DEPARTEMEN KESEHATAN

REPUBLIK INDONESIA
RS
Sistem Registrasi Kanker di Indonesia (SRiKandI)
No Registrasi

Pasien
No. Rekam Medis

Auto Number

No. Epidemiologi

Nama Lengkap

Jenis Kelamin
Nama Depan

Nama Belakang

Nama Keluarga

No.Identitas / KTP
Tempat Lahir

Agama
0. Unknown
1. Islam
2. Katolik

dd-mm-yy
Alamat Rumah

Kode Pos

0. Unknown
1. Laki-laki
2. Perempuan

3. Protestan
4. Hindu
5. Budha
9. Lain-lain

Kel.

Kec.

Umur pada kunjungan pertama/ tahun

Kab.
Prop.

:
:

Status perkawinan
0. Unknown
1. Menikah

2. Janda / Duda
3. Lajang

Keterangan
Suku/ dalam daftar
Pekerjaan/ dalam daftar
Tumor
Topography
(Lokasi tumor)
Morphology
(Jenis tumor)

Behaviour
0. Benign
1. Uncertain
2. Carcinoma In Situ

ICD-O kode C

ICD-O kode M

Stage / TNM
0. Stage 0
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
9. Unknown

A
B
C
D

Treatment at reporting institution

0. No Treatment
6. Radiotherapy &
1. Surgery
Chemotherapy
2. Radiotherapy
7. Surg, Radiotherapy &
3. Surgery &
Chemotherapy
Radiotherapy
8. Other Therapy
4. Chemotherapy
9. Unknown
5. Surgery &
Chemotherapy

Grade
3. Malignant, primary site
1. Well Differentiated
6. Malignant, metastatic site 2. Moderately Differentiated
9. Malignant, uncertain
3. Poorly Differentiated
4. Undifferentiated
5. Positive T-cell

Most valid basic of diagnosis of cancer

1. Clinical only
5. Cytology/ Haematology
2. Lab, X-ray, Endoscopy,
6. Histology of metastasis
Isotopes Angiography, EEG 7. Histology of primary
3. Surgent/ Autopsy without
8. Autopsy with histology
histology
9. Unknown
4. Spesific biochemical/
Immunology tests

Clinical extent of disease

before treatment
1. Insitu
2. Localized
3. Direct Extension
4. Regional Lymph node
Involvement

Site (s) of distant metastases

0. None
1. Distant lymph node
2. Bone
3. Liver
4. Lung and/ or pleura

Laterality
1. Right
2. Left
3. Central
4. Bilateral

5. Brain
6. Ovary
7. Skin
8. Other
9. Unknown

6. Positive B-cell
7. Null Cell
8. NK (Natural Killer) Cell
9. Not Applicable
10. Dedifferentiated

5. Direct Extension with

regional lymph node
involvement
6. Distant metastases
8. Not applicable
9. Unknown

5. Multiple
6. Not Applicable
9. Unknown

Tanggal pertama kali didiagnosa kanker

dd-mm-yy
Sources / Follow-up
Tgl. Periksa
Kode Rumah Sakit

Nama Rumah Sakit

Unit ID

Status at last contact

Unit

No. PA / Lab

Date of last contact

dd-mm-yy

1. Alive, no evidence of cancer

2. Alive, localized tumour
3. Alive, direct extension or local involvement
4. Alive, distant metastases

5. Alive, subsequent primary discovery or first primary discovered when previously unknown
6. Alive, nothing further specified
7. No follow-up
8. Dead
9. Unknown

Kesimpulan

Registrar :

TTD / Tanggal :

Verifikator :

TTD / Tanggal :

SRiKandI

Sistem Registrasi Kan

Pasien
No. Rekam Medis
Nama Lengkap
Nama Depan

Nama Belakang

Nama Keluarga

No.Identitas / KTP
Tempat Lahir
dd-mm-yyyy

Alamat Rumah

Kode Pos

Kel.

Kec.

Kab.

Prop.

