LAMPIRAN 1

FORM Self Assessment

FORM SELF ASSESSMENT
REVIEW DIAGNOSA 4A (Berdasarkan Permenkes 5/2014 dan Kepmenkes 514/2015)
Nama FKTP :
Alamat :
Jenis FKTP : Puskesmas/Klinik Pratama/DPP/RS D Pratama (lingkari salah satu)
Waktu Assessment : tanggal/bulan/tahun
KC BPJS Kesehatan : CIMAHI

Dapat Tuntas Ditangani di

No. Nama Diagnosa Kode ICD X Faskes Saudara (*mohon di
Kendala
checklist)
Ya Tidak *) (Agar dituliskan dengan lengkap tiap jenis kendala)
1 Typhoid fever A01.0
2 Acute amoebic dysentery A06.0
3 Other and unspecified gastroenteritis and colitis of infectious origin A09.0
4 Respiratory tuberculosis, bacteriologically and histologically confirmed A15.0
5 Leptospirosis, unspecified A27.9
6 Indeterminate leprosy A30.0
7 Other tetanus A35
8 Gonococcal infection, unspecified A54.9
9 Dengue fever [classical dengue] A90
10 Dengue haemorrhagic fever A91
11 Herpesviral infection, unspecified B00.9
12 Varicella without complication B01.9
13 Zoster without complication B02.9
14 Measles without complication B05.9
15 Viral warts B07
16 Molluscum contagiosum B08.1
17 Acute hepatitis A B15
18 Mumps orchitis B26.0
19 Dermatophytosis B35
20 Tinea barbae and tinea capitis B35.0
21 Tinea unguium B35.1
22 Tinea manuum B35.2
23 Tinea pedis B35.3
24 Tinea corporis B35.4
25 Tinea cruris B35.6
26 Other dermatophytoses B35.8
27 Pityriasis versicolor B36.0
28 Candidiasis, unspecified B37.9
29 Unspecified malaria B54
 Dapat Tuntas Ditangani di
No. Nama Diagnosa Kode ICD X Faskes Saudara (*mohon di
Kendala
checklist)
Ya Tidak *) (Agar dituliskan dengan lengkap tiap jenis kendala)
30 Schistosom due schis haematobium [urin schistosom] B65.0
31 Schistosomiasis due to Schistosoma japonicum B65.2
32 Schistosomiasis, unspecified B65.9
33 Taenia solium taeniasis B68.0
34 Taeniasis, unspecified B68.9
35 Filariasis due to wuchereria bancrofti B74.0
36 Ancylostomiasis B76.0
37 Hookworm disease, unspecified B76.9
38 Ascariasis, unspecified B77.9
39 Intestinal strongyloidiasis B78.0
40 Strongyloidiasis, unspecified B78.9
41 Pediculosis due to pediculus humanus capitis B85.0
42 Phthiriasis B85.3
43 Scabies B86
44 Benign lipomatous neoplasm, unspecified D17.9
45 Iron deficiency anaemia secondary to blood loss (chronic) D50.0
46 Iron deficiency anaemia, unspecified D50.9
47 Non-insulin-dependent diabetes mellitus without complications E11.9
48 Hypoglycaemia, unspecified E16.2
49 Unspecified protein-energy malnutrition E46
50 Obesity, unspecified E66.9
51 Hyperlipidaemia, unspecified E78.5
52 Hyperuricaem without sign inflamm arthritis+tophaceous dis E79.0
53 Somatization disorder F45.0
54 Nonorganic insomnia F51.0
55 Migraine without aura [common migraine] G43.0
56 Migraine, unspecified G43.9
57 Tension-type headache G44.2
58 Bell's palsy G51.0
59 Hordeolum and other deep inflammation of eyelid H00.0
60 Blepharitis H01.0
61 Entropion and trichiasis of eyelid H02.0
62 Other disorders of lacrimal gland H04.1
63 Acute atopic conjunctivitis H10.1
64 Conjunctivitis, unspecified H10.9
65 Episcleritis H15.1
66 Hypermetropia H52.0
67 Myopia H52.1
 Dapat Tuntas Ditangani di
No. Nama Diagnosa Kode ICD X Faskes Saudara (*mohon di
Kendala
checklist)
Ya Tidak *) (Agar dituliskan dengan lengkap tiap jenis kendala)
68 Astigmatism H52.2
69 Presbyopia H52.4
70 Night blindness H53.6
71 Other specified disorders of eye and adnexa H57.8
72 Otitis externa, unspecified H60.9
73 Impacted cerumen H61.2
74 Acute serous otitis media H65.0
