INSTRUMEN MONITORING DAN EVALUASI
CAPAIAN
INDIKATOR-INDIKATOR KEGIATAN
PUSKESMAS
WELAHAN I
TAHUN
2015
|
PUSKESMAS |
WELAHAN I |
|
KABUPATEN |
JEPARA |
|
HARI/ TANGGAL |
|
|
TIM MONEV |
1. 2. 3. 4. |
PEMERINTAH
KABUPATEN JEPARA
DINAS
KESEHATAN KABUPATEN JEPARA
UPT
PUSKESMAS WELAHAN I
I.
DATA PUSKESMAS
a. Data Sasaran
|
1. Jumlah
penduduk laki-laki 2. Jumlah
penduduk perempuan 3. Jumlah total
penduduk 4. Jumlah Bayi 5. Jumlah anak
balita 6. Jumlah anak
usia sekolah 7. Jumah remaja 8. Jumlah Ibu
hamil 9. Jumlah Ibu
nifas 10. Jumlah kader
kesehatan 11. Jumlah Desa 12. Jumlah RT /
RW 13. Jumlah Rumah 14. Jumlah KK 15. Jumlah
Puskesmas Pembantu 16. Jumlah PKD 17. Jumlah
Posyandu 18. Jumlah
Posyandu Usila 19. Jumlah Dokter
swasta 20. Jumlah Klinik
Pratama 21. Jumlah BPM 22. Jumlah Apotik
23. Jumlah TK 24. Jumlah SD/ MI 25. Jumlah SMP/ MTs 26. Jumlah SMA/
MA 27. Jumlah Pondok
Pesantren |
: …………………………………….. : …………………………………….. : …………………………………….. : …………………………………….. : …………………………………….. : …………………………………….. : …………………………………….. : …………………………………..... : …………………………………….. : …………………………………….. : ……………………………………. : ……………………………………. : …………………………………..... : …………………………………….. : …………………………………….. : ……………………………………. : ……………………………………. : ……………………………………. : …………………………………….. : ……………………………………. : ……………………………………. : ……………………………………. : ……………………………………. : ……………………………………. : ……………………………………. : ……………………………………. : ……………………………………. |
b. Data Sumber
Daya Manusia Kesehatan
|
1. Jumlah dokter
umum 2. Jumlah dokter
gigi 3. Jumlah
Sarjana Kes Mas 4. Jumlah
Sarjana Keperawatan 5. Jumlah Bidan 6. Jumlah Bidan desa 7. Jumlah
Perawat 8. Jumlah Tenaga
Gizi 9. Jumlah Tenaga
Sanitarian 10. Jumlah Tenaga
Laboratorium 11. Jumlah Tenaga
Radiologi 12. Jumlah Tenaga
Rekam Medik 13. Jumlah Tenaga
Administrasi |
: ……………………………………. : ……………………………………. : ……………………………………. : ……………………………………. : ……………………………………. : …………………………………….. : ……………………………………. : ……………………………………. : …………………………………….. : ……………………………………. : ……………………………………. : ……………………………………. : …………………………………….. |
II.
