Klaim April 2017

REKAPITULASI PENGAJUAN KLAIM RAWAT JALAN UMUM
PUSKESMAS : JABUNGSISIR
BULAN : APRIL 2017
TEMPAT PELAYAN : POLI KIA
JNS KELAMIN KUNJUNGAN LOKET
NO. TGL. JML L P TOTAL
PELAYANAN PASIEN B L B L
B L B L
1 1-Apr-17 5 0 1 3 1 3 2 Rp 15,000 Rp 10,000 Rp 25,000
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
3 3-Apr-17 3 0 1 0 2 0 3 Rp - Rp 15,000 Rp 15,000
4 4-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp 5,000
5 5-Apr-17 3 0 2 0 1 0 3 Rp - Rp 15,000 Rp 15,000
6 6-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp 5,000
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
10 10-Apr-17 5 0 2 0 3 0 5 Rp - Rp 25,000 Rp 25,000
11 11-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
12 12-Apr-17 4 0 1 0 3 0 4 Rp - Rp 20,000 Rp 20,000
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
14 14-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp 10,000
15 15-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp 5,000
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
17 17-Apr-17 3 0 1 2 0 2 1 Rp 10,000 Rp 5,000 Rp 15,000
18 18-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp 10,000
19 19-Apr-17 3 0 1 0 2 0 3 Rp - Rp 15,000 Rp 15,000
20 20-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp 10,000
21 21-Apr-17 6 1 3 1 1 2 4 Rp 10,000 Rp 20,000 Rp 30,000
22 22-Apr-17 4 1 2 0 1 1 3 Rp 5,000 Rp 15,000 Rp 20,000
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
25 25-Apr-17 2 0 2 0 0 0 2 Rp - Rp 10,000 Rp 10,000
26 26-Apr-17 8 0 4 0 4 0 8 Rp - Rp 40,000 Rp 40,000
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
31 1-May-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
JUMLAH 55 3 23 6 23 9 46 Rp 45,000 Rp 230,000 Rp 275,000
KETERANGAN :
L: 26 B: 3
L: 23
P: 29 B: 6
L: 23
BULAN : APRIL 2017
TEMPAT PELAYAN : POLI GIGI
B L B L
1 1-Apr-17 3 0 2 0 1 0 3 Rp - Rp 15,000 Rp 15,000
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
3 3-Apr-17 2 0 0 1 1 1 1 Rp 5,000 Rp 5,000 Rp 10,000
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
5 5-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
6 6-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp 5,000
7 7-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp 5,000
8 8-Apr-17 2 1 1 0 0 1 1 Rp 5,000 Rp 5,000 Rp 10,000
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
11 11-Apr-17 2 0 0 1 1 1 1 Rp 5,000 Rp 5,000 Rp 10,000
12 12-Apr-17 3 0 1 0 2 0 3 Rp - Rp 15,000 Rp 15,000
13 13-Apr-17 2 1 0 0 1 1 1 Rp 5,000 Rp 5,000 Rp 10,000
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
17 17-Apr-17 2 1 0 0 1 1 1 Rp 5,000 Rp 5,000 Rp 10,000
18 18-Apr-17 3 1 1 0 1 1 2 Rp 5,000 Rp 10,000 Rp 15,000
19 19-Apr-17 5 0 4 0 1 0 5 Rp - Rp 25,000 Rp 25,000
20 20-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp 10,000
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
22 22-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp 5,000
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
25 25-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
26 26-Apr-17 4 1 1 1 1 2 2 Rp 10,000 Rp 10,000 Rp 20,000
27 27-Apr-17 3 1 0 1 1 2 1 Rp 10,000 Rp 5,000 Rp 15,000
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
29 29-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp 5,000
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
JUMLAH 38 7 12 5 14 12 26 Rp 60,000 Rp 130,000 Rp 190,000
KETERANGAN :
L: 19 B: 7
L: 12
P: 19 B: 5
L: 14
BULAN : APRIL 2017
TEMPAT PELAYAN : BP
TGL. JML
NO. L P TOTAL
B L B L
1 1-Apr-17 7 0 2 1 4 1 6 Rp 5,000 Rp 30,000 Rp 35,000
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
3 3-Apr-17 2 0 0 0 2 0 2 Rp - Rp 10,000 Rp 10,000
4 4-Apr-17 6 0 2 0 4 0 6 Rp - Rp 30,000 Rp 30,000
5 5-Apr-17 3 0 2 1 0 1 2 Rp 5,000 Rp 10,000 Rp 15,000
6 6-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp 5,000
7 7-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp 5,000
8 8-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp 10,000
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
10 10-Apr-17 5 0 2 0 3 0 5 Rp - Rp 25,000 Rp 25,000
11 11-Apr-17 2 1 0 0 1 1 1 Rp 5,000 Rp 5,000 Rp 10,000
12 12-Apr-17 4 0 3 0 1 0 4 Rp - Rp 20,000 Rp 20,000
13 13-Apr-17 3 0 1 1 1 1 2 Rp 5,000 Rp 10,000 Rp 15,000
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
15 15-Apr-17 10 0 3 0 7 0 10 Rp - Rp 50,000 Rp 50,000
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
17 17-Apr-17 5 2 2 1 0 3 2 Rp 15,000 Rp 10,000 Rp 25,000
18 18-Apr-17 7 0 1 1 5 1 6 Rp 5,000 Rp 30,000 Rp 35,000
19 19-Apr-17 4 0 3 0 1 0 4 Rp - Rp 20,000 Rp 20,000
20 20-Apr-17 8 0 2 2 4 2 6 Rp 10,000 Rp 30,000 Rp 40,000
21 21-Apr-17 7 1 2 0 4 1 6 Rp 5,000 Rp 30,000 Rp 35,000
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
25 25-Apr-17 7 0 4 0 3 0 7 Rp - Rp 35,000 Rp 35,000
26 26-Apr-17 3 0 1 0 2 0 3 Rp - Rp 15,000 Rp 15,000
27 27-Apr-17 10 0 2 0 8 0 10 Rp - Rp 50,000 Rp 50,000
28 28-Apr-17 4 2 0 0 2 2 2 Rp 10,000 Rp 10,000 Rp 20,000
29 29-Apr-17 3 1 1 0 1 1 2 Rp 5,000 Rp 10,000 Rp 15,000
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
JUMLAH 104 7 36 7 54 14 90 Rp 70,000 Rp 450,000 Rp 520,000
KETERANGAN :
L: 43 B: 7
L: 36
P: 61 B: 7
L: 54
BULAN : APRIL 2017
TEMPAT PELAYAN : POLINDES JABUNG CANDI
B L B L
1 1-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
3 3-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
5 5-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
6 6-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
11 11-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
19 19-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
26 26-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
JUMLAH 0 0 0 0 0 0 0 Rp - Rp - Rp -
KETERANGAN :
L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : APRIL 2017
TEMPAT PELAYAN : POLINDES JABUNG WETAN
TGL. JML
NO. L P TOTAL
B L B L
1 1-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
3 3-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
4 4-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
5 5-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
6 6-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp 5,000
7 7-Apr-17 2 1 0 1 0 2 0 Rp 10,000 Rp - Rp 10,000
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
11 11-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
19 19-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
26 26-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
JUMLAH 7 2 0 5 0 7 0 Rp 35,000 Rp - Rp 35,000
KETERANGAN :
L: 2 B: 2
L: 0
P: 5 B: 5
L: 0
BULAN : APRIL 2017
TEMPAT PELAYAN : POSKESDES KALIKAJAR KULON
B L B L
1 1-Apr-17 2 0 0 2 0 2 0 Rp 10,000 Rp - Rp 10,000
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
3 3-Apr-17 2 1 0 1 0 2 0 Rp 10,000 Rp - Rp 10,000
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
5 5-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
6 6-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp 5,000
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
10 10-Apr-17 2 0 0 1 1 1 1 Rp 5,000 Rp 5,000 Rp 10,000
11 11-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
15 15-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp 5,000
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
19 19-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
25 25-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp 5,000
26 26-Apr-17 2 2 0 0 0 2 0 Rp 10,000 Rp - Rp 10,000
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
JUMLAH 11 5 1 4 1 9 2 Rp 45,000 Rp 10,000 Rp 55,000
KETERANGAN :
L: 6 B: 5
L: 1
P: 5 B: 4
L: 1
BULAN : APRIL 2017
TEMPAT PELAYAN : PUSTU KALIKAJAR WETAN
TGL. JML
NO. L P TOTAL
B L B L
1 1-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
2 2-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp 5,000
3 3-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp 10,000
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
5 5-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp 5,000
6 6-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp 5,000
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
11 11-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
19 19-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
26 26-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
JUMLAH 5 0 1 0 4 0 5 Rp - Rp 25,000 Rp 25,000
KETERANGAN :
L: 1 B: 0
L: 1
P: 4 B: 0
L: 4
BULAN : APRIL 2017
TEMPAT PELAYAN : POLINDES SIDODADI
B L B L
1 1-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
3 3-Apr-17 2 1 0 1 0 2 0 Rp 10,000 Rp - Rp 10,000
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
5 5-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
6 6-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
7 7-Apr-17 3 0 1 0 2 0 3 Rp - Rp 15,000 Rp 15,000
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
10 10-Apr-17 2 0 0 2 0 2 0 Rp 10,000 Rp - Rp 10,000
11 11-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp 5,000
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
13 13-Apr-17 2 0 2 0 0 0 2 Rp - Rp 10,000 Rp 10,000
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
15 15-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
17 17-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp 10,000
18 18-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp 10,000
19 19-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
22 22-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp 5,000
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
26 26-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp 5,000
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
29 29-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp 5,000
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
JUMLAH 18 1 9 4 4 5 13 Rp 25,000 Rp 65,000 Rp 90,000
KETERANGAN :
L: 10 B: 1
L: 9
P: 4 B: 4
L: 0
BULAN : APRIL 2017
TEMPAT PELAYAN : POLINDES RANDUMERAK
TGL. JML
NO. L P TOTAL
B L B L
1 1-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
3 3-Apr-17 2 1 0 1 0 2 0 Rp 10,000 Rp - Rp 10,000
4 4-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
5 5-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
6 6-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
10 10-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
11 11-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp 5,000
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
13 13-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
15 15-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp 5,000
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
17 17-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp 5,000
18 18-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp 5,000
19 19-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
21 21-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
25 25-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp 5,000
26 26-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
27 27-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp 5,000
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp -
JUMLAH 14 6 0 8 0 14 0 Rp 70,000 Rp - Rp 70,000
KETERANGAN :
L: 6 B: 6
L: 0
P: 8 B: 8
L: 0
BULAN : APRIL 2017

