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Lap BP Gigi 2023

The monthly report summarizes dental clinic data from PUSKESMAS BAA and its network for July 2023. Key details include: - Total clinic visits were 17, with the highest numbers in Metina (5 visits) and Namodale (4 visits). - Most patients were between 5-9 years old (3 visits) and 10-14 years old (3 visits). - The majority of patients were students (SD/MI) with 5 visits total. - All patients attended clinics directly, with no referrals. - Most common diagnoses were caries (3 visits) and other issues (6 visits). - No further information was provided on treatment actions

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Yunike Mbado
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27 views42 pages

Lap BP Gigi 2023

The monthly report summarizes dental clinic data from PUSKESMAS BAA and its network for July 2023. Key details include: - Total clinic visits were 17, with the highest numbers in Metina (5 visits) and Namodale (4 visits). - Most patients were between 5-9 years old (3 visits) and 10-14 years old (3 visits). - The majority of patients were students (SD/MI) with 5 visits total. - All patients attended clinics directly, with no referrals. - Most common diagnoses were caries (3 visits) and other issues (6 visits). - No further information was provided on treatment actions

Uploaded by

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

REKAPITULASI POLI GIGI DI PUSKESMAS DAN JEJARINGNYA


PUSKESMAS BAA
BULAN : JUlI 2023
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - 2 4 5 2 4 2 2 - - - 4 1 2 6 1 2 - - 1 - - - - - 1 1 - - 1 - - - 1 - 2
2 Kumulatif s.d. Bulan lalu 5 10 13 13 12 13 5 12 1 - - 5 5 7 11 6 4 3 - 6 - 1 1 - 3 4 2 - 1 4 1 1 1 3 - 2

II Kelompok Umur : - 2 4 5 2 4 2 2 - - - 4 1 2 6 1 2 - - 1 - - - - - 1 1 - - 1 - - - 1 - 2
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 0 2 0 2 1 0 0 0 0 0 2 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1
3 10 – 14 tahun 0 0 2 1 0 0 0 2 0 0 0 0 0 1 3 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 1 0 3 0 2 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 45 – 54 tahun 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 0 2 4 5 2 4 2 2 0 0 0 4 1 2 6 1 2 0 0 1 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 2


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 0 0 2 1 2 1 0 0 0 0 0 2 1 0 4 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 1
4 Lain-lain 0 2 2 4 0 3 2 2 0 0 0 2 0 1 1 0 2 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1

IV Asal Pasien : - 2 4 5 2 4 2 2 - - - 4 1 2 6 1 2 - - 1 - - - - - 1 1 - - 1 - - - 1 - 2
1 Datang sendiri 0 2 4 5 2 4 2 2 0 0 0 4 1 2 6 1 2 0 0 1 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 2
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 0 2 4 5 2 4 2 2 0 0 0 4 1 2 6 1 2 0 0 1 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 2
1 Karies 0 0 0 2 0 0 0 0 0 0 0 2 1 2 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 2
2 Penyakit Gusi 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 0 2 4 2 2 4 2 2 0 0 0 2 0 0 6 1 1 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : - 2 4 5 2 5 2 2 - - - 4 1 2 7 1 2 - - 1 - - - - - 1 1 - - 2 - - - 1 - 2
701 Konsultasi Dokter Gigi 0 0 2 0 0 0 0 1 0 0 0 0 0 0 2 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 1 0 1 2 0 0 0 0 0 1 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 2 1 5 1 3 2 1 0 0 0 3 1 2 2 1 1 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 1 0 2

VII Rujukan : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - - 1 1 - - - - - - - - 1 - 1 - - - - - - - 1 1 - - - - - - - -
2 Kumulatif s.d. Bulan lalu 1 - 1 1 2 - - - - - - - 2 - 1 - 1 - - - 3 2 2 1 1 2 4 - - - - -

II Kelompok Umur : - - 1 1 - - - - - - - - 1 - 1 - - - - - - - 1 1 - - - - - - - -
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0
6 45 – 54 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0

IV Asal Pasien : - - 1 1 - - - - - - - - 1 - 1 - - - - - - - 1 1 - - - - - - - -
1 Datang sendiri 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0
1 Karies 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0
2 Penyakit Gusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : - - 1 1 - - - - - - - - 1 - 1 - - - - - - - 1 1 - - - - - - - -
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0

VII Rujukan : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - - - - - - - - 6 11 16 17 22 28 50
2 Kumulatif s.d. Bulan lalu - - - 1 2 - - - 44 49 41 49 85 98 183

II Kelompok Umur : - - - - - - - - 6 11 16 17 22 28 50
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 - 1 1 - 1 1 2
2 5 – 9 tahun 0 0 0 0 0 0 0 0 3 3 3 4 6 7 13

3 10 – 14 tahun 0 0 0 0 0 0 0 0 - 1 6 3 6 4 10

4 15 – 19 tahun 0 0 0 0 0 0 0 0 3 1 1 1 4 2 6

5 20 – 44 tahun 0 0 0 0 0 0 0 0 - 3 1 6 1 9 10

6 45 – 54 tahun 0 0 0 0 0 0 0 0 - 1 1 1 1 2 3

7 55 – 59 tahun 0 0 0 0 0 0 0 0 - 1 1 1 1 2 3

8 60 – 69 tahun 0 0 0 0 0 0 0 0 - - 2 - 2 - 2

9 > 70 tahun 0 0 0 0 0 0 0 0 - - - 1 - 1 1

III Kelompok Sasaran : 0 0 0 0 0 0 0 0 6 11 16 17 22 28 50


1 Bumil 0 0 0 0 0 0 0 0 - - 1 - 1 - 1
2 Balita 0 0 0 0 0 0 0 0 - 1 - - - 1 1
3 Anak SD/MI 0 0 0 0 0 0 0 0 3 2 7 5 10 7 17
4 Lain-lain 0 0 0 0 0 0 0 0 3 8 8 12 11 20 31

IV Asal Pasien : - - - - - - - - 6 11 16 17 22 28 50
1 Datang sendiri 0 0 0 0 0 0 0 0 6 11 16 17 22 28 50
2 Rujukan 0 0 0 0 0 0 0 0 - - - - - - -
3 Kiriman kader 0 0 0 0 0 0 0 0 - - - - - - -

