Form Hasil Permeriksaan Laboratorium.docx

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PEMERINTAH KABUPATEN SUKABUMI DINAS KESEHATAN

UPTD PUSKESMAS KALIBUNDER Jalan Raya Kalibunder KM 14 Jampangkulon Sukabumi e_mail: [email protected] Kalibunder Kode Pos 43185

FORMULIR HASIL PEMERIKSAAN LABORATORIUM Dokter Pengirim

:

No.Register Nama Umur Jenis kelamin Alamat

NO

Tanggal Pemeriksaan :

: ..................... : ..................... : ..................... : ..................... : .....................

Jam Pengambilan SP Jam pemeriksaan

JENIS PEMERIKSAAN

1

HEMATOLOGI Hemoglobin

1

URINALISA SG

2

PH

3

Leukosit

4

Protein

5

Glucosa

6

Ketones

7

UBG

8

Bil

9

Ery

10

Hb

HASIL

: ...................... WIB : ...................... WIB

NILAI RUJUKAN

KIMIA KLINIK 1

Glukosa

90 - 134 mg/dl (beneChek)

2

Asam Urat

5.8 - 134 mg/dl (BeneChek)

3

Kolesterol Total

156 - 235 (EasyTouch)

PARASITOLOGI 1

Microbakterium (BTA) IMUNOLOGI

1

Anti HIV

2

Golongan Darah `

Pemeriksa

.........................

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