8/17/2019 Blangko Home Visite Prolanis

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BPJS Kesehatan

Kantor Cabang Pekalongan

BLANGKO HOME VISITE PROLANIS

A. DATA DASAR

1. Nama Peserta : ..........................................................................2. No. Kartu BPJS Kesehatan : ..........................................................................

3. Alamat Rumah : ..............................................................................................................

4. No. Telp : ..........................................................................

5. Jenis Penyakit Prolanis : Diabetes Mellitus / Hipertensi

6. Nama Faskes Pengelola : ..................................................................... Kode Faskes : .................

7. Nama Klub Prolanis : ..........................................................................

B. ALASAN KUNJUNGAN

Alasan Kunjungan Check List

Pasca Opname

Angka GDPP buruk selama 3 bln

Tdk datang selama 3 bln berturut-turut

Pasien adlh peserta baru

C. HASIL KUNJUNGAN

Kondisi : Baik Buruk

Minum Obat : Rutin Tidak Rutin

Keluhan Lain :........................................................................................................................................................................

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Jika tidak datang berturut-turut tuliskan alasannya :

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Peserta,

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