V Diagnosa : 0 0 0 0 0 0 0 0 6 11 16 17 22 28 50
1 Karies 0 0 0 0 0 0 0 0 3 2 1 7 4 9 13
2 Penyakit Gusi 0 0 0 0 0 0 0 0 - - - 1 - 1 1
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 - 1 - - - 1 1
4 Lain - lain 0 0 0 0 0 0 0 0 3 8 15 9 18 17 35
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
VI Tindakan : - - - - - - - - 6 13 17 17 23 30 53
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 1 - 5 1 6 1 7
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 - - - - - - -
703 Tumpatan sementara 0 0 0 0 0 0 0 0 - - - - - - -
704 Tumpatan tetap 0 0 0 0 0 0 0 0 - - - - - - -
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 - - - - - - -
706 Insisi abses 0 0 0 0 0 0 0 0 - - - - - - -
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 1 4 4 1 5 5 10
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 - - - - - - -
709 Lain-lain 0 0 0 0 0 0 0 0 4 9 8 15 12 24 36

VII Rujukan : - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 - - - - - - -
2 Rumah sakit 0 0 0 0 0 0 0 0 - - - - - - -
3 Faskes lainnya 0 0 0 0 0 0 0 0 - - - - - - -

Mengetahui Yang Melapor


Kepala UPTD Puskesmas Baa

drg. Gevilawati Pandie Helmi K. Manafe, A.Md.KG


NIP. 19750201 200904 2 005 NIP. 19730520 199303 2 012
LAPORAN BULANAN
REKAPITULASI POLI GIGI DI PUSKESMAS DAN JEJARINGNYA
PUSKESMAS BAA 16
BULAN : JUNI 2023
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - 1 1 1 1 3 7 3 - 1 1 1 1 5 1 6 - - - - - - - 1 1 1 - - - - 1 - 1 1 1 2
2 Kumulatif s.d. Bulan lalu 5 9 10 9 11 12 10 13 1 1 1 2 5 10 6 11 2 3 - 5 - 1 1 1 4 4 1 - 1 3 2 1 2 3 1 2

II Kelompok Umur : - 1 1 1 1 3 7 3 - 1 1 1 1 5 1 6 - - - - - - - 1 1 1 - - - - 1 - 1 1 1 2
1 ≤ 5 tahun 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
2 5 – 9 tahun 0 1 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 0 1 0 0 0 2 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 0 0 1 0 1 0 3 0 0 0 1 0 3 0 3 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 2
6 45 – 54 tahun 0 0 0 0 0 0 2 0 0 0 0 0 0 1 0 2 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 0 1 1 1 1 3 7 3 0 1 1 1 1 5 1 6 0 0 0 0 0 0 0 1 1 1 0 0 0 0 1 0 1 1 1 2


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
3 Anak SD/MI 0 1 1 0 0 1 2 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 0 0 0 1 1 2 4 3 0 0 1 1 0 5 0 5 0 0 0 0 0 0 0 1 1 1 0 0 0 0 1 0 0 1 1 2

IV Asal Pasien : - 1 1 1 1 3 7 3 - 1 1 1 1 5 1 6 - - - - - - - 1 1 1 - - - - 1 - 1 1 1 2
1 Datang sendiri 0 1 1 1 1 3 7 3 0 1 1 1 1 5 1 6 0 0 0 0 0 0 0 1 1 1 0 0 0 0 1 0 1 1 1 2
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 0 1 1 1 1 3 7 3 0 1 1 1 1 5 1 6 0 0 0 0 0 0 0 1 1 1 0 0 0 0 1 0 1 1 1 2
1 Karies 0 0 1 1 0 3 5 2 0 0 0 1 0 2 0 3 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0
2 Penyakit Gusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 0 1 0 0 1 0 2 1 0 1 1 0 1 3 1 3 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 0 1 0 1 2
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : - 1 1 1 1 3 7 3 - 1 1 1 1 4 1 7 - - - - - - - 1 1 1 - - - - 1 - 1 - 1 2
701 Konsultasi Dokter Gigi 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 2 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 1 0 0 0 0 1 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 0 1 0 1 3 5 3 0 0 1 1 0 3 0 3 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 1 0 1 2

VII Rujukan : - - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - - - - - 1 - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - - - - - - - - - - - - - - - - - - - - - - 3 - - - - - - - - -
2 Kumulatif s.d. Bulan lalu 1 - - - 2 - - - - - - - 1 - - - 1 - - - 3 2 4 - 1 2 4 - - - - -

II Kelompok Umur : - - - - - - - - - - - - - - - - - - - - - - 3 - - - - - - - - -
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 45 – 54 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0

IV Asal Pasien : - - - - - - - - - - - - - - - - - - - - - - 3 - - - - - - - - -
1 Datang sendiri 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0
1 Karies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : - - - - - - - - - - - - - - - - - - - - - - 3 - - - - - - - - -
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0

VII Rujukan : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - - - - - - - - 4 12 15 13 19 25 44
2 Kumulatif s.d. Bulan lalu - - - 1 2 - - - 42 50 40 45 82 95 177

II Kelompok Umur : - - - - - - - - 4 12 15 13 19 25 44
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 1 - 1 - 2 - 2
2 5 – 9 tahun 0 0 0 0 0 0 0 0 - 3 1 1 1 4 5

3 10 – 14 tahun 0 0 0 0 0 0 0 0 1 1 4 - 5 1 6

4 15 – 19 tahun 0 0 0 0 0 0 0 0 - 1 - - - 1 1

5 20 – 44 tahun 0 0 0 0 0 0 0 0 - 6 - 10 - 16 16

6 45 – 54 tahun 0 0 0 0 0 0 0 0 1 1 3 2 4 3 7

7 55 – 59 tahun 0 0 0 0 0 0 0 0 - - - - - - -

8 60 – 69 tahun 0 0 0 0 0 0 0 0 1 - 6 - 7 - 7

9 > 70 tahun 0 0 0 0 0 0 0 0 - - - - - - -

III Kelompok Sasaran : 0 0 0 0 0 0 0 0 4 12 15 13 19 25 44


1 Bumil 0 0 0 0 0 0 0 0 - - - - - - -
2 Balita 0 0 0 0 0 0 0 0 1 - 1 - 2 - 2
3 Anak SD/MI 0 0 0 0 0 0 0 0 1 3 4 1 5 4 9
4 Lain-lain 0 0 0 0 0 0 0 0 2 9 10 12 12 21 33