TEMPAT PELAYANAN JML L P TOTAL
PASIEN B L B L
B L B L
POLI KIA 55 3 23 6 23 9 46 Rp 45,000 Rp 230,000 Rp 275,000
POLI GIGI 38 7 12 5 14 12 26 Rp 60,000 Rp 130,000 Rp 190,000
POLI BP 104 7 36 7 54 14 90 Rp 70,000 Rp 450,000 Rp 520,000
POLINDES JABUNG CANDI 0 0 0 0 0 0 0 Rp - Rp - Rp -
POLINDES JABUNG WETAN 7 2 0 5 0 7 0 Rp 35,000 Rp - Rp 35,000
POSKESDES KALIKAJAR
11 5 1 4 1 9 2 Rp 45,000 Rp 10,000 Rp 55,000
KULON
PUSTU KALIKAJAR WETAN 5 0 1 0 4 0 5 Rp - Rp 25,000 Rp 25,000
POLINDES SIDODADI 18 1 9 4 4 5 13 Rp 25,000 Rp 65,000 Rp 90,000
POLINDES RANDUMERAK 14 6 0 8 0 14 0 Rp 70,000 Rp - Rp 70,000
JUMLAH 252 31 82 39 100 70 182 Rp 350,000 Rp 910,000 Rp 1,260,000
KETERANGAN :
L: 113 B: 31
L: 82
P: 139 B: 39
L: 100
Jabungsisir, APRIL 2017

MENGETAHUI,
KEPALA PUSKESMAS JABUNGSISIR BENDAHARA PUSKESMAS JABUNGSISIR
dr. YUNIAR INDAH SAVITRI TRIANA SETYAWULAN

NIP. 19840630 201001 2 018 NIP.19800112 200903 2 002
No. Kode Kegiatan : 1.02.1.02.01.16.17
Bendahara Pengeluaran Dinas Kesehatan Kabupaten Probolinggo
Satu Juta Tujuh Ratus Tujuh Puluh Tujuh Ribu Rupiah
Biaya Rawat Jalan Umum bulan Agustus 2015

Puskesmas : Jabungsisir
Mengetahui, Bendahara
Kepala Puskesmas Jabungsisir Puskesmas Jabungsisir

NIP. 19840630 201001 2 018 NIP.19800112 200903 2 002
#REF!
Agustus 2015
Juli 2015
Agustus 2015
#REF! Satu Juta Tujuh Ratus Tujuh Puluh Tujuh Ribu Rupiah
1260000 Satu Juta Dua Ratus Delapan Puluh Lima Ribu Rupiah
#REF! Satu Juta Tujuh Ratus Tujuh Puluh Tujuh Ribu Rupiah
REKAPITULASI PENGAJUAN KLAIM RAWAT JALAN LANSIA
BULAN : APRIL 2017
TEMPAT PELAYAN : PUSKESMAS JABUNGSISIR
TGL. JML
NO. L P TINDAKAN TOTAL
B L B L
1 1-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Apr-17 3 0 2 0 1 0 3 Rp - Rp 15,000 Rp - Rp 15,000
5 5-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp - Rp 5,000
6 6-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
8 8-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp - Rp 5,000
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp - Rp 5,000
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp - Rp 5,000
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp - Rp 10,000
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Apr-17 2 0 2 0 0 0 2 Rp - Rp 10,000 Rp - Rp 10,000
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 13 0 9 0 4 0 13 Rp - Rp 65,000 Rp - Rp 65,000
KETERANGAN :
L: 9 B: 0
L: 9
P: 4 B: 0
L: 4
BULAN : APRIL 2017
TGL. JML
B L B L
1 1-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Apr-17 2 0 0 0 2 0 2 Rp - Rp 10,000 Rp - Rp 10,000
6 6-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp - Rp 5,000
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 3 0 1 0 2 0 3 Rp - Rp 15,000 Rp - Rp 15,000