75 Other acute nonsuppurative otitis media H65.1
76 Acute suppurative otitis media H66.0
77 Essential (primary) hypertension I10
78 Varicose veins lower extremities without ulcer or inflamm I83.9
79 Internal thrombosed haemorrhoids I84.0
80 Internal haemorrhoids without complication I84.2
81 Unspecified haemorrhoids without complication I84.9
82 Acute nasopharyngitis [common cold] J00
83 Acute pharyngitis J02
84 Acute pharyngitis, unspecified J02.9
85 Acute tonsillitis J03
86 Acute tonsillitis, unspecified J03.9
87 Acute laryngitis J04.0
88 Influenza, virus not identified J11.0
89 Bronchopneumonia, unspecified J18.0
90 Pneumonia, unspecified J18.9
91 Acute bronchitis, unspecified J20.9
92 Vasomotor rhinitis J30.0
93 Allergic rhinitis, unspecified J30.4
94 Abscess, furuncle and carbuncle of nose J34.0
95 Chronic tonsillitis J35.0
96 Asthma, unspecified J45.9
97 Stomatitis and related lesions K12
98 Gastro-oesophageal reflux disease without oesophagitis K21.9
99 Gastritis, unspecified K29.7
100 Malabsorption due to intolerance, not elsewhere classified K90.4
101 Impetigo [any organism] [any site] L01.0
102 Cutaneous abscess, furuncle and carbuncle of face L02.0
103 Cutaneous abscess, furuncle and carbuncle of trunk L02.2
104 Cutaneous abscess, furuncle and carbuncle of other sites L02.8
105 Acute lymphadenitis, unspecified L04.9
 Dapat Tuntas Ditangani di
No. Nama Diagnosa Kode ICD X Faskes Saudara (*mohon di
Kendala
checklist)
Ya Tidak *) (Agar dituliskan dengan lengkap tiap jenis kendala)
106 Pyoderma L08.0
107 Erythrasma L08.1
108 Other atopic dermatitis L20.8
109 Seborrhoea capitis L21.0
110 Diaper [napkin] dermatitis L22
111 Irritant contact dermatitis due to detergents L24.0
112 Generalized skin eruption due to drugs and medicaments L27.0
113 Dermatitis due to ingested food L27.2
114 Pityriasis rosea L42
115 Allergic urticaria L50.0
116 Atrophic disorder of skin, unspecified L50.9
117 Acne vulgaris L70.0
118 Perioral dermatitis L71.0
119 Hidradenitis suppurativa L73.2
120 Miliaria, unspecified L74.3
121 Ulcer of lower limb, not elsewhere classified L97
122 Gout M10
123 Acute tubulo-interstitial nephritis N10
124 Urinary tract infection, site not specified N39.0
125 Redundant prepuce, phimosis and paraphimosis N47
126 Inflammatory disorders of breast N61
127 Acute vaginitis N76.0
128 Complication associated with artificial fertilization, unspecified N98.9
129 Spontaneous abortion, Complete or unspecified, without complication O03.9
130 First degree perineal laceration during delivery O70.0
131 Single spontaneous delivery, unspecified O80.9
132 Retracted nipple associated with childbirth O92.0
133 Omphalitis of newborn with or without mild haemorrhage P38
134 Epistaxis R04.0
135 Dizziness and giddiness R42
136 Febrile convulsions R56.0
137 Injury of unspecified body region T14
138 Open wound of unspecified body region T14.1
139 Foreign body on external eye, part unspecified T15.9
140 Foreign body in nostril T17.1
141 Burn of first degree, body region unspecified T30.1
142 Burn of second degree, body region unspecified T30.2
143 Venom of other arthropods T63.4
 Dapat Tuntas Ditangani di
No. Nama Diagnosa Kode ICD X Faskes Saudara (*mohon di
Kendala
checklist)
Ya Tidak *) (Agar dituliskan dengan lengkap tiap jenis kendala)
144 Anaphylactic shock, unspecified T78.2
145 Asymptomatic human immunodeficiency virus [HIV] infection status Z21

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