IV Asal Pasien : - - - - - - - - 4 12 15 13 19 25 44
1 Datang sendiri 0 0 0 0 0 0 0 0 4 12 15 13 19 25 44
2 Rujukan 0 0 0 0 0 0 0 0 - - - - - - -
3 Kiriman kader 0 0 0 0 0 0 0 0 - - - - - - -

V Diagnosa : 0 0 0 0 0 0 0 0 4 12 15 13 19 25 44
1 Karies 0 0 0 0 0 0 0 0 - 6 9 7 9 13 22
2 Penyakit Gusi 0 0 0 0 0 0 0 0 - - - - - - -
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 - - - - - - -
4 Lain - lain 0 0 0 0 0 0 0 0 4 6 6 6 10 12 22
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
VI Tindakan : - - - - - - - - 4 10 15 14 19 24 43
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 - 2 1 3 1 5 6
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 - - - - - - -
703 Tumpatan sementara 0 0 0 0 0 0 0 0 - - - - - - -
704 Tumpatan tetap 0 0 0 0 0 0 0 0 - - - - - - -
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 - - - - - - -
706 Insisi abses 0 0 0 0 0 0 0 0 - - - - - - -
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 1 2 2 - 3 2 5
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 1 - - 2 1 2 3
709 Lain-lain 0 0 0 0 0 0 0 0 2 6 12 9 14 15 29

VII Rujukan : - - - - - - - - - 2 - - - 2 2
1 Puskesmas 0 0 0 0 0 0 0 0 - - - - - - -
2 Rumah sakit 0 0 0 0 0 0 0 0 - 2 - - - 2 2
3 Faskes lainnya 0 0 0 0 0 0 0 0 - - - - - - -

Mengetahui Yang Melapor


Kepala UPTD Puskesmas Baa

drg. Gevilawati Pandie Helmi K. Manafe, A.Md.KG


NIP. 19750201 200904 2 005 NIP. 19730520 199303 2 012
LAPORAN BULANAN
REKAPITULASI POLI GIGI DI PUSKESMAS DAN JEJARINGNYA
PUSKESMAS BAA
BULAN : MEI 2023
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - 1 2 3 3 6 - 2 1 1 6 1 4 5 3 3 1 1 - - - - - - - 3 1 - 1 3 2 - 1 1 - 1
2 Kumulatif s.d. Bulan lalu 5 9 11 11 13 15 3 12 1 1 6 2 8 10 8 8 3 4 - 5 - 1 1 - 3 6 2 - 2 6 3 1 2 3 - 1

II Kelompok Umur : - 1 2 3 3 6 - 2 1 1 6 1 4 5 3 3 1 1 - - - - - - - 3 1 - 1 3 2 - 1 1 - 1
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
2 5 – 9 tahun 0 1 0 0 1 1 0 1 0 0 0 1 1 1 0 3 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 0 1 0 1 0 0 0 0 0 0 0 1 0 2 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
5 20 – 44 tahun 0 0 1 1 1 5 0 1 1 1 4 0 1 1 1 0 0 1 0 0 0 0 0 0 0 2 0 0 1 1 0 0 0 1 0 1
6 45 – 54 tahun 0 0 0 2 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 0 1 2 3 3 6 0 2 1 1 6 1 4 5 3 3 1 1 0 0 0 0 0 0 0 3 1 0 1 3 2 0 1 1 0 1


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
3 Anak SD/MI 0 1 1 0 1 1 0 1 0 0 0 0 1 0 2 3 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0
4 Lain-lain 0 0 1 3 2 5 0 1 1 1 6 1 3 4 1 0 0 1 0 0 0 0 0 0 0 2 0 0 1 2 2 0 1 1 0 1

IV Asal Pasien : - 1 2 3 3 6 - 2 1 1 6 1 4 5 3 3 1 1 - - - - - - - 3 1 - 1 3 2 - 1 1 - 1
1 Datang sendiri 0 1 2 3 3 6 0 2 1 1 6 1 4 5 3 3 1 1 0 0 0 0 0 0 0 3 1 0 1 3 2 0 1 1 0 1
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 0 1 2 3 3 6 0 2 1 1 6 1 4 5 3 3 1 1 0 0 0 0 0 0 0 3 1 0 1 3 2 0 1 1 0 1
1 Karies 0 1 1 2 0 4 0 1 0 0 0 0 2 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 3 0 0 0 1 0 1
2 Penyakit Gusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 0 1 0 0 0 0 1 3 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0
4 Lain - lain 0 0 1 1 2 2 0 1 1 0 3 1 2 3 2 3 1 1 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : - 1 2 3 3 6 - 2 1 1 6 1 4 5 3 4 1 1 - - - - - - - 3 1 - 1 3 2 - 1 1 - 1
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 1 0 0 0 0 1 0 0 0 1 1 1 2 4 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 1 1 3 3 6 0 1 0 1 5 0 3 4 1 0 0 1 0 0 0 0 0 0 0 3 1 0 1 3 1 0 1 1 0 1

VII Rujukan : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini 1 - - - - 1 - - - - 1 - - - - - - - - - - - - - - - - - - - - -
2 Kumulatif s.d. Bulan lalu 2 - - - 2 1 - - - - 1 - 1 - - - 1 - - - 3 2 1 - 1 2 4 - - - - -

II Kelompok Umur : 1 - - - - 1 - - - - 1 - - - - - - - - - - - - - - - - - - - - -
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 45 – 54 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

IV Asal Pasien : 1 - - - - 1 - - - - 1 - - - - - - - - - - - - - - - - - - - - -
1 Datang sendiri 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 Karies 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : 1 - - - - 1 - - - - 1 - - - - - - - - - - - - - - - - - - - - -
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

VII Rujukan : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - - - - - - - - 12 22 15 10 27 32 59
2 Kumulatif s.d. Bulan lalu - - - 1 2 - - - 49 60 40 42 89 102 191

II Kelompok Umur : - - - - - - - - 12 22 15 10 27 32 59
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 - 2 - - - 2 2
2 5 – 9 tahun 0 0 0 0 0 0 0 0 3 4 1 5 4 9 13