L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : APRIL 2017
TGL. JML
B L B L
1 1-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Apr-17 2 0 0 2 0 2 0 Rp 10,000 Rp - Rp - Rp 10,000
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp - Rp 5,000
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 3 0 0 3 0 3 0 Rp 15,000 Rp - Rp - Rp 15,000

L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : APRIL 2017
TGL. JML
B L B L
1 1-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Apr-17 2 2 0 0 0 2 0 Rp 10,000 Rp - Rp - Rp 10,000
5 5-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp - Rp 5,000
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp - Rp 5,000
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp - Rp 5,000
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Apr-17 1 0 0 1 0 1 0 Rp 5,000 Rp - Rp - Rp 5,000
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 6 2 0 4 0 6 0 Rp 30,000 Rp - Rp - Rp 30,000

L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : APRIL 2017
TGL. JML
NO. PELAYANAN PASIEN L P TINDAKAN TOTAL
B L B L
B L B L
1 1-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp - Rp 5,000
5 5-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp - Rp 5,000
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp - Rp 5,000
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Apr-17 2 0 0 0 2 0 2 Rp - Rp 10,000 Rp - Rp 10,000
19 19-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
20 20-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
21 21-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 10 1 2 0 7 1 9 Rp 5,000 Rp 45,000 Rp - Rp 50,000

L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : APRIL 2017
NO. TGL. JML L P TINDAKAN TOTAL
B L B L
1 1-Apr-17 3 0 0 2 1 2 1 Rp 10,000 Rp 5,000 Rp - Rp 15,000
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Apr-17 2 0 0 0 2 0 2 Rp - Rp 10,000 Rp - Rp 10,000
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
11 11-Apr-17 2 1 0 1 0 2 0 Rp 10,000 Rp - Rp - Rp 10,000
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp - Rp 5,000
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp - Rp 10,000
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Apr-17 2 0 1 0 1 0 2 Rp - Rp 10,000 Rp - Rp 10,000
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 17 1 3 3 10 4 13 Rp 20,000 Rp 65,000 Rp - Rp 85,000

L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : APRIL 2017
B L B L
1 1-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Apr-17 6 1 0 5 0 6 0 Rp 30,000 Rp - Rp - Rp 30,000
19 19-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Apr-17 3 1 0 2 0 3 0 Rp 15,000 Rp - Rp - Rp 15,000
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Apr-17 2 0 0 2 0 2 0 Rp 10,000 Rp - Rp - Rp 10,000
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 11 2 0 9 0 11 0 Rp 55,000 Rp - Rp - Rp 55,000

L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : APRIL 2017

TEMPAT PELAYANAN JML L P TINDAKAN TOTAL
PASIEN B L B L
B L B L
PUSKESMAS JABUNGSISIR 13 0 9 0 4 0 13 Rp - Rp 65,000 Rp - Rp 65,000
POLINDES JABUNG CANDI 3 0 1 0 2 0 3 Rp - Rp 15,000 Rp - Rp 15,000
POLINDES JABUNG WETAN 3 0 0 3 0 3 0 Rp 15,000 Rp - Rp - Rp 15,000
POSKESDES KALIKAJAR 6 2 0 4 0 6 0 Rp 30,000 Rp - Rp - Rp 30,000

KULON
PUSTU KALIKAJAR WETAN 10 1 2 0 7 1 9 Rp 5,000 Rp 45,000 Rp - Rp 50,000
POLINDES SIDODADI 17 1 3 3 10 4 13 Rp 20,000 Rp 65,000 Rp - Rp 85,000
POLINDES RANDUMERAK 11 2 0 9 0 11 0 Rp 55,000 Rp - Rp - Rp 55,000
JUMLAH 63 6 15 19 23 25 38 Rp 125,000 Rp 190,000 Rp - Rp 315,000
KETERANGAN :
L: 21 B: 6
L: 15
P: 42 B: 19
L: 23

MENGETAHUI,

NIP. 19840630 201001 2 018 NIP.19800112 200903 2 002
No. Kode Kegiatan : 1.02.1.02.01.16.17
Tiga Ratus Sepuluh Ribu Rupiah
Biaya kunjungan Lansia Puskesmas Jabungsisir bulan Agustus 2015

NIP. 19840630 201001 2 018 NIP.19800112 200903 2 002
#REF!
Biaya kunjungan 0 0 0 0 0 0
#REF! Tiga Rat 0 0 0 0 0
Biaya kunjungan Lansia Puskesmas Jabungsisir bulan Juli 2015
315000 Dua Ratus Dua Belas Ribu Lima Ratus Rupiah
Biaya kunjungan Lansia Puskesmas Jabungsisir bulan Agustus 2015
#REF! Tiga Ratus Sepuluh Ribu Rupiah
REKAPITULASI PENGAJUAN KLAIM RAWAT JALAN JAMKESDA
BULAN : APRIL 2017
TEMPAT PELAYAN : PUSKESMAS JABUNG SISIR
B L B L
1 1-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : MARET 2017
B L B L
1 1-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
12 12-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
20 20-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
23 23-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
27 27-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
31 31-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : MARET 2017
B L B L
1 1-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
12 12-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
20 20-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
23 23-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
27 27-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
31 31-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : MARET 2017
B L B L
1 1-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
12 12-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
20 20-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
23 23-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
27 27-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
31 31-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : MARET 2017
B L B L
1 1-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
12 12-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
20 20-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
23 23-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
27 27-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
31 31-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : APRIL 2017
B L B L
1 1-Apr-17 1 1 0 0 0 1 0 Rp 5,000 Rp - Rp - Rp 5,000
2 2-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
3 3-Apr-17 2 2 0 0 0 2 0 Rp 10,000 Rp - Rp - Rp 10,000
4 4-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Apr-17 2 0 1 1 0 1 1 Rp 5,000 Rp 5,000 Rp - Rp 10,000
6 6-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Apr-17 2 0 0 0 2 0 2 Rp - Rp 10,000 Rp - Rp 10,000
9 9-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Apr-17 1 0 0 0 1 0 1 Rp - Rp 5,000 Rp - Rp 5,000
12 12-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Apr-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp - Rp 5,000
14 14-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
15 15-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
20 20-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
23 23-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
27 27-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Apr-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 9 3 2 1 3 4 5 Rp 20,000 Rp 25,000 Rp - Rp 45,000

