form rujukan pasien jamkesmas utk klaim buku rujukan 2013.xls

7/25/2019 FORM RUJUKAN PASIEN JAMKESMAS UTK KLAIM BUKU RUJUKAN 2013.xls

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FORMAT RUJUKAN PASIEN JAMKESMAS

PUSKESM : PEGIRIAN

BULAN : JANUARI

NO TGL NAMA No. KTPL P ALA

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NO JAMKESMAS RNO SURATRUJUKAN


2/43

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3/43

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4/43

FORMAT RUJUKAN PASIE

PUSKESM : PEGIRIAN

BULAN : FEBRUARI 2013

NO TGL NAMA No. KTPL P

1 1 ' 13 JUMA*ATI 1653608373 3578167006510291 62 5,2,13,0101 2 EDI "ANTO"O 1653397525 1256240806760001 37 3,2,13,0101 3 NOE!I$AH 1653337181 3578165705530002 60 2,2,13,0101 4 HOTIJAH 1653335785 1256247006480036 84 1,2,13,0101

5 AI"AH 1653416684 3578165707840007 29 8,2,13,0101 6 MI"NATI 1653601138 1256245406460002 67 9,2,13,0101 7 KAMA! 1653360535 1256241712450001 60 11,2,13,0101 8 2 ' 13 MI"NATI 1653581711 3578167006580391 55 15,2,13,0101 9 !OM#I 1653581709 3578163006560089 57 14,2,13,0101

10 "A#IM AHMI 1653613266 1256243006710058 42 13,2,13,0101 11 A#I "UMA!DI 1653613751 3578162203680004 48 12,2,13,0101 12 HA!MAJI 1653336516 3578163006530109 60 17,2,13,0101 13 MA!DI$ANTO 1653351682 3578162905780002 35 19,2,13,0101 14 MUNI'AH 1653384846 3578167006540182 59 20,2,13,0101 15 MA"#I$AH 1653384407 1256246812550001 58 22,2,13,0101 16 4 ' 13 "T MA!$AM 3578165111800006 33 35,2,13,0101 17 $A"IN 1653370481 3578161302490001 63 29,2,13,0101 18 AD MUIN 1653652743 1256243003460001 70 28,2,13,0101

19 HAI!UNNI"A 1653582622 1256245810950002 17 27,2,13,0101 20 KHO"I$EH 1653339148 3578165401760003 34 32,2,13,0101 21 KIMI 1653584826 1256247006280116 85 26,2,13,0101 22 "A#HA 1653573238 3578164908590003 54 25,2,13,010123 KA!"INI 1653413962 1256247006420148 70 24,2,13,010124 I!'AN A 1653574954 3578160803810001 30 23,2,13,0101 25 KATINI 1653345213 3578167006680314 42 36,2,13,0101 26 JUMI#U! 1653573295 3578160704840003 29 31,2,13,0101 27 5 ' 13 !I'*AN 1653412656 1256242428980004 15 54,2,13,010128 !OEHI#AH 1653576478 1256243006420228 71 46,2,13,0101 29 "T "HO#IHA 1653335807 1256247006400241 75 52,2,13,0101 30 "UMIATI 1653561483 3578164105720002 41 51,2,13,1010 31 "UJEK 1653584793 1256244905530001 59 50,2,13,0101 32 I"MAI# 1653578403 1256242806410001 70 49,2,13,0101

33 "U$ATUN 1653318497 1256244101470004 63 44,2,13,0101 34 !ODHI 3578163006540306 56 42,2,13,0101 35 AGU" A 789932968 3578161809940007 19 41,2,13,0101 36 M A#I 1653585129 1256240308030004 10 39,2,13,0101 37 "A'ITA! 1653585107 3578165805730004 37 38,2,13,0101 38 !UMI$AH 1653394994 1256247006540390 59 63,2,13,0101 39 !UKI$AH 1653395218 3578167006600481 53 62,2,13,0101 40 MA"NING 1653638916 3578167006480013 65 65,2,13,0101 41 M !OM#I 1653650853 3578163006530196 60 61,2,13,0101 42 6 ' 13 AMINAH 1653597303 3578165010520004 54 66,2,13,0101 43 ANGGI 'ATMA 1653584771 15 67,2,13,0101 44 "U!OTO 789885279 1256240204530002 58 75,2,13,0101 45 JO"EPHINA 1653341499 1256244701700003 39 74,2,13,0101 46 "ITI !OHANA 1653356744 3578164204510001 56 72,2,13,0101

47 MUK$I 788604669 3578160709500002 63 71,2,13,0101 48 !UMINAH 788858098 3578167006420225 71 68,2,13,0101 49 TU!GEM 789310247 3578167006410247 71 70,2,13,0101 50 7 ' 13 MAIMUNAH 1653601645 1256245508570002 54 83,2,13,30101 51 I#HAM 1653638894 1256242704020008 8 82,2,13,0101 52 !O!I 1653401068 1256243006770201 34 81,2,13,0101 53 "UHE!MAN 1653608621 1256242003630004 41 80,2,13,0101 54 T%IN !AHA$U 1653644485 3578166702750001 34 77,2,13,0101 55 TUKINI 788862734 3505044703430001 70 86,2,13,0101 56 8 ' 13 HE!MAN"$AH 1653629951 3578161201650006 48 91,2,13,0101 57 "UPI$AH 788469726 3578167006430163 70 89,2,13,010158 "ITI "O'I$AH 1653564598 1256247006360015 77 91,2,13,0101 59 !IADI 1653587234 3578160112690004 44 92,2,13,0101

NO JAMKESMASUMUR(TH)

NO SURATRUJUKAN


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60 9 ' 13 "ITI AMINAH 1653587256 125624450336000 71 98,2,13,0101 61 !OM#AH 1653653474 3578164206540003 59 93,2,13,0101 62 AMANG H " 1653343217 1256242504540001 59 94,2,13,0101 63 "U"IATI 1653358799 3578164512540001 59 100,2,13,0101 64 NU!!OHMA 1653588011 3578162707750008 34 101,2,13,0101 65 "UMA!IAH 789268882 3578165502720007 7 99,2,13,010166 11 ' 13 $ADI 1653359387 3578160111510001 58 105,2,13,0101 67 AMANG 788652325 1256243006620176 48 109,2,13,0101 68 KATINEM 1653615303 3578165108630002 50 108,2,13,0101

69 "U#A"T!I 1653610059 3578167006620303 47 106,2,13,0101 70 "AMIAH 788776604 3578165707830002 30 114,2,13,0101 71 12 ' 13 MOEJAHID 1653651011 3578161306570001 52 117,2,13,0101 72 MA"#AHAH 1653633786 3578165501790002 34 116,2,13,0101 73 GA#UH 1653589923 1256245411950001 25 118,2,13,0101 74 HIMAH 789268724 3578166205750010 38 119,2,13,0101 75 PATIMAH 788970486 3578166471250001 56 120,2,13,0101 76 ACH MAH'UD 1653383575 3578160405640001 48 121,2,13,0101 77 !ANGGA 1653633235 1256242807990002 14 128,2,13,0101 78 MI!AT 1653585355 1256243006410095 72 122,2,13,0101 79 'AHMI HU"AINI 1653567996 3578161510950002 18 123,2,13,0101 80 D%I INDA$ATI 1653399764 1256246709750006 365 124,2,13,0101 81 AU#IA ! 1653598179 3578165510040001 7 129,2,13,0101 82 %INA!TI 1653389886 357816204690003 42 132,2,13,0101

83 !AHMA%ATI 1653380673 3578165110690001 38 131,2,13,0101 84 MUJIONO 1653250829 3578167006590004 52 135,2,13,0101 85 13 ' 13 MU#$ONO 789985427 1256243006340288 78 148,2,13,0101 86 NU! AINI 1653361323 3578165704870002 26 137,2,13,0101 87 %A!"INI 1653582126 3578167006580572 55 138,2,13,0101 88 MAMIK 1653581182 3578166709680001 43 139,2,13,0101 89 "T NU! HO#I'AH 789034556 3578164203770010 36 142,2,13,0101 90 MU"#IM 790539210 1256241002460001 65 143,2,130,101 91 "OEMA#I 1653397931 3578160203460002 63 146,2,13,0101 92 EDI "ANTO"O 1653397525 1256240806760001 37 147,2,13,0101 93 MUTA%A!"I#A 789394678 3578164306950001 18 151,2,13,0101 94 KHOI!I$AH 1653334277 3578164512710001 42 152,2,13,0101 95 14 ' 13 #I%AU# H 790084541 3578166807960005 17 160,2,13,0101 96 "U%ANTO 1653636791 3578162504520001 61 162,2,13,0101 97 #I#IK 1653636802 3578164710570001 56 163,2,13,010198 HA"AN 1653388839 12562430063201117 81 159,2,13,0101 99 CHA$IMAH 1653581698 1256245204520001 61 158,2,13,0101

100 "!I HANDA$ANI 1653411644 1256244807720007 38 157,2,13,0101101 "UPI$AH 789662845 1256245208540001 59 155,2,13,0101102 JATIMAH 1653406391 3578167006490181 62 154,2,13,0101 103 "ENEN 1653603669 3578163006420085 70 164,2,13,0101104 15 ' 13 KA!"I$ATI 789122002 3578164501510001 62 167,2,13,0101 105 H MU"TAIN 1653383518 357816100329423 82 169,2,13,0101 106 PAMIATIN 1653587245 3578165009690004 44 171,2,13,0101 107 "UCIPTO 789820299 3578161506600003 53 172,2,13,0101 108 MA!DIANTO 1653351682 3578162905780002 34 173,2,13,0101 109 16 ' 13 "#A%I 1653360974 1256240310450002 63 177,2,13,0101 110 M AMIN 789822011 3578160402620003 51 176,2,13,0101 111 AGI# HADI 1653412757 3578160511010003 11 174,2,13,0101 112 MA"DUKI 1653587987 3578163006480118 65 179,2,13,0101 113 18 ' 13 JOKO 1653341545 1256240109580002 55 192,2,13,0101 114 MU"A#'AK 1653339958 1256241404740008 39 186,2,13,0101 115 TA"#IMAH 1653342306 3578161512380002 75 185,2,13,0101 116 M HIJ!OH 1653584073 3578160108540004 57 181,2,13,0101 117 "UTIAH 1653583059 1256245006550400 58 180,2,13,0101 118 I"MANI$AH 788701364 3578166503030012 10 195,2,13,0101 119 19 ' 13 "UTI$AH 1653408674 3578167006490159 64 203,2,13,0101 120 ANI" 788761091 3578163006630142 50 205,2,13,0101 121 "U#IATI 1653413319 1256244003670001 46 206,2,13,0101 122 PATEMI 1653362425 1256247006330157 76 209,2,13,0101 123 !OHAN 789885156 3578162103820005 30 202,2,13,0101


6/43

124 "UPA!MAN 1653594715 1256243005390002 74 212,2,13,0101 125 "U#A"T!I 1653412926 1256244710390001 74 211,2,13,0101 126 #UT'IANI 1653365046 3578165009700005 43 213,2,13,0101 127 "ITI NA"I$EH 789956741 3578165705740002 39 221,2,13,0101 128 NO&IDA #AI#A 1653342311 3578167103020002 8 214,2,13,0101 129 M KOMA!U# 1653677982 3578160112670002 46 218,2,13,0101 130 ENDANG " 1653346293 1256247006630149 49 215,2,13,0101 131 JUMINAH 78968834 3578165907710005 42 216,2,13,0101 132 20 ' 13 JUNAEDI 1653349656 3578162311840003 29 231,2,13,0101

133 "T COMA!IA 788722795 1256245505850009 28 225,2,13,0101 134 HAMINAH 788642291 1256247006580052 55 228,2,13,0101 135 A"NO "U%ONO 788962342 3578160606500003 63 229,2,13,0101 136 !O"IDEH 789316626 1256247006630183 50 230,2,13,0101 137 "U%A!NO 1653401946 3578163006470059 66 221,2,13,0101 138 "A!MI 1653646408 1256247006560087 56 222,2,13,0101 139 PATINI 57 223,2,13,0101 140 INAJATI 789343942 3578167006550274 58 227,2,13,0101 141 A$U MU#$ANING"IH 789131755 3578166404040003 9 226,2,13,0101 142 21 ' 13 HA!IANTO 788215948 1256240603770003 36 242,2,13,0101 143 MA!IJAH 1653611084 1256247006580654 55 243,2,13,0101 144 22 ' 13 M A!$A 'AJA! 790149554 3578161007990005 18 247,2,13,0101 145 "ITI HO#I#AH 788570695 3518165308970007 16 249,2,13,0101 146 DINDA 788753834 3578164607010002 12 244,2,13,0101 147 PONIMAH 1653375969 3578166108540001 54 254,2,13,0101 148 ATI!AH 1653589397 1256240812627 42 252,2,13,0101 149 23 ' 13 MU"!I'AH 1653630737 1256244601610008 51 254,2,13,0101 150 MU#KI 1653334288 1256245902980002 12 253,2,13,0101 151 MUNI'AH 1653384846 3578167006540182 56 256,2,13,0101 152 25 ' 13 PONI$EM 1653582071 3578167006520279 57 258,2,13,0101 153 DA!MUDJI 1653632651 3578160501540001 55 251,2,13,0101 154 MAT "A'I 1653568737 1256243006410160 69 257,2,13,0101 155 'ATHU# I))A 1653619454 3578165007920005 18 260,2,13,0101 156 HOM"ATUN 1653570562 3578166303850003 26 262,2,13,0101 157 %A"INI 1653574858 1256247006520167 60 264,2,13,0101 158 !AKIMIN 1653358037 3578162707550001 57 265,2,13,0101 159 26 ' 13 HIM#ATU# 1653408162 1256244706040008 9 277,2,13,0101 160 !OKA$AH 1653646533 3578167006470245 63 272,2,13,0101 161 "UM!I$AH 1653336055 3578167006510063 58 269,2,13,0101 162 NA%I$AH 788723965 3578167006560380 57 279,2,13,0101 163 "E#AMIN 1653650302 125624180590003 50 280,2,13,0101 164 27 ' 13 MI'TAHU# 1653632379 1256242107980009 15 287,2,13,0101 165 "AH!U# ! 1653643574 3578160810020003 11 282,2,13,0101 166 #A"IMAH 789957909 3578165602750003 38 286,2,13,0101 167 MU"TA!I 790158036 3578163006550159 58 288,2,13,0101 168 28 ' 13 "!I "UEKTI 1653394882 3578167006570098 55 297,2,13,0101 169 MOCHAMMAD 1653607686 1256243103840002 29 296,2,13,0101 170 KAMA! 1653360535 1256241712450001 68 292,2,13,0101 171 M "EIHUN 789244446 1256243006710067 42 291,2,13,0101 172 DA!MAJI 1653632651 3578160501540001 55 293,2,13,0101 173 "A!TINI 788744283 1256245502680001 45 299,2,13,0101 174 !I)A# 789729322 1256242407890001 21 298,2,13,0101 175 "U!O"O 790153547 3578161103700003 42 300,2,13,0101176 DA!MAN 790118111 3578163006610201 52 302,2,13,0101 177 "UJAI 1653627249 1256240103950001 67 304,2,13,0101178 $A$UK 789729568 3578165002810003 32 305,2,13,0101