3 10 – 14 tahun 0 0 0 0 0 0 0 0 3 1 4 - 7 1 8

4 15 – 19 tahun 0 0 0 0 0 0 0 0 - 2 1 - 1 2 3

5 20 – 44 tahun 0 0 0 0 0 0 0 0 4 12 6 3 10 15 25

6 45 – 54 tahun 0 0 0 0 0 0 0 0 - 1 2 2 2 3 5

7 55 – 59 tahun 0 0 0 0 0 0 0 0 1 - 1 - 2 - 2

8 60 – 69 tahun 0 0 0 0 0 0 0 0 1 - - - 1 - 1

9 > 70 tahun 0 0 0 0 0 0 0 0 - - - - - - -

III Kelompok Sasaran : 0 0 0 0 0 0 0 0 12 22 15 10 27 32 59


1 Bumil 0 0 0 0 0 0 0 0 - - - - - - -
2 Balita 0 0 0 0 0 0 0 0 - 2 - - - 2 2
3 Anak SD/MI 0 0 0 0 0 0 0 0 4 4 5 4 9 8 17
4 Lain-lain 0 0 0 0 0 0 0 0 8 16 10 6 18 22 40

IV Asal Pasien : - - - - - - - - 12 22 15 10 27 32 59
1 Datang sendiri 0 0 0 0 0 0 0 0 12 22 15 10 27 32 59
2 Rujukan 0 0 0 0 0 0 0 0 - - - - - - -
3 Kiriman kader 0 0 0 0 0 0 0 0 - - - - - - -

V Diagnosa : 0 0 0 0 0 0 0 0 12 22 15 10 27 32 59
1 Karies 0 0 0 0 0 0 0 0 2 11 4 4 6 15 21
2 Penyakit Gusi 0 0 0 0 0 0 0 0 - - - - - - -
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 2 3 4 - 6 3 9
4 Lain - lain 0 0 0 0 0 0 0 0 8 8 7 6 15 14 29
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
VI Tindakan : - - - - - - - - 12 22 15 11 27 33 60
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 1 - 1 - 2 - 2
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 - - - - - - -
703 Tumpatan sementara 0 0 0 0 0 0 0 0 - - - - - - -
704 Tumpatan tetap 0 0 0 0 0 0 0 0 - - - - - - -
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 - - - - - - -
706 Insisi abses 0 0 0 0 0 0 0 0 - - - - - - -
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 3 2 4 6 7 8 15
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 - - 1 - 1 - 1
709 Lain-lain 0 0 0 0 0 0 0 0 8 20 9 5 17 25 42

VII Rujukan : - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 - - - - - - -
2 Rumah sakit 0 0 0 0 0 0 0 0 - - - - - - -
3 Faskes lainnya 0 0 0 0 0 0 0 0 - - - - - - -

Mengetahui Yang Melapor


Kepala UPTD Puskesmas Baa

drg. Gevilawati Pandie Helmi K. Manafe, A.Md.KG


NIP. 19750201 200904 2 005 NIP. 19730520 199303 2 012
LAPORAN BULANAN
REKAPITULASI POLI GIGI DI PUSKESMAS DAN JEJARINGNYA
PUSKESMAS BAA
BULAN : APRIL 2023
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini 1 2 2 2 1 2 3 3 1 - - 1 3 2 2 1 - - - - - - - - - - - 1 - 1 - - - - - -
2 Kumulatif s.d. Bulan lalu 6 10 11 10 11 11 6 13 2 - - 2 7 7 7 6 2 3 - 5 - 1 1 - 3 3 1 1 1 4 1 1 1 2 - -

II Kelompok Umur : 1 2 2 2 1 2 3 4 1 - - 1 3 2 2 1 - - - - - - - - - - - 1 - 1 - - - - - -
1 ≤ 5 tahun 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 1 1 1 0 1 0 2 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
3 10 – 14 tahun 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 0 1 0 0 1 0 0 0 0 0 1 1 2 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0
6 45 – 54 tahun 0 0 0 1 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 1 2 2 2 1 2 3 3 1 0 0 1 3 2 2 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 1 0 0 0 1 0 1 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
4 Lain-lain 0 2 2 2 0 1 1 2 1 0 0 1 2 2 2 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0

IV Asal Pasien : 1 2 2 2 1 2 3 3 1 - - 1 3 2 2 1 - - - - - - - - - - - 1 - 1 - - - - - -
1 Datang sendiri 1 2 2 2 1 2 3 3 1 0 0 1 3 2 2 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 1 2 2 2 1 2 3 4 1 0 0 1 3 3 2 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0
1 Karies 0 1 0 0 0 0 1 2 1 0 0 0 2 2 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 1 1 2 2 1 1 2 2 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : 1 2 1 2 2 2 3 3 1 - - 1 3 2 2 1 - - - - - - - - - - - 1 - 1 - - - - - -
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 1 1 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 1 1 2 0 2 3 3 1 0 0 1 2 2 2 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0

VII Rujukan : - - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - - - - - - - - - 1 2 - - - - - - - 1 - - 1 - - - - - - - - - -
2 Kumulatif s.d. Bulan lalu 1 - - - 2 - - - - 1 2 - 1 - - - 1 - 1 - 3 3 1 - 1 2 4 - - - - -

II Kelompok Umur : - - - - - - - - - 1 2 - - - - - - - 1 - - 1 - - - - - - - - - -
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
6 45 – 54 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0

IV Asal Pasien : - - - - - - - - - 1 2 - - - - - - - 1 - - 1 - - - - - - - - - -
1 Datang sendiri 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0
1 Karies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : - - - - - - - - - 1 2 - - - - - - - 1 - - 1 - - - - - - - - - -
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0

VII Rujukan : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - 1 - - - - - - 6 10 10 8 16 18 34
2 Kumulatif s.d. Bulan lalu - 1 - 1 2 - - - 44 48 35 40 79 88 167

II Kelompok Umur : - 1 - - - - - - 6 10 10 9 16 19 35
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 - 1 1 - 1 1 2
2 5 – 9 tahun 0 0 0 0 0 0 0 0 3 3 3 - 6 3 9

3 10 – 14 tahun 0 0 0 0 0 0 0 0 - - 2 1 2 1 3

4 15 – 19 tahun 0 0 0 0 0 0 0 0 1 - - 1 1 1 2

5 20 – 44 tahun 0 1 0 0 0 0 0 0 1 5 1 3 2 8 10

6 45 – 54 tahun 0 0 0 0 0 0 0 0 1 - 2 2 3 2 5

7 55 – 59 tahun 0 0 0 0 0 0 0 0 - 1 - - - 1 1

8 60 – 69 tahun 0 0 0 0 0 0 0 0 - - 1 - 1 - 1

9 > 70 tahun 0 0 0 0 0 0 0 0 - - - 2 - 2 2

III Kelompok Sasaran : 0 1 0 1 0 0 0 0 6 10 10 9 16 19 35


1 Bumil 0 0 0 0 0 0 0 0 - - - - - - -
2 Balita 0 0 0 0 0 0 0 0 - 1 1 - 1 1 2
3 Anak SD/MI 0 0 0 0 0 0 0 0 3 2 3 1 6 3 9
4 Lain-lain 0 1 0 1 0 0 0 0 3 7 6 8 9 15 24