L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : MARET 2017
B L B L
1 1-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
2 2-Mar-17 2 0 0 0 2 0 2 Rp - Rp 10,000 Rp - Rp 10,000
3 3-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
4 4-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
5 5-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
6 6-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
7 7-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
8 8-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
9 9-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
10 10-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
11 11-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
12 12-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
13 13-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
14 14-Mar-17 1 0 1 0 0 0 1 Rp - Rp 5,000 Rp - Rp 5,000
15 15-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
16 16-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
17 17-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
18 18-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
19 19-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
20 20-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
21 21-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
22 22-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
23 23-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
24 24-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
25 25-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
26 26-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
27 27-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
28 28-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
29 29-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
30 30-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
31 31-Mar-17 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 3 0 1 0 2 0 3 Rp - Rp 15,000 Rp - Rp 15,000
L: 0 B: 0
L: 0
P: 0 B: 0
L: 0
BULAN : APRIL 2017 \

JML
TEMPAT PELAYANAN L P TINDAKAN TOTAL
PASIEN B L B L
B L B L
PUSKESMAS JABUNGSISIR 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
POLINDES JABUNG CANDI 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
POLINDES JABUNG WETAN 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
POSKESDES KALIKAJAR 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
KULON
PUSTU KALIKAJAR WETAN 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
POLINDES SIDODADI 9 3 2 1 3 4 5 Rp 20,000 Rp 25,000 Rp - Rp 45,000
POLINDES RANDUMERAK 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -
JUMLAH 9 3 2 1 3 4 5 Rp 20,000 Rp 25,000 Rp - Rp 45,000
KETERANGAN :
L: 5 B: 3
L: 2
P: 4 B: 1
L: 3

MENGETAHUI,

NIP. 19840630 201001 2 018 NIP.19800112 200903 2 002
No. Kode Kegiatan : 1.02.1.02.01.16.17
Lima Puluh Ribu Rupiah
Biaya rawat jalan Jamkesda bulan Agustus 2015

Puskesmas : Jabungsisir

NIP. 19840630 201001 2 018 NIP.19800112 200903 2 002
#REF!
Agustus 2015 Dec-99 #REF! Lima Puluh Ribu Rupiah
Juli 2015 45000 Lima Puluh Ribu Rupiah
Agustus 2015 #REF! Lima Puluh Ribu Rupiah
REKAPITULASI PENGAJUAN KLAIM RAWAT INAP
PESERTA PROGRAM JAMINAN KESEHATAN MASYARAKAT DAERAH (JAMKESMASDA)
PUSKESMAS JABUNGSISIR
BULAN : APRIL 2017
Tanggal Tanggal Hari Visite Pemeriksaan

Akomo Adminis
No Nama Pasien L/P Umur No Kartu Diagnosa Makan Askep Tindakan Total
dasi trasi
Masuk Keluar Rawat Dokter Penunjang
1 Th - - - - -
Jumlah - - - - - - - - -
KEPALA PUSKESMAS JABUNGSISIR
dr. YUNIAR INDAH SAVITRI

NIP. 19840630 201001 2 018
REKAPITULASI PENGAJUAN KLAIM RAWAT INAP PESERTA LANSIA
BULAN : APRIL 2017

Tanggal Tanggal Hari Akomo Visite Adminis Pemeriksaan
Masuk Luar Rawat dasi Dokter trasi Penunjang
1 th - - - - - -
2 th - - - - - -
Jumlah 0 - - - - - - - -

NIP. 19840630 201001 2 018
REKAPITULASI PENGAJUAN KLAIM RAWAT INAP PESERTA SKM
BULAN : MARET 2014

Tanggal Tanggal Hari Akomo Visite Adminis Pemeriksaan
Masuk Luar Rawat dasi Dokter trasi Penunjang
BGM+KEJANG
1 HAIKAL FIKRI L 21 Bln 3513122206130003 07-03-2013 10-03-2014 3 30,000 48,000 18,000 18,000 - 12,500 126,500
DEMAM
THYPOID
2 MUNASIK L 58 Th 3513120710550001 15-03-2014 18-03-2014 3 30,000 48,000 18,000 18,000 - 42,500 36,500 193,000
ABDOMEN+ISPA
Jumlah 6 60,000 96,000 36,000 36,000 - 55,000 36,500 319,500

NIP. 19840630 201001 2 018
17500
11000
8000
36500
No. Kode Kegiatan : 1.02.1.02.01.16.17
Seratus Tujuh Belas Ribu Rupiah
Biaya rawat inap Jamkesda PKM Jabungsisir a/n. 0 mulai tgl. 12/30/1899
s/d 0 selama 0 hari
No. Kode Rekening : 5.2.2.03.14
Jabungsisir,
dr. Yuniar Indah Savitri Sri Hartutik

NIP. 19840630 201001 2 018 NIP.19620811 198703 2 008
0.00
No. Kode Kegiatan : 1.02.1.02.01.16.17
Seratus Dua Puluh Enam Ribu Lima Ratus Rupiah
Biaya rawat inap Lansia PKM Jabungsisir a/n. 0 mulai tgl. 30-12-1899
s/d 30-12-1899 selama 0 hari

Jabungsisir,

NIP. 19840630 201001 2 018 NIP.19800112 200903 2 002
0.00
113000 Seratus Tiga Belas Ribu Rupiah
103000 Seratus Tiga Ribu Rupiah
43000 Empat Puluh Tiga Ribu Rupiah
78000 Tujuh Puluh Delapan Ribu Rupiah
513000 Lima Ratus Tiga Belas Ribu Rupiah
98000 Sembilan Puluh Delapan Ribu Rupiah
133000 Seratus Tiga Puluh Tiga Ribu Rupiah
53000 Lima Puluh Tiga Ribu Rupiah
68000 Enam Puluh Delapan Ribu Rupiah
0 0 0 0 0 Seratus Tujuh Belas Ribu Rupiah

SHOLEHUDD 16-10-2013 18-10-2013 2 78,000 Tujuh Puluh Delapan Ribu Rupiah
1 hari 63,000 Enam Puluh Tiga Ribu Rupiah
1 hari 50,000 Lima Puluh Ribu Rupiah
2 hari 78,000 Tujuh Puluh Delapan Ribu Rupiah
2 hari 78,000 Tujuh Puluh Delapan Ribu Rupiah
#REF! #REF! #REF! #REF! #REF! Dua Ratus Empat Puluh Delapan Ribu Lima Ratus Rupiah
#REF! #REF! #REF! #REF! #REF! Seratus Tujuh Belas Ribu Rupiah
SUCI
#REF! #REF! 2
LESTARI #REF! Delapan Puluh Delapan Ribu Lima Ratus Rupiah
ATINA 06-08-2014 08-08-2014 2 #REF! Delapan Puluh Delapan Ribu Lima Ratus Rupiah
MAULANA
15-08-2014 16-08-2014 1 #REF!
ISHAQ Enam Puluh Delapan Ribu Lima Ratus Rupiah
#REF! #REF! #REF! #REF! #REF! Seratus Lima Puluh Lima Ribu Rupiah
#REF! #REF! #REF! #REF! #REF! Dua Ratus Tiga Puluh Satu Ribu Rupiah
#REF! #REF! #REF! #REF! #REF! Seratus Tujuh Belas Ribu Rupiah
0 12/30/1899 0 0 - Seratus Tujuh Belas Ribu Rupiah