DATA KEGIATAN
1. Pendapatan
Puskesmas
|
NO |
URAIAN |
TARGET |
REALISASI
BULAN |
JML |
||
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||||
|
I |
RAWAT INAP |
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1 |
Sewa
kamar bangsal |
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2 |
Sewa
kamar kelas |
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3 |
Ransum
makan pasien bangsal |
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4 |
Ransum
makan pasien kelas |
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5 |
Visite
bangsal |
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6 |
Visite
kelas |
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7 |
Tindakan
medis ringan |
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8 |
Tindakan
medis sedang |
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9 |
Tindakan
pasang infus |
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10 |
UGD
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II |
RAWAT JALAN |
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1 |
Kunjungan
umum |
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III |
PEMERIKSAAN
KESEHATAN |
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1 |
Pelajar |
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2 |
Calon
Pengantin |
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3 |
Melamar
Kerja |
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4 |
Calon
Jemaah Haji |
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IV |
PEMERIKSAAN
DIAGNOSTIK |
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1 |
Pemeriksaan
rontgent |
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2 |
Pemeriksaan
Laborat |
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V |
PEMERIKSAAN
GIGI |
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1 |
Tindakan
Gigi |
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VI |
RUJUKAN |
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1 |
Rujukan
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2. Kunjungan
Pasien Per Jenis
|
NO |
KUNJUNGAN |
TARGET |
REALISASI
BULAN |
JML |
||
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||||
|
1 |
Gratis |
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2 |
BPJS |
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3 |
Jamkemasda |
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4 |
Bayar |
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5 |
UKS |
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6 |
Lain |
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7 |
Jumlah |
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3. Kunjungan
Pasien per Pos
|
NO |
KUNJUNGAN |
TARGET |
REALISASI
BULAN |
JML |
||
|
|
|
|
||||
|
1 |
PUSKESMAS |
|
|
|
|
|
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2 |
PUSLING |
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3 |
PUSTU TELUK WETAN |
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4 |
PUSTU GIDANGELO |
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5 |
PKD WELAHAN |
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6 |
PKD GEDANGAN |
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7 |
PKD KETILENG S |
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8 |
PKD KALIPCNG WETAN |
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9 |
PKD BRANTAK S. |
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10 |
PKD KALIPCNG KULON |
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|
JUMLAH |
|
|
|
|
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4. Kunjungan
Pasien Rawat Inap
|
NO |
KUNJUNGAN |
TARGET |
REALISASI
BULAN |
JML |
||
|
|
|
|
||||
|
I |
STATUS PASIEN |
|
|
|
|
|
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1 |
Kelas |
|
|
|
|
|
|
1 |
Bangsal |
|
|
|
|
|
|
2 |
BPJS |
|
|
|
|
|
|
3 |
Jamkesmasda |
|
|
|
|
|
|
4 |
Jumlah |
|
|
|
|
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|
II |
LAMA HARI |
|
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1 |