7/43


8/43

FORMAT RUJUKAN PASIEN JAMKESM

PUSKESM : PEGIRIAN

BULAN : MARET

NO TGL NAMA No. KTPL P

1 1 Ma 13 "!I !AMA$ANTI 789369254 3578165909710003 42 5,3,13,0101 KA!ANG TEM2 HA!I "UP!A$ITNO 789920008 31 9,3,13,0101 TENGGUMUN3 ENDANG M 788652544 3578165604700005 43 10,3,13,0101 "A%AH PU#O4 2 Ma 13 E!I$AH 789708071 3578164705570003 56 12,3,13,0101 "A%AH PU#O5 KA"IMIN 788779394 1256247006780228 75 13,3,13,0101 %ONOKU"UM6 "UPI$AH 790104281 125624600290003 23 17,3,13,0101 "A%AHPU#O

7 4 Ma 12 JATINI 1653585952 1256243006550945 58 18,3,13,0101 JATI"!ONO 8 KIMI 789477208 1256247006280116 85 19,3,13,0101 JATI"!ONO 9 AD MUI" 1653652743 1256243003460001 70 20,3,13,0101 HANGTUAH 8

10 "UMA!NI 1653607091 1256247006920043 71 21,3,13,0101 HANGTUAH 211 HA!MAJI 788994235 3578163006530109 60 25,3,13,0101 "A%AH 212 GONDO 789384194 1256241810510001 62 22,3,13,0101 TENGGUMUN13 "U#I$AH 788783084 3578166909710003 42 23,3,13,0101 %ONOKU"UM14 A"MADI 789574645 3578161201640004 49 27,3,13,0101 TENGGUMUN15 #A"I$EM 789753521 3578164412630003 50 28,3,13,0101 JATI"!ONO T16 5 Ma 13 "ITI HOTIJA 789675175 3578164105700011 43 46,3,13,0101 "A%AH PU#O17 "U!OTO 1653372911 1256240204530003 60 45,3,13,0101 %ONOKU"UM18 NU!AINI 1653361323 3578165704870002 22 47,3,13,0101 KA!ANG TEM19 ANI"A 1653346528 1256247010550001 54 44,3,13,0101 %ONOKU"UM20 MUKI$AT 788759019 3578167006470037 66 43,3,13,0101 %ONOKU"UM

21 "U!OTO 789885279 1256240204530002 58 40,3,13,0101 %ONOKU"UM22 AG$# %AH$U 1653348824 3578162908910002 22 38,3,13,0101 %ONOKU"UM23 ENDAH " 1653601735 1256247006770221 43 37,3,13,0101 "A%AH PU#O24 INA$ATI 789343942 3578167006550274 58 41,3,13,0101 TENGGUMUN25 IN"UPIATUN 1653607629 1256247006580092 54 33,3,13,0101 HANGTUAH 826 6 Ma 13 MUH$I 788604669 3578160709500002 63 50,3,13,0101 HANGTUAH 827 'AU)A 1653576039 3578165605520001 61 49,3,13,0101 "A%AH PU#O28 "ITI !OHANA 1653356744 3578164204570001 42 52,3,13,0101 TENGGUMUN29 DJUMAATI 789935163 3578164304640002 49 53,3,13,0101 PEGI!IAN 6/830 KUNTUM 1653627295 1256242110590001 53 54,3,13,0101 HANGTUAH 531 M "AI'U# 789542414 3578161005670006 43 57,3,13,0101 %ONO"A!I 132 7 Ma 13 A!TINI 1653345213 3578167006680314 42 71,3,13,0101 %ONO"A!I 833 CHOTIMAH 1653402238 3578167006740092 35 73,3,13,0101 %ONOKU"UM34 ENDAH 1653348508 12562468117200030 37 74,3,13,0101 %ONOKU"UM

35 JA"IKUN 1653348486 1256240402440001 71 75,3,13,0101 %ONOKU"UM36 "UGENG 788863353 3578161004690006 44 77,3,13,0101 TENGGUMUN37 NANIK 789555746 1256244202830002 30 69,3,13,0101 KEDINDING #38 "A*DI$AH 7816100307 3578167006500156 62 67,3,13,0101 KA!ANG TEM39 "U$ATIN 1653348497 1256244101470004 63 76,3,13,0101 %ONOKU"UM40 MA"NING 1653638916 3578167006480034 65 66,3,13,0101 JATI"!ONO T41 NA"IHA 1653597865 1256245208450003 68 65,3,13,0101 "A%AH PU#O42 NO!MA 1653603513 3578167006400208 73 62,3,13,0101 JATIPU!%O 43 H "T "O#IHA 1653335807 1256247006400241 75 58,3,13,0101 KA!ANG TEM44 !OE#IANA 1653364089 3578165204600001 52 59,3,13,0101 %ONOKU"UM45 8 Ma 13 JUM!OTU# A 789398638 3578166510890001 24 87,3,13,0101 "A%AH PU#O46 D%I INA$ATI 1653399764 1256246709740006 35 92,3,13,0101 TENGGUMUN47 A"TUTIK 1653581283 3578167006590055 55 84,3,13,0101 JATI"!ONO T48 #UT'IA 790175316 3578164606870001 26 91,3,13,0101 "A%AH PU#O49 A#'IAN 789794054 3578164606720007 17 85,3,13,0101 %ONOKU"UM50 !UMIKAH 788858098 3578167006420225 71 81,3,13,0101 TENGGUMUN51 "U$ANTI 1653596223 3578166203610001 52 88,3,13,0101 HANGTUAH 252 "ITI 788236738 3578167006410245 71 80,3,13,0101 JATI"!ONO T53 MU!TADJI 1653344853 1256240308400001 71 79,3,13,0101 %ONO"A!I 154 JUMA*ATI 789183303 3578167006510291 62 78,3,13,0101 JATIPU!%O 6

NOJAMKESMAS

RNO SURATRUJUKAN


9/43

55 9 Ma 13 "ADE#I 789732404 3578163006600126 68 94,3,13,0101 JATIPU!%O 56 !OJAIMIN 790237967 3578163112650006 48 97,3,13,0101 HANGTUAH 557 AD "OMAD 789628511 3578163006480106 62 96,3,13,0101 JATI"!ONO T58 AM"E 1653652719 3578163006520153 57 95,3,13,0101 JATIPU!%O 159 !OM#I 788668007 3578163006560089 57 101,3,13,0101 JATI"!ONO T60 MI"NATI 78868457 3578167006580391 55 102,3,13,0101 JATI"!ONO T61 E##A 789987892 1256134305900002 23 103,3,13,0101 %ONOKU"UM62 MU!$ATI 789987644 1256137006690045 43 104,3,13,0101 %ONOKU"UM63 "U"IATI 1653358798 3578164512540001 59 107,3,13,0101 JATI"!ONO T64 NU!!AHMA 1653588011 3578162707750008 37 106,3,13,0101 JATI"!ONO T65 !I$ATI 788655519 3578164208650002 48 108,3,13,0101 "A%AH PU#O

66 11 Ma 13 "T CHOI!I$AH 1653583061 3578167001860002 25 120,3,13,0101 JATI"!ONO T67 NU!!OHMAH 1653641651 3578164505600002 52 119,3,13,0101 "A%AH PU#O68 TUKIMAN 1653350027 1256240101300001 83 118,3,13,0101 %ONOKU"UM69 AGU" A 789932968 3578161809940007 19 117,3,13,0101 TENGGUMUN70 NA"IHA 788825632 3578166708730003 46 124,3,13,0101 %ONOKU"UM71 HOTIJAH 1653335785 1256247006480036 84 116,3,13,0101 KA!ANG TEM72 "T CHOMA!I$A 788722798 1256245505850009 28 115,3,13,0101 JATIPU!%O 473 AGU" 788675433 3578161204830004 30 113,3,13,0101 "A%AH PU#O74 !I"MINAH 1653565307 3578165606520001 60 112,3,13,0101 "A%AH PU#O75 AMANG 788652325 1256243006620176 51 110,3,13,0101 "A%AH PU#O76 DJATIM 788340756 3578163006510097 62 125,3,13,0101 %ONOKU"UM77 13 Ma 13 'ATIMAH 1653397593 3578165503570003 53 131,3,13,0101 TENGGUMUN78 AMA#$A ' 1653406378 10 126,3,13,0101 KA!ANG TEM79 "UGI$ANTO 1653349364 1256242501360003 77 127,3,13,0101 %ONOKU"UM

80 EDI "ANTO"O 1653397525 1256240806760001 37 128,3,13,0101 TENGGUMUN81 "UPI$AH 789662845 1256245208540001 59 129,3,13,0101 JATI"!ONO 82 U!A%I 1653349689 1256243006320130 81 132,3,13,0101 %ONOKU"UM83 NU! !O'II$AH 789778258 3578165710860001 27 133,3,13,0101 "A%AH PU#O84 MU"TO'A 789035095 3578161112990003 14 138,3,13,0101 KA!ANG TEM85 PANDI 789177622 3578161203580005 54 139,3,13,0101 JATIPU!%O 486 "T "UM!I$AH 1653388558 1256246607740002 39 140,3,13,0101 KA!ANG TEM87 AD #ATI' 1653578897 3578161605650002 48 142,3,13,0101 JATIPU!%O 488 "!I "UHE!TIN 1653341602 1256246512680002 45 143,3,13,0101 KA!ANG TEM89 "AM"U!I 789587594 3578162903590002 54 146,3,13,0101 KA!ANG TEM90 14 Ma 13 MAMIK 1653581182 3578166709680001 43 147,3,13,0101 JATI"!ONO 191 MI!AT 788235974 1256243006410095 72 148,3,13,0101 JATI"!ONO T92 MAIMUNAH 1653601645 1256245508570002 56 153,3,13,0101 "A%AH PU#O93 "#A%I 1653360974 1256240310450002 63 163,3,13,0101 KA!ANG TEM

94 H MU"TAIN 1653383518 357816100329423 83 158,3,13,0101 KA!ANG TEM95 MU"!I'A 1653565138 3578165504720001 41 155,3,13,0101 "A%AH PU#O96 HAI!UNNI"A 788646903 1256245810950002 17 149,3,13,0101 JATI"!ONO T97 "T MAIMUNA 1653563531 1256245506800008 33 165,3,13,0101 "A%AH PU#O98 MA!$AMAH 789749223 357816006550113 58 159,3,13,0101 JATI"!ONO T99 !I"AI$AH 1653566534 1256246601990007 14 161,3,13,0101 "A%AH PU#O

100 OCTA!IANI 790026816 12562452110960001 18 166,3,13,0101 %ONOKU"UM101 HO"AMAH 790134669 3578164907930004 19 168,3,13,0101 ENTENG 1/2102 15 Ma 13 !ODO% JOHANA 789724833 3578167006640291 49 169,3,13,0101 TENGGUMUN103 16 Ma 13 MAT !A%I 789421241 3578163006520161 62 178,3,13,0101 JATI"!ONO T104 "UTI*AH 1653583059 1256245006550400 58 177,3,13,0101 JATI"!ONO T105 MA"DUKI 789900074 3578163006980118 65 176,3,13,0101 JATI"!ONO T106 "UGIONO 789956098 3578162601730001 40 174,3,13,0101 TENGGUMUN107 MU"TO'A 788711084 3578163108790007 32 172,3,13,0101 JATI"!ONO T108 M AMIN 789822011 3578160402620003 51 173,3,13,0101 JATIPU!%O 6109 $ATIMAH 789921988 3578166805720004 38 179,3,13,0101 JATI"!ONO 110 18 Ma 13 #I#IK 1653636802 3578164710570001 56 192,3,13,0101 "A%AH PU#O111 !U"MIN 1653569335 1256243006380024 75 191,3,13,0101 "A%AH PU#O112 TITIK 1653610083 3578167112860001 27 182,3,13,0101 JATIPU!%O 3113 %A!"INI 1653582126 3578167006580572 55 184,3,13,0101 JATI"!ONO T


10/43

114 ACH E'ENDI 1653630308 3578160703030007 10 183,3,13,0101 "A%AH PU#O115 A"NANDA! 789765298 3578161506550002 58 185,3,13,0101 "A%AH PU#O116 !OM#AH 1653653474 3578164206540003 59 187,3,13,0101 JATIPU!%O 3117 A"MAH 1653653237 1256244306360005 77 188,3,13,0101 JATIPU!%O 3118 "UCIPTO 789820299 3578161506600003 53 190,3,13,0101 TENGGUMUN119 "UCIATI 789882377 3578167006660246 47 193,3,13,0101 "A%AH PU#O120 "A'I*AH 789883042 3578164509690002 44 195,3,13,0101 ENTENG TIM121 !AKIMIN 789758695 3578162707550001 58 197,3,13,0101 KA!ANG TEM122 19 Ma 13 'IT!I A 789473643 1256246211960007 17 202,3,13,0101 "A%AH PU#O123 AGI# HADI 1653412757 3578160511010003 11 2004,3,13,0101 TENGGUMUN124 "U#A"T!I 790193428 3578167006620303 51 199,3,13,0101 JATIPU!%O 4

125 KA!"I$ATI 789122002 3578164501510001 67 203,3,13,0101 "A%AH PU#O126 %INA!TI 1653389886 3578165204690003 44 208,3,13,0101 TENGGUMUN127 "U%A!NI 1653389302 3578167006550279 58 209,3,13,0101 KA!ANG TEM128 PATIMAH 788970486 3578164712500001 56 210,3,13,0101 TENGGUMUN129 DU!A"UNA 1653566049 3578163006630004 53 211,3,13,0101 "A%AH PU#O130 "AIMAN 789955571 3578163006700128 42 215,3,13,0101 %ONO"A!I 3131 HA"ANAH 790107101 3578165907820002 31 213,3,13,0101 KA!ANG TEM132 "U!OTO 1653372911 1256240204530002 60 218,3,13,0101 %ONOKU"UM133 MUHAMMAD 788655093 3578162107720002 41 220,3,13,0101 "A%AH PU#O134 NU! AMA#IA 789391642 3578165711970001 16 219,3,13,0101 %ONO"A!I 3135 20 Ma 13 KATINI 789904271 3578168194480003 65 222,3,13,0101 JATI"!ONO T136 !OHAN 789885156 3578162103820005 30 221,3,13,0101 JATIPU!%O 4137 "EIMAH 789268724 3578166205750010 38 223,3,13,0101 JATI"!ONO T138 "UHA!TONO 788858122 3578160402700006 43 224,3,13,0101 TENGGUMUN

