pkbrs

1. No. Register Faskes
PKBRS MAJENE
5
Kode Provinsi
0
NAMA FASKES/
JARINGAN/JEJARING No. Jaringan/
Jejaring Faskes
1. Petugas Entri
Data
2
:
0
1
6
Lembar
0 Bulan :
R/I/KB/20
Kode
Kabupaten/
Kota
7
REGISTER PELAYANAN KB
ISTRI
8
NO.
PELAYANAN
BERGERAK
TANGGAL
PASCA
KEGUGURAN
INFORMED
CONSENT
17
PESERTA KB
22
KEGAGALAN
TIDAK
2
TANGGAL
LAHIR
19
9 14
OPERATIF/
PEMBERIAN/
PEMASANGAN
APBD
23
MANDIRI
NAMA
NO. HANDPHONE
11
STATUS
PESERTA
KB
(Kode)
PASCA
PERSALINAN
16
PENCABUTAN
APBN
ALAMAT
13 15
KOMPLIKASI
BERAT
1
NAMA SUAMI
PENCABUTAN
DAN
20
7 18
LAINNYA
6
3 24
21
NIK (NOMOR INDUK KEPENDUDUKAN)
5
BPJS
KESEHATAN
12
4 10
JENIS TINDAKAN
(Kode)
Kasus
(Kode)
PENGGUNAAN
ASURANSI
SUMBER ALOKON
2
2023
5
12
6
V
1 4
3
7 9 11
8
2
01-Oct-2023 0
0
0 8 1
Juraedah 0
0 1
3
6
Dandi 2 0
4 0
5 1 0
5
7 6 0 0
1
1
Teppo Banua
1 31-Dec-1979
0
1 0
5
02-Oct-2023 0
1
0 0 1
Habidi 0
0 1
4
6
Arman 7 0
4 0
1 1 0
5
7 7 0 0
1
0
Passarang
9 31-Dec-1997
3
2 0
8
03-Oct-2023 0
0
0 0 3
Amalia 0
0 1
4
6
- 6 0
4 0
9 0 0
5
7 7 0 0
1
0
Simullu
4 31-Dec-2006
2
3 0
9
04-Oct-2023 0
0
0 9 1
Rosmina 0
8 1
6
6
- 0 0
7 0
4 1 0
5
7 7 0 0
1
0
Luaor
6 31-Dec-0979
2
4 2
2
05-Oct-2023 0
0
0 9 3
Masdalia 0
0 1
3
6
Saleh 2 0
5 0
6 0 0
5
7 1 0 0
1
0
Pamboang
4 31-Dec-1991
0
5 1
3
06-Oct-2023 0
0
0 9 1
Haslinda 0
0 1
6
6
Asriadi 9 0
4 0
6 1 0
5
7 9 0 0
1
0
Labuang Selatan
1 31-Dec-1997
0
6 0
2
07-Oct-2023 0
0
0 3 1
Desi Nurhamila 0
0 1
3
6
- 2 0
6 0
0 1 0
5
7 5 0 0
1
1
Kampung Baru
1 31-Dec-2005
0
7 0
1
08-Oct-2023 0
0
0 9 1
Rosdiana 0
0 1
8
6
Muhlis 5 0
5 0
2 1 0
5
7 4 0 0
1
1
Soreang
1 31-Dec-1989
0
8 0
2
09-Oct-2023 0
0
0 8 1
Muna 0
0 1
8
6
A.M. Risal 2 0
5 0
3 1 0
5
7 4 0 0
1
1
BTN Mangga
2 31-Dec-1998
0
9 0
2
10-Oct-2023 0
0
0 9 3
Masdalia 0
0 1
3
6
Saleh 2 0
5 0
6 0 0
5
7 1 0 0
1
0
Pamboang
4 31-Dec-1991
0
10 1
4
11-Oct-2023 0
0
0 9 1
Mirnawati 0
0 1
8
6
Aswad 0 0
4 0
3 1 0
1
7 4 0 0
1
1
Pamboang
1 31-Dec-1990
2
11 0
3
12-Oct-2023 0
0
0 7 1
Heriati 0
0 1
6
6
Amran 9 0
7 0
1 1 0
5
7 2 0 0
1
0
Seppong
6 31-Dec-2003
0
12 1
6
13-Oct-2023 0
0
0 8 1
Fitriani 0
0 1
4
6