0 0 0 0 0 Seratus 0
HANIFA #REF! #REF! #REF! #REF! Seratus Lima Puluh Satu Ribu Rupiah
ARTIJO #REF! #REF! #REF! #REF! Dua Ratus Tiga Puluh Delapan Ribu rupiah
SENEWI ASIR #REF! #REF! #REF! #REF! Tiga Ratus Tujuh Puluh Empat Ribu Rupiah
SATUKI #REF! #REF! #REF! #REF! Dua Ratus Satu Ribu Rupiah
SARIYAH #REF! #REF! #REF! #REF! Dua Ratus Sembilan Puluh Tiga Ribu Rupiah
NAHAR #REF! #REF! #REF! #REF! Tiga ratus Tujuh Belas Ribu Rupiah
0 0 0 0 - Seratus Enam Puluh Empat Ribu Lima Ratus Rupiah

0 0 0 0 - Seratus Dua Puluh Enam Ribu Lima Ratus Rupiah
#REF! #REF! #REF! #REF! #REF! Seratus Enam Puluh Empat Ribu Lima Ratus Rupiah
#REF! #REF! #REF! #REF! #REF! Seratus Enam Puluh Empat Ribu Lima Ratus Rupiah
#REF! #REF! #REF! #REF! #REF! Seratus Sembilan Puluh Tiga Ribu Rupiah
#REF! #REF! #REF! #REF! #REF! Sembilan Puluh Delapan Ribu Rupiah
atus Rupiah
ibu rupiah
bu Rupiah
Ribu Rupiah
Lima Ratus Rupiah

ma Ratus Rupiah
Lima Ratus Rupiah
Lima Ratus Rupiah
REKAPITULASI PENGAJUAN KLAIM UGD
PUSKESMAS : JABUNG SISIR PROPINSI : JAWA TIMUR
BULAN : JANUARI 2013 KABUPATEN : PROBOLINGGO
NOMOR KODE NOMOR BIAYA TINDAKAN

TANGGAL
NO NAMA L/P UMUR ALAMAT MEDICAL DIAGNOSA
KUNJUNGAN
PESERTA RECORD ( Rp ) ( Rp )
1 NURUL HUDA L 33 Th SUMBERAN 1005220 28326 GE 05 -01-2013 Rp 12,500 Rp -
2 QOMARUDIN L 18 Th JABUNGSISIR 1005220 24159 VULMUS APP 12 -01-2013 Rp 12,500 Rp 7,000
3 ARINI P 4 Th BESUK KIDUL 1005220 27577 25 -01-2013 Rp 12,500 Rp 15,000

ASMA
JUMLAH Rp 37,500 Rp 22,000
JUMLAH TOTAL Rp 59,500
Probolinggo,
dr. Hj. LILIEK EKOWATI, MMKes
NIP. 19640928 199003 2 006

BULAN : FEBRUARI 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 HASANATUL P 9 BLN SIDODADI 1005220 23734 ISPA, SESAK 18 -02-2013 Rp 12,500 Rp 15,000
2 TIFA L 58 Th SUMBERAN 1005220 28331 OBS. FEBRIS 28 -02-2013 Rp 12,500
3 ARINI P 5 Th BESUK 1005220 27577 28 -02-2013 Rp 12,500

ASMA
JUMLAH Rp 37,500 Rp 15,000
Probolinggo,
NIP. 19640928 199003 2 006

BULAN : MARET 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 ARINA M P 10 Th SUMBERAN 1005220 2555 VULNUS APP 28 -03-2013 Rp 12,500
JUMLAH Rp 12,500 Rp -
Probolinggo,
NIP. 19640928 199003 2 006

BULAN : APRIL 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 NIHIL
JUMLAH Rp - Rp -
Probolinggo,
NIP. 19640928 199003 2 006

BULAN : MEI 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 NIHIL
JUMLAH Rp - Rp -
Probolinggo,
NIP. 19640928 199003 2 006

BULAN : JUNI 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 NIHIL
JUMLAH Rp - Rp -
Probolinggo,
NIP. 19640928 199003 2 006

PUSKESMAS : JABUNGSISIR PROPINSI : JAWA TIMUR
BULAN : JULI 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 FEBRI L 10 Th JABUNGSISIR 100522023836 COMBUSTIA 17 -07-2013 Rp 12,500 Rp 7,000
2 FEBRI L 10 Th JABUNGSISIR 100522023836 COMBUSTIA 18 -07-2013 Rp 12,500 Rp 7,000
JUMLAH Rp 25,000 Rp 14,000
TOTAL Rp 39,000
Probolinggo,

NIP. 19640928 199003 2 006
BULAN : AGUSTUS 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
NIHIL
JUMLAH Rp - Rp -
Probolinggo,
NIP. 19640928 199003 2 006
BULAN : SEPTEMBER 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 NOVITA APRILIA P 4.5 TH KALIKAJARKULON 100522023932 CELEBRAL PALSI 26 09-2013 Rp - Rp 10,000
JUMLAH Rp - Rp 10,000
Probolinggo,

NIP. 19640928 199003 2 006
BULAN : OKTOBER 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 NOVITA APRILIA P 2 Th KALIKAJARKULON 100522023933 CP + HIDROSEFALUS 04 -10-2013 Rp 12,500 Rp 20,000
JUMLAH Rp 12,500 Rp 20,000
Probolinggo,
NIP. 19640928 199003 2 006
BULAN : NOPEMBER 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 NOVITA APRILIA P 4 Th KALIKAJARKULON 100522023933 CP + HIDROSEFALUS 01-11-2013 Rp 12,500 Rp 20,000
JUMLAH Rp 12,500 Rp 20,000

Probolinggo,
dr. Hj. LILIEK EKOWATI, MM.Kes
NIP. 19640928 199003 2 006
BULAN : NOVEMBER 2012 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 NAHRAWI L 76 Th ALASTENGAH 35.13.130.107360080 OBS. FEBRIS 12 -11-2012 Rp 12,500
2 ARSIDIN ROSIDI L 68 Th JABUNGSISIR 35.13.120.1074405 HERNIA SCROTALIS 12 -11-2012 Rp 12,500
3 RIYADI L 71 Th KALIKAJARKULON 35.13.12.100641.001 S.KP + ASMA 21 -11-2012 Rp 12,500
4 YADI L 80 Th KALIKAJARWETAN 12.13.130.002.481045 CVA 30 -11-2012 Rp 12,500

Probolinggo,
NIP. 19640928 199003 2 006
BULAN : DESEMBER 2012 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 M. SABIDI L 5 Th BESUK KIDUL 1005220 27524 VULLNUS APP 03 -12-2012 Rp 12,500 Rp 7,000
2 NUR ZAINAB P 28 Th SUMBERAN 1005220 28256 SNAKE BITE 07 -12-2012 Rp 12,500 Rp 29,000
3 NUR ZAINAB P 28 Th SUMBERAN 1005220 28256 POST SNAKE BITE 10 -12-2012 Rp 12,500 Rp 7,000
4 M. FATUR ROHMA L 3 Th SUMBERAN 1005220 28268 OBS. FEBRIS 10 -12-2012 Rp 12,500
NUR ZAINAB P 28 Th SUMBERAN 1005220 28256 POST SNAKE BITE 11 -12-2012 Rp 12,500 Rp 7,000
MUH. SYAFI'I L 10 Th JABUNGWETAN 1005220 24075 KEJANG DEMAM 23 -12-2012 Rp 12,500
HADIATUL MAULA P 3 Th KALIKAJARKULON 1005220 23867 TF 26 -12-2012 Rp 12,500