139 HE!MIANTO 789064277 43 225,3,13,0101 TENGGUMUN140 "UMA!NO 1653401946 1256243006470109 66 227,3,13,0101 %ONOKU"UM141 MU"#IM 790539219 1256241002460001 67 228,3,13,0101 "A%AH PU#O142 !O"IDEH 789316626 3578167006630303 50 229,3,13,0101 KA!ANG TEM143 KATINEM 789598574 3578165108630002 50 231,3,13,0101 HANGTUAH 5144 "T AMINAH 1653587256 1256244503360002 71 230,3,13,0101 JATI"!ONO T145 21 Ma 13 "ITI 790203058 3578167006480017 65 236,3,13,0101 JATI"!ONO T146 JATI MUA%ANAH 788602173 3578167004610001 52 238,3,13,0101 DANAKA!$A147 "A!MI 1653646408 3578167006560008 57 237,3,13,0101 JATI"!ONO T148 KOMA#UDIN 1653593264 3578163006450165 68 235,3,13,0101 HANGTUAH 5149 'ATIMAH 788073661 3578164501430006 41 242,3,13,0101 "A%AH PU#O150 22 Ma 13 A$U M 789131755 3578166404040003 9 247,3,13,0101 "A%AH PU#O151 A"NO "U%ONO 788962342 357816060650003 63 246,3,13,0101 %ONOKU"UM152 M NU!DIN 1653345819 1256240806450003 68 244,3,13,0101 %ONOKU"UM

153 M MACHMUD 1653362447 3578162910670003 46 245,3,13,0101 KA!ANG TEM154 "U#IATI 1653413319 1256244003670001 46 248,3,13,0101 TENGGUMUN155 23 Ma 13 !ODHI 3578163006540306 60 251,3,13,0101 KA!ANG TEM156 OEMA!/MAT JAI 789900265 1256249703495 73 250,3,13,0101 PEGI!IAN 5/1157 TI!AH 789086114 3578167006290056 84 252,3,13,0101 HANGTUAH 1158 "UHA!"I 789582734 3578167006510146 65 253,3,13,0101 %ONO"A!I 1159 25 Ma 12 M HIDDJ!OH 1653584073 3578160108540004 57 258,3,13,0101 JATI"!ONO 160 I!'AN 780457858 3578162806940006 19 266,3,13,0101 JATIPU!%O 6161 KA!"INI 1653413962 1256247006420148 70 259,3,13,0101 TENGGUMUN162 "UH!IAH 789743957 3578167006550156 58 268,3,13,0101 HANGTUAH 7163 !ADMATU" 78603107 3578164107670002 46 264,3,13,0101 TENGGUMUN164 "U#A"T!I 1653412926 1256244710390001 74 265,3,13,0101 TENGGUMUN165 TITIK 1653389526 1256247006630340 50 261,3,13,0101 TENGGUMUN166 $U"I PUT!I 1653399088 3578166306970003 16 269,3,13,0101 TENGGUMUN167 "U*I 1653356632 1256243006370049 76 262,3,13,0101 TENGGUMUN168 AINU# 'II 789729041 1256242502010005 12 263,3,13,0101 "A%AH PU#O169 "UJOI 1653627249 1256240103450001 68 274,3,13,0101 HANGTUAH 5170 26 Ma 13 NU!U# 'IT!IA 1653342928 1256245006860006 33 278,3,13,0101 KA!ANG TEM171 PATEMI 1653362425 1256247006330157 80 282,3,13,0101 KA!ANG TEM172 JUMI!AH 1653587054 1256247006450291 68 283,3,13,0101 JATI"!ONO T


11/43

173 A#AM 1653614684 3578163006410107 69 284,3,13,0101 HANGTUAH 6/174 DJUA!I$AH 16533570066 1256245103680001 45 285,3,13,0101 "A%AH PU#O175 MOEDJAHIT 788642245 3578161306570001 52 286,3,13,0101 JATIPU!%O 1/176 MU"TA!I 790158036 3578163006550159 58 289,3,13,0101 %ONO"A!I 3/177 KANI$AH 790159206 3578165212730013 39 290,3,13,0101 %ONO"A!I 3/178 TA"#IMIN 1653342366 3578161512380002 75 295,3,13,0101 KA!ANG TEM179 AD A)I" 789067539 3578162911820001 31 296,3,13,0101 KA!ANG TEM180 NAPIA 788666084 3578166203580001 55 298,3,13,0101 ENTENG DA#181 28 Ma 13 NA%I$AH 788723965 3578167006560380 57 314,3,13,0101 "IDO!AME 40182 KAMA! 789120652 1256241712450001 68 313,3,13,0101 KA!ANG TEM183 TUKINI 788862734 3505044703430001 70 317,3,13,0101 TENGGUMUN

184 DA!MAN 790118111 3578163006610201 52 316,3,13,0101 HANGTUAH 5/185 "ITI )AENA 789711017 3578163006890002 24 318,3,13,0101 JATIPU!%O 5/186 A$U 1050190435 3578163006060001 7 320,3,13,0101 TENGGUMUNG187 MU"!I'AH 1653630737 1256244601610008 52 321,3,13,0101 JATIPU!%O 4/188 DA!MUDJI 1653632651 3578160501540001 55 322,3,13,0101 JATI"!ONO 30


12/43

FORMAT RUJUKAN PASIEN JAMKE

PUSKESM : PEGIRIAN

BULAN : APRIL

NO TG# NAMA N? KTP# P

1 1 A 13 ENDANG 788757625 3578167006710363 42 17,4,13,0101 "A%A2 %A"MAN 789248024 3578160906600003 53 9,4,13,0101 "A%A

3578162511820002 , , ,4 HA!MADJI 788994235 3578163006530109 60 10,4,13,0101 "A%A5 HA"AN 1050191054 1256243006320147 81 14,4,13,0101 KA!AN

, , ,

7 I!MA D%I 789034961 3578166112750004 38 6,4,13,0101 TENG8 PATMI 789157719 3578167006530103 57 2,4,13,0101 TENG , , ,

, , ,11 2 A 13 !I!IN " 1653372077 3578166305810003 32 25,4,13,0101 %ONO12 NONA "U!$ANI 789908512 3578164988050002 71 24,4,13,0101 %ONO

, , ,14 ATIAH 1653589397 3578167810670006 46 23,4,13,0101 JATI"!15 $ADI 1653359387 3578160111510001 62 19,4,13,0101 %ONO

, , ,, , ,

18 3 A 13 #A"I$EM 789753521 3578164412630003 50 35,4,13,0101 JATI"!19 "OET!I"NO 790124556 1256240502480001 64 37,4,13,0101 JATIPU

, , ,21 INA$ATI 789343942 3578167006550274 58 41,4,13,0101 TENG22 AD KA"AN 788706729 1256243006530050 60 44,4,13,0101 "A%A

, , ,24 "U!OTO 1653372911 1256240204530002 60 46,4,13,0101 %ONO25 AD MUIN 1653652743 1256243003460001 70 47,4,13,0101 HANG26 "!I !AMA$ANTI 789369254 3578165909710003 32 51,4,13,0101 KA!AN

, , ,28 NANING 1050193899 3578165807840002 29 68,4,13,0101 TENG29 A"MAD 1050194169 357816300620002 91 71,4,13,0101 %ONO

, , ,31 HAMI!AN 788642291 3578167006580375 55 75,4,13,0101 JATIPU32 !OHA$A 788960441 3578167006540215 59 78,4,13,0101 %ONO33 6 A 13 MI'TAHU# JANAH 789017951 3578165208930006 20 80,4,13,0101 "IDO!

, , ,35 "UMA!MI 790158047 1256247006920043 71 93,4,13,0101 HANG36 MAT #A"AP 1050233826 3578162302510002 56 91,4,13,0101 "A%A

, , ,

38 "ITI HA"IAH 789083976 1256245805660001 47 97,4,13,0101 JATIPU39 KADI! 789825497 1256240407470003 66 98,4,13,0101 JATIPU , , ,

, , ,42 M "AI'U# 789542414 3578161005670006 45 112,4,13,0101 %ONO43 "U!$ATI 789550569 3578167006540289 55 108,4,13,0101 %ONO

, , ,45 AD "OMAD 789628511 3578163006480106 62 104,4,13,0101 JATI"!46 M TOHA 789085034 3578163006790142 34 102,4,13,0101 "A%A

, , ,, , ,

49 "A!TUNI 788744283 1256245502680001 50 99,4,13,0101 JATI"!50 10 A 13 HOTIJAH 1050196116 1256247006480036 72 133,4,13,0101 KA!AN

, , ,52 HA#IMA 1050195565 3578167006580242 55 140,4,13,0101 TENG53 "ITI HATIJA 789675175 3587164105700011 43 131,4,13,0101 "A%A

, ,55 M HA'I 788874513 3578161503760008 37 122,4,13,0101 %ONO56 M !I)A# 789729322 1256242407890001 21 124,4,13,0101 "IDO!57 "ITIA"I$A 789655285 357816470720003 36 125,4,13,0101 "A%A

, , ,59 MAT !IPAI 789037198 1256243006360194 57 134,4,13,0101 %ONO60 MA!MUKAH 789420598 1256247006350174 77 135,4,13,0101 JATI"!

, , ,

NO JAMKE"MA" UMU!THFNO "U!AT!UJUKAN

JENI"KE#AMIN


13/43

62 NU!AHMAH 790190954 3578162707750008 34 138,4,13,0101 JATI"!63 HOM"ATUN 78960667 3578166303850003 26 139,4,13,0101 "A%A

, , ,65 "O'I$AH 789051565 1256246708000004 13 142,4,13,0101 HANG66 DJUMA*ATI 789935163 3578164304640002 49 148,4,13,0101 PEGI!

, , ,68 NADIA "A#"AI#A 789193743 3578166506060003 7 160,4,13,0101 JATIPU69 "AIN M 789828669 3578163006680173 45 155,4,13,0101 JATIPU

, , , 71 13 A 13 !OM#I 788668007 3578163006560089 57 164,4,13,0101 JATI"!72 MI"NATI 78868457 3578167001580391 55 163,4,13,0101 JATI"!

, , ,

74 15 A 13 M "A!O'I 788677522 1256240111880005 25 187,4,13,0101 JATIPU75 "E#ADIN 789049293 3578162702510001 61 178,4,13,0101 "A%A, , ,, , ,

78 TA"KI$A 789130359 3578161604010003 12 171,4,13,0101 "A%A, , ,, , ,

81 "U#I$AH 788783084 3578166907710003 42 185,4,13,0101 %ONO82 TA"#IMIN 789984101 3578161512380002 75 169,4,13,0101 KA!A

, , ,84 16 A 13 JO'I NO&IANTO 788416953 1256242010960002 17 194,4,13,0101 %ONO85 #IND!A%ATI 789068643 3578166502950003 18 199,4,13,0101 TENG

, , ,, , ,

88 "!IPUJI A 789035422 3578165109590002 54 205,4,13,0101 TENG89 "T !OHMAH 10050225704 3578165107710002 41 207,4,13,0101 "A%A

, , ,91 MI"U!I 789075549 3578163006500253 63 211,4,13,0101 PEGI!92 MAU#ANI 1050194744 357816030847 66 213,4,13,0101 TENG

, , ,94 MU#$ONO 788784783 3578160912900002 23 215,4,13,0101 "A%A95 MAI# 789965212 3578161705680003 45 218,4,13,0101 PEGI!

, , ,97 TA"NI 788693578 3578167006400119 73 220,4,13,0101 %ONO98 'ATIMAH 788073661 3578164504730006 40 224,4,13,0101 "A%A

, , ,100 19 A 13 PANDI 789177622 3578161203580005 54 235,4,13,0101 JATIPU101 HANA 789734755 3578167006580028 58 236,4,13,0101 "A%A

, , ,103 M MACH"UM 789610893 1256242009630002 50 241,4,13,0101 HANG104 "AIMAN 789955571 3578163006700128 42 240,4,13,0101 %ONO

, , , , , ,

107 !OM#AH 788593285 3578164206540003 59 248,4,13,0101 JATIPU108 MAMIN 789822011 3578160402620003 51 247,4,13,0101 JATIPU

, , ,110 MUNI!AH 790049474 3578166105680005 45 251,4,13,0101 JATIPU111 22 A 13 "UJAI 1050237123 3578160103450001 68 265,4,13,0101 HANG

, , , KA#IM113 PATIMAH 788970486 3578166471250001 56 260,4,13,0101 TENG114 "A'A*A 789485376 3578167006670082 44 261,4,13,0101 JATIPU

, , ,116 "UHA!"I 789582734 3578167006510146 62 253,4,13,0101 %ONO119 MAT NAIM 789901053 3578161001800001 31 257,4,13,0101 PEGI!

, , , , , ,

122 MA"DUKI 789900074 3578163006480118 65 279,4,13,0101 JATI"!

, , , , , ,125 "U%A!NI 1050198513 3578167006550279 58 276,4,13,0101 KA!A126 AGI# HADI 788904551 3578160511010003 11 275,4,13,0101 TENG

, , , 128 "EIMAH 789268724 3578166205750010 38 273,4,13,0101 JATI"!129 MAT "A'I 788686593 1256243006410160 72 269,4,13,0101 "A%A

, , ,131 ENDANG M 788652549 3578165604700005 40 285,4,13,0101 "A%A132 %AND$ 789769754 3578160861860003 57 286,4,13,0101 "A%A


14/43

, , ,134 24 A 13 ACH "UKA!DI 789086957 1256242006760006 35 292,4,13,0101 JATI"!135 )AKI$AH 789900873 3578167006520306 61 295,4,3,0101 PEGI!

