LAMPIRAN 1 FORM Self Assessment
FORM SELF ASSESSMENT REVIEW DIAGNOSA 4A (Berdasarkan Permenkes 5/2014 dan Kepmenkes 514/2015) Nama FKTP Alamat Jenis FKTP Waktu Assessment KC BPJS Kesehatan
No.
: : : Puskesmas/Klinik Pratama/DPP/RS D Pratama (lingkari salah satu) : tanggal/bulan/tahun : CIMAHI
Nama Diagnosa
Kode ICD X
Dapat Tuntas Ditangani di Faskes Saudara (*mohon di Ya
1 Typhoid fever 2 Acute amoebic dysentery pe ecifi ed ed gas tr troenter it itis and coli ti tis of inf ec ectious or ig igin 3 Other and uns p es pi pi ra rat or or y t ub ube rc rc ul ul os os is is , b ac ac te te ri ri ol ol og og ic ic al al ly ly an an d h is is to to lo lo gi gi ca cal ly ly co co nf nf ir ir me me d 4 R es
A01.0 A06.0 A09.0 A 15 15 .0 .0
5 Leptospirosis, unspecified 6 Indeterminate leprosy
A27.9
7 Other tetanus 8 Gonococcal infection, unspecified
A35
A30.0 A54.9
9 Dengue fever [classical dengue] 10 Dengue haemorrhagic fever
A91
11 Herpesviral infection, unspecified 12 Varicella without complication
B01.9
13 Zoster without complication 14 Measles without complication 15 Viral warts 16 Molluscum contagiosum 17 Acute hepatitis A 18 Mumps orchitis
A90 B00.9 B02.9 B05.9 B07 B08.1 B15 B26.0
19 Dermatophytosis 20 Tinea barbae and tinea capitis
B35.0
B35
21 Tinea unguium 22 Tinea manuum
B35.2
B35.1
23 Tinea pedis 24 Tinea corporis
B35.3
25 Tinea cruris 26 Other dermatophytoses
B35.6
B35.4 B35.8
27 Pityriasis versicolor 28 Candidiasis, unspecified
B37.9
B36.0
29 Unspecified malaria
B54
Kendala
checklist)
Tidak *)
(Agar dituliskan dengan lengkap tiap j enis kendala)
No.
Nama Diagnosa
Kode ICD X
Dapat Tuntas Ditangani di Faskes Saudara (*mohon di Ya
30 Schistosom due schis haematobium [urin schistosom] 31 Schistosomiasis due to Schistosoma japonicum
B65.0 B65.2
32 Schistosomiasis, unspecified 33 Taenia solium taeniasis
B68.0
34 Taeniasis, unspecified 35 Filariasis due to wuchereria bancrofti
B74.0
B65.9 B68.9
36 Ancylostomiasis
B76.0
37 Hookworm disease, unspecified 38 Ascariasis, unspecified
B76.9
39 Intestinal strongyloidiasis 40 Strongyloidiasis, unspecified
B78.0
41 Pediculosis due to pediculus humanus capitis 42 Phthiriasis
B85.0
43 Scabies
B86
44 Benign lipomatous neoplasm, unspecified 45 Iron deficiency anaemia secondary to blood loss (chronic)
D50.0
46 Iron deficiency anaemia, unspecified diabetes me mellitus wi without complications 47 Non-insulin-dependent di
E11.9
48 Hypoglycaemia, unspecified 49 Unspecified protein-energy malnutrition
E46
B77.9 B78.9 B85.3 D17.9 D50.9 E16.2
50 Obesity, unspecified
E66.9
51 Hyperlipidaemia, unspecified inflamm arthritis+tophaceous dis 52 Hyperuricaem without sign in
E78.5 E79.0
53 Somatization disorder 54 Nonorganic insomnia
F45.0
55 Migraine without aura [common migraine] 56 Migraine, unspecified
G43.0
57 Tension-type headache
G44.2
58 Bell's palsy 59 Hordeolum and other deep inflammation of eyelid
H00.0
60 Blepharitis 61 Entropion and trichiasis of eyelid
H02.0
62 Other disorders of lacrimal gland 63 Acute atopic conjunctivitis
H10.1
64 Conjunctivitis, unspecified
H10.9
65 Episcleritis 66 Hypermetropia
H15.1
67 Myopia
H52.1
F51.0 G43.9 G51.0 H01.0 H04.1
H52.0
Kendala
checklist)
Tidak *)
(Agar dituliskan dengan lengkap tiap j enis kendala)
No.
