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<html>
<head><link href="file2.css" rel="stylesheet" type="text/css" /><table width='4500' border='0' align='center' cellpadding='3px' cellspacing='0' class='tbl_form'><tr class='isi2'><td valign='top' align='center'><font size='4' face='Tahoma'>RS SIMRS KHANZA</font><br>GUWOSARI, Pajangan, Bantul<br>Hp: 08562675039, 085296559963, E-mail : khanzasoftmedia@gmail.com<br><br><font size='2' face='Tahoma'>KARTU INDEKS PENYAKIT PASIEN RAWAT JALAN PERIODE 02-11-2017 S.D. 02-11-2019<br>Diagnosa : Congestive heart failure<br>Kode ICD X : I50.0<br><br></font></td></tr></table>
</head>
<body>
<table width="4500px" border="0" align="center" cellpadding="3px" cellspacing="0" class="tbl_form">
<tr class="isi">
<td valign="middle" bgcolor="#FFFAF8" align="center" width="10px" rowspan="3">
NO.
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="40px" rowspan="3">
NO.R.M.
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="50px" rowspan="3">
TGL.MASUK
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="200px" colspan="18">
GOLONGAN UMUR
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="60px" rowspan="3">
DIAGNOSA KOMPILASI
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="70px" rowspan="2" colspan="3">
TINDAK LANJUT PERAWATAN
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="50px" rowspan="2" colspan="2">
KASUS BARU
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="50px" rowspan="2" colspan="2">
KASUS LAMA
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="2800px" rowspan="2" colspan="40">
KETERANGAN
</td>
</tr>
<tr class="isi">
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
0-6 hr
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
7-27hr
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
28hr-‹1th
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
1-4th
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
5-14th
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
15-24th
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
25-44th
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
45-64th
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
› 64
</td>
</tr>
<tr class="isi">
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
PULANG
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
RAWAT
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
RUJUK
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
L
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
P
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
-
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
AA International
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi / Pihak ke - III
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi ABDA
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi ACA
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Adira ( Medicillin )
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi AIA
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Allianz
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Astra Aviva Life
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Avrist
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Axa Financial
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Axa Services/Mandiri
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Bintang
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi BNI Life
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi CAR
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi FWD
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Garda Medika
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Lippo
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Manulife
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Mega
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Sinarmas
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Asuransi Tugu Mandiri
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
BPJS
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
BPJS
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
BPJS
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Cynergy Care
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
JAMINAN BOGOR
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
Mandiri Inhealth
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
PBI (APBD)
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
PBI (APBN)
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
PEGAWAI BUMN
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
PEGAWAI PEMERINTAH NON PNS
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
PEKERJA MANDIRI
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
PNS DAERAH
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
PNS DAERAH
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
PT. Hasnur Riung Sinergi
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
PT. PLN ADMEDIKA
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
TMS Healthcare
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
TNI ANGKATAN UDARA
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center">
UMUM
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
222343
</td>
<td valign="middle" align="center">
2019-09-19
</td>
<td valign="middle" align="center">
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0100100
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2019-10-09
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</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
</tr>
<tr class="isi">
<td valign="middle" align="center">
3
</td>
<td valign="middle" align="center">
0100100
</td>
<td valign="middle" align="center">
2019-10-11
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
V
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
V
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
V
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
V
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
</td>
</tr>
<tr class="isi">
<td valign="middle" align="right" colspan="3">
Total :
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
2
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
</td>
<td valign="middle" align="center">
3
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
2
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
1
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>
<td valign="middle" align="center">
0
</td>