KEMENTRIAN KESEHATAN REPUBLIK INDONESIA

Data Pasien
NIK Sex 1. laki-laki 2. Perempuan 9. Unknown
MRN Race 00. Tdk diketahui 03. Mongoloid
tujuh digit kode RS No MR 01. Melayu 04. Non-mongoloid
First name 02. Non-Melayu
Middle name Religion 0. Unknown 4. Hindu
Family name 1. Islam 5. Budha
Place of birth 2. Katolik 9. Other
Date of birth …../…../……………………….. Aged 3. Protestan
Alamat tetap Status 1. Menikah 3. Belum menikah
Pernikahan 2. Janda/Duda 9. Unknown
Pov/Kab/Kota Occupation 00. Unknown 05. Ibu R.Tangga
Kode pos 01. Staf kantor 06. Tenaga medis
Alamat sementara 02.Petani 07. Guru
03. Buruh pabrik 08. Pedagang
Pov/Kab/Kota 04. Militer/polisi 99. Other
Kode pos No. Telp/HP
Data Tumor
Topography Behaviour Grade
(lokasi tumor) ICD-0 Kode C 0. Benign 2. Insitu 00.Unknown 06.Pos B-cell
Morphology 1. Uncertain 3. Malignant 01.Well diff 07.Null cell
(Jenis tumor) ICD-0 Kode M 9. Unknown 02.Mod diff 08.NK cell
Most valid Basic of diagnosis cancer 03.Poor diff 09.Not applicable
0. Death Certificate Only 5. Cytology 04.Undiff 10 - Dediff
1. Clinical Only 6. Histology of metastase 05.Pos T-cell
2. Clin. Invest./Ult Soun 7. Histology of primary Stage
3. Surgery/Autopsy 8. Autopsy/Histology 001.1 011.3B
4. Laboratory test 9. Unknown 002.1A 012.3C
Clinical ext. of disease before treatment 003.1B 013.4
1. In situ 8. Not applicable 004.1C 014.4A
2. Localized 9. Unknown 005.2 015.4B
3. Direct extension 006.2A 016.4C
4. Regional LN involvement 007.2B 018.7
5. Direct extension with regional LN involvement 008.2C 019.8
6. Distant metastases 009.3 020.9
Treatment at reporting institution Distant metastases 010.3A
00. No Treatment 05. Targeted Therapy 00.None 08.Stomach Laterality
01. Surgery 06. Immuno Therapy 01.Lymph Node 09.Bone Marrow 1. Right
02. Radiotherapy 07. Hormonal Therapy 02.Bone 10.Endocrine 2.Left
03. Chemotherapy 08. Other Therapy 03.Liver 11.Cavum Pleura 3.Central
04. Chemoradiation 09. Unknown 04.Lung 12.Bladder 4.Bilateral
05.Brain 13.Colon 5.Multiple
06.Ovary 14.Others 8.Not applicable
Diagnosis Date 07.Skin 15 - Unknown 9 - Unknown
dd/mm/yyyy No.of metastases

Sources / Follow up
Tgl. Periksa Kode Rumah Sakit Nama Rumah Sakit Unit ID Unit No. PA/Lab

Kesimpulan

Admission date Registrar Verifier

Date last contact Date of abstract Date of Verification
Status 1. Hidup 2. Meninggal 9. Unknown