, , ,, , ,

138 A#I$AH "ITI 788790835 3578160711660007 46 300,4,13,0101 "A%AH139 KA!"I$ATI 789122002 3578164501510001 62 289,4,13,0101 "A%AH140 KATINEM 789598574 3578165208630002 50 301,4,13,0101 HANGT

, , ,142 MU"TO'A 788711084 3578163108790007 79 302,4,13,0101 JATI"!143 HE!MANTO 789064277 3578160902700004 43 303,4,13,0101 TENGG144 MI)AN ' 789418247 3578163006510180 62 304,4,13,0101 %ONO

, , ,, , ,147 JUMINAH 1050225884 1256247006450291 68 310,4,13,0101 JATI"!148 26 A 13 'IT!I 789473643 1256246211960007 17 316,4,13,0101 "A%AH149 UNTUNG "U%ANDI 789138257 3578160912880002 25 318,4,13,0101 TENGG

, , , 151 !I$ATI 788655519 3578164208650002 48 321,4,13,0101 "A%AH152 NAP"IAH 788666084 3578166203580001 55 322,4,13,0101 ENTE153 27 A 13 MUJIKA# 790145403 3578167006570107 56 325,4,13,0101 TENGG

, , , , , , aan

156 CHOD!I$AH 788936769 3578164904910001 22 333,4,13,0101 %ONO157 "UCIPTO 789820299 3578161506600003 53 334,4,13,0101 TENGG

, , ,, , ,

160 CHOTIMAH 791026175 3578167006740092 39 342,4,13,0101 %ONO

161 30 A 13 M DJAH'A! 788944015 3578163006530298 60 353,4,13,0101 "A%AH162 "AM"U# A 789532806 3578160706700003 43 355,4,13,0101 "A%AH, , ,

164 "ANIAH 789701861 3578166404540002 45 348,4,13,0101 %ONO165 MA!IANA 789129167 3578167108550004 58 351,4,13,0101 "A%AH166 PATMI 789157719 3578167006530103 60 345,4,13,0101 TENGG

, , ,, , ,


15/43

FORMAT RUJUKAN PA

PUSKESM : PEGIRIAN

BULAN : MEI

NO TG# NAMA NO JAMKE"MA" N? KTPJENI"

#1 1 Ma 13 'ATIMAH 789263594 3578167006450181 68 2,5,13,01012 !I"MA 1050237887 3578165510020002 10 3,5,13,01013 HA!MAJI 788994235 3578163006530109 60 6,5,13,0101 4 ENI E!NA%ATI 788701465 3578164102770001 33 7,5,13,0101

5 ATIAH 789801355 3578167810670006 46 9,5,13,01016 MOENA%ATI 788668053 3578164506410001 72 13,5,13,01017 JO"EPHINA 788862058 1256244701700003 42 12,5,13,01018 DJAENA 789181615 3578167006500014 63 11,5,13,01019 "OEGIONO 789181558 3578163006500159 63 10,5,13,0101 10 2 Ma 13 HOI!UNNI"A 788646903 1256245810950002 17 15,5,13,010111 INAJATI 789343942 3578167006550274 58 18,5,13,010112 NAU!I$AH 788723965 3578167006560380 57 17,5,13,010113 !O'II$AH 789778258 3578165710860001 27 20,5,13,010114 A"TUTIK 790378547 3578167006590005 55 21,5,13,010115 NU!#IA 756436735 3524174101600109 53 19,5,13,010116 TA!ANI 790378244 3578160101470004 64 25,5,13,0101 17 3 Ma 13 KA!TINI 789904271 3578168194480003 65 30,5,13,010118 %A"NAN 789248024 3578160906600003 53 31,5,13,0101 19 %A"INI 789841192 3578167006520254 61 27,5,13,010120 AD MUIN 789502555 1256243003460001 64 33,5,13,0101 21 4 Ma 13 "UTIAH 789743957 3578167006550156 58 40,5,13,010122 "ATU!I 1050191970 3578161804640001 49 42,5,13,0101 23 6 Ma 13 HA'IKA 1050109086 3578167006600263 53 53,5,13,010124 MUKE"AM 788577737 3578163006390103 74 56,5,13,0101 25 MI"#AN 790163425 1256243006510275 62 44,5,13,0101 26 MU#$ATI 790164101 1256247006580465 55 45,5,13,010127 "UPI$AH 789662845 1256245208540001 59 47,5,13,010128 TUKIMIN 788862734 3505044703430001 70 48,5,13,010129 HANIKA# 788642291 3578167006580375 55 52,5,13,010130 7 Ma 13 MUDA!I 789533605 3578163006540173 59 61,5,13,0101 31 "UPI$AH 790164281 1256246502900003 23 65,5,13,010132 MUDA!I 789533605 3578163006540173 59 61,5,13,0101 33 MUNANJA! 788812367 3578163006620161 51 62,5,13,0101 34 ADENAN 789390753 3578163006620260 46 63,5,13,0101 35 "!I PUJI A 788990255 3578166503660001 47 66,5,13,010136 MAT !OM#I 788616336 3578160108470001 66 71,5,13,0101 37 MU"TA!I 790158036 3578163006550159 58 74,5,13,0101 38 KANI$AH 790159206 3578165212730013 40 75,5,13,010139 D%I H 105019508 3578165303800004 33 81,5,13,010140 HO#I#AH 788938121 357816574750001 38 84,5,13,010141 8 Ma 13 MU"#IM 790539219 1256241002460001 67 91,5,13,0101 42 AM"E 789884392 3578163006520153 61 88,5,13,0101 43 DIMA" 789456958 3578161907000005 13 94,5,13,0101 44 "A'IUDIN 790253504 3578162201790010 34 95,5,13,0101

45 10 Ma 13 "U!OTO 789885279 1256240204530002 60 112,5,13,0101 46 KA"MINI 790414007 3578166807730002 40 111,5,13,010147 NU!AHMA 790190954 3578162707750008 38 110,5,13,0101 48 "U"IATI 790190357 3578164512540001 59 109,5,13,010149 HA"ANA 7901071 3578165907820002 31 108,5,13,010150 "T A"I$A 789655285 3578164707200003 36 107,5,13,010151 "ANI$EH 789317526 1256244101810014 32 101,5,13,010152 JUHOI!I$AH 1050185722 3578164606760006 37 97,5,13,010153 "T HOTIJA 789675175 3578164105700011 43 106,5,13,010154 MI!AT 788235974 1256243006410095 72 103,5,13,0101

UMU!THF

NO "U!AT!UJUKAN


16/43

55 A"MA%I 788632885 3578163006560191 57 113,5,13,0101 56 "AM"U# A!I'IN 789742945 3578160404800005 32 115,5,13,0101 57 DE%I 788456542 3578166808220001 91 114,5,13,010158 11 Ma 13 "T "UM!I$AH 1050199211 1256246607740002 39 122,5,13,010159 !IAT 1050194237 3578160803600002 53 123,5,13,0101 60 "UPENO 789064514 3578162512560001 57 118,5,13,0101 61 MA!DJUKI 788598821 3578161704690004 44 124,5,13,0101 62 E!I$AH 789708071 3578164705570003 56 125,5,13,010163 "AM"U# A!I'IN 790128437 3578162001730008 42 126,5,13,0101 64 14 Ma 13 AGU" A 789932968 3578161809940007 16 149,5,13,0101

65 MADENI 788434108 3578163006330048 59 150,5,13,0101 66 HA#IMA 788534109 3578167006580242 49 141,5,13,010167 MUNI'AH 788804122 3578167006450182 56 152,5,13,010168 HA#IMA 1050195565 3578167006580242 55 151,5,13,010169 M )AINI 788256314 3578163006770152 35 152,5,13,0101 70 %IDJI A 788881948 3578166803840003 25 156,5,13,010171 15 Ma 13 HOTIJAH 10501961116 12562470064800036 72 162,5,13,010172 "OET!I"NO 790124556 3578160502480001 64 158,5,13,0101 73 "AM"U# A!I'IN 789889561 3578161605910006 22 161,5,13,0101 74 NU!%I$ATI 789065381 3578167005530002 63 159,5,13,010175 !AKIMIN 789758695 3578162707550001 57 177,5,13,010176 M HA'I 788874513 3578161503760008 37 180,5,13,0101 77 M AMIN 789822011 3578160402620003 51 179,5,13,0101

78 HOM"ATUN 78960667 3578166303850003 26 175,5,13,010179 #A"I$EM 789753521 3578164412630003 46 172,5,13,010180 IMANIAH 789066988 3578167006610101 50 169,5,13,010181 "I!I$AH 789672622 3578164903560002 56 166,5,13,010182 !UDI$EH 788654665 3578167006410082 72 165,5,13,010183 16 Ma 13 PA!MAN 789393486 3578163101550001 58 184,5,13,0101 84 %AGITO 1050197139 3578160902580002 54 185,5,13,0101 85 !OM#I 7886680007 3578163006560089 57 186,5,13,0101 86 MI"NATI 78868457 3578167006880391 55 187,5,13,010187 "ITI 'ATIMAH 789341174 3578166609840004 29 192,5,13,010188 "A#IMA 789783827 3578164111600002 50 193,5,13,010189 HA"AN 788778819 3578163006530310 60 194,5,13,0101 90 !I$ATUN 789049416 12562446036800021 45 195,5,13,0101

91 !O"IDEH 789316626 3578167006630303 50 196,5,13,010192 17 Ma 13 !INA 789121899 3578164411950001 9 208,5,13,010193 MI"NOI 789075549 3578163006500253 63 207,5,13,0101 94 M "A'I*I 789764174 3578162011850002 28 200,5,13,0101 95 MAI# 789965212 3578161705680003 45 201,5,13,0101 96 MAU#ANI 1050194744 3578160308470001 66 210,5,13,0101 97 "!I %IDA$ATI 789810647 3578165405550001 58 202,5,13,0101 98 M HAMDA 789745015 3578160204020010 12 203,5,13,0101 99 TOTOK 1050238427 1256241507660003 47 213,5,13,0101 100 18 Ma 13 "T !OHMAH 1050225704 3578165207710002 42 214,5,13,0101101 "!IMA! 789955571 3578163006700128 42 217,5,13,0101 102 20 Ma 13 DJUMI#AH 789839177 3578165802620002 51 219,5,13,0101103 M MACH"UM 789610893 1256242009630002 50 227,5,13,0101

104 #UT'IA 790175316 3578164606870001 25 232,5,13,0101105 MA!I$AMAH 789749223 357816006550113 56 231,5,13,0101106 TA"NI 788693578 3578167006400119 75 229,5,13,0101107 "U%A!NI 1050198513 3578167006550279 68 230,5,13,0101108 "U#I$AH 788783084 3578166907710003 40 228,5,13,0101109 21 Ma 13 "UJAI 1050237123 3578160103450001 68 242,5,13,0101 110 "A'IAH 788220472 3578164406860003 27 241,5,13,0101111 A"MAD 1050194109 3578163006200002 91 240,5,13,0101 112 !I)A# 789729322 1256242407890001 29 235,5,13,0101 113 !OM#AH 788593285 3578164206540003 59 236,5,13,0101


17/43

114 "ANU!I 789146662 3578163006590156 54 237,5,13,0101 115 "!IJANI 788704255 3578164809540001 59 238,5,13,0101116 MU"TAIN 788968078 3578163006290029 84 249,5,13,0101 117 I"TIANAH 790724935 3578164905680005 44 247,5,13,0101118 22 Ma 13 "ATUMA 789937378 3578164807570002 56 254,5,13,0101119 !UMIKA# 788858098 3578167006420225 71 252,5,13,0101120 MOEJAHIT 788642245 3578161306970001 52 251,5,13,0101 121 M "AI'U# 789542414 3578161005670006 45 256,5,13,0101 122 23 Ma 13 MA#IHA 789464474 3578165307960005 17 259,5,13,0101123 MAIMUNAH 790024397 3578165508570002 56 262,5,13,0101

124 CHO#I# 1050236649 3578163006490177 64 266,5,13,0101 125 24 Ma 13 "AMU!I 789146662 3578163006590156 54 264,5,13,0101 126 MAT #A"AP 1050233826 3578162302570002 55 265,5,13,0101 127 KA!"I$ATI 789122002 3578164501510001 62 266,5,13,0101128 I"TI$ANAH 790724935 3578164905680005 44 260,5,13,0101129 "EIMAH 789268724 3578166205750010 37 267,5,13,0101130 UNTUNG 789138257 3578160912880002 25 269,5,13,0101 131 'ATIMAH 788073661 3578164504730006 41 271,5,13,0101132 PAI"AH 1056225344 3578167006500253 63 276,5,13,0101133 "A'A*A 789485376 3578167006670082 42 273,5,13,0101134 27 Ma 13 NU! JAMI#A 789030009 3578165104770009 36 284,5,13,0101135 MI"NANDA! 1050224174 3578160602610001 53 286,5,13,0101 136 )AKI$AH 789900873 3578167006520306 61 289,5,13,0101

137 M 'AI"A# 789504805 3578161808970005 16 291,5,13,0101 138 MOEDAHI 789623357 3578163006530316 60 293,5,13,0101 139 KAMA! 789120652 1256241712450001 68 283,5,13,0101 140 KADI! 789825497 1256240407470003 66 282,5,13,0101 141 M "IDI 789308346 3578162012750001 37 281,5,13,0101 142 A#I $AH"I 788790835 3578160711660007 47 278,5,13,0101 143 OEMA! 789900265 1256249703495 72 288,5,13,0101 144 28 Ma 13 M HADI!I 1050239136 3578163006560188 56 297,5,13,0101 145 "AH!I 788736115 3578163006400135 70 306,5,13,0101 146 MA"!I$AH 789491362 3578165500770004 35 305,5,13,0101147 "ITI A"I$AH 789655285 357816470720003 36 304,5,13,0101148 MUHAMMAD 788655093 35781621077200041 41 303,5,13,0101 149 NO!MA 790020145 3578167006400208 73 302,5,13,0101

150 AMANG 788652325 1256243006620176 51 301,5,13,0101 151 CHOI!UN NI"A 788937423 3578164601940004 19 300,5,13,0101152 MU"TO'A 788711084 3578163108790007 79 298,5,13,0101 153 AMANG H " 1050188218 1256242504540001 59 308,5,13,0101 154 ENDANG 788652549 3578165604700005 43 309,5,13,0101155 "A!MONA 789274528 3578162811380002 75 310,5,13,0101 156 "UNA!TI 789457836 35786146203790002 34 311,5,13,0101157 MA!IJATI 788709971 3578167006290140 84 314,5,13,0101158 HADI!I 1050239136 3578163006560188 57 297,5,13,0101 159 PATIMAH 788970486 357816471250001 58 318,5,13,0101160 A#IMAN 790344044 3578162607630003 50 323,5,13,0101 161 K ATIM 1050199233 3578161704470001 62 322,5,13,0101 162 29 Ma 13 A "AMAD 789628511 357816300640106 62 326,5,13,0101

163 "A!I*I 789129832 3578163007480002 65 332,5,13,0101 164 "A#EHA 780129966 3578167006600518 53 334,5,13,0101165 "UPA!NO 1050231712 3578160310820006 30 335,5,13,0101 166 HO#IK 790215884 3578162711690002 44 336,5,13,0101 167 30 Ma 13 MUH$I 788604669 35781607095000002 63 342,5,13,0101 168 NU!OHMA 788676039 3578164505600002 52 340,5,13,0101169 "!I % 789864974 3578164711780001 35 337,5,13,0101170 IMAMA 1050228887 3578166207770001 36 344,5,13,0101171 MA"DUKI 789900074 3578163006480118 58 345,5,13,0101


18/43

172 JUMI!AH 1050225884 1256247006450291 68 346,5,13,0101173 MUHAMMAD 790189323 3578160203010006 54 351,5,13,0101 174 HO"NI$AH 789480944 357816706660020 47 350,5,13,0101175 "IANI 790020538 3578164206860005 27 352,5,13,0101176 31 Ma 13 'ATIMAH 789263594 3578167006450181 68 355,5,13,0101177 "AMA# 789701861 3578166404540002 45 357,5,13,0101178 HE!MANTO 789064277 357816091270004 43 354,5,13,0101 179 !O"IDEH 1050230766 3578166003850001 28 359,5,13,0101180 DA!MAN 790118111 3578163006610201 52 360,5,13,0101