IV Asal Pasien : - 1 - 1 - - - - 6 10 10 9 16 19 35
1 Datang sendiri 0 1 0 1 0 0 0 0 6 10 10 9 16 19 35
2 Rujukan 0 0 0 0 0 0 0 0 - - - - - - -
3 Kiriman kader 0 0 0 0 0 0 0 0 - - - - - - -

V Diagnosa : 0 1 0 1 0 0 0 0 6 11 10 10 16 21 37
1 Karies 0 1 0 0 0 0 0 0 3 5 3 3 6 8 14
2 Penyakit Gusi 0 0 0 0 0 0 0 0 - 1 - - - 1 1
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 - - - 1 - 1 1
4 Lain - lain 0 0 0 1 0 0 0 0 3 5 7 6 10 11 21
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
VI Tindakan : - 1 - - - - - - 7 10 9 8 16 18 34
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 1 - 1 - 2 - 2
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 - - - - - - -
703 Tumpatan sementara 0 0 0 0 0 0 0 0 - - - - - - -
704 Tumpatan tetap 0 0 0 0 0 0 0 0 - - - - - - -
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 - - - - - - -
706 Insisi abses 0 0 0 0 0 0 0 0 - - - - - - -
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 3 3 1 - 4 3 7
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 - - - - - - -
709 Lain-lain 0 1 0 0 0 0 0 0 3 7 7 8 10 15 25

VII Rujukan : - - - - - - - - - - 1 - 1 - 1
1 Puskesmas 0 0 0 0 0 0 0 0 - - - - - - -
2 Rumah sakit 0 0 0 0 0 0 0 0 - - 1 - 1 - 1
3 Faskes lainnya 0 0 0 0 0 0 0 0 - - - - - - -

Mengetahui Yang Melapor


Kepala UPTD Puskesmas Baa

drg. Gevilawati Pandie Helmi K. Manafe, A.Md.KG


NIP. 19750201 200904 2 005 NIP. 19730520 199303 2 012
LAPORAN BULANAN
REKAPITULASI POLI GIGI DI PUSKESMAS DAN JEJARINGNYA
PUSKESMAS BAA
BULAN : MARET 2023
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini 3 3 4 1 3 4 1 4 1 - - - 2 2 3 3 1 - - 1 - - - - 1 1 1 - - 1 - - - - - -
2 Kumulatif s.d. Bulan lalu 5 8 9 8 10 9 3 10 1 - - 1 4 5 5 5 2 3 - 5 - 1 1 - 3 3 1 - 1 3 1 1 1 2 - -

II Kelompok Umur : 3 3 4 1 3 4 1 4 1 - - - 2 2 3 3 1 - - 1 - - - - 1 1 1 - - 1 - - - - - -
1 ≤ 5 tahun 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 2 1 0 0 1 0 0 0 0 0 0 0 0 1 0 3 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 0 1 0 0 0 1 2 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 1 2 2 1 1 2 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
6 45 – 54 tahun 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 3 3 4 1 3 4 1 4 1 0 0 0 2 2 3 3 1 0 0 1 0 0 0 0 1 1 1 0 0 1 0 0 0 0 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 2 1 1 0 1 0 1 2 0 0 0 0 1 1 1 3 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0
4 Lain-lain 1 2 3 1 1 3 0 2 1 0 0 0 1 1 2 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0

IV Asal Pasien : 3 3 4 1 3 4 1 4 1 - - - 2 2 3 3 1 - - 1 - - - - 1 1 1 - - 1 - - - - - -
1 Datang sendiri 3 3 4 1 3 4 1 4 1 0 0 0 2 2 3 3 1 0 0 1 0 0 0 0 1 1 1 0 0 1 0 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 3 3 4 1 3 4 1 4 1 0 0 0 2 2 3 3 1 0 0 1 0 0 0 0 1 1 1 0 0 1 0 0 0 0 0 0
1 Karies 1 1 0 0 2 1 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 1 1 0 1 1 2 1 2 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0
4 Lain - lain 1 0 4 0 0 1 0 2 1 0 0 0 1 1 1 3 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : 3 3 4 1 3 4 1 4 1 - - - 2 2 3 3 1 - - 1 - - - - 1 1 1 - - - - - - - - -
701 Konsultasi Dokter Gigi 0 2 1 0 0 0 0 1 0 0 0 0 0 1 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 2 1 3 1 3 4 1 2 1 0 0 0 2 0 3 0 1 0 0 1 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0

VII Rujukan : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - - - - - - - - - - - - - - - - - - - - - 1 - - - 2 2 - - - - -
2 Kumulatif s.d. Bulan lalu 1 - - - 2 - - - - - - - 1 - - - 1 - - - 3 2 1 - 1 2 4 - - - - -

II Kelompok Umur : - - - - - - - - - - - - - - - - - - - - - 1 - - - 2 2 - - - - -
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
3 10 – 14 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0
6 45 – 54 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 2 2 0 0 0 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
4 Lain-lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 2 0 0 0 0 0

IV Asal Pasien : - - - - - - - - - - - - - - - - - - - - - 1 - - - 2 2 - - - - -
1 Datang sendiri 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 2 2 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 2 2 0 0 0 0 0
1 Karies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 2 0 0 0 0 0
4 Lain - lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : - - - - - - - - - - - - - - - - - - - - - 1 - - - 2 2 - - - - -
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 2 2 0 0 0 0 0

VII Rujukan : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - - - 1 - - - - 11 14 11 10 22 24 46
2 Kumulatif s.d. Bulan lalu - - - 1 2 - - - 38 38 25 32 63 70 133

II Kelompok Umur : - - - 1 - - - - 11 14 11 10 22 24 46
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 1 2 - - 1 2 3
2 5 – 9 tahun 0 0 0 0 0 0 0 0 5 4 - 3 5 7 12