Kelas |
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2 |
Bangsal |
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3 |
BPJS |
|
|
|
|
|
|
4 |
Jamkesmasda |
|
|
|
|
|
|
5 |
Jumlah |
|
|
|
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III |
BOR |
|
|
|
|
|
|
1 |
% BOR |
|
|
|
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5. Penyakit
Penderita rawat jalan semua umur
|
NO |
KUNJUNGAN |
REALISASI
BULAN |
JML |
||
|
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|
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|||
|
1 |
|
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|
2 |
|
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3 |
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4 |
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5 |
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6 |
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|
7 |
|
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|
8 |
|
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|
9 |
|
|
|
|
|
|
10 |
|
|
|
|
|
6. Penyakit
Penderita rawat inap
|
NO |
KUNJUNGAN |
REALISASI
BULAN |
JML |
||
|
|
|
|
|||
|
1 |
|
|
|
|
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|
2 |
|
|
|
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|
3 |
|
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|
4 |
|
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|
5 |
|
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|
6 |
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|
7 |
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|
8 |
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|
9 |
|
|
|
|
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|
10 |
|
|
|
|
|
7. Kunjungan
Pasien Radiologi
|
NO |
JENIS |
REALISASI
BULAN |
JML |
||
|
|
|
|
|||
|
1 |
Thorax |
|
|
|
|
|
2 |
BNO |
|
|
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|
3 |
Vertebra |
|
|
|
|
|
4 |
Extremitas |
|
|
|
|
|
|
JUMLAH |
|
|
|
|
8. Kunjungan
Pasien UGD
|
NO |
JENIS |
REALISASI
BULAN |
JML |
||
|
|
|
|
|||
|
1 |
RINGAN |
|
|
|
|
|
2 |
SEDANG |
|
|
|
|
|
3 |
BERAT |
|
|
|
|
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|
JUMLAH |
|
|
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|
9. Kunjungan Rawat
jalan Gigi
|
NO |
JENIS |
REALISASI
BULAN |
JML |
||
|
|
|
|
|||
|
A |
DIAGNOSIS |
|
|
|
|
|
1 |
Caries Dentis |
|
|
|
|
|
2 |
Kelainan Pulpa dan periapikal |
|
|
|
|
|
3 |
Kelainan Gusi dan Periodental |
|
|
|
|
|
4 |
Kelainan Dento Fasial |
|
|
|
|
|
5 |
Persistensi |
|
|
|
|
|
6 |
Jaringan lunak mulut (Mucosa) |
|
|
|
|
|
7 |
Abses Ginggiva |
|
|
|
|
|
8 |
Fraktur Rahang |
|
|
|
|
|
9 |
Fraktur Gigi |
|
|
|
|
|
10 |
Lain-lain |
|
|
|
|
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|
JUMLAH |
|
|
|
|
|
B |
PERAWATAN
DAN TERAPI |
|
|
|
|
|
1 |
Tumpatan gigi tetap |
|
|
|
|
|
2 |
Tumpatan gigi susu |
|
|
|
|
|
3 |
Pengobatan jaringanpulpa |
|
|
|
|
|
4 |
Cabut gigi tetap |
|
|
|
|
|
5 |
Cabut gigi susu |
|
|
|
|
|
6 |
Scalling |
|
|
|
|
|
7 |
Pengobatan Periodontal |
|
|
|
|
|
8 |
Pengobatan Abses |
|
|
|
|
|
9 |
Lain-lain |
|
|
|
|
|
|
JUMLAH |
|
|
|
|
10. Kunjungan
Laboratorium
|
NO |
JENIS |
REALISASI
BULAN |
JML |
||
|
|
|
|
|||
|
A |
RAWAT
INAP |
|
|
|
|
|
1 |
HB |
|
|
|
|
|
2 |
LEKOSIT |
|
|
|
|
|
3 |
LED |
|
|
|
|
|
4 |
DIFF |
|
|
|
|
|
5 |
TROMBOSIT |
|
|
|
|
|
6 |
HT |
|
|
|
|
|
7 |
WIDAL |
|
|
|
|
|
8 |
GOL DARAH |
|
|
|
|
|
9 |
GDS |
|
|
|
|
|
10 |
CHOLSTEROL |
|
|
|
|
|
11 |
VA |
|
|
|
|
|
12 |
OT |
|
|
|
|
|
13 |
PT |
|
|
|
|
|
14 |
UR |
|
|
|
|
|
|
JUMLAH |
|
|
|
|
|
B |
RAWAT
JALAN |
|
|
|
|
|
1 |
HB |
|
|
|
|
|
2 |
LEKOSIT |
|
|
|
|
|
3 |
LED |
|
|
|
|
|
4 |
DIFF |
|
|
|
|
|
5 |
TROMBOSIT |
|
|
|
|
|
6 |
HT |
|
|
|
|
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7 |
WIDAL |
|
|
|
|
|
8 |
GOL DARAH |
|
|
|
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|
9 |
GDS |
|
|
|
|
|
10 |
CHOLSTEROL |
|
|
|
|
|
11 |
VA |
|
|
|
|
|
12 |
