Harapan Kita.pdf

,,zt RS. Jantuno I P.mbutuh Deh HaEDan Xita Jl. Lctlen S. Paman X.vA7, SttEt, Jatalt BaEt.|l / / T.lF (021) 568'lllr {H(nlrno) F . ltzl} 56&rio

page 1 of8

{20

Prnrbd by LAPORAN RS / D3Le _ 12/oll20t9 09.30.31

RINCIAN BIAYA SEMENTARA

NoMR Nama

Pasien

:132305

Pengirim

:

dr

:

Masuk

:

O4lO1l2O19 09:17:27

MUHAMMAD ANDRE AJ, TN.

Alamat : PERUM BUMI l\rAS U3 01/04 I/IOJOREJO, Koia : MADIUN Jaminan i 01 PRIBADi Tanggal

TAt\rAN MADTUN

Kode Yan/ltem Layanan

Sp/CAR/Paru/Anak/dll

No.Kunjungan: 190'1MEE02R0027 Paoses

Masuk

:

RSCC

Nama

Dokter

:

POPPY S. ROEBIONO

otv

Tarif

Subtotal

Diskon

Umum 05-01-2019

962111

KAMAR

OPERASI

o5-01-2019 s.d. os-o1-2019

04-01-2019

999181

0

2OO2

qqo

MEDICAL DAN BE 2oo2

0

2.600.000

KAMAR & VISITE ICU MEDICAL DAN BE 2002

3

2.600 000

DO55

3

17.73a

53.214

0

DO55

-,|

't7.738

-17.734

0

05-01-2019

999931

KAMAR & VISITE

lcu

2OO2

05-01-2019 s.d. 05-01-2019 05-01-2019 s.d. 08-01-2019

05-01-2019

710006

09-0'1-2019

7'10006

09-0'1-201S

710006

I

710006

05-01-2019

710008

06-01-2019

710008

I

710008

09-01-2019

710008

11-01-2019

710008

r

1-01-2019

710008

v-01-2019

710009

0&01-2019

71000s

09-01-2019

710009

11-O1-2019

71000s

1

'1-0't -201

07-0'1 -20't

0t01-2019

7'100'10

06-01-201S

710010

07-0'1-2019

7'10010

09-01-2019

710010

I

710010

11-01-2019

710010

11-01-2019

7100'10

05-0'1-2019

710011

06-01-20't9

710011

06-0'1-2019

710011

07-01-20'19

710011

09-01-201S

71001'1

10-01-2019

710011

11-O1-2019

7

05-01-201S

710012

'1

0-0'1 -201

too1'l

0

3.000

KAMARRAWAT.I.W.MEDIKALANAK 08-01-2019 s.d. 11-01-2019

710001

':t

1 000 000

999927

09-01-2019

0

3

-01-201S

710001

e'r'

1.650.000

KAMAR RWT PAV SUKAMAN SAPPHIRE 2Oo2 11-01-2019 s.d. 12-01-2019

05-01-2019

0

1.650.000

999.18.1

9S9931

5qo

1.650.000

20'19

05-01-2019

0

0

KAMAR RWT PAV SUKAMAN SAPPHIRE 2oO2

o4-01-2019 s.d. o5-01-2019

11-01

0

SET BLOOD SET BLOOD

CC DISP SYRINGE 1CC DISP SYRINGE 1 CC DISP SYRINGE 1CC DISP SYRINGE 5 CC DISP SYRINGE 5 CC DISP SYRINGE 5 cC DISP SYRINGE 5 CC DISP SYRINGE 5 CC DISP SYRINGE 5 CC DISP SYRINGE 10Cc DISP SYRINGE 10 CC DISP SYRINGE 10Cc DISP SYRINGE 10 Cc DISP SYRINGE 20 CC DISPSYRINGE20CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC CATH TIP DISP SYRINGE

'1

1.,1.'