3 10 – 14 tahun 0 0 0 0 0 0 0 0 1 - 4 2 5 2 7

4 15 – 19 tahun 0 0 0 0 0 0 0 0 - 1 - 1 - 2 2

5 20 – 44 tahun 0 0 0 1 0 0 0 0 3 7 3 3 6 10 16

6 45 – 54 tahun 0 0 0 0 0 0 0 0 1 - - - 1 - 1

7 55 – 59 tahun 0 0 0 0 0 0 0 0 - - 1 - 1 - 1

8 60 – 69 tahun 0 0 0 0 0 0 0 0 - - 3 1 3 1 4

9 > 70 tahun 0 0 0 0 0 0 0 0 - - - - - - -

III Kelompok Sasaran : 0 0 0 1 0 0 0 0 11 14 11 10 22 24 46


1 Bumil 0 0 0 0 0 0 0 0 - - - - - - -
2 Balita 0 0 0 0 0 0 0 0 1 1 - - 1 1 2
3 Anak SD/MI 0 0 0 0 0 0 0 0 5 4 4 5 9 9 18
4 Lain-lain 0 0 0 1 0 0 0 0 5 9 7 5 12 14 26

IV Asal Pasien : - - - 1 - - - - 11 14 11 10 22 24 46
1 Datang sendiri 0 0 0 1 0 0 0 0 11 14 11 10 22 24 46
2 Rujukan 0 0 0 0 0 0 0 0 - - - - - - -
3 Kiriman kader 0 0 0 0 0 0 0 0 - - - - - - -

V Diagnosa : 0 0 0 1 0 0 0 0 11 14 11 10 22 24 46
1 Karies 0 0 0 0 0 0 0 0 6 2 1 - 7 2 9
2 Penyakit Gusi 0 0 0 0 0 0 0 0 - 3 - - - 3 3
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 2 6 5 3 7 9 16
4 Lain - lain 0 0 0 1 0 0 0 0 3 3 5 7 8 10 18
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
VI Tindakan : - - - 1 - - - - 11 13 11 10 22 23 45
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 - 3 1 3 1 6 7
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 - - - - - - -
703 Tumpatan sementara 0 0 0 0 0 0 0 0 - - - - - - -
704 Tumpatan tetap 0 0 0 0 0 0 0 0 - - - - - - -
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 - 1 - - - 1 1
706 Insisi abses 0 0 0 0 0 0 0 0 - - - - - - -
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 1 - - 2 1 2 3
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 - - - - - - -
709 Lain-lain 0 0 0 1 0 0 0 0 10 9 10 5 20 14 34

VII Rujukan : - - - - - - - - - 1 - - - 1 1
1 Puskesmas 0 0 0 0 0 0 0 0 - - - - - - -
2 Rumah sakit 0 0 0 0 0 0 0 0 - 1 - - - 1 1
3 Faskes lainnya 0 0 0 0 0 0 0 0 - - - - - - -

Mengetahui Yang Melapor


Kepala UPTD Puskesmas Baa

drg. Gevilawati Pandie Helmi K. Manafe, A.Md.KG


NIP. 19750201 200904 2 005 NIP. 19730520 199303 2 012
LAPORAN BULANAN
REKAPITULASI POLI GIGI DI PUSKESMAS DAN JEJARINGNYA
PUSKESMAS BAA
BULAN : FEBRUARI 2023
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini 1 1 2 1 2 4 2 3 - - - 1 1 2 2 2 - 1 - 2 - - - - 2 1 - - - 1 1 - 1 1 - -
2 Kumulatif s.d. Bulan lalu 2 5 5 7 7 5 2 6 - - - 1 2 3 2 2 1 3 - 4 - 1 1 - 2 2 - - 1 2 1 1 1 2 - -

II Kelompok Umur : 1 1 2 1 2 4 2 3 - - - 1 1 2 2 2 - 1 - 2 - - - - 2 1 - - - 1 1 - 1 1 - -
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 1 0 0 0 1 2 0 0 0 0 0 0 0 2 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0
3 10 – 14 tahun 0 0 0 0 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
5 20 – 44 tahun 0 1 0 1 0 0 0 2 0 0 0 0 1 0 1 0 0 0 0 2 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0
6 45 – 54 tahun 0 0 0 0 1 0 1 1 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 1 1 2 1 2 4 2 3 0 0 0 1 1 2 2 2 0 1 0 2 0 0 0 0 2 1 0 0 0 1 1 0 1 1 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 1 0 0 0 1 4 1 0 0 0 0 0 0 2 0 0 0 1 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 1 0 0
4 Lain-lain 0 1 2 1 1 0 1 3 0 0 0 1 1 0 2 2 0 0 0 2 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0

IV Asal Pasien : 1 1 2 1 2 4 2 3 - - - 1 1 2 2 2 - 1 - 2 - - - - 2 1 - - - 1 1 - 1 1 - -
1 Datang sendiri 1 1 2 1 2 4 2 3 0 0 0 1 1 2 2 2 0 1 0 2 0 0 0 0 2 1 0 0 0 1 1 0 1 1 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 1 1 2 1 2 4 2 3 0 0 0 1 1 2 2 2 0 1 0 2 0 0 0 0 2 1 0 0 0 1 1 0 1 1 0 0
1 Karies 0 0 0 0 2 2 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0
2 Penyakit Gusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 1 1 2 1 0 0 1 2 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 0 0 0 0 0 2 1 1 0 0 0 0 1 2 2 1 0 1 0 2 0 0 0 0 1 0 0 0 0 1 1 0 1 0 0 0
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : 1 1 2 1 2 4 3 3 - - - 1 1 3 2 1 - 1 - 2 - - - - 2 1 - - - 1 1 - - 1 - -
701 Konsultasi Dokter Gigi 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 0 0 0 0 2 0 0 0 0 0 0 3 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 1 1 2 1 2 3 1 3 0 0 0 1 1 0 2 1 0 0 0 2 0 0 0 0 1 1 0 0 0 1 1 0 0 1 0 0

VII Rujukan : - - - - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - - 1 - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini 1 - - - - - - - - - - - - - - - - - - - 1 1 1 - 1 - 2 - - - - -
2 Kumulatif s.d. Bulan lalu 1 - - - 2 - - - - - - - 1 - - - 1 - - - 3 1 1 - 1 - 2 - - - - -

II Kelompok Umur : 1 - - - - - - - - - - - - - - - - - - - 1 1 1 - 1 - 2 - - - - -
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0
4 15 – 19 tahun 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 2 0 0 0 0 0
6 45 – 54 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 2 0 0 0 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 2 0 0 0 0 0