OT |
|
|
|
|
|
13 |
PT |
|
|
|
|
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14 |
UR |
|
|
|
|
|
|
JUMLAH |
|
|
|
|
11. Kegiatan Upaya
Kesehatan Ibu
|
NO |
Kegiatan |
TARGET |
REALISASI
BULAN |
JML |
||
|
|
|
|
||||
|
1 |
Kunjungan K 1 |
|
|
|
|
|
|
2 |
Kunjungan K 4 |
|
|
|
|
|
|
3 |
Bumil TT 1 |
|
|
|
|
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4 |
Bumil TT 2 |
|
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|
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5 |
Bumil TT 3 |
|
|
|
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6 |
Bumil TT 4 |
|
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|
7 |
Bumil TT 5 |
|
|
|
|
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|
8 |
Bumil T2 + |
|
|
|
|
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|
9 |
Bumil Fe 1 |
|
|
|
|
|
|
10 |
Bumil Fe 3 |
|
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|
|
|
11 |
Deteksi Risti Nakes |
|
|
|
|
|
|
12 |
Deteksi Risti Masyarakat |
|
|
|
|
|
|
13 |
Rujukan kasus Risti maternal |
|
|
|
|
|
|
14 |
Persalinan Normal oleh Nakes |
|
|
|
|
|
|
15 |
Persalinan Normal di Faskes |
|
|
|
|
|
|
16 |
Persalinan Normal non Nakes |
|
|
|
|
|
|
17 |
Komplikasi maternal ditangani |
|
|
|
|
|
|
18 |
Kunjungan neonates |
|
|
|
|
|
|
19 |
Kunjungan nifas KF 1 |
|
|
|
|
|
|
20 |
Kunjungan nifas KF 2 |
|
|
|
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|
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21 |
Kunjungan nifas KF 3 |
|
|
|
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|
12. Kegiatan Upaya Pelayanan
KB
|
NO |
KEGIATAN |
TARGET |
REALISASI
BULAN |
JML |
||
|
|
|
|
||||
|
1 |
KB Aktif |
|
|
|
|
|
|
2 |
Peserta KB Baru |
|
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|
a. Pil |
|
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b. Suntik |
|
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c. Implant |
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d. Kondom |
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e. IUD |
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f. MOW |
|
|
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g. MOP |
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13. Kegiatan Upaya
Kesehatan Anak
|
NO |
KEGIATAN |
TARGET |
REALISASI
BULAN |
JML |
||
|
|
|
|
||||
|
1 |
Cakupan KN 1 |
|
|
|
|
|
|
2 |
Cakupan KN lengkap |
|
|
|
|
|
|
3 |
Cakupan neonates komplikasi yang di tangani |
|
|
|
|
|
|
4 |
Cakupan kunjungan bayi |
|
|
|
|
|
|
5 |
Cakupan pelayanan balita |
|
|
|
|
|
|
6 |
Cakupan anak prasekolah |
|
|
|
|
|
|
7 |
Balita berkunjung ke Pusk |
|
|
|
|
|
|
8 |
Balita dapat pelayanan MTBS |
|
|
|
|
|
14. Kegiatan Upaya
Pelayanan Gizi
|
NO |
Kegiatan |
TARGET |
REALISASI
BULAN |
JML |
||
|
|
|
|
||||
|
1 |
Jumlah Balita (S) |
|
|
|
|
|
|
2 |
Jumlah Balita punya KMS (K) |
|
|
|
|
|
|
3 |
Jumlah Balita di timbang (D) |
|
|
|
|
|
|
4 |
Jumlah Balita naik BB (N) |
|
|
|
|
|
|
5 |
Jumlah BGM |
|
|
|
|
|
|
6 |
Jumlah 2 T |
|
|
|
|
|
|
7 |
Jumlah status gizi buruk |
|
|
|
|
|
|
8 |
Jumlah status gizi kurang |
|
|
|
|
|
|
9 |
Jumlah status gizi baik |
|
|
|
|
|
|
10 |
Jumlah gizi buruk dapat perawatan |
|
|
|
|
|
|
11 |
Jumlah bayi lahir |
|
|
|
|
|
|
12 |
Jumlah BBLR |
|
|
|
|
|
|
13 |
Jumlah Bumil KEK |
|
|
|
|
|
|
14 |
Jumlah Bumil Anemi |
|
|
|
|
|
|
15 |
Jumlah Bumil Fe 1 |
|
|
|
|
|
|
16 |
Jumlah Bumil Fe 3 |
|
|
|
|
|
|
17 |
Jumlah Bayi dapat vitamin A |
|
|
|
|
|
|
18 |
Jumlah Balita dapat vitamin A |
|
|
|
|
|
|
19 |
Jumlah Bufas dapat Vitamin A |
|
|
|
|
|
|
20 |
Jumlah Bufas KEK |
|
|
|
|
|
|
21 |
Jumlah Bufas Anemi |
|
|
|
|
|
|
22 |
Jumlah Bayi ASI Eksklusif |
|
|
|
|
|
15. Kegiatan Upaya
Pencegahan dan Pengendalian penyakit (P2P)
|
NO |
KEGIATAN |
TARGET |
REALISASI
BULAN |
JML |
||
|
|
|
|
||||
|
I |
P2P TBC |
|
|
|
|
|
|
1 |
Cakupan suspek penderita TB Paru |
|
|
|
|
|
|
2 |
Cakupan penderita TB Paru + |
|
|
|
|
|
|
3 |
Cakupan penderita TB Paru sembuh |
|
|
|
|
|
|
II |
P2P DBD |
|
|
|
|
|