19/43

FORMAT RUJUKAN PA

PUSKESM : PEGIRIAN

BULAN : JUNI

NO TG# NAMA NO JAMKE"MA" N? KTPJENI"

#2 03/06/2013 "UMA!MI 790158047 1256247006920043 70 16,6,13,01014 "UPI$A 789662845 3578165208540001 58 12,6,13,01015 AM"E 789884392 3578160401083449 57 10,6,13,01017 KIMI 789477208 1256247006280116 84 18,6,13,01018 NO!HIDA$AH 789334301 3578164306560001 57 24,6,13,0101

10 KATI!I 789904271 3578168194480003 63 28,6,13,010111 E##A 789987892 3578164305900004 20 30,6,13,010112 A"TUTIK 790378547 3578167006540055 54 32,6,13,010114 05/06/2013 CHO#I#A 788642302 3578165308570002 56 39,6,13,010119 !UMINAH 790259444 3578164402590004 54 40,6,13,010123 "UTI!AH 789743957 3578167006550156 54 59,6,13,010124 08/06/2013 "U%A!TI 789649244 3578167006440155 69 67,6,13,010125 10/6/2013 TIEH 789261491 3578165604480003 65 70?6?13?010126 "!I "UHE!#IN 1050187634 1256246512680002 45 72?6?13?010128 KANI$AH 790159206 3578165212730013 40 76?6?13?010129 HAMI!AH 788642291 3578167006580375 55 78?6?13?010131 ATIKA 789834609 3578164605560001 35 93?6?13?010134 DINDA 788753834 3578164607010002 12 86?6?13?0101

35 ATIAH 789801355 3578167816670006 46 87?6?13?010136 TUKINI 788862734 3505044703430001 70 90?6?13?010137 DE%I 788456542 3578166808220001 91 94?6?13?010139 PATMI 789157719 3578167006530105 60 95?6?13?010141 DJOEA!I$AH 789318797 3578167006510059 62 102?6?13?010143 KATINEM 789598574 3578165108630002 50 105?6?13?010144 "UMA!TI 788802175 3578165009600002 53 106?6?13?010145 HOTIMAH 1050233613 3578164210670003 46 108?6?13?010150 "T "UM!I$AH 1050199211 1256246607740002 39 109?6?13?010153 13/6/2013 E!I$AH 789708071 3578164705570003 56 134?6?13?010155 MU#$ATI 790164101 1256247006580465 55 129?6?13?010157 "T KHOTIJAH 789675175 3578164105700011 43 136?6?13?010159 MI"NATI 78868457 3578167006580391 55 141?6?13?010160 "A%ATI 1050233207 1256247006470101 66 144?6?13?0101

UMU!THF

NO "U!AT!UJUKAN


20/43

63 15/6/2013 NA%I$AH 788723965 3578167006560380 57 150?6?13?010165 "T !OHMAH 1050225704 3578165107710002 42 153?6?13?010167 17062013 NOE!I$AH 789065381 3578167055300002 60 156?6?13?010171 "U"IATI 790190357 3578164512540001 59 179?6?13?010172 "I!I$AH 789672622 3578164903560002 56 176?6?13?010173 !I$ATUN 789049416 3578164003680002 45 172?6?13?010174 NADIA 789183371 3578166510720002 41 171?6?13?010175 HOTIJAH 1050196116 1256247006480036 84 170?6?13?010177 #UT'IA 790175316 3578164606870001 26 183?6?13?010178 HA#IMA 1050195565 3578167006580242 55 184?6?13?0101

79 !I$ATI 788655519 3578164208650002 48 185?6?13?010180 UANI 789596954 3578167006480109 65 186?6?13?010181 1962013 "ITI CHOMA!IA 788722795 1256245505850009 25 190?6?13?010182 NU!MAH 789947987 3578167006560336 57 210?6?13?010183 NU! !A'ID$A 789778258 3578165710860001 26 206?6?13?010184 MOENA$AH 788974841 3578194605450001 68 205?6?13?010186 !O"IDEH 789316626 3578167006630303 49 202?6?13?010187 20062013 AP!I#IA 788681518 3578165104020002 11 211?6?13?010188 I#'I NU!DIANA 789064031 3578166109030002 10 212?6?13?010190 #A"I$EM 789753521 3578164412630003 50 216?6?13?010191 "A#IMA 789783827 3578164111600002 50 213?6?13?010193 INA$ATI 7893439432 3578167006550274 58 222?6?13?010195 "UTI$AH 789893199 3578167006490159 64 221?6?13?0101100 22062013 "A'A*A 789485376 3578167006670082 44 235?6?13?0101101 "UGIA!TI 789971422 3578167007600001 53 233?6?13?0101102 'ATIMA 789180129 3578166504660002 45 232?6?13?0101103 24062013 MA!I$AMAH 789749223 357816006550113 58 244?6?13?0101104 HOTIJAH 790173022 3578166005590004 50 243?6?13?0101106 !OM#AH 788593285 3578164206540003 58 241?6?13?0101108 KA!"I$ATI 789122002 3578164501510001 62 237?6?13?0101110 !ODI$EH 788746577 3578164107640141 59 249?6?13?0101112 25062013 'ATMAH 788073661 3578164504730006 41 258?6?13?0101114 "!I %IDA$ATI 789810647 3578165405550001 58 257?6?13?0101116 HA"ANA 790107107 3578165907820002 31 262?6?13?0101117 "T !OHA$AH 789795843 3578165006940011 19 263?6?13?0101119 DJAENA 789181615 3578167006500014 63 269?6?13?0101121 "UMIATI 1050224635 3578167006760169 37 270?6?13?0101

123 MUTIMAH 1050227346 3578167006640032 45 274?6?13?0101124 26062013 "O'I$AH 788220472 3578164406860003 27 276?6?13?0101126 !UMINAH 788858098 3578167006420225 71 280?6?13?0101127 DJUMI!AH 105022884 1256247006450291 68 285?6?13?0101128 MOEJAHID 788642245 3578161306570001 56 282?6?13?0101129 "UMIATI 789066808 3578167006630125 50 287?6?13?0101


21/43

130 A$U " 790018288 3578166501050008 8 288?6?13?0101131 27062013 MA!DI$A 789870666 3578167006470050 66 293?6?13?0101132 ANGG!AENI 787665284 3578164202970004 16 291?6?13?0101133 MOENA%ATI 788668053 3578164500410001 72 298?6?13?0101134 MUNI'AH 788804122 3578167006540182 57 300?6?13?0101135 "O#IKAH 788993807 3578167006560368 58 301?6?13?0101136 IMANIAH 789066988 3578167006610101 52 302?6?13?0101137 28062013 "EIMAH 789268724 3578166205750010 38 306?6?13?0101138 $ANTI 788343851 3578165507630001 50 308?6?13?0101140 %A!"INI 789841192 3578167006510254 62 310?6?13?0101

141 )AKI$AH 789960873 3578167006520306 61 311?6?13?0101142 MAIMUNAH 790024397 3578165508510002 56 313?6?13?0101146 29062013 A'I MONAH 788790216 3578164609840001 68 321?6?13?0101


22/43

FORMAT RUJUKAN PAS

PUSKESM : PEGIRIAN

BULAN : JULI

NO TG# NAMA NO JAMKE"MA" N? KTPJENI" KE

#1 1/7/2013 M "AH!I 788736115 3578163006400135 70 3?7?13?0101 2 "UPI$A 789662845 3578165208540001 58 2?7?13?01013 M UDI 1050232184 3578163006510126 39 1?7?13?0101 4 "UJAI 1050237123 357816103450001 24 4?7?13?0101

5 !OM#I 789852574 3578161605270005 27 5?7?13?0101 6 MUJIONO 789534808 3527041205812498 32 6?7?13?0101 7 HA!MAJI 788994235 3578163006530109 60 7?7?13?0101 8 "ITI 790221295 3578165102560001 57 8?7?13?01019 !IA 788627092 1256246710970002 16 9?7?13?010110 "A#EHA 780129966 3578167006600518 53 11?7?13?010111 A$U M 789131755 3578166404040003 9 12?7?13?010112 MA"ONI 790846413 3578165908680002 45 14?7?13?010113 "UPENO 789064514 3578162512560001 57 16?7?13?0101 14 2/7/2013 MU"TA'A 788711084 3578163108790007 34 18?7?13?0101 15 MONICA 789754904 3578165506980002 15 17?7?13?010116 NU!OHMAH 788676039 3578164505600002 54 20?7?13?010117 MOHAMMAD 788655093 3578162107720002 41 21?7?13?0101 18 M HO"A 1050234434 3578162005920011 21 24?7?13?0101 19 !O"IDAH 1050230766 3578166003850001 28 23?7?13?010120 AMANG P 788650325 3578163006620162 51 26?7?13?0101 21 !I"KI 789433863 3578160301080005 11 27?7?13?0101 22 "ITI !OHMAH 789473957 3578164409940005 19 30?7?13?010123 "U#I$AH 788783084 3578166707710003 42 32?7?13?010124 MI)AN 789418247 3578163006510180 62 33?7?13?0101 25 "A'I$AH 789418596 3578167006510050 62 34?7?13?010126 3/7/2013 M "A$UTI 790026243 3578163006700181 43 41?7?13?0101 27 HA"AN 788778819 3578163006530310 60 39?7?13?0101 28 "A!TINI 788744283 3578165502680009 45 43?7?13?010129 DA!MAN 790118111 3578163006610201 52 38?7?13?0101 30 MUNA%E!AH 789598102 3578166409550001 57 44?7?13?010131 HE!MANTO 789064277 3578160913700004 43 46?7?13?0101 32 4/7/2013 KATINI 789904271 3578168194480003 65 55?7?13?010133 MU"I$AH 789498898 3578167006460114 67 53?7?13?010134 "U$ONO 787942991 3578162001770004 34 54?7?13?0101 35 MA"DUKI 789900074 3578163006480118 68 56?7?13?0101 36 !AKIMIN 789758695 3578162707550001 58 58?7?13?0101 37 AINU# 'IIH 789729041 1256242502010005 12 57?7?13?0101 38 5/7/2013 A"MA%I 788632885 3578163006560191 57 64?7?13?0101 39 "ATU!I 1050191976 3578161804640001 46 65?7?13?0101 40 TA"#IMIN 789984101 3578161512380002 75 67?7?13?0101 41 "A!MONO 789274528 3578162811380002 75 72?7?13?0101 42 MAU#ANI 1050194744 3578160308470001 66 73?7?13?0101 43 "UM!I$AH 789821234 3578164802580003 55 63?7?13?010144 6/7/2013 'IT!I 789473643 1256246211960001 17 76?7?13?0101

45 HANDI$AK"A 1050222778 1256240707000001 13 78?7?13?0101 46 KA!"INAH 789974065 3578164206700004 43 83?7?13?010147 OE"INTEN 790051713 1256244506310002 45 79?7?13?010148 8/7/2013 UMMI 789118211 3578167006540403 57 89?7?13?010149 MU#$ONO 789985427 1256243006340288 78 93?7?13?0101 50 PATIMAH 788971486 3578164712500001 56 90?7?13?010151 NU! HA$ATI 789731897 1256245804710003 39 86?7?13?010152 "#AMET 788273368 3578163006510248 58 91?7?13?0101 53 AMANG H " 1050188218 1256242504540001 59 87?7?13?0101 54 !UMINAH 790259444 3578164402590004 54 88?7?13?010155 A"TUTIK 790378547 3578167006590055 55 96?7?13?010156 TA!ANI 790378244 3578160101470004 66 95?7?13?0101 57 #ATI'A 1050187689 3578164901860005 27 97?7?13?0101

UMU!THF

NO "U!AT!UJUKAN


23/43

58 MA!TIJAH 1050231014 1256247006590636 52 99?7?13?0101


24/43

59 9/7/2013 KAMI$AH 790159206 3578165212730013 40 105?7?13?010160 NO!MA 790020145 3578167006400208 73 104?7?13?010161 MU"TA!I 790158036 3578163006550159 58 106?7?13?0101 62 M "IDI 789308346 3578162012750001 37 109?7?13?0101 63 TIEH 789261491 3578165604480003 65 110?7?13?010164 "UP!I$AH 790164281 1256246502900003 23 112?7?13?010165 "ATUMA 789937378 3578164807570002 56 115?7?13?010166 !ODI$EH 789114009 3578165108800001 33 119?7?13?010167 DE%I 788456542 3578166808220011 91 123?7?13?010168 10/7/2013 "UTI!AH 789743957 3578167006550156 58 125?7?13?0101

69 ANITA 789076653 3578166910850005 28 132?7?13?010170 KADI! 789825497 1256240407470003 66 130?7?13?0101 71 11/7/2013 MAT !OM#I 788616336 3578160108470001 66 139?7?13?0101 72 "T CHOMA!IA 788722795 1256245505850009 28 136?7?13?010173 PAI"A# 1050225344 3578167006500253 63 138?7?13?010174 JA#A#I 788719959 3578160201300001 83 141?7?13?0101 75 "U!TINING"IH 788727745 3578167006640280 48 145?7?13?010176 12/7/2013 E!I$AH 789708071 3578164705570003 56 151?7?13?010177 HOI!I$AH 789684704 3578164901800002 33 152?7?13?010178 "UMA!$ANTO 788444886 3578161503690007 44 147?7?13?0101 79 "AM"U# A!I'IN 789889566 3578161605910006 22 146?7?13?0101 80 13/7/2013 M DJAK'A! 7887944015 3578163006530298 60 155?7?13?0101 81 15/7/2013 A"MAD 1050194169 3578163006200002 91 163?7?13?0101

82 KAMA! 789120652 1256241712450001 68 166?7?13?0101 83 "T !OHMAH 1050225704 3578165107710002 42 162?7?13?010184 MI"NATI 78868457 3578167006580391 55 160?7?13?010185 !OM#I 78868007 357816300656089 57 159?7?13?0101 86 MUK#I" 789780421 3578160509690004 44 158?7?13?0101 87 1672013 TUKINI 788862734 3505044703430001 70 171?7?13?010188 HOTIJAH 1050196116 1256247006480036 84 172?7?13?010189 AM"E 789884392 3578163006520003 61 173?7?13?0101 90 "T "UM!I$AH 1050199211 1256246607740002 39 177?7?13?010191 AGU" A 789932968 3578161809940007 19 175?7?13?0101 92 KA!EP 788794266 3578163006240022 89 176?7?13?0101 93 "AM"U# A!I'IN 790128437 3578162001730008 42 180?7?13?0101 94 1772013 NANANG 790175283 3578160910820002 31 189?7?13?0101