Nama Diagnosa
Kode ICD X
Dapat Tuntas Ditangani di Faskes Saudara (*mohon di Ya
68 Astigmatism 69 Presbyopia
H52.2
70 Night blindness 71 Other specified disorders of eye and adnexa
H53.6 H57.8
72 Otitis externa, unspecified 73 Impacted cerumen
H61.2
H52.4
H60.9
74 Acute serous otitis media
H65.0
75 Other acute nonsuppurative otitis media 76 Acute suppurative otitis media
H65.1 H66.0
77 Essential (primary) hypertension 78 Varicose veins lower extremities without ulcer or inflamm
I83.9
I10
79 Internal thrombosed haemorrhoids 80 Internal haemorrhoids without complication
I84.2
81 Unspecified haemorrhoids without complication
I84.9
82 Acute nasopharyngitis [common cold] 83 Acute pharyngitis
J00
84 Acute pharyngitis, unspecified 85 Acute tonsillitis
J02.9
86 Acute tonsillitis, unspecified 87 Acute laryngitis
J03.9
88 Influenza, virus not identified
J11.0
89 Bronchopneumonia, unspecified 90 Pneumonia, unspecified
J18.0
91 Acute bronchitis, unspecified 92 Vasomotor rhinitis
J20.9
I84.0
J 02 J03 J04.0
J18.9 J30.0
93 Allergic rhinitis, unspecified 94 Abscess, furuncle and carbuncle of nose
J34.0
95 Chronic tonsillitis
J35.0
96 Asthma, unspecified 97 Stomatitis and related lesions
K12
98 Gastro-oesophageal reflux disease without oesophagitis 99 Gastritis, unspecified
J30.4
J45.9 K21.9 K29.7
100 Malabsorption due to intolerance, not elsewhere classified 101 Impetigo [any organism] [any site]
K90.4
102 Cutaneous abscess, furuncle and carbuncle of face
L02.0
103 Cutaneous abscess, furuncle and carbuncle of trunk 104 Cutaneous abscess, furuncle and carbuncle of other sites
L02.2
105 Acute lymphadenitis, unspecified
L04.9
L01.0
L02.8
Kendala
checklist)
Tidak *)
(Agar dituliskan dengan lengkap tiap j enis kendala)
No.
Nama Diagnosa
Kode ICD X
Dapat Tuntas Ditangani di Faskes Saudara (*mohon di Ya
106 Pyoderma 107 Erythrasma
L08.0 L08.1
108 Other atopic dermatitis 109 Seborrhoea capitis
L20.8
110 Diaper [napkin] dermatitis 111 Irritant contact dermatitis due to detergents
L22 L24.0
112 Generalized skin eruption due to drugs and medicaments
L27.0
113 Dermatitis due to ingested food 114 Pityriasis rosea
L27.2
115 Allergic urticaria 116 Atrophic disorder of skin, unspecified
L50.0 L50.9
117 Acne vulgaris 118 Perioral dermatitis
L71.0
119 Hidradenitis suppurativa
L73.2
120 Miliaria, unspecified 121 Ulcer of lower limb, not elsewhere classified
L97
122 Gout 123 Acute tubulo-interstitial nephritis
N10
124 Urinary tract infection, site not specified 125 Redundant prepuce, phimosis and paraphimosis
N47
126 Inflammatory disorders of breast
N 61
127 Acute vaginitis associated wi with ar artificial fe fertilization, un unspecified 128 Complication as
N98.9
L21.0
L42
L70.0
L74.3 M10 N39.0
N76.0
on ta ta ne ne ou ou s a bo bo rt rti on on , C om om pl pl et et e o r u ns ns pe pe ci ci fi fi ed ed , w it ith ou ou t c om omp lili ca ca ti ti on on 129 Sp on 130 First degree perineal laceration during delivery
O 03 03 .9 .9
131 Single spontaneous delivery, unspecified 132 Retracted nipple associated with childbirth
O80.9 O92.0
133 Omphalitis of newborn with or without mild haemorrhage
P38
134 Epistaxis 135 Dizziness and giddiness
R42
136 Febrile convulsions 137 Injury of unspecified body region
T14
O70.0
R04.0 R56.0
138 Open wound of unspecified body region 139 Foreign body on external eye, part unspecified
T14.1
140 Foreign body in nostril
T17.1
141 Burn of first degree, body region unspecified 142 Burn of second degree, body region unspecified
T30.2
143 Venom of other arthropods
T63.4
T15.9 T30.1
Kendala
checklist)
Tidak *)
(Agar dituliskan dengan lengkap tiap j enis kendala)
No.
Nama Diagnosa
Kode ICD X
Dapat Tuntas Ditangani di Faskes Saudara (*mohon di Ya
144 Anaphylactic shock, unspecified human im immunodeficiency vi virus [H [HIV] in infection st status 145 Asymptomatic hu
Kendala
checklist)
Tidak *)
(Agar dituliskan dengan lengkap tiap j enis kendala)
T78.2 Z21
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