Keterangan

Tumor
Topography

Behaviour

(Lokasi tumor) ICD-O kode C

0. Benign
1. Uncertain
2. Carcinoma In Situ

Morphology
(Jenis tumor)

3. Malignant, primary site

6. Malignant, metastatic site
9. Malignant, uncertain

ICD-O kode M

Stage / TNM

Most valid basic of diagnosis of cancer

0. Stage 0
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
9. Unknown

1. Clinical only
2. Lab, X-ray, Endoscopy,
Isotopes Angiography, EEG
3. Surgent/ Autopsy without
histology
4. Spesific biochemical/
Immunology test

A
B
C
D

5. Cytology/ Haematology
6. Histology of metastasis
7. Histology of primary
8. Autopsy with histology
9. Unknown

Treatment at reporting institution

Site (s) of distant metastases

0. No Treatment

0. None

6. Radiotherapy &

5. Brain

1. Surgery
2. Radiotherapy
3. Surgery &
Radiotherapy
4. Chemotherapy
5. Surgery &
Chemotherapy

Chemotherapy
7. Surgery, Radio &
Chemotherapy
8. Other Therapy
9. Unknown

1. Distant lymph node

2. Bone
3. Liver
4. Lung and/ or pleura

6. Ovary
7. Skin
8. Other
9. Unknown

Tanggal pertama kali didiagnosa kanker

dd-mm-yy

Sources / Follow-up
Tgl. Periksa

Kode Rumah Sakit

Nama Rumah Sakit

Unit ID

Status at last contact

1. Alive, no evidence of cancer
2. Alive, localized tumour
3. Alive, direct extension or local involvement
4. Alive, distant metasates

Kesimpulan

5. Alive, subsequent primary discovery or first primary discover

6. Alive, nothing further specified
7. No follow-up
8. Dead
9. Unknown

strasi Kanker di Indonesia

No Registrasi
Epid. No.
Jenis Kelamin

Keluarga

d-mm-yyyy

gnant, primary site

gnant, metastatic site
gnant, uncertain

logy/ Haematology
ology of metastasis
ology of primary
psy with histology

Auto Number

0. Unknown
1. Laki-laki
2. Perempuan

Agama
0. Unknown

3. Protestan

1. Islam

4. Hindu

2. Katolik

5. Budha
9. Lain-lain

Umur pada kunjungan pertama/ tahun

Status perkawinan
0. Unknown

2. Janda / Duda

1. Menikah

3. Lajang

Suku/ dalam daftar

Grade
1. Well Differentiated
2. Moderately Differentiated
3. Poorly Differentiated
4. Undifferentiated
5. Positive T-cell

6. Positive B-cell
7. Null Cell
8. NK (Natural Killer) Cell
9. Not Applicable
10. Dedifferentiated

Clinical extent of disease

before treatment
1. Insitu
2. Localized
3. Direct Extension
4. Regional Lymph node
Involvement

5. Direct Extension with

regional lymph node
involvement
6. Distant metastases
8. Not applicable
9. Unknown

Laterality
1. Right

5. Multiple

2. Left
3. Central
4. Bilateral

Unit ID

6. Not Applicable
7. Unknown

Unit

or first primary discovered when previously unknown

9. Unknown

No. PA / Lab

SRiKandI Sistem Registrasi Kanker

Pasien
No. Rekam Medis
Nama Lengkap
Nama Depan

Nama Belakang

Nama Keluarga

No.Identitas / KTP
Tempat Lahir
dd-mm-yyyy

Alamat Rumah

Kode Pos

Kel.

Kec.

Kab.

Prop.