0oo |

e

.'-

0

0

7.8oo.0oo ' rr.\.,;:i,::

,l

0

D055

7

2-0'18

14.126

0

DO55

-,|

2.O1A

-2.O18

0

D055

1

2.O14

2.O18

0

DO55

2

2.O18

4.036

0

DOS5

7

2.000

14.000

0

D055

5

2.000

10.000

0

Do55

4

2.000

8.000

0

Do55

2

2.000

4-000

0

DO55

3

2,000

6.000

0

0055

1

2.000

2.000

0

D055

10

2.500

25.000

0

DO55

3

2.500

7.500

0

D055

-2

2.500

-5_000

0

2.500

5.000

0

D055 Do55

4

ooss

3.850

15.400

0

3.850

19.250

0

Doss

1

3.850

3.850

0

DO55

1

3.850

3.850

0

,|

3.850

3_850

0

DO55

1

3.850

3,850

0

DO5S

2

3.850

7.700

0

Do55

3

9.676

29.02a

0

DO55

2

s.676

D0S5

19.352

0

48.380

0

s.676

29.024

0

DO55

D055 Do55

2

9_676

'19.352

0

DOS5

1

s-676

9.676

0

DO55

2

9.676

19.352

0

Do55

1

21.450

21.450

0

2

RS. J.ntu.c a P.mbuluh O.6h H.ap.n Kita Jl. L.tl.n S. P.m. Xav87,slipi, J.*arE BaEt 11420 TalP: {o2l) 5631111 (Hunling) F&: {o21) 56a4130

page 2 of 8 Print€d by LAPORAN RS / Date: 12f01/2019 09:32:58

RINCIAN BIAYA SEMENTARA No MR

:

132305

Pengidm

dr Sp/CAR/Paru/AnaUdll

Nama Pasien

:

MUHAMMAD ANDRE AJ, TN.

Masuk

MlO1nO19 09.17:.27

Alamat

:

PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN

No.Kunjungan

1S0104EE02R0027

Kota

:

IUADIUN

Proses Masuk

RSCC

Jaminan

I

01

Nama Dokter

POPPY S- ROEBIONO

Tanggal

Kode Yan/ltem Layanan

PRIBADI

atv

Tarif

Subtotal

Diskon

Umum 1't{1-2019

710025

0

1-2019

710032

0m't-2019

710032

07-01-2019

7'loo32

09-01-20'19

710032

09{1-2019

710032

10-01-2019

710032

10-01-2019

710032

'10-01-2019

710032

11-01-2019

710032

11-01-2019

710032

09{1-2019 't'1{1-20't9

710040

22 18 DISP NEEoLE No. '18 DISP NEEDLE NO. 18 DISP NEEDLE No. 18 DISP NEEDLE NO. 18 DISP NEEDLE NO. 18 DISP NEEDLE NO. 18 DISP NEEDLE NO, 18 DISP NEEDLE NO. '18 DISP NEEDLE NO. 18 IV CATHETER NO

DISP. NEEDLE NO.

710'153

1141-2019

710153

I

710207

INFUSION SET WITH BURETTE

0$.01-2019 09-01-2019

7'10065

710071

09-01-2019

710081

09-01-2019

710087

11-0't-2019

7'10087

114't-20'19

vooaT

11-01-2019

710091

0to1-2019

710092

07-0'1-2019

710092

09{1-20'19

710092

0t01-20'i

09-01-2019

'1o.444

10.444

0

Do55

544

5.,14O

0

D05S

10

544

5.440

0

DO55

1

544

544

0

DoS5

3

544

oo55

1

544

544

0

Doss

3

544

1.632

0

Do55

2

544

1_088

0

,i

u4

544

0

1

544

544

0

D055

09-01-2019

11-01-2019

09.01-2019

1

10

Do55

JMS SOLADM SET/ INFUS SET JMS THREE WAY BERBUNTUT TEGADERM 1622 FLOW CONTROLLER CIAVE CLAVE CONNECTOR CLAVE CONNECTOR CLAVE CONNECTOR TEGADERM 1624 NITRIL GLOVE NITRIL GLOVE NITRIL GLOVE MEDITAPE 1/2inch JMS( 300 ) MEDITAPE 1/2inchJMS( 300 )