IV Asal Pasien : 1 - - - - - - - - - - - - - - - - - - - 1 1 1 - 1 - 2 - - - - -
1 Datang sendiri 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 2 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 2 0 0 0 0 0
1 Karies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 2 0 0 0 0 0
4 Lain - lain 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : 1 - - - - - - - - - - - - - - - - - - - 1 1 1 - 1 - 2 - - - - -
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 2 0 0 0 0 0

VII Rujukan : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini 0 0 0 0 1 - - - 11 12 10 9 21 21 42
2 Kumulatif s.d. Bulan lalu - - - - 2 - - - 27 24 14 22 41 46 87

II Kelompok Umur : - - - - 1 - - - 11 12 10 9 21 21 42
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 1 - - - 1 - 1
2 5 – 9 tahun 0 0 0 0 1 0 0 0 4 7 - - 4 7 11

3 10 – 14 tahun 0 0 0 0 0 0 0 0 2 2 1 - 3 2 5

4 15 – 19 tahun 0 0 0 0 0 0 0 0 2 - - 1 2 1 3

5 20 – 44 tahun 0 0 0 0 0 0 0 0 1 3 4 5 5 8 13

6 45 – 54 tahun 0 0 0 0 0 0 0 0 1 - 1 3 2 3 5

7 55 – 59 tahun 0 0 0 0 0 0 0 0 - - 3 - 3 - 3

8 60 – 69 tahun 0 0 0 0 0 0 0 0 - - 1 - 1 - 1

9 > 70 tahun 0 0 0 0 0 0 0 0 - - - - - - -

III Kelompok Sasaran : 0 0 0 0 1 0 0 0 11 12 10 9 21 21 42


1 Bumil 0 0 0 0 0 0 0 0 - - - - - - -
2 Balita 0 0 0 0 0 0 0 0 1 - - - 1 - 1
3 Anak SD/MI 0 0 0 0 0 0 0 0 4 8 1 - 5 8 13
4 Lain-lain 0 0 0 0 1 0 0 0 6 4 9 9 15 13 28

IV Asal Pasien : - - - - 1 - - - 11 12 10 9 21 21 42
1 Datang sendiri 0 0 0 0 1 0 0 0 11 12 10 9 21 21 42
2 Rujukan 0 0 0 0 0 0 0 0 - - - - - - -
3 Kiriman kader 0 0 0 0 0 0 0 0 - - - - - - -

V Diagnosa : 0 0 0 0 1 0 0 0 11 12 10 9 21 21 42
1 Karies 0 0 0 0 0 0 0 0 3 3 1 1 4 4 8
2 Penyakit Gusi 0 0 0 0 0 0 0 0 - - - - - - -
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 3 2 5 4 8 6 14
4 Lain - lain 0 0 0 0 1 0 0 0 5 7 4 4 9 11 20
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
VI Tindakan : - - - - 1 - - - 10 13 11 8 21 21 42
701 Konsultasi Dokter Gigi 0 0 0 0 1 0 0 0 1 2 - - 1 2 3
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 - - - - - - -
703 Tumpatan sementara 0 0 0 0 0 0 0 0 - - - - - - -
704 Tumpatan tetap 0 0 0 0 0 0 0 0 - - - - - - -
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 - - - - - - -
706 Insisi abses 0 0 0 0 0 0 0 0 - - - - - - -
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 1 4 2 - 3 4 7
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 - - - - - - -
709 Lain-lain 0 0 0 0 0 0 0 0 8 7 9 8 17 15 32

VII Rujukan : - - - - - - - - 1 - - 1 1 1 2
1 Puskesmas 0 0 0 0 0 0 0 0 - - - - - - -
2 Rumah sakit 0 0 0 0 0 0 0 0 1 - - 1 1 1 2
3 Faskes lainnya 0 0 0 0 0 0 0 0 - - - - - - -

Mengetahui Yang Melapor


Kepala UPTD Puskesmas Baa

drg. Gevilawati Pandie Helmi K. Manafe, A.Md.KG


NIP. 19750201 200904 2 005 NIP. 19730520 199303 2 012
LAPORAN BULANAN
REKAPITULASI POLI GIGI DI PUSKESMAS DAN JEJARINGNYA
PUSKESMAS BAA
BULAN : JANUARI 2023
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini 1 4 3 6 5 1 - 3 - - - - 1 1 - - 1 2 - 2 - 1 1 - - 1 - - 1 1 - 1 - 1 - -
2 Kumulatif s.d. Bulan lalu 1 4 3 6 5 1 - 3 - - - - 1 1 - - 1 2 - 2 - 1 1 - - 1 - - 1 1 - 1 - 1 - -

II Kelompok Umur : 1 4 3 6 5 1 - 3 - - - - 1 1 - - 1 2 - 2 - 1 1 - - 1 - - 1 1 - 1 - 1 - -
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 2 1 0 4 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0
5 20 – 44 tahun 0 0 1 4 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0
6 45 – 54 tahun 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 1 4 3 6 5 1 0 3 0 0 0 0 1 1 0 0 1 2 0 2 0 1 1 0 0 1 0 0 1 1 0 1 0 1 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 1 2 2 0 3 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 0 2 1 6 2 1 0 2 0 0 0 0 0 1 0 0 1 2 0 2 0 1 1 0 0 1 0 0 1 1 0 1 0 1 0 0

IV Asal Pasien : 1 4 3 6 5 1 - 3 - - - - 1 1 - - 1 2 - 2 - 1 1 - - 1 - - 1 1 - 1 - 1 - -
1 Datang sendiri 1 4 3 6 5 1 0 3 0 0 0 0 1 1 0 0 1 2 0 2 0 1 1 0 0 1 0 0 1 1 0 1 0 1 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 1 4 3 6 5 1 0 3 0 0 0 0 1 1 0 0 1 2 0 2 0 1 1 0 0 1 0 0 1 1 0 1 0 1 0 0
1 Karies 0 3 2 1 1 0 0 0 0 0 0 0 1 0 0 0 1 2 0 2 0 0 0 0 0 1 0 0 1 0 0 1 0 1 0 0
2 Penyakit Gusi 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 1 2 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 1 1 1 3 2 1 0 2 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0
Metina Namodale Oelunggu Mokdale Baadale T uanatuk Holoama Sanggaoen Helebeik
No Elemen Data B L B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : 1 3 2 5 5 1 - 3 - - - - 1 1 - - 1 2 - 2 - 1 1 - - 1 - - 1 1 - 1 - 1 - -
701 Konsultasi Dokter Gigi 1 2 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 1 1 4 4 0 0 2 0 0 0 0 1 0 0 0 1 2 0 1 0 1 1 0 0 1 0 0 1 1 0 0 0 1 0 0