JUMLAH Rp 112,500 Rp 64,000
Probolinggo,
NIP. 19640928 199003 2 006

TANGGAL
KUNJUNGAN
1 MUKTI SUDARSO L 77 Th KARANGANYAR 35.13.12.11.0635.0001 KP 06 -12-2012 Rp 12,500
2 ARWAMI P 71 Th RANDUMERAK 35.13.12.46431.0001 ISPA 12 -12-2012 Rp 12,500
3 ESU P 62 Th JABUNGWETAN 35.13.12.480350.002 GE 15 -12-2012 Rp 12,500
4 PATOYA P 66 Th ALAS KANDANG 35.13.134107.460.138 TF 27 -12-2012 Rp 12,500
5 SAWATI P 62 Th JABUNGWETAN 35.13.267940.0002 OBS. FEBRIS 28 -12-2012 Rp 12,500
Probolinggo,
NIP. 19640928 199003 2 006

LINGGO
RAWAT LUKA
NEBULIZER
LINGGO
NEBUL
LINGGO
LINGGO
LINGGO
LINGGO
LINGGO
LINGGO
LINGGO
PEMASANGAN MAG SLANG

LINGGO
AFF + PSG NGT (PASANG ATAU BUKA MAG SELANG) : 10000 &10000
LINGGO
AFF + PSG NGT (PASANG ATAU BUKA MAG SELANG) : 10000 &10000
LINGGO
LINGGO
CROSS INSISI
LINGGO
Kepala Dinas Kesehatan Kab. Prob
Selaku
Pengguna Anggaran Bendahara Pengeluaran Dinas Kesehatan Kabupaten Probolinggo
Tiga puluh dua ribu lima ratus rupiah

dr. Hj. Endang Astuti, MM
NIP. 19601103 198802 2 001 Biaya Klaim UGD Jamkesda bulan Nopember 2013 PKM Jabungsisir
Pejabat Pelaksana
Teknis Kegiatan Mengetahui, Bendahara
TUNIK, SE. MMKes

NIP.19580511 198008 2 002 dr. Hj. Liliek Ekowati, MMKes Triana Setyawulan
NIP. 19640928 199003 2 006 NIP.19800112 200903 2 002
Lunas Dibayar :
Bendahara Pengeluaran
Dyah Retno Widowati, S.Sos 32,500.00

NIP.19630224 198508 2 004
Nopember 2013 Dec-88 Tiga puluh dua ribu lima ratus rupiah
Januari 2013 59,500 Lima Puluh Sembilan Ribu Lima Ratus Rupiah
Februari 2013 52,500 Lima Puluh Dua Ribu Lima Ratus Rupiah
Maret 2013 12,500 Dua Belas Ribu Lima Ratus Rupiah
April 2013
Mei 2013
Juni 2013
Juli 2013 39,000 Tiga Puluh Sembilan Ribu Rupiah
Agustus 2012 62,500 Enam Puluh Dua Ribu Lima Ratus Rupiah
September 2013 10,000 Sepuluh ribu rupiah
Oktober 2013 32,500 Tiga puluh dua ribu lima ratus rupiah
Nopember 2013 32,500 Tiga puluh dua ribu lima ratus rupiah
November 2012 50,000 Lima Puluh Ribu Rupiah
Desember 2012 176,500 Seratus Tujuh Puluh Enam Ribu Lima Ratus Rupiah
PESERTA PROGRAM LANSIA
BULAN : JANUARI 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 RIYADI L 71 Th KALIKAJARKULON 3513121006410001 ASMA 09 -01-2013 Rp 12,500 Rp -
2 SUKATI P 76 Th JABUNGSISIR 12.13.130.011.461037.07622 TF 12 -01-2013 Rp 12,500 Rp -
3 JANTO / MADUN L 68 Th JABUNGWETAN 35.13.12.201145.0001 14 -01-2013 Rp 12,500 Rp -

S.KP
4 SUKUR L 73 Th JABUNGSISIR 34.13.12.010740.0037 18 -01-2013 Rp 12,500 Rp -

GE
5 ARBIYA P 76 Th JABUNGSISIR 35.13.24.10739.0031 31 -01-2013 Rp 12,500 Rp -

GE
Probolinggo,
NIP. 19640928 199003 2 006

BULAN : FEBRUARI 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 KAMINA P 73 Th ALAS KANDANG 35.13.13.410740.0174 HT 02 -02-2013 Rp 12,500
2 MARSAID L 83 Th JABUNG SISIR 35.13.12.010735.0037 ASMA 11 -02-2013 Rp 12,500
3 MARYATI P 85 Th RANDU MERAK 35.13.12.550628.0001 POST GE 23 -02-2013 Rp 12,500
4 MUTMAINAH P 79 Th ALAS SUMUR LOR 35.13.13.410734.0112 POST TF 23 -02-2013 Rp 12,500
Probolinggo,
NIP. 19640928 199003 2 006

BULAN : MARET 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 NITI L 75 Th SUMBERAN 35.13.13.410743.0193 GE 6 -03-2013 Rp 12,500
2 SAGINA P 76 Th RANDU JALAK 35.13.13.450137.0001 DM 9 -03-2013 Rp 12,500
3 KAMTIJA P 70 Th SIDODADI 35.13.12.410143.0002 HT 20 -03-2013 Rp 12,500
4 SUKRO L 60 Th JABUNGSISIR 35.13.12.010753.0072 TF 24 -03-2013 Rp 12,500
5 JUMA'ATI P 66 Th KALIKAJARKULON 35.13.12.410747.0047 TF 24 -03-2013 Rp 12,500
Probolinggo,
NIP. 19640928 199003 2 006

BULAN : APRIL 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 MASINIK P 68 Th SIDODADI 351312420145002 ASMA 1 -04-2013 Rp 12,500
2 SATROJA L 70 Th RANDUMERAK 3513121204430002 VULNUS APP 15 -04-2013 Rp 12,500 Rp 22,000
3 SATROJA L 70 Th RANDUMERAK 3513121204430002 KONTROL VULNUS APP 18 -04-2013 Rp 12,500 Rp 7,000
4 PAINI P 62 Th JABUNGCANDI 35.13.12.410150.0002 GE 26 -04-2013 Rp 12,500
JUMLAH Rp 50,000 Rp 29,000
TOTAL Rp 79,000
Probolinggo,

