ke 1 obgyn
prolaps uteri gynec
post sc 2 jam sc obgyn
post sc 3.5 jam sc obgyn
post sc 4 jam sc obgyn
hamil dg kpd + letsu obgyn
hamil dg gea obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc hari ke 3 dg vomiting obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 1 jam sc obgyn
kpd obgyn
post sc 2.5 jam sc obgyn
pua a/I mioma + anemia gynec
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 1.5 jam sc obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt induksiobgyn
bo curetage obgyn
post sc 1 jam sc obgyn
post sc 2 jam sc obgyn
post partum 6 jam spt b obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
abortus incomplite curetage obgyn
post sc hari ke 1 sc obgyn
oligohidramnion + kpdsc obgyn
post sc 2 jam sc obgyn
pua curetage gynec
post partum 6 jam spt od obgyn
abortus incomplite curetage obgyn
post partum 6 jam spt b obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
ca cervix + gangguan fungsi ginjagynec
post partum 6 jam spt b obgyn
post sc 4 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 4 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 4 jam sc obgyn
post sc 3 jam sc obgyn
post sc 6 jam sc obgyn
post curetage curetage obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
bo curetage obgyn
ca cx + anemia gynec
post sc 2 jam sc obgyn
post partum 6 jam spt b obgyn
post sc 1 jam sc obgyn
post sc 2 minggu + leukositosis obgyn
post partum 6 jam spt b obgyn
ket + pneumonia + a laparatomy obgyn
kpd + gagal konservatisc obgyn
post partum 6 jam spt b obgyn
post partum 6 jam spt od obgyn
post sc 3 jam sc obgyn
post sc 4 jam sc obgyn
post partum 6 jam spt b obgyn
post sc 1.5 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2.5 jam sc obgyn
post sc 2.5 jam sc obgyn
post curetage curetage obgyn
abortus incomplite curetage obgyn
post sc hari ke 13 + leukositosis obgyn
kpd + ppi obgyn
post partum 6 jam spt od obgyn
post partum 6 jam spt od obgyn
post partum 6 jam spt od obgyn
post sc 2 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 1.5 jam sc obgyn
heg obgyn
kpd obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
hamil dg asma bronciale obgyn
kista ovarium gynec
post biopsi dilatasi kur gynec
post sc 2 jam sc obgyn
post partum 6 jam spt b obgyn
ca cervix + anemia gynec
post sc 4 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
retensio urin obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
rest plasenta obgyn
heg obgyn
post curetage curetage obgyn
post partum 6 jam spt b obgyn
post sc 3 jam sc obgyn
heg obgyn
kpd obgyn
hamil dg asma bronciale obgyn
post sc 2 jam sc + mow obgyn
post sc 3 jam sc obgyn
post sc 2.5 jam sc obgyn
post sc hari ke 2 obgyn
post sc hari ke 2 obgyn
mioma uteri histerekto gynec
post curetage curetage obgyn
post sc 4 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post partum 6 jam spt od obgyn
post partum 6 jam ekstraksi toobgyn
post sc 45 menit sc obgyn
kista ovarium gynec
pua gynec
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 2 jam sc obgyn
post sc 1 jam sc obgyn
post sc 3 jam sc obgyn
post sc 3 jam sc obgyn
post sc 2 jam sc obgyn
ca cervic + anemia gynec
post curetage curetage obgyn
post curetage curetage obgyn
post sc 3 jam sc obgyn
heg obgyn
post partum 6 jam spt od obgyn
post sc 2 jam sc obgyn
Ruangan permata
Jumlah TT 10

JK Cara bayar
No. NO RM NAMA TGL LAHIR Umur
L P Umum BPJS SKTM jps JR BPJS TK

1 03.03.28 elok faiqotul himmah 1 5/5/1998 25


2 03.53.32 suheni 1 1/6/1985 38 1
3 01.76.53 siti aminah 1 1/18/2000 23 1
4 05.97.40 sumiani 1 12/30/88 34 1
5 05.95.25 miftakhur rohmi 1 3/19/97 26 1
6 05.80.94 faidul hikmah 1 08-11-2000 23 1
7 02.52.70 nurul hidayah 1 9/27/92 30 1
7 04.12.05 silviana devi 1 5/26/99 24 1
8 05.97.13 masrurotul aini 1 1/2/1993 30 1
9 05.97.59 elsa maisaroh 1 5/14/2001 22
10 05.97.67 iza ufrotul romadhona 1 10/28/200022
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
JUMLAH 0 11 0 8 0 0 0 0

1 KOLOM WARNA UNGU TIDAK USAH DIISI


2 NAMA RUANGAN & JML TT POJOK KIRI ATAS TOLONG SELALU DIISI
3 PENULISAN NOMOR RM MENGGUNAKAN TANPA TITIK (032215)
4 KOLOM WARNA BIRU WAJIB DI ISI
5 KOLOM WARNA KUNING DIISI JIKA ADA
6 PENGHITUNGAN LAMA DIRAWAT (TGL KRS - TGL MRS), JIKA TGL KRS & MRS SAMA DI HITUNG 1
7 PENULISAN UMUR JIKA SATUAN TAHUN CUKUP DITULIS ANGKA SAJA, JIKA UMUR DI BAWAH 1 TAHUN ( 5 BULAN =
8 KOLOM PELAYANAN DITULIS SESUAI SPESIALISNYA
9 PENULISAN HURUF MENGGUNAKAN HURUF KAPITAL
10 JIKA PX MRS BULAN SEBELUMNYA DAN KRS BULAN INI, MAKA UTK TGL MRS DI BERI WARNA MERAH
Kondisi Keluar Status Pulang
Cara bayar Tanggal Lama BRM
dirawat kembali Hidup Mati
Sembuh
PG JKN RG kmk Lain MRS KRS < 48 > 48 < 48 > 48

1 30 1 2 1 1
30
30 1 2 1 1
31 1 1 1 1
31 1 1 1 1
31 1 1 1 1
31 1 1 1 1
1
1
1 31
1 1
3 0 0 0 248 6 8 0 5 0 0 5

krs dr vk

WAH 1 TAHUN ( 5 BULAN = 5 B, 7 HARI = 7 H)

RNA MERAH
Status Pulang
Alamat Diagnosa Tindakan
Pindah (Desa) Primer ICD (Operasi) Pelayanan
APS Rujuk
Ruang

sememu post sc 3 jam sc obgyn


kalibendo hamil dg bronkitis obgyn
jarit hamil dg plac previa totalis obgyn
bago ppi obgyn
nguter rest plasenta curetage obgyn
sememu post sc 3.5 jam sc obgyn
selokanyar post sc 3 jam sc obgyn
selokawar post partum 6 jam spt b obgyn
sumberurip post curetage curetage obgyn
nguter post sc 4 jam sc obgyn
sememu post sc 2.5 jam sc obgyn
0 0

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