VII Rujukan : - 1 1 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini - - - - 2 - - - - - - - 1 - - - 1 - - - 2 - - - - - - - - - - -
2 Kumulatif s.d. Bulan lalu - - - - 2 - - - - - - - 1 - - - 1 - - - 2 - - - - - - - - - - -

II Kelompok Umur : - - - - 2 - - - - - - - 1 - - - 1 - - - 2 - - - - - - - - - - -
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 5 – 9 tahun 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 10 – 14 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 15 – 19 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0
5 20 – 44 tahun 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 45 – 54 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 55 – 59 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 60 – 69 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 > 70 tahun 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

III Kelompok Sasaran : 0 0 0 0 2 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0


1 Bumil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Balita 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Anak SD/MI 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain-lain 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0

IV Asal Pasien : - - - - 2 - - - - - - - 1 - - - 1 - - - 2 - - - - - - - - - - -
1 Datang sendiri 0 0 0 0 2 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0
2 Rujukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Kiriman kader 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

V Diagnosa : 0 0 0 0 2 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0
1 Karies 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
2 Penyakit Gusi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lain - lain 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
Oematamboli Kolobolon Bebalain Suelain Kuli Oeleka Lekunik Loleoen
No Elemen Data B L B L B L B L B L B L B L B L
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
VI Tindakan : - - - - 2 - - - - - - - 1 - - - 1 - - - 2 - - - - - - - - - - -
701 Konsultasi Dokter Gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
702 Konsultasi Dokter Gigi Diluar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
703 Tumpatan sementara 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
704 Tumpatan tetap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
706 Insisi abses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
707 Pencabutan gigi sulung 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
709 Lain-lain 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0

VII Rujukan : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Rumah sakit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Faskes lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
I Total Kunjungan Poli Gigi :
1 Bulan ini 0 0 0 0 1 - - - 16 12 4 13 20 25 45
2 Kumulatif s.d. Bulan lalu - - - - 1 - - - 16 12 4 13 20 25 45

II Kelompok Umur : - - - - 1 - - - 16 12 4 13 20 25 45
1 ≤ 5 tahun 0 0 0 0 0 0 0 0 - - - - - - -
2 5 – 9 tahun 0 0 0 0 0 0 0 0 6 2 1 1 7 3 10

3 10 – 14 tahun 0 0 0 0 0 0 0 0 1 1 1 - 2 1 3

4 15 – 19 tahun 0 0 0 0 1 0 0 0 4 3 - 1 4 4 8

5 20 – 44 tahun 0 0 0 0 0 0 0 0 2 4 1 7 3 11 14

6 45 – 54 tahun 0 0 0 0 0 0 0 0 - 2 - 3 - 5 5

7 55 – 59 tahun 0 0 0 0 0 0 0 0 1 - - - 1 - 1

8 60 – 69 tahun 0 0 0 0 0 0 0 0 1 - 1 1 2 1 3

9 > 70 tahun 0 0 0 0 0 0 0 0 1 - - - 1 - 1

III Kelompok Sasaran : 0 0 0 0 1 0 0 0 16 12 4 13 20 25 45


1 Bumil 0 0 0 0 0 0 0 0 - - - - - - -
2 Balita 0 0 0 0 0 0 0 0 - - - - - - -
3 Anak SD/MI 0 0 0 0 0 0 0 0 6 2 2 1 8 3 11
4 Lain-lain 0 0 0 0 1 0 0 0 10 10 2 12 12 22 34

IV Asal Pasien : - - - - 1 - - - 16 12 4 13 20 25 45
1 Datang sendiri 0 0 0 0 1 0 0 0 16 12 4 13 20 25 45
2 Rujukan 0 0 0 0 0 0 0 0 - - - - - - -
3 Kiriman kader 0 0 0 0 0 0 0 0 - - - - - - -

V Diagnosa : 0 0 0 0 1 0 0 0 16 12 4 13 20 25 45
1 Karies 0 0 0 0 1 0 0 0 8 7 2 4 10 11 21
2 Penyakit Gusi 0 0 0 0 0 0 0 0 - - - 1 - 1 1
3 Penyakit Pulpa 0 0 0 0 0 0 0 0 2 - - 2 2 2 4
4 Lain - lain 0 0 0 0 0 0 0 0 6 5 2 6 8 11 19
Kuli Aisele Luar Total TOTAL
No Elemen Data B L B L B L
L P L+P
L P L P L P L P L P L P
VI Tindakan : - - - - 1 - - - 16 11 3 12 19 23 42
701 Konsultasi Dokter Gigi 0 0 0 0 1 0 0 0 2 4 1 3 3 7 10
702 Konsultasi Dokter Gigi Diluar Jam Dinas 0 0 0 0 0 0 0 0 - - - - - - -
703 Tumpatan sementara 0 0 0 0 0 0 0 0 - - - - - - -
704 Tumpatan tetap 0 0 0 0 0 0 0 0 - - - - - - -
705 Pembersihan karang gigi 0 0 0 0 0 0 0 0 - - - - - - -
706 Insisi abses 0 0 0 0 0 0 0 0 - - - - - - -
707 Pencabutan gigi sulung 0 0 0 0 0 0 0 0 2 - - 1 2 1 3
708 Pencabutan gigi permanen 0 0 0 0 0 0 0 0 - - - - - - -
709 Lain-lain 0 0 0 0 0 0 0 0 12 7 2 8 14 15 29

VII Rujukan : - - - - - - - - - 1 1 1 1 2 3
1 Puskesmas 0 0 0 0 0 0 0 0 - - - - - - -
2 Rumah sakit 0 0 0 0 0 0 0 0 - 1 1 1 1 2 3
3 Faskes lainnya 0 0 0 0 0 0 0 0 - - - - - - -

Mengetahui Yang Melapor


Kepala UPTD Puskesmas Baa

drg. Gevilawati Pandie Helmi K. Manafe, A.Md.KG


NIP. 19750201 200904 2 005 NIP. 19730520 199303 2 012

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