95 TOTOK 1050238427 1256241507660003 47 186?7?13?0101 96 NU!AHMAN 790190954 3578162707750008 38 191?7?13?0101 97 "U"IATI 790190357 3578164512540001 59 192?7?13?010198 'A!I)IA 788646745 3578165110930003 17 193?7?13?010199 1872013 "ITI HOTIJA 789675175 3578164105700011 43 203?7?13?0101100 AD KO%I 790145864 3578163006450108 68 201?7?13?0101 101 "UMA!MI 790158047 1256247006920043 71 198?7?13?0101102 KA"MU 788779394 1256247006380228 65 196?7?13?0101103 HA%I$AH 788723965 3578167006560380 57 195?7?13?0101104 A#IMAN 790344044 3578162607630003 50 205?7?13?0101 105 1972013 JUA!I$AH 789318797 3578167006510059 62 215?7?13?0101106 MU"!I'AH 1256244601610008 52 214?7?13?0101107 MAT !A%I 789421241 3578163006520161 62 213?7?13?0101

108 M MU"TAJA 788629645 3578162112530002 60 212?7?13?0101 109 TAI 789306107 3578163006510157 62 209?7?13?0101 110 HAMIKA# 788642291 3578167006580375 55 208?7?13?0101111 MI!AT 788235974 1256243006410095 72 207?7?13?0101 112 2072013 !I$ATUN 789049416 3578164603680002 45 218?7?13?0101113 DJUMI#AH 789839177 3578165802620002 51 221?7?13?0101114 "A'IAH 788732425 3578164802600003 48 220?7?13?0101115 2272013 MAT "A'I*I 788686593 1256243006910160 72 222?7?13?0101 116 "AT!A%I 790270749 3578163006320048 81 228?7?13?0101 117 MU"A'AK 789850653 3578161403940007 39 224?7?13?0101 118 "I!I$AH 789672622 3578164903560002 56 232?7?13?0101119 ACH !IDOI 789900603 357816090890002 14 237?7?13?0101 120 MA"*U#A 789606898 3578166304920003 21 238?7?13?0101

121 "AMU!I 789146662 3578163006590156 54 239?7?13?0101


25/43

122 2372013 CHO#I# 1050236649 3578163006490177 64 244?7?13?0101 123 ? ? ?124 "AMI$AH 790173022 1256246005590002 54 246?7?13?0101125 "UGIA!TI 789971422 3578167007600001 53 250?7?13?0101126 !I$ATI 788655589 3578164208650002 48 252?7?13?0101127 NU! MAU#IDA 789752417 3578165505030005 10 251?7?13?0101128 TAI 789558513 3578163006390112 74 254?7?13?0101 129 'AH!U# 788465204 3578162303750008 38 255?7?13?0101 130 MU"DO#I'A 790163201 3578164302040003 9 256?7?13?0101131 A"I'A ! 788782926 3578164405710002 41 257?7?13?0101

132 )AH!U# AIDIN 789049721 3578162606870009 26 258?7?13?0101 133 2472013 !I)A# 789729322 1256249710611 29 263?7?13?0101 134 !UMINAH 788858098 3578167006420225 71 259?7?13?0101135 "A'IAH 789883042 3578164509690002 40 265?7?13?0101136 DE%I H 789117434 3578164611740001 39 266?7?13?0101137 PATMI 789157719 3578167006530102 60 269?7?13?0101138 MAT !I'AI 789037198 1256243006360116 76 270?7?13?0101139 2572013 "AM"U!I 790877812 3578161208670003 46 273?7?13?0101140 NU!%I$AH 789065381 357816705530002 60 274?7?13?0101141 "A'A*A 789485376 3578167006670082 44 277?7?13?0101142 2672013 "AM"U# A!I'IN 789532806 3578160706700004 43 279?7?13?0101 143 TUMAJI 789969666 3578163006590150 57 280?7?13?0101 144 AP!I#IA ' 789394544 3578166204030002 10 288?7?13?0101

145 H MU"TA!I 788968078 3578163006290029 82 289?7?13?0101 146 2772013 "UM!I$A 789743441 3578165209970001 16 294?7?13?0101147 2972013 !OM#AH 788593285 3578164206540003 59 296?7?13?0101148 DJUMI!AH 1050225884 1256247006450291 68 297?7?13?0101149 EMAD 790162154 3578163006440032 69 303?7?13?0101 150 #A"I$EM 789753521 3578164412630003 50 304?7?13?0101151 "A#IMA 789783827 3578164111600002 53 302?7?13?0101152 ATIMONA 788790216 3578164609840001 68 309?7?13?0101153 M 'AI"O# 789504805 3578161808970005 16 310?7?13?0101 154 "UPENO 789064514 3578162512560001 57 311?7?13?0101 155 3072013 MAT HO!I 789742675 3578163006540095 59 317?7?13?0101 156 MOENA%ATI 788668053 3578164506410001 72 315?7?13?0101157 "UPI$AH 789662845 3578165208540001 59 314?7?13?0101

158 DJATIM 790744612 3578163006550161 58 313?7?13?0101 159 AD A)I) 789065471 1256242509880001 25 318?7?13?0101 160 M IA# 788882477 3578162905970009 16 321?7?13?0101 161 KA!"I$ATI 789122002 3578164501510001 62 323?7?13?0101162 )AKI$AH 789900873 3578167006520306 61 324?7?13?0101163 ADU##AH 788675962 3578160101480003 64 326?7?13?0101 164 )UAI!OH 788596198 3578164511800004 33 328?7?13?0101165 MA$A 790173459 35783036409760005 36 327?7?13?0101166 3172013 !O"IDEH 1050230766 3578166003850001 28 336?7?13?0101167 !OM#I 789852574 3578161685270005 27 335?7?13?0101 168 'IT!IANI 7888588007 3578165108800003 32 333?7?13?0101169 MU"#IM 790539219 3578161008460001 67 331?7?13?0101 170 NU! !A'I 789778258 3578165710860001 27 330?7?13?0101171 AD "OMAD 789628511 3578163006480106 62 327?7?13?0101 172 MOEDAH!I 789623357 3578163006530316 60 326?7?13?0101 173 MUJIONO 789534808 3527042006110005 32 324?7?13?0101 174 "!I %IDA$ATI 7889810647 3578165405550001 58 323?7?13?0101


26/43


27/43

FORMAT RUJUKAN PAS

PUSKESM : PEGIRIAN

BULAN : AGUSTUS


#1 1/8/2013 HA"AN 1050191054 3578163006320047 81 9?8?13?0101 2 "U#IMAH 764825973 3526125203580001 55 8?8?13?01013 HA!MADJI 788994235 3578163006530109 60 7?8?13?0101 4 AMANG P 788652325 3578163006620162 51 5?8?13?0101

5 "ATI$AH 788220472 3578164406860003 27 6?8?13?01016 M HA"ID 789426066 3578160708560001 57 4?8?13?0101 7 "ADJO 789566319 3578161609390001 74 3?8?13?0101 8 "#AMET 788703783 3578162004780011 34 10?8?13?0101 9 2/8/2013 TONI H 789818220 3578166404610001 50 16?8?13?0101 10 ADI 1050194485 3578161205520001 61 17?8?13?0101 11 MUHAMMAD 788655093 3578162107720004 41 18?8?13?0101 12 A"MA%I 788632885 3578163006560191 57 19?8?13?0101 13 "UTI$AH 789893199 3578167006490159 64 20?8?13?010114 !ODI$EH 788746577 3526144107640141 59 23?8?13?010115 MAIMUNAH 790024397 3578165508570002 56 24?8?13?010116 "A%ATI 1050233207 1256247006470101 66 25?8?13?010117 JOKO 789612535 3578163008750002 55 27?8?13?0101 18 3/8/2013 ATIKAH 789801355 3578167810670006 46 28?8?13?010119 DA!MON 790118111 3578163006610201 52 31?8?13?0101 20 5/8/2013 "ATU!I 1050191976 3578161804640001 40 33?8?13?0101 21 HA!IATI 789917714 3578167006620323 51 35?8?13?010122 HU"NU# A 788713143 3578161502760005 37 36?8?13?0101 23 MU"I$AH 789498898 3578167006460114 67 37?8?13?010124 6/8/2013 MAT !OM#I 788616336 3578160108470001 66 39?8?13?0101 25 MA!)UKI 788598821 3578161704690004 44 40?8?13?0101 26 7/8/2013 E!I$AH 789708071 3578164705570003 56 41?8?13?010127 MA"ONI 790846413 3578165908680002 45 42?8?13?0101 28 12/8/2013 'A!HAN 789812223 3578161612000003 13 45?8?13?0101 29 AHMAD 789310023 3578160806800004 33 66?8?13?0101 30 AMANG H " 1050188218 1256242504540001 59 62?8?13?0101 31 "UMA!$ANTO 788444886 3578161503690007 44 56?8?13?0101 32 MA!MUKAH 789420598 1256247006350174 78 55?8?13?010133 MUKE"AN 788577737 3578163006390103 74 53?8?13?0101 34 "AIDI 790051252 3578163006540175 59 52?8?13?0101 35 DE%I 788456542 3578166808220001 91 67?8?13?010136 "U!TINING"IH 788727745 3578167006640280 48 68?8?13?010137 TUTIK 784336278 3578165309590001 46 69?8?13?010138 "T CHOMA!IA 788722795 1256245505850009 28 51?8?13?010139 $U#IA # 789508967 35781640107060001 7 49?8?13?010140 DIANA 789508754 3578166304980002 15 48?8?13?010141 "UMA!"IH 788926763 3578166509250001 61 65?8?13?010142 1382013 M "AINI 790242096 3578161201570002 56 86?8?13?0101 43 MUNTAMA 1050198614 3578165904740001 39 85?8?13?010144 A "$AH!ONI 788880587 3578160107860002 43 74?8?13?0101

45 INAJATI 789343942 3578167006550274 58 77?8?13?010146 A!IP 789960047 3578160402960005 17 78?8?13?0101 47 PATIMAH 788970486 3578164712500001 56 81?8?13?010148 MI""A " 1050186688 3578165207570001 56 82?8?13?010149 AGU" A 789932968 3578161809940007 19 88?8?13?0101 50 AD #ATI' 788646699 3578161605650002 48 89?8?13?0101 51 ACH HANDI$AK"A 1050222778 1256240707000001 13 90?8?13?0101 52 NU!MAT 789947987 3578167006560336 57 91?8?13?010153 1482013 NU! HIDA$ATI 789334301 3578164306560001 57 95?8?13?010154 I!MA 787902423 3578166109910003 22 96?8?13?010155 !UMIMAH 790259444 3578164402590004 54 97?8?13?010156 M A!$A ' 790149554 3578161007990005 14 98?8?13?0101? 57 MU"TO'A 788711084 3578163108790007 34 99?8?13?0101

UMU!THF

NO "U!AT!UJUKAN


28/43

58 JUM!OTIN 788689732 3578166912780002 35 103?8?13?010159 KANI$AH 790159206 3578165212730013 40 105?8?13?010160 MU"TA!I 790158036 3578163006550159 58 104?8?13?0101 61 HE!MANTO 789064277 3578160902700004 43 107?8?13?0101 62 1582013 !OM#I 788668007 3578163006560089 57 111?8?13?0101 63 MI"NATI 788668457 3578167006580391 55 112?8?13?010164 "T CHOI!I$AH 788630005 1256244512920003 21 113?8?13?010165 'ATIMA 789180129 3578166504660002 45 116?8?13?010166 MA!$AMAH 789749223 3578167006550113 58 117?8?13?010167 1682013 AM"E 789884382 3578163006520153 61 122?8?13?0101

68 I"TIANAH 790724935 3578164905680005 44 127?8?13?010169 1982013 %A!"INI 789841192 3578167006520254 61 134?8?13?010170 "UJAI 1050237123 3578160103450001 68 130?8?13?0101 71 NANIK 789850359 3578166205860002 27 131?8?13?010172 "T HOTIJA 789675175 3578164105700011 43 140?8?13?010173 TUKINI 788862734 3505044703430001 70 139?8?13?010174 MAT "A#EH 1050223454 3578163006520162 61 129?8?13?0101 75 DJUMI#AH 789839177 3578165802620002 51 128?8?13?010176 M "AH!I 788736115 3578163006400135 70 136?8?13?0101 77 !AKIMIN 789758695 3578162707550001 58 135?8?13?0101 78 'A!IHA 789724697 3578167006590518 64 137?8?13?010179 ENDANG 789817443 3578164910770002 36 138?8?13?010180 "UTI!AH 789743957 3578167006550156 58 142?8?13?0101

81 MU"!I'AH 789679293 3578164601610008 52 144?8?13?010182 M I#HAM 789406885 1256242707060006 9 145?8?13?0101 83 2082013 MU"A''AK 789850653 3578161404740007 39 160?8?13?0101 84 HOI!I$AH 789684704 3578164901800002 33 151?8?13?010185 MI!AT 788235974 1256243006410095 72 152?8?13?0101 86 ACH "UHA!DI 789086957 12562420067660006 35 154?8?13?0101 87 E!"A 1050238405 3578162010950002 18 158?8?13?0101 88 MUHAMMAD 788629645 3578162112530002 60 159?8?13?0101 89 "ATUMA 789937378 3578164807570002 56 160?8?13?010190 MU*MINA 788192291 29 161?8?13?010191 A"MAD 1050194169 357816300620002 91 163?8?13?0101 92 !O"IDEH 789316626 3578167006630303 51 166?8?13?010193 MUNI'A 788804122 3578167006540182 55 169?8?13?0101

94 2182013 KATINI 789904271 3578168194480003 65 175?8?13?010195 "A!TINI 788744283 3578165502680009 45 177?8?13?010196 IMAMA 1050228887 3578161207770001 36 174?8?13?010197 "UJATNO 788883165 3578162801640001 49 183?8?13?0101 98 'IT!I 789473643 1256246211960001 17 179?8?13?010199 JO"EPHINA 788862058 1256244701700003 39 180?8?13?0101100 MA"DUKI 789900074 3578163006480118 58 185?8?13?0101 101 MAT !I'AI 789037198 1256243006360199 76 191?8?13?0101 102 'ATIMAH 788073661 3578164504730006 41 192?8?13?0101103 2282013 MU#$ATI 790164101 1256247006580405 55 197?8?13?0101 104 "ITI A"I$A 789655285 3578164707200003 41 199?8?13?0101105 !I)A# 789729322 1256249710611 24 200?8?13?0101 106 "T HA"IAH 789083976 1256240805660001 47 201?8?13?0101