Bulia 7 0
6 0
9 1 0
5
7 2 0 0
1
0
Pellattoang
1 31-Dec-1991
0
13 1
6
14-Oct-2023 0
0
0 2 1
Laswia 0
8 1
6
6
Muhtar 0 0
3 0
0 1 0
5
7 8 0 0
1
0
Leppe
1 31-Dec-1982
0
14 9
6
15-Oct-2023 0
1
0 6 1
Munawar 0
3 0
11
6
Ismail Marsuki 0 0
8 0
1 1 0
5
7 8 0 0
1
1
Rangas Barat
4 31-Dec-1993
0
15 2
1
16-Oct-2023 0
0
0 0 1
Sitti Nur 0
0 0
11
6
- 3 0
6 0
6 1 0
5
7 3 0 0
1
1
Simullu
1 31-Dec-1981
2
16 0
8
17-Oct-2023 0
3
0 4 1
Syamsiah 0
0 1
4
6
M. Nasir 7 0
7 0
1 1 0
5
7 2 0 0
1
0
Kampung Baru
6 31-Dec-1974
0
17 1
2
18-Oct-2023 0
0
0 0 1
Nur Atika 0
0 1
3
6
Asnuddin 0 0
5 0
7 1 0
5
7 8 0 0
1
1
Kampung Baru
2 31-Dec-2000
0
18 0
1
19-Oct-2023 0
0
0 1 1
Risnawati 0
0 1
3
6
- 9 0
4 0
1 1 0
5
7 1 0 0
1
1
Palipi
1 31-Dec-1997
7
19 1
1
20-Oct-2023 0
8
0 9 1
Mulia 0
0 1
3
6
Amiruddin 9 0
7 0
1 1 0
5
7 2 0 0
1
1
Soreang
3 31-Dec-1997
0
20 1
1
21-Oct-2023 0
0
0 3 1
Safriani 0
0 1
3
6
Mansur 9 0
1 0
1 1 0
5
7 0 0 0
1
1
Soreang
1 31-Dec-1990
2
21 1
2
22-Oct-2023 0
6
0 0 1
Irmala 0
0 1
3
6
Busman 2 0
4 0
1 1 0
5
7 7 0 0
1
1
Pamboang
8 31-Dec-2001
0
22 0
1
23-Oct-2023 0
7
0 0 1
Musdalipa 0
0 1
4
6
Saeful 0 2
7 0
1 1 0
5
7 2 0 0
1
0
Palipi Soreang
5 31-Dec-2002
2
23 1
8
24-Oct-2023 0
0
0 6 1
- 0
0 1
6
6
Bakhtiar 5 0
2 0
3 1 0
5
7 0 0 0
1
0
Tanjung Batu
1 31-Dec-1965
0
24 1
7
25-Oct-2023 0
0
0 9 1
Warnida 0
0 1
4
6
Dedi Bangsawan 2 0
9 0
2 1 0
5
7 4 0 0
1
0
Jl. Ahmad Yani
1 31-Dec-1992
1
25 0
2
26-Oct-2023 0
0
0 0 1
Ade Hartina 0
0 1
3
6
- 0 0
5 0
7 1 0
5
7 2 0 0
1
1
Binanga
2 31-Dec-1996
1
26 2
1
27-Oct-2023 0
0
1 9 1
Nisma Faris 0
0 1
3
3
Wahyudi 0 0
4 0
1 1 0
5
7 6 0 0
1
1
Lembang
1 31-Dec-1990
0
27 0

2. 3
28-Oct-2023 0
0
0 9 1
Musdalipa 0
0 1
3
6
Sukiman 9 0
4 0
6 1 0
5
7 9 0 0
1
1
Tanjung Batu
1 31-Dec-1988
0
28 0
3
29-Oct-2023 0
2
0 8 1
Nursani 0
0 1
6
6
Ruslan 1 0
7 0
1 1 0
5
7 2 0 0
1
0
Somba
8 31-Dec-1981
0
29 1
7
30-Oct-2023 0
0
0 8 1
Wahdania 0
0 1
3
6
Jasna 5 0
4 0
7 1 0
5
7 2 0 0
1
1
Parabaya
1 31-Dec-1985
0
30 1
1
31-Oct-2023 0
4
0 9 1
Masniar 0
0 1
3
6
Jawahir 2 0
7 0
1 1 0
5
7 2 0 0
1
1
Kalasi
7 31-Dec-1993
0
31 1
Peserta KB Baru
2)