Keterangan

Tumor
Topography

Behaviour

(Lokasi tumor) ICD-O kode C

0. Benign
1. Uncertain
2. Carcinoma In Situ

Morphology
(Jenis tumor)

3. Malignant, primary site

6. Malignant, metastatic site
9. Malignant, uncertain

ICD-O kode M

Stage / TNM

Most valid basic of diagnosis of cancer

0. Stage 0
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
9. Unknown

1. Clinical only
2. Lab, X-ray, Endoscopy,
Isotopes Angiography, EEG
3. Surgent/ Autopsy without
histology
4. Spesific biochemical/
Immunology tests

A
B
C
D

5. Cytology/ Haematology
6. Histology of metastasis
7. Histology of primary
8. Autopsy with histology
9. Unknown

Treatment at reporting institution

Site (s) of distant metastases

0. No Treatment

0. None

6. Radiotherapy &

5. Brain

1. Surgery
2. Radiotherapy
3. Surgery &
Radiotherapy
4. Chemotherapy
5. Surgery &
Chemotherapy

Chemotherapy
7. Surg, Radiotherapy &
Chemotherapy
8. Other Therapy
9. Unknown

1. Distant lymph node

2. Bone
3. Liver
4. Lung and/ or pleura

6. Ovary
7. Skin
8. Other
9. Unknown

Tanggal pertama kali didiagnosa kanker

dd-mm-yy

Sources / Follow-up
Tgl. Periksa

Kode Rumah Sakit

Nama Rumah Sakit

Unit ID

Status at last contact

1. Alive, no evidence of cancer
2. Alive, localized tumour
3. Alive, direct extension or local involvement
4. Alive, distant metastases

Kesimpulan

5. Alive, subsequent primary discovery or first primary discover

6. Alive, nothing further specified
7. No follow-up
8. Dead
9. Unknown

si Kanker di Indonesia
No Registrasi
Epid. No.
Jenis Kelamin

Keluarga

d-mm-yyyy

gnant, primary site

gnant, metastatic site
gnant, uncertain

logy/ Haematology
ology of metastasis
ology of primary
psy with histology

Auto Number

0. Unknown
1. Laki-laki
2. Perempuan

Agama
0. Unknown

3. Protestan

1. Islam

4. Hindu

2. Katolik

5. Budha
9. Lain-lain

Umur pada kunjungan pertama/ tahun

Status perkawinan
0. Unknown

2. Janda / Duda

1. Menikah

3. Lajang

Suku/ dalam daftar

Pekerjaan/ dalam daftar
Grade
1. Well Differentiated
2. Moderately Differentiated
3. Poorly Differentiated
4. Undifferentiated
5. Positive T-cell

6. Positive B-cell
7. Null Cell
8. NK (Natural Killer) Cell
9. Not Applicable
10. Dedifferentiated

Clinical extent of disease

before treatment
1. Insitu
2. Localized
3. Direct Extension
4. Regional Lymph node
Involvement

5. Direct Extension with

regional lymph node
involvement
6. Distant metastases
8. Not applicable
9. Unknown

Laterality
1. Right

5. Multiple

2. Left
3. Central
4. Bilateral

Unit ID

6. Not Applicable
9. Unknown

Unit

Date of last contact

or first primary discovered when previously unknown

9. Unknown

No. PA / Lab

dd-mm-yy

PETUNJUK PENGISIAN

No. Registrasi

: Otomatis akan terisi

Biodata Pasien
1 No. Rekam Medis
2 Nama Lengkap
- Nama Depan
- Nama Belakang
- Nama Keluarga
3 Nomor Identitas / KTP
4 Tempat Lahir
- Tanggal Lahir
5 Alamat rumah
6 Kode Pos
- Kelurahan
- Kecamatan
- Kabupaten
- Propinsi
7 Keterangan
8 Epid No.
9 Jenis Kelamin
10 Agama
11 Umur pada kunjungan pertama/ tahun
12 Status perkawinan
13 Suku/ dalam daftar
14 Pekerjaan/ dalam daftar

Tumor
15
16
17
18
19
20
21
22
23
24
25

Topography
: Lokasi tumor, diisi dengan kode C menggunakan ICD-O
Morphology
: Jenis tumor, diisi dengan kode M menggunakan ICD-O
Behaviour
:
Grade
:
Stage / TNM
:
Most valid basic of diagnosis of cancer
Clinical extent of disease before treatment
Treatment at reporting institution
Site (s) of distant metastases
Laterality
Tanggal pertama kali didiagnosa kanker

Sources / Follow-up
26 Status at last contact
27 Date of last contact
28 Kesimpulan
29
30
31
32