107 "$AI'U# AN%A! 789119122 1256242509890002 24 202?8?13?0101 108 "AM"U# A!I'IN 789532806 3578160706700003 43 203?8?13?0101 109 NU! !AHMAN 790190954 3578162707750008 48 205?8?13?0101 110 A"TUTIK 790378547 3578167006590055 55 207?8?13?0101111 "AMU!I 789146662 3578163006590156 54 208?8?13?0101 112 MUHAMMAD 788682442 3578161605070005 46 209?8?13?0101 113 2382013 KAMA! 789120652 1256241712450001 68 211?8?13?0101 114 TAI 789306107 3578163006510157 62 212?8?13?0101 115 AD !O)AK 789690475 3578161902600003 53 219?8?13?0101 116 MAU#ANI 1050194744 3578160308470001 66 217?8?13?0101 117 2482013 %A"NAN 789248024 3578160906600003 53 228?8?13?0101 118 #A"IMAH 789957909 3578165602750003 38 226?8?13?0101119 MA!DI$AH 789870666 3578167006470050 66 225?8?13?0101

120 !I$ATUN 789049416 3578164603680002 45 229?8?13?0101


29/43

121 "UGIANTI 789971422 3578167007600001 53 232?8?13?0101122 ? ? ?123 MU"DI 788884571 3578160710740001 36 256?8?13?0101 124 KA"MU 788779394 1256247006380228 75 234?8?13?0101125 PATMI 789157719 3578167006530105 60 236?8?13?0101126 "T A#I$AH 787928949 3578166905740004 39 238?8?13?0101127 "ITI !OHMAH 1050225704 3578165107710002 42 259?8?13?0101128 "U#I$AH 788783084 3578166707710003 42 239?8?13?0101129 HU"NU# 789688168 3578165011020006 11 240?8?13?0101130 MATTA!I 7885963206 3578160308520001 61 244?8?13?0101

131 'E!DIAN"$AH 789241555 3578161601000003 13 250?8?13?0101 132 HA"ANAH 790107107 3578165907820002 31 253?8?13?0101133 HOTIJAH 1050196116 1256247006480036 84 258?8?13?0101134 2782013 "O'IAH 789883042 3578164509690002 40 275?8?13?0101135 KA!"I$ATI 789122002 3578164501510001 62 264?8?13?0101136 M ADU!!OHIM 789406839 3578162707060005 10 265?8?13?0101 137 TOTOK 1050238427 1256241507660003 47 267?8?13?0101 138 HOTIJAH 790173022 3578166005590004 50 268?8?13?0101139 MUKMINA 788192291 3578165607840003 29 270?8?13?0101140 KATINEM 789598574 3578165108630002 50 273?8?13?0101141 HA"AN 788778819 3578163006530310 60 274?8?13?0101 142 TA!ANI 790378244 3578160101470004 66 279?8?13?0101 143 !UM"IAH 789739975 3578167006620001 51 280?8?13?0101

144 2882013 "AM"U# A 789889566 3578161605910006 22 285?8?13?0101 145 A$U MU#$ANING"IH 789131755 3578166404040003 10 286?8?13?0101146 "UN$OTO 789850258 3578160404630003 50 288?8?13?0101 147 "UPI$AH 790164281 1256246502900003 23 283?8?13?0101148 "UM!OH 788697911 3578164206840004 35 291?8?13?0101149 !OM#AH 789366993 3578166107640001 45 290?8?13?0101150 IMANIAH 789066988 3578167006610101 51 292?8?13?0101151 AM!I$AH 789456328 3578169302730004 40 296?8?13?0101152 3082013 NA%I$AH 788723965 3578167006560380 57 297?8?13?0101153 JIIN 788224105 3578160107700017 53 302?8?13?0101 154 KHANI 789479208 1256247006280116 84 303?8?13?0101155 M "INHAJI 788544759 3578163006030004 10 301?8?13?0101 156 AINU! ! 789558094 3578166702040004 8 304?8?13?0101 157 "A'A*A 789485376 3578167006670082 44 305?8?13?0101158 "A$$ADI 789865626 3578162808790001 34 308?8?13?0101 159 DJATIM 788340756 3578163006510097 62 307?8?13?0101 160 !O"IDAH 1050230766 3578166003850001 28 311?8?13?0101161 3182013 !OM#AH 788593285 3578164206540003 58 312?8?13?0101162 MAKKI 789428755 3578160204620001 53 313?8?13?0101 163 IDA 'ATMA%ATI 788502835 3578165605920001 21 314?8?13?0101164 "$A'IAH 788732425 3578164802600003 53 317?8?13?0101165 "ITI "UM!I$AH 1050199211 1256246607740002 39 318?8?13?0101


30/43

FORMAT RUJUKAN PAS

PUSKESM : PEGIRIAN

BULAN : SEPTEMBER


#1 2/9/2013 $UNI 789977103 3578164406920003 21 12?9?13?01012 !E&ANDI 789795797 1256240504060001 7 15?9?13?0101 3 TA"#IMIN 789984101 3578161512380002 75 5?9?13?0101 4 MUJIONO 789534808 3527042006110005 32 10?9?13?0101

5 "A'I$AH 788220472 3578164406860003 27 6?9?13?01016 !U"MIN 788688843 3578163006380034 75 7?9?13?0101 7 NU!OHMAH 788676039 3578164505600002 54 14?9?13?01018 HA$AT 789133061 3578161408700001 33 17?9?13?0101 9 TA"NI 788693578 3578167006400119 73 18?9?13?010110 A"MA%I 788632885 3578163006560191 57 22?9?13?0101 11 'AU)AN 789114104 3578170612010007 10 21?9?13?0101 12 "ITI HA"ANAH 790521805 3578164808780007 30 20?9?13?010113 ACH !IDO 789465813 3578162811050001 7 19?9?13?0101 14 ACH GU'!ON 789958629 3578162805000001 12 23?9?13?0101 15 3/9/2013 )AKI$AH 789900873 3578167006520306 53 34?9?13?010116 HA!IMADJI 788994235 3578163006530109 60 38?9?13?0101 17 M JAK'A! 788914015 3578163006530298 60 36?9?13?0101 18 NATA"$A 789374913 3578166706050005 8 27?9?13?010119 MUH$I 788604669 3578160709500002 63 30?9?13?0101 20 "!I "UHE!#IN 1050187634 1256246512680002 45 25?9?13?010121 CHO#I# 1050236649 3578163006490177 64 24?9?13?0101 22 MI)AN 'AU)I 789418247 3578163006510188 62 44?9?13?0101 23 "A'I$AH 789418596 3578167006510050 62 45?9?13?010124 DA*I 789021235 3578163006590158 54 46?9?13?0101 25 4/9/2013 MI'TAHU# 788697358 1256242167980009 14 51?9?13?0101 26 NO!MA 790020145 3578167006400208 69 47?9?13?010127 MAT HO!I 789742675 3578163006540095 59 55?9?13?0101 28 MU"AMAH 790279288 3578165507680011 45 56?9?13?010129 5/9/2013 "UPI$AH 789662845 1256245208540001 58 57?9?13?010130 MAT !A%I 789421241 3578163006520161 62 60?9?13?0101 31 "ATU!I 1050191976 3578161804640001 40 64?9?13?0101 32 6/9/2013 MUHAMMAD 788655093 3578162107720004 41 68?9?13?0101 33 "UTI$AH 789893199 3578167006490159 64 66?9?13?010134 HA!IATI 789917714 3578167006620323 51 69?9?13?010135 DA!MAN 790118111 3578163006610201 52 70?9?13?0101 36 MU#$ADI 788725978 3578162610820007 31 72?9?13?0101 37 9/9/2013 KU"NA 788925712 3578160909460002 65 91?9?13?0101 38 "A'I$A 788723302 3578164308940006 19 90?9?13?010139 N$OTO 790049158 3578163006640140 49 88?9?13?0101 40 "UJEK 789476346 1256244905530001 59 87?9?13?0101 41 M DA"UKI 789806913 3578161706660001 47 86?9?13?0101 42 "!I %IDA$ATI 789810647 3578165405550001 58 85?9?13?010143 MU"I$AH 789498898 3578167006460114 67 84?9?13?010144 "AHIM 788500743 3578163006560148 57 82?9?13?0101

45 AD "OMED 789628511 3578163006480106 64 83?9?13?0101 46 AMANG P 788652325 3578163006620162 51 79?9?13?0101 47 MA"ONI 790846413 3578165908680002 45 80?9?13?0101 48 E!I$AH 789708071 3578164705570003 56 81?9?13?010149 "U%A!NI 1050198513 3578167006550279 58 92?9?13?010150 MOCH "AM"UDIN 1050228944 3578160701680002 45 94?9?13?0101 51 10/9/2013 "ITI 789434021 3578165009470001 60 100?9?13?010152 ACH AIDO%I 788709497 3578163006600216 52 110?9?13?0101 53 HAMI!AH 788642291 3578167006580375 55 102?9?13?010154 MOEJAHIT 788642245 3578161306570001 56 103?9?13?0101 55 M HO#I# 789893684 3578163006570301 56 97?9?13?0101 56 HO"NI$AH 789480944 3578167006660020 47 104?9?13?010157 M "EIHUN 789244446 1256243006710067 42 105?9?13?0101

UMU!THF

NO "U!AT!UJUKAN


31/43

58 "ITI !AHMATU# 790057056 3578166304000006 13 107?9?13?0101


32/43

59 MAT !OM#I 788616336 3578160108470001 66 109?9?13?0101 60 JUMI!AH 1050225884 1256247006450291 68 108?9?13?010161 MOCH )AH!ONI 789851531 3578164119800003 12 99?9?13?0101 62 MAT !UI 789933144 3578160507640004 49 113?9?13?0101 63 11/9/2013 HA"AN 1050191054 3578163006320047 81 115?9?13?0101 64 HA!NI/%ATINI 790175327 3578165306360001 77 114?9?13?010165 "A%ATI 1050233207 1256247006470101 66 116?9?13?010166 MENIK 789121664 3578165612750002 34 118?9?13?010167 "T ANI"AH 789348025 3578167107940001 19 120?9?13?010168 12/9/2013 "T CHOMA!IA 788722795 1256245505850009 28 122?9?13?0101

69 DE%I 788456542 3578166808220001 81 129?9?13?010170 13913 AGU" 789932968 3578161809940007 16 135?9?13?0101 71 $ANTI 788805093 1256245507630002 50 138?9?13?010172 "ATU!I 1050191976 3578161804640001 40 140?9?13?0101 73 MA!"AI 789280378 3578167006490283 60 141?9?13?0101 74 1492013 NA"I!AH 1050239081 3578167006490283 64 148?9?13?010175 "ITI 790221295 3578165102560001 57 147?9?13?010176 "ENEN 1050226299 3578163006420085 70 146?9?13?0101 77 "A'IAH 788732425 3578164802600003 48 149?9?13?010178 MI"NATI 78868457 3578167006580391 55 143?9?13?010179 !OM#I 788668007 3578163006560089 57 144?9?13?0101 80 1692013 !UMINAH 790259444 3578169402590004 54 151?9?13?010181 MI""A "AMO"A 1050186688 3578165207570001 56 153?9?13?0101

82 I"TI$ANAH 790724935 3578164905680005 44 154?9?13?010183 KHU"%ATUN 788508088 3578165512790002 34 158?9?13?010184 'A!HAN % 789812223 3578161612000003 13 159?9?13?0101 85 MA!I$AMAH 789749223 357816006550113 58 164?9?13?010186 ANA 789236684 3578165611790002 34 165?9?13?010187 TEJA AP!I#ANDI 788827882 1256243004850001 28 166?9?13?0101 88 1792013 "UJAI 1050237123 3578160103450001 64 170?9?13?0101 89 "UMAI$AH 789410171 3578165502510001 60 176?9?13?010190 PATIMAH 788970486 3578166471250001 56 179?9?13?010191 MAI"A!OH 790064212 3578167006830091 30 184?9?13?010192 MU"TA!I 790158036 3578163006550159 58 183?9?13?0101 93 KANI$AH 790159206 3578165212730013 40 182?9?13?010194 "OEANDI 788905089 3578163006480082 65 187?9?13?0101

95 1892013 M HU"NI 790144301 3578160511810003 32 190?9?13?0101 96 "ANI$AH 789361727 3578164209690002 43 189?9?13?010197 M 'ATHU! 788793715 3578161907040002 9 191?9?13?0101 98 "T MUTMAINA 790198547 3578165208010007 20 192?9?13?010199 INAJATI 789343942 3578167006550274 58 193?9?13?0101100 ANITA 789076653 3578166910850005 28 196?9?13?0101101 MU"TO'A 789940528 3578163006530264 52 197?9?13?0101 102 1992013 TIAH 789704289 3578165308530001 60 198?9?13?0101103 "UMA!TO 789268487 3578160204750002 38 199?9?13?0101 104 DJUMI#AH 789839177 3578165802620002 51 200?9?13?0101105 "ATUMA 789937378 3578164807570002 56 201?9?13?0101106 "U!TINING"IH 788727745 3578167006640280 48 202?9?13?0101107 "UGI$O 788689326 1256241902780007 35 203?9?13?0101

108 "OEGIONO 789181558 3578163006500159 63 204?9?13?0101 109 DJAENA 789181615 3578167006500014 63 202?9?13?0101110 2092013 "ITI 790203053 3578167006480017 65 215?9?13?0101111 MOCHAMMAD 788682442 3578161605670005 46 212?9?13?0101 112 JUA!I$AH 789318797 3578167006510059 62 213?9?13?0101113 )AH!U# A 789049721 3578162606870009 26 217?9?13?0101 114 2192013 M TAJA 788629645 3578162112530002 61 220?9?13?0101 115 "UMA!"I 789035117 3578165909550002 58 219?9?13?0101116 TAI 789306107 3578163006510157 62 221?9?13?0101 117 "UMA!$ANTO 788444886 3578161503690007 44 222?9?13?0101 118 "AHAH 788204373 3578163006260028 87 223?9?13?0101 119 MUNI'AH 788804122 3578167006540182 56 224?9?13?0101120 2492013 PATMI 789151719 35781670065301035 60 258?9?13?0101

121 'ATIMAH 1053397593 3578165503570003 52 263?9?13?0101


33/43

122 MA!DI$AH 789870666 3578167006470050 68 261?9?13?0101123 NU!UDIN 789051521 3578161503750001 37 264?9?13?0101 124 "ATIMAH 789189906 3578165101590003 52 266?9?13?0101125 M I#HAM 789406885 1256242707060006 7 269?9?13?0101 126 AD !O)AK 789690475 3578161902600003 53 270?9?13?0101 127 2592013 HO!I$AH 789684704 3578164901800002 33 275?9?13?0101128 MAI"UMA 788654035 3578165403610001 55 274?9?13?0101129 KA"MU 788779394 1256247006380228 75 273?9?13?0101130 !OHIM 788778909 1256243006310118 82 272?9?13?0101 131 MA!DI$AH 789504052 3578167006440018 69 283?9?13?0101