NIP. 19640928 199003 2 006
BULAN : MEI 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 UWI L 74 Th ALAS SUMUR LOR 35.13.13.010.739.0000 TF 04 -05-2013 Rp 12,500
2 TIMA P 75 Th JABUNGWETAN 351312491041001 ANEMIA 08 -05-2013 Rp 12,500
3 SAYATI P 75 Th JABUNGSISIR 35.13.12.4107380121 HIPOTENSI 11 -05-2013 Rp 12,500
4 SAMIN L 61 Th ALAS SUMUR LOR 35.13.13.1704520001 GE 13 -05-2013 Rp 12,500
5 SUTRISNO L 72 Th ALAS KANDANG 3513134107400170 HT 19 -05-2013 Rp 12,500
Probolinggo,

NIP. 19640928 199003 2 006

BULAN : JUNI 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 KAMINA P 72 Th ALASKANDANG 3513134107400174 ISPA 05 -06-2013 Rp 12,500
2 SUPARTO P 77 Th SUMBERAN 178/617.017/IV/2013 HT 14 -06-2013 Rp 12,500
3 RAMBAK P 70 Th TAMANSARI 3512144107390030 GE 14 -06-2013 Rp 12,500
4 PA'I L 69 Th ALASSUMURLOR 3513130107490142 ASMA 15 -06-2013 Rp 12,500
5 MISTUKI L 65 Th SUMBERAN 1213140017500533192565 THYPOID FEVER 15 -06-2013 Rp 12,500
6 SANAPI L 68 Th SIDODADI 3513120408450002 GE 17 -06-2013 Rp 12,500
7 MISYA P 67 Th KKW 3513135503460001 GE 18 -06-2013 Rp 12,500
8 HENDRIK L 61 Th MATEKAN 3513131603520001 HT 19 -06-2013 Rp 12,500
9 TAJAB P 84 Th JABUNGSISIR 3513124306290002 HT 22 -06-2013 Rp 12,500
10 NIJO L 67 Th BESUKKIDUL 3513131603460001 POST COR 30 -06-2013 Rp 12,500
Probolinggo,

NIP. 19640928 199003 2 006
BULAN : JULI 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 BUSIA P 65 Th ALASTENGAH 3513134504430002 KEP 01 -07-2013 Rp 12,500
2 HAJAR / HATIJA P 70 Th ALASTENGAH 35134107360058 HT 03 -07-2013 Rp 12,500
3 SAHRIYA P 76 Th SUMBERAN 1230140017440837061948 VERTIGO 05 -07-2013 Rp 12,500
4 ATNATI P 60 Th KKW 3513124206530000 GED 11 -07-2013 Rp 12,500
5 JOTO L 67 Th KKW 3513120107460024 OBS. FEBRIS 14 -07-2013 Rp 12,500
6 SURAHMI P 62 Th ALASSUMUR 3513134107510147 S. KP 15 -07-2013 Rp 12,500
7 SALANI ARIF P 67 Th BESUK AGUNG 3513134107460042 GE 31 -07-2013 Rp 12,500
TOTAL Rp 87,500
Probolinggo,
NIP. 19640928 199003 2 006
BULAN : AGUSTUS 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
NIHIL
JUMLAH Rp - Rp -
Probolinggo,
NIP. 19640928 199003 2 006
BULAN : SEPTEMBER 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
NIHIL
JUMLAH Rp - Rp -
Probolinggo,
NIP. 19640928 199003 2 006
BULAN : OKTOBER 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 SANADIN L 72 Th KALIKAJARKULON 3513122605410001 BPH 08 -10-2013 Rp 12,500 Rp 20,000
JUMLAH Rp 12,500 Rp 20,000
Probolinggo,

NIP. 19640928 199003 2 006
BULAN : NOPEMBER 2013 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 SANADIN L 72 Th KALIKAJARKULON 3513122605410001 BPH 08 -11-2013 Rp 12,500 Rp 20,000
JUMLAH Rp 12,500 Rp 20,000
Probolinggo,
NIP. 19640928 199003 2 006
BULAN : NOVEMBER 2012 KABUPATEN : PROBOLINGGO

TANGGAL
KUNJUNGAN
1 NAHRAWI L 76 Th ALASTENGAH 35.13.130.107360080 OBS. FEBRIS 12 -11-2012 Rp 12,500
2 ARSIDIN ROSIDI L 68 Th JABUNGSISIR 35.13.120.1074405 HERNIA SCROTALIS 12 -11-2012 Rp 12,500
3 RIYADI L 71 Th KALIKAJARKULON 35.13.12.100641.001 S.KP + ASMA 21 -11-2012 Rp 12,500
4 YADI L 80 Th KALIKAJARWETAN 12.13.130.002.481045 CVA 30 -11-2012 Rp 12,500

Probolinggo,
NIP. 19640928 199003 2 006

TANGGAL
KUNJUNGAN
1 M. SABIDI L 5 Th BESUK KIDUL 1005220 27524 VULLNUS APP 03 -12-2012 Rp 12,500 Rp 7,000
2 NUR ZAINAB P 28 Th SUMBERAN 1005220 28256 SNAKE BITE 07 -12-2012 Rp 12,500 Rp 29,000
3 NUR ZAINAB P 28 Th SUMBERAN 1005220 28256 POST SNAKE BITE 10 -12-2012 Rp 12,500 Rp 7,000
4 M. FATUR ROHMA L 3 Th SUMBERAN 1005220 28268 OBS. FEBRIS 10 -12-2012 Rp 12,500
MUH. SYAFI'I L 10 Th JABUNGWETAN 1005220 24075 KEJANG DEMAM 23 -12-2012 Rp 12,500
HADIATUL MAULA P 3 Th KALIKAJARKULON 1005220 23867 TF 26 -12-2012 Rp 12,500

JUMLAH Rp 112,500 Rp 64,000
Probolinggo,
NIP. 19640928 199003 2 006

TANGGAL
KUNJUNGAN
1 MUKTI SUDARSO L 77 Th KARANGANYAR 35.13.12.11.0635.0001 KP 06 -12-2012 Rp 12,500
2 ARWAMI P 71 Th RANDUMERAK 35.13.12.46431.0001 ISPA 12 -12-2012 Rp 12,500
3 ESU P 62 Th JABUNGWETAN 35.13.12.480350.002 GE 15 -12-2012 Rp 12,500
4 PATOYA P 66 Th ALAS KANDANG 35.13.134107.460.138 TF 27 -12-2012 Rp 12,500
5 SAWATI P 62 Th JABUNGWETAN 35.13.267940.0002 OBS. FEBRIS 28 -12-2012 Rp 12,500
Probolinggo,
NIP. 19640928 199003 2 006

HEATING 4 & RAWAT LUKA
RWT LUKA
AFF + PSG DC (BUKA & PASANG CATETER) : 10000 & 10000
AFF + PSG DC (BUKA & PASANG CATETER) : 10000 & 10000
CROSS INSISI
Kepala Dinas Kesehatan Kab. Prob
Selaku
Pengguna Anggaran Bendahara Pengeluaran Dinas Kesehatan Kabupaten Probolinggo
Tiga puluh dua ribu lima ratus rupiah

dr. Hj. Endang Astuti, MM
NIP. 19601103 198802 2 001 Biaya Klaim UGD Lansia bulan Nopember 2013 Puskesmas Jabungsisir
Pejabat Pelaksana
Teknis Kegiatan Mengetahui, Bendahara
TUNIK, SE. MMKes