710040

DO55

SOLADM SET/ INFUS SET

D05S

1

4

u4

0

Do55

1

9.213

9.213

0

DO55

1

9.213

9.213

0

Do55

1

22.243

22.243

0

DO55

1

5.989

5.989

0

DO55

1

88.625

88.625

0

DO55

1

21.313

21.313

0

DO55

2

21.313

42.626

0

Do55

1

21.313

oO55

I

2.803

2-803

0

Do55

100

843

84.300

0

D055

'100

843

84.300

0

DO55

-100

843

-84.300

0

D055

1

9.166

9.166

D055

1

9.166

9.166

0

DO55

I

75.625

75.625

0

710207

INFUSIoN SET WITH BURETTE lF-BR-o oo55

1

7s.625

75.625

0

710299

LINEAR BAG

1

59.606

59.606

0

710341

NASAL CANULLA PEDIATRIC ( 0206 )

1

8.250

8.250

0

lF-BR{

wlTHoUT SOLIDIFYING

A Do55

B

Do55

1

4.500

4.500

0

D055

6

1.423

8.538

0

0055

10

1.423

14.230

0 0

OXYGEN SUPPLYTUBING ( 0401 ) B-Mt Do55

05-01-2019

710473

DISP SYRINGE 3

06-01-2019

710473

07-01-20'19

710473

09-01-2019

710473

10-01-2019

710473

10-01-2019

710/.73

11-01-2019

710473

05-01-2019

710/41

06-01-2019

710481

07-01-2019

710441

0741-2019

0

0

710436

0941-20'19

0

710441

cc DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB

DO55

8

1.423

'11.384

DO55

6

1.423

8.538

0

DO55

5

1.423

7.'115

0

1.423

8.538

0

3

1.423

4.269

0

D055

20

250

5.000

0

DO55

10

250

2.500

0

DO55

10

250

2.500

0

250

250

0

D055 D055

DO55

1

Page J

ps Janruno t Pembuluh Da6h Ha6D6n Kir. -^ I .r'itirli, s nam"n Kav87, iripl, r.k.n.8arai i1420 --,/ i;lo. rb21t s5a1r11 (Hunt,ns) ru. tozlr 55a4130

ftlrned

ol8

by LAPORAN RA / Dato , 1201/2019 09-32 58

RINCIAN BIAYA SEMENTARA Pengirim

:

drsp/CAR/Paru/Anaudll

MUHAMMAD ANDRE AJ' TN.

Masuk

:

O4lO1l2O19 09:17.27

:

PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN

No.Kunjungan

:'190't04EE02R0027

Kota

:

MADIUN

Proses Masuk

:

RSCC

Jaminan

:01

Nama Dokter

:

POPPY S. ROEBIONO

Tanggal

Kode Yan/ltem Layanan

No MR

:

132305

Nama Pasien

:

Alamat

PRIBADI

Tarif

atv

Subtotal

Diskon

Umum 0941-2019

71c/,8',1

09{'r -2019

nMal

1G01-2019

71(N81

10-01-2019

71M41

10-01-2019 ,1-01-20',|9

710481

\-r1

-01 -20'l

I

06-01-2019 06-01-2019

710481

ALKOHOLSWAB ALKOHOLSWAA ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB

DO55

1

250

250

0

DO55

8

250

2-000

0

DO55

6

250

1.500

0

OO55

1

250

2fi

0

DO55

10

250

2.500

0

D055

8

250

2-000

0

0055

4

250

1.000

0

'1',t0521

TRG.SENSOSURGE STERIL GLOVE NO Dos5

4

29.976

0

710521

TRO-SENSOSURGE STERIL GLOVE NO D055

10

7AU 7AU

74.940

0

7.494

'14.988

0

7't0481

09{1-2019

710521

TRO-SENSoSURGE STERIL GLOVE No Dos5

044't-2019

711007

SURGICAL CLIPPER

090't -2019

711147

1'1-01-2019

7',t1147

11-01-2019

711158

09-0'1-201S

711393

BLADE MANOMETER LINE MANOMETERLINE NEBULIZER PAED SALTER '1'173

D055

1

76.863

76.863

0

D055

5

25.438

127.190

0

25.438

50.876

0

D055 D055

1

24.990

24.990

0

THREE WAY STOPCOCK 4624 BD BIAS, DO55

4

11.688

46.752

0

1

'11.688

11.688

0

4

4.496

17.9U

0

44.960

0

I

7't'1393

THREE WAY STOPCOCK 4624 BD BIAS, D055

0641-2019

711691

SUCTION CATH No.14

'1'1-01 -201

HOSPITECH HOSPITECH

D055

09i't -2019

71't69't

SUCTION CATH NO.14

DO55

10

4.496

0s-0't -2019

711698

CONECTING TUBE NO.7 EUROPLAST/ I D055

2

26.250

52.500

0

04{1-2019

71172',1

ONESCRUB 4 % lOO

'1

27

04-o't -2019

712242

Ecc

I

712242

ECG TAB ELECTRODE

11-01-2019

ML

_5N

27.500

0

D055

10

1.733

'17-330

0

DO55

10

'I

_733

17.330

0

712243

ECG ELECTRoDE NEoNATE PRE WIRE D055

1

36.094

36.0S4

0

-201 9

714089

SWIFEL ELBOW 15 F

DO55

1

59.606

59.606

0

09-01 -2019

714091

D055

1

97.350

97.350

0

05-01-2019

716079

Do55

1

43.312.500

43.312.500

0

2

57.475

'114.950

0

OO55

2

57.475

114.950

0

57.475

-57.475

0

1.760

7.UO

0

'11

-01 -20'l

DO55

24 RT 24

TAB ELECTRODE RT

09{1-2019

730007

3512 RESERVOTR BAG I L28'10 CoNTEGRA MEDTRONIC 20 MM GELOFUSIN INF 5OO ML GELOFUSIN INF 5OO ML GELOFUSIN INF 5OO ML

DO55

-1

0101-2019

730051

ADRENALIN (EPINEPHRINE) INJ 1 MG / oo55

4

054'l-2019

730051

ADRENALIN (EPINEPHRINE) INJ 1 MG / 9655

..-,$0't

0

1-2019

730007

05-o'l -2019

730007

OO55

'l

-760

14_080

0

5.280

0

064 r -20'19

730051

ADRENALIN (EPINEPHRINE) INJ 1 MG

/

D055

3

1.760

06{'l -2019

730051

ADRENALIN (EPINEPHRINE) INJ 1 MG

/ 0055

10

1.760

17.600

0

08-01-2019

730051

ADRENALIN (EPINEPHRINE) INJ 1 MG

i

-7

1-760

-12.320

0

1

54.994

54.994

0 0

09-0'l-201s

730065

0641-2019

730066

10-01-2019

730066

11-01-2019

730066

05-01-20'19

730067

0t01-20'19

730067

0G01-2019

730067

tNVtcLoT tNJ 25.000 lu / 5

ML LASIX INJ 20 MG/2 ML LASIX INJ 20 MGi2 ML MORPHINE INJ 10 MG MORPHINE INJ 10 MG 10 MG MORPHINE LASIX INJ 20 MG/2

'NJ

ML

Do55 D055 DOSS

10

15.196

'r51.960

DO55

-5

15-196

-75.980

0 0

OO5S

1

15-196

15.196

DO55

2

42.563

85-'126

0

OOSS

2

42.563

85.126

0

42.563

'127.689

0

DO55

J

.)

RS. Janlunq E P.mbuluh Da6h HaED.n Kit Jl. L.ten S. Pa@an Kav.87, Sllpr, J.k+rrr Ba.rt 11420 (021) 668,Itl {Hunung) Fir:(o21) 56a!130

page 4 of 8 Print€d by IAPORAN RS / Dal6 : lZOlZO.tg 09:32:5a

ftrp:

RINCIAN BIAYA SEMENTARA No MR

:

132305

Pengirim

dr. Sp/CAR/Paru/Anak/dll

Nama Pasien

:

MUHAMMAD ANORE AJ, TN.

Masuk

MlO1l2O19 09.17:27

Alamat

:

PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN

No.Kunjungan

190104EE02R0027

Kotia

:

MADIUN

Proses Masuk

RSCC

Jaminan

:01

Nama Dokter

POPPY S. ROEBIONO

Tanggal

Kode Yan/ltein Layanan

PRIBADI

otv

Tarif

Subtotal

Diskon

Umum 0s01-2019

7s0073

OTSU KCL 7.46% 25 ML

D055

2

4.029

1041-2019

730073

D055

2

oto1-2019

730078

OTSU KCL 7,46% 25 ML OTSU NACL 0.9 % . 25 ML

D055

6

0s01-2019

730078

OTSU NACL 0,9 % - 25 ML

D055

6

06-01-2019

730078

OTSU NACL 0,9

' 25 ML

D055

06-0'l-201s

730078

6

730078

D055

6

09-01-2019

730078

D055

6

'10-01-2019

730078

OTSU NACL 0,9 % - 25 ML OTSU NACL 0,9 % . 25 ML OTSU NACL 0,9 % . 25 ML OTSU NACL 0,9 % . 25 ML

D055

07-01-2019

D055

3

't0-01-2019

730078

OTSU NACL 0,9 % - 25 ML

D055

2

6.s31

13.062

0

11-O1-2019 '11-01-2019

730078

OTSU NACL 0,9

' 25 ML

D055

4

6.531

26.124

0

730078

OTSU NACL 0,9 % - 25 ML

D055

3

6.53't

'19.593

0

05{'t -2019

730079

OTSU MGSO4 20 25 ML

D055

2

4.'160

8.320

0

06-01-20'19

73008'1

OTSU WFI 25 ML

D055

3.575

17.87s

0

0901-2019

73008'r

OTSU WFI 25 ML

09-0'1-201I

730081

OTSU WFI 25 ML

O/O

O/O

8.058

0

4.O29

8.058

0

6.531

39.186

0

6.53't

39.186

0

6.53'1

32.655

0

6-531

39.'t 86

0

6.531

39.'186

0

6.531

39.186

0

19-593

0

D055

1

3.575

3.575

0

D055

b

3.57s

21.450

0

3.575

0

1041-2019

730081

OTSU WFI 25 ML

D055

1

3.575

11-01-20'19

730081

OTSU WFI 25 ML

3-575

3.575

0

I

D055

1

73008'l

OTSU WFI 25 ML

D055

3.575

10.725

0

'11-01-2019

730'163

VENTOLIN NEBULES 2,5 MG

D055

2

5.000

'10.000

0

0tu1-20'19

730252

CALCIUM GLUCONAS INJ

10 ML

D055

5

12.939

64.695

0

0641-2019

730252

CALCIUM GLUCONAS INJ 10% 10 ML

D055

3

12.939

38.817

0

I

730252

CALCIUM GLUCONAS INJ 10% 10 ML

D055

.,|

'12.939

-'12.939

0

,|

11-01-20't

1

'1

-0'l -201

1OON

0m1-2019

730373

OTSU NACL 0,9 % PIGGY BACK

1OO

ML D055

10.725

10.725

0

1041-2019

730373

OTSU NACL 0,9 % PIGGY BACK

1OO

ML D055

1

10.725

10.725

0

0

1-2019

730469

SEDACUM INJ 15 MG / 3 ML

D055

2