132 KATINI 789904271 3578168194480003 65 281?9?13?0101133 "AI'U# AN%A! 789119122 1256242509890002 24 289?9?13?0101 134 MI!AT 788235974 1256243006410045 72 290?9?13?0101 135 DAE!I 1050198243 1256243006430215 65 291?9?13?0101 136 A HANDI$AK"A 1050222778 1256240707000001 13 292?9?13?0101 137 M AA" 789776752 3578162010670002 46 286?9?13?0101 138 'ATIMA 789180129 3578166504660002 45 277?9?13?0101139 IMAMA 1050228887 3578166207770001 36 279?9?13?0101140 "A!TINI 788744283 3578165502080009 45 280?9?13?0101141 "UGIA!TI 789971422 3578167007600001 53 284?9?13?0101142 M "AH!I 788736115 3578163006400135 70 276?9?13?0101 143 2692013 ATIMONAH 788790216 3578164609890001 68 294?9?13?0101144 "T HOTIJAH 789267633 3578166008830003 30 296?9?13?0101

145 !O"IDEH 789316626 3578167006630303 50 297?9?13?0101146 !I$ATUN 789049416 3578164603680002 44 300?9?13?0101147 AD !O)AK 789531287 3578161510980002 8 299?9?13?0101 148 AD #ATI' 788646699 3578161605650002 48 302?9?13?0101 149 'E!DIAN"$AH 789241555 3578161601000003 13 303?9?13?0101 150 NU!U# 'A!IDA 789371054 3578165206000002 13 298?9?13?0101151 "T !OHMAH 1050225704 3578165107710002 42 304?9?13?0101152 2792013 UMMI 789118211 3578167006540403 59 305?9?13?0101153 %AHID 789060914 3578161807670001 46 310?9?13?0101 154 NGATMINI 789201303 3578167006520023 60 307?9?13?0101155 MU"!I'AH 789679293 3578164601610008 52 308?9?13?0101156 !AKIMIN 789758695 3578162707550001 58 313?9?13?0101 157 HA"AN 788778819 3578163006530310 60 312?9?13?0101

158 !OM#AH 789366993 3578166107640001 45 311?9?13?0101159 "T A#I$AH 787928949 3578126905740004 39 316?9?13?0101160 E!"A D 1050238405 3578162010950002 28 319?9?13?0101 161 2892013 GUNA%AN 789334064 3578161608490001 64 322?9?13?0101 162 ATIKAH 789801355 3578167810670006 46 323?9?13?0101163 TUKINI 788862734 350504470343001 70 326?9?13?0101164 "A#EHA 780129966 3578167006600518 53 327?9?13?0101165 KA!"I$AH 789122002 3578164501510001 62 328?9?13?0101166 A"TUTIK 790378547 3578167006590055 59 330?9?13?0101167 3092013 MUNI!AH 789301552 1256245102390002 74 341?9?13?0101168 "AT!O%I 790270749 3578163006320048 81 342?9?13?0101 169 MAKKI 789428755 3578160204620001 53 339?9?13?0101 170 NANIK 789850359 3578166205860002 27 336?9?13?0101171 !OM#AH 788593285 3578164206540003 58 331?9?13?0101172 "UPIJAH 790164281 1256246502900003 23 343?9?13?0101173 MAIMUNAH 790024397 3578165508570002 56 344?9?13?0101174 EDI "UGIONO 1050191717 35781607780004 35 347?9?13?0101


34/43


35/43

FORMAT RUJUKAN PASI

PUSKESM : PEGIRIAN

BULAN : OKTOBER


#1 1/10/2013 HA!MADJI 788994235 3578163006530109 60 11?10?13?0101 6 KA"IATI 789089679 3578166711740002 39 8?10?13?01017 KEMI 789477208 1256247006280116 85 10?10?13?0101

11 2/10/2013 $ATINI 789033306 3578166310780003 35 32?10?13?0101

12 "ATIMAH 789189906 3578165101590003 52 31?10?13?010115 NGATMINAH 789066639 3578167006600266 53 24?10?13?010117 KATINEM 789598574 3578165108630002 50 26?10?13?010118 !O"IDAH 1050230766 3578166003850001 28 28?10?13?010120 3/10/2013 "UPI$AH 789662845 1256245208540001 59 38?10?13?010122 NAPIA 788666084 3578166203580001 55 41?10?13?010125 MU"AMAH 790279288 3578165507680011 45 47?10?13?010127 !I$ATI 788655519 3578164208650002 48 55?10?13?010130 "UPI$AH 788797574 3578164565690004 40 63?10?13?010132 TA"NI 788693578 3578167006400119 73 66?10?13?010133 "UMAKI$AH 789816778 1256246516470001 64 69?10?13?010134 "ITI "UM!I$AH 1050199211 1256246607740002 39 71?10?13?010135 A$U MU#$ANING"IH 789131755 3578160404040003 9 73?10?13?010137 8/10/2013 "UM!I$AH 790101415 3578166301700001 43 93?10?13?010138 "U%A!TI* 1050197141 3578167006610234 57 89?10?13?010140 NU!MAH 789947987 3578167006560336 57 95?10?13?010141 HO"NI$AH 789980944 3578167006660030 47 101?10?13?010142 "AKI$AH 789900873 3578167006520306 61 104?10?13?010144 HAMI!AH 788642291 3578167006580376 55 125?10?13?010148 IMANIAH 789066988 3578167006610101 50 130?10?13?010149 11/10/2013 MA!%ATI 789417832 3578167005440001 58 132?10?13?010152 $ATMI!AH 789161106 3578166104530001 60 138?10?13?010153 NU!UN 789202337 3578165809920010 21 140?10?13?010154 12/10/2013 "UJIATI 1050188229 3578165608580002 55 142?10?13?010155 NU! AMA#IA 789391642 3578165711970001 16 143?10?13?010157 DIANA 1050234603 3578166112820008 24 146?10?13?0101

UMU!THF

NO "U!AT!UJUKAN


36/43

59 I"TI$ANAH 790724935 3578164905680005 44 148?10?13?010162 MOENA%ATI 788668053 3578164506410001 72 154?10?13?010163 MI"NATI 788668457 3578167006580391 55 158?10?13?010165 "ODIK P 790227472 3578160308550002 58 167?10?13?010168 KANI$AH 790159206 3578165212730013 40 173?10?13?010169 MUNI!AH 787894042 3578165706550003 58 174?10?13?010170 HA!IATI 789917714 3578167006620323 51 179?10?13?010172 NU!OHMAH 788676039 3578164505600002 53 183?10?13?010174 "UMA!"IH 789035117 3578165909550002 58 189?10?13?010175 E##A 788647061 3578165910940004 19 194?10?13?0101

77 HA"ANAH 790107107 3578165907820002 31 196?10?13?010179 "U"IATI 790190357 3578164512540001 59 198?10?13?010181 21102013 %A"INI 789841192 3578167006520254 61 217?10?13?010183 "!I %IDA$ATI 789810647 3578165405550001 58 211?10?13?010185 "ATUMA 789937378 3578164807570002 56 213?10?13?010186 "ITI 790221295 3578165102560001 57 215?10?13?010187 MUNI'AH 788804122 3578167006540182 56 223?10?13?010189 "U#I$EH 788783084 3578166407710003 42 226?10?13?010193 22102013 'IT!IANI 788858807 3578165208800003 32 237?10?13?010196 PATIMAH 788970488 3578164712500001 56 245?10?13?010197 MA!I$AMAH 789749223 3578160016550113 58 248?10?13?010198 !UMINAH 790259444 3578164402590004 54 234?10?13?010199 "UM!I$AH 789821234 3578164802580003 55 240?10?13?0101

101 %I%IN 789118885 3578165303770001 36 241?10?13?0101102 %AKINAH 789715653 3578164607460002 67 252?10?13?0101105 "U"IATI 1050192066 3578767006570250 56 259?10?13?0101106 23102013 MU"I$AH 788498896 3578167006460114 67 262?10?13?0101107 !UM"IAH 789739975 357816700662031 51 267?10?13?0101108 #A"I$EM 789753655 3578164412630003 50 269?10?13?0101109 INAJATI 789343942 3578167006550274 58 271?10?13?0101112 HO"I#AH 789623706 3578167006760155 30 278?10?13?0101113 NO!MA 790020145 3578167006400208 73 273?10?13?0101115 MAKI!A 1050223768 1256247006390190 74 286?10?13?0101116 25102013 "T JAMI#A 789375993 3578164507780004 35 287?10?13?0101117 NU! "UPIAH 1050199391 3578166907690003 44 290?10?13?0101118 DJU!I$AH 789318797 3578167006510059 62 292?10?13?0101

119 26102013 "ITI !OM#AH 1050225704 3578165107710002 42 295?10?13?0101120 !I$ATUN 789049416 3578164603680002 45 294?10?13?0101


37/43

122 ? ? ? 123 IMAMAH 1050228887 3578166207770001 36 308?10?13?0101 124 "U$ATI 1050195442 3578166608620001 51 299?10?13?0101 126 "!I !AMA$ANTI 789369254 3578165909710003 42 301?10?13?0101 127 "A!TINI 788744283 3578165502680009 45 304?10?13?0101 128 "A'A*A 789485376 3578167006670082 44 311?10?13?0101 130 "UMA!"IH 788926263 3578166509250001 61 312?10?13?0101 133 29102013 KATINI 789904271 3578168194480003 65 319?10?13?0101 135 NA%I$AH 788723965 3578167006560380 57 324?10?13?0101 136 A"TUTIK 790378547 3578167006590005 55 325?10?13?0101

138 "U$ANTI 789267644 3578166203610001 52 327?10?13?0101 139 "UMA!MI 790158047 1256247006920043 71 328?10?13?0101 143 30102013 !O"IDEH 789316626 3578167006630303 50 337?10?13?0101 144 "U"I KA"TINI 788612139 3578164104640004 49 339?10?13?0101 146 31102013 $ANTI 788343851 3578165507630001 50 345?10?13?0101 148 MU#$ATI 790164101 1256247006580465 55 346?10?13?0101 150 MUNI!AH 789301552 1256245102390002 74 353?10?13?0101


38/43

FORMAT RUJUKAN PASI

PUSKESM : PEGIRIAN

BULAN : NOEMBER


#1 1/11/2013 AM"E 789884392 3578163006520153 61 2?11?13?0101 2 !OM#AH 788593285 3578164206540003 59 3?11?13?01013 IDA 'ATMA%ATI 788502835 3578165605920001 21 5?11?13?01016 "U!TINING"IH 788727745 3578167006640280 48 8?11?13?0101

10 "UTI$AH 789893199 3578167006490159 64 15?11?13?010111 TUKINI 788862734 3505044703430001 70 16?11?13?010112 4/11/2013 MA!DI$AH 789870666 3578167006470050 66 23,11,13,010114 6/11/2013 "A'I$AH 789418598 3578167006510052 61 47?11?13?010116 TATUK 1050238394 3578164504700009 42 44?11?13?010117 "ANI$EH 789361727 3578164209690002 43 43?11?13?010122 T!I A 789127953 3578160404010007 10 31?11?13?010124 MOE!A%ATI 788668053 3578164506410001 59 36?11?13?010125 "ATIMAH 789189906 3578165101590003 54 35?11?13?010126 DJUMA*ATI 789183303 3578167006510291 62 32?11?13?010127 #INDA 790056077 1256246311030003 9 30?11?13?010128 "A%ATI 1050233207 1256247006470101 62 29?11?13?010133 MA#IHA 789464474 3578165307960005 17 61?11?13?010134 "U!ATI 1050224185 3578167006690100 44 47?11?13?010135 8/11/2013 MI"A "AMO"I! 1050186688 3578165207570001 56 69?11?13?010136 JU#IANTI 789268015 3578165207790006 32 72?11?13?010139 9/11/2013 )AKI$AH 789900873 3578167006520306 60 81?11?13?010140 "ITI "AMI$AH 790147473 3578164602770001 36 78?11?13?010142 "ITI !OM#AH 789238078 3578166101680003 45 80?11?13?010144 'A!I)IA 788646745 3578165110930003 17 100?11?13?010145 !O"IDAH 1050230766 3578166003850001 28 101?11?13?010146 I"TI$ANAH 790724935 3578164905680005 44 102?11?13?010147 "ITI "UM!I$AH 1050199211 1256246607740002 39 103?11?13?010148 "ITI MAIMUNAH 790062715 1256245506800008 31 104?11?13?010149 HOTIJAH 1050196116 1256247006480036 72 105?11?13?010150 PATMI 789157719 3578167006530105 57 106?11?13?010151 OE"INTEN 790051713 1256244506310002 43 107?11?13?0101

52 "UPI$ATIN 788797574 3578164505690004 44 108?11?13?010153 12/11/2013 KATINEM 789598574 3578165108630002 50 118?11?13?010154 HA!NI 790175327 3578165303630001 77 113?11?13?010155 NGATMINI 789201393 3578167006520023 60 112?11?13?010156 HO"NI$AH 789480944 3578167006660020 42 116?11?13?0101

UMU!THF

NO "U!AT!UJUKAN


39/43

59 JUM!UTIN 788689732 3578166912780002 33 123?11?13?010164 "ITI HO#IPAH 788690766 3578164804950001 11 132?11?13?010165 E!I$AH 789708071 3578164705570003 55 135?11?13?010167 141113 "ITI CHOMA!IA 788722795 1256245505850009 28 147?11?13?010169 UANI 789596954 357816700 65 145?11?13?010175 A"MAU# HU"NA 789832089 3578164308920004 20 160?11?13?010178 HAIAH 789411778 3578164703570002 56 156?11?13?010179 HA!IATI 789917714 3578167006620323 51 159?11?13?010180 16112013 DIANA M 1050234603 3578166112820008 24 163?11?13?010181 DJAENA 789181615 3578167006500014 63 165?11?13?0101

85 MI"$ANI 789340443 3578167006320173 81 175?11?13?010187 KANI$AH 790159206 3578165212730013 40 168?11?13?010191 191113 "UTI!AH 789743957 3578167006550156 58 194?11?13?010193 MA$A 790173459 3578036409760005 36 207?11?13?010195 201113 "T CHOI!I$AH 789422141 3578167001860002 27 210?11?13?010196 $U#IA #AI#ATU" 789508754 3578164807060001 7 209?11?13?010199 !UMINAH 788858098 3578167006420225 71 220?11?13?0101102 211113 MA!I$AMAH 789749223 3578160065500113 58 229?11?13?0101103 MA!TIJAH 1050231014 1256247006590636 52 231?11?13?0101105 MI"NATI 78868457 3578167006580391 55 240?11?13?0101106 !INA A 790067788 3578166308660003 47 241?11?13?0101107 NAI#A CAME#IA 788690417 1256245504040003 8 244?11?13?0101108 DE%I 788456542 3578166808220001 81 245?11?13?0101

109 22112013 TIEH 789261491 3578165604480003 65 246?11?13?0101111

form rujukan pasien jamkesmas utk klaim buku rujukan 2013.xls

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