Peserta KB Ulangan 3 Implan 1 Batang
5 Pil Progestin
8
3 1 :
:
:
IUD
4 :
:
Suntikan 3 Bulanan
11 Tubektomi
Peserta KB Ganti
:
: Kondom
:
1 7
4
1)
Suntikan 3 Bulanan
Pil Kombinasi
Komplikasi :
:
Keterangan Kode
Vasektomi
6
STATUS PESERTA KB
: 10
KODE JENIS ALOKON (Diisi Pada Jenis Tindakan dan Kasus)
Suntikan 1 Bulanan
Implan 2 Batang
SELAIN STATUS PESERTA KB, JENIS TINDAKAN DAN KASUS DIISI TANDA CENTANG (V)
:
2
9
2
:
:
:

3. Lembar
LAMPIRAN R/I/KB/20
No. Jaringan/
Jejaring Faskes
3
Lamp.R/I/KB/20
Kode Provinsi
7
No. Register Faskes
PKBRS MAJENE
6
Kode
Kabupaten/
Kota
2
:
Bulan :
0
NAMA FASKES/
JARINGAN/JEJARING
0
5
0
1. Petugas Entri
Data
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
RINGKASAN HASIL PELAYANAN KB
PENCABUTAN
8
JUMLAH
PESERTA KB BARU (PB)
TOTAL PB
PEMBERIAN
INFORMED CONSENT
(Untuk Peserta KB
Ulangan)
0
1
1
1
1
1
1
1
1
1
1
1
1
0
0
1
1
1
1
1
1
1
1
2
PB PASCA
PERSALINAN
28
PB DAN KESERTAAN JKN
10
PELAYANAN ULANG
PESERTA KB ULANGAN
11
SUNTIKAN
IMPLAN
SUNTIKAN
SUNTIKAN
IMPLAN
MOW
PIL
SUNTIKAN
SUNTIKAN
SUNTIKAN
SUNTIKAN
IMPLAN
SUNTIKAN
SUNTIKAN
SUNTIKAN
SUNTIKAN
SUNTIKAN
KONDOM
SUNTIKAN
KONDOM
KONDOM
PIL
9 13
17
KOMPLIKASI BERAT
NO.
PELAYANAN KASUS
KEGAGALAN
0
PB PASCA
KEGUGURAN
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
0
0
0
5 12
PEMBERIAN INFORMED
CONSENT
(Untuk PB)
GANTI CARA
3
28
METODE
KONTRASEPSI
1
0
0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
PB JKN
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
0
1
1
1
1
1
0
0
1
1
1
0
1
0
0
0
14
PB NON JKN
6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
7
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3 4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
28
1
1
1
1
1
1
1
1
1
1
1
1
0
0
1
1
1
1
1
1
1
1
12
7 9
2 6
8
2023
11
V
4 5
1 3
1
1
1
1
1
1
1
1
1
1
1
1
0
0
1
1
1
1
1
1
1
1
Majene 08-November-2023
,
Pimpinan Faskes KB/Jaringan/Jejaring*
Hj. Nur Rezki, S.St., M.keb
( .................................................................................................)
197803232005022009
NIP/NRP
* Coret yang tidak perlu