NIP.19580511 198008 2 002 dr. Hj. Liliek Ekowati, MMKes Triana Setyawulan
NIP. 19640928 199003 2 006 NIP.19800112 200903 2 002
Lunas Dibayar :
Bendahara Pengeluaran
Dyah Retno Widowati, S.Sos 32,500.00

NIP.19630224 198508 2 004
Nopember 2013 Dec-88 Tiga puluh dua ribu lima ratus rupiah
Januari 2013 62500 Enam Puluh Dua Ribu Lima Ratus Rupiah
Februari 2013 50000 Lima Puluh Ribu Rupiah
Maret 2013 62500 Enam Puluh Dua Ribu Lima Ratus Rupiah
April 2013 79000 Tujuh Puluh Sembilan Ribu Rupiah
Mei 2013 62500 Enam Puluh Dua Ribu Lima Ratus Rupiah
PKH Mei 2013 12500 Dua belas ribu lima ratus rupiah
Juni 2013 125000 Seratus Dua Puluh Lima Ribu Rupiah
Juli 2013 87500 Delapan Puluh Tujuh Ribu Lima Ratus Rupiah
Agustus 2013 0
September 2013 0 Lima Puluh Ribu Rupiah
Oktober 2013 32,500 Tiga puluh dua ribu lima ratus rupiah
Oktober 2012 69500 Tiga puluh dua ribu lima ratus rupiah
Nopember 2013 32,500 Tiga puluh dua ribu lima ratus rupiah
Desember 2012 176500 Seratus Tujuh Puluh Enam Ribu Lima Ratus Rupiah
Desember 2012 62500 Enam Puluh Dua Ribu Lima Ratus Rupiah

Klaim April 2017

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REKAPITULASI PENGAJUAN KLAIM RAWAT JALAN UMUM

JNS KELAMIN KUNJUNGAN LOKET

POLI KIA 55 3 23 6 23 9 46 Rp 45,000 Rp 230,000 Rp 275,000

POLI GIGI 38 7 12 5 14 12 26 Rp 60,000 Rp 130,000 Rp 190,000

POLI BP 104 7 36 7 54 14 90 Rp 70,000 Rp 450,000 Rp 520,000

POLINDES JABUNG CANDI 0 0 0 0 0 0 0 Rp - Rp - Rp -

POLINDES JABUNG WETAN 7 2 0 5 0 7 0 Rp 35,000 Rp - Rp 35,000

PUSTU KALIKAJAR WETAN 5 0 1 0 4 0 5 Rp - Rp 25,000 Rp 25,000

POLINDES SIDODADI 18 1 9 4 4 5 13 Rp 25,000 Rp 65,000 Rp 90,000

POLINDES RANDUMERAK 14 6 0 8 0 14 0 Rp 70,000 Rp - Rp 70,000

JUMLAH 252 31 82 39 100 70 182 Rp 350,000 Rp 910,000 Rp 1,260,000

Jabungsisir, APRIL 2017

dr. YUNIAR INDAH SAVITRI TRIANA SETYAWULAN

Bendahara Pengeluaran Dinas Kesehatan Kabupaten Probolinggo

Satu Juta Tujuh Ratus Tujuh Puluh Tujuh Ribu Rupiah

Biaya Rawat Jalan Umum bulan Agustus 2015

dr. YUNIAR INDAH SAVITRI TRIANA SETYAWULAN

JUMLAH 3 0 1 0 2 0 3 Rp - Rp 15,000 Rp - Rp 15,000

JUMLAH 3 0 0 3 0 3 0 Rp 15,000 Rp - Rp - Rp 15,000

JUMLAH 6 2 0 4 0 6 0 Rp 30,000 Rp - Rp - Rp 30,000

JUMLAH 10 1 2 0 7 1 9 Rp 5,000 Rp 45,000 Rp - Rp 50,000

JUMLAH 17 1 3 3 10 4 13 Rp 20,000 Rp 65,000 Rp - Rp 85,000

JUMLAH 11 2 0 9 0 11 0 Rp 55,000 Rp - Rp - Rp 55,000

JNS KELAMIN KUNJUNGAN LOKET

PUSKESMAS JABUNGSISIR 13 0 9 0 4 0 13 Rp - Rp 65,000 Rp - Rp 65,000

POLINDES JABUNG CANDI 3 0 1 0 2 0 3 Rp - Rp 15,000 Rp - Rp 15,000

POLINDES JABUNG WETAN 3 0 0 3 0 3 0 Rp 15,000 Rp - Rp - Rp 15,000

POSKESDES KALIKAJAR 6 2 0 4 0 6 0 Rp 30,000 Rp - Rp - Rp 30,000

PUSTU KALIKAJAR WETAN 10 1 2 0 7 1 9 Rp 5,000 Rp 45,000 Rp - Rp 50,000

POLINDES SIDODADI 17 1 3 3 10 4 13 Rp 20,000 Rp 65,000 Rp - Rp 85,000

POLINDES RANDUMERAK 11 2 0 9 0 11 0 Rp 55,000 Rp - Rp - Rp 55,000

JUMLAH 63 6 15 19 23 25 38 Rp 125,000 Rp 190,000 Rp - Rp 315,000

Jabungsisir, APRIL 2017

dr. YUNIAR INDAH SAVITRI TRIANA SETYAWULAN

Bendahara Pengeluaran Dinas Kesehatan Kabupaten Probolinggo

Tiga Ratus Sepuluh Ribu Rupiah

Biaya kunjungan Lansia Puskesmas Jabungsisir bulan Agustus 2015

dr. YUNIAR INDAH SAVITRI TRIANA SETYAWULAN

JUMLAH 9 3 2 1 3 4 5 Rp 20,000 Rp 25,000 Rp - Rp 45,000

JNS KELAMIN KUNJUNGAN LOKET

POLINDES JABUNG CANDI 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -

POLINDES JABUNG WETAN 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -

PUSTU KALIKAJAR WETAN 0 0 0 0 0 0 0 Rp - Rp - Rp - Rp -

POLINDES SIDODADI 9 3 2 1 3 4 5 Rp 20,000 Rp 25,000 Rp - Rp 45,000

JUMLAH 9 3 2 1 3 4 5 Rp 20,000 Rp 25,000 Rp - Rp 45,000

Jabungsisir, APRIL 2017

dr. YUNIAR INDAH SAVITRI TRIANA SETYAWULAN

Bendahara Pengeluaran Dinas Kesehatan Kabupaten Probolinggo

Lima Puluh Ribu Rupiah

Biaya rawat jalan Jamkesda bulan Agustus 2015

dr. YUNIAR INDAH SAVITRI TRIANA SETYAWULAN

BULAN : APRIL 2017

Tanggal Tanggal Hari Visite Pemeriksaan

KEPALA PUSKESMAS JABUNGSISIR

dr. YUNIAR INDAH SAVITRI

BULAN : APRIL 2017

KEPALA PUSKESMAS JABUNGSISIR

dr. YUNIAR INDAH SAVITRI

BULAN : MARET 2014