u.375

64.750

0

08{1-2019

730469

SEDACUM INJ 15 MG / 3 ML

D055

-2

34.375

s8.750

0

04-01-2019

730512

OXTERCIO INJ 750 MG

D055

12

58.988

707.856

0

05{1-20'19

7305'12

OXTERCID INJ 750 MG

D055

4

58.988

235.952

0

o7-01-2019

730s12

OXTERCID INJ 750 MG

D055

2

58.988

117.976

0

05-0't-20'1s

730525

ECRON INJ 10 MG

D055

2

133.646

267.292

0

05-01-20't9

730529

ECRON INJ

MG

D055

4

133.646

534.584

0

05-01-201S

730529

ECRON INJ 10 MG

D055

2

133.646

267.292

0

08-01-2019

730529

ECRON INJ 10 MG

D055

-1

'133.646

-133.646

0

D055

3

257.125

771.375

0

257.125

514.250

0

1O

05-01-2019

730589

INOVAD INJ 10 MG/10 ML

05-01-2019

730589

INOVAD INJ 10 MG/10 ML

D055

2

06-01-2019

730s89

INOVAD INJ

1O

MG/10 ML

D055

3

257.125

771.375

0

06-01-2019

730589

INOVAD INJ

1O

MG/10 ML

D055

3

257.'t25

771.375

0

07-o't-2019

730589

INOVAD INJ '10 MG/10 ML

D055

257.125

514.250

0

08-01-2019

730589

INOVAD INJ

07-o t-2019

730604

1O

MG/l0 ML

PROSOGAN INJ 30 MG

D055

o055

4

257 _125

2

'1'15.050

-1.028.500

0

230.'100

0

Jantunq E Pembuluh Oa6h HaED.n Krra /^ RS.L.tien S. Parman Xav,87, Stipi,Jalana Ean|t lr42o _/ Jl Icrp: "-/ {021) 563tlll {Huhtrng) Fd: (02,t,5634,t30

pag6 5 of 8 Printad by LAPORAN RS / Dat6 : 1Z0il2019 O9:32:s8

RINCIAN BIAYA SEMENTARA No MR

:

132305

Pengirim

;

dr. Sp/CAFYPaT/Anak/dll

Nama Pasien

:

MUHAMMAD ANDRE AJ, TN.

Masuk

i

MlO1l2O19 09,'17:27

Alamat

:

PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN

No.Kunjungan

;

'190 t

Kota

:

MADIUN

Proses Masuk

:

RSCC

Jaminan

:

01

Nama Dokter

:

POPPY S. ROEBIONO

Tanggal

Kode Yan/ltem Latranan

PRIBADI

otv

04EE02R0027

Tarit

Subtotal

Oiskon

Umum 09-01-2019

7306M

10{1-2019

730604

11{1-2019

730604

06-01-2019

730759

0m1-2019

730759

'41-2019

730759

l\rc MG PROSOGAN INJ 30 MG PROSoGAN INJ 30

PROSoGAN INJ 30

ML oNDANCETRON INJ 4 MG / 2 ML ONDANCETRON INJ 4 MG / 2 ML ONDANCETRON INJ 4 MG / 2 ML ONDANCETRON INJ 4 MG / 2

D055

'l

115.050

115.050

0

OOSS

1

115.050

115.050

0

ooss

1

115.050

115.050

0

D05b

2

1.338

2.676

0

D055

2

1.338

2.676

0

Do55

2

,'.338

2.676

0

1.338

-2.676

0

1

2.431

2.431

0

1

't2.155

12.155

0

12.155

08{1-2019

730759

05-01-2019

730915

07{1-2019

730950

ASAM TRANEKSAMAT INJ 500 MG / 5 M OO55 WIDA D5 - 1/4 NS D055

0901-2019

730950

DO5S

1

12.155

0

06-01-2019

730951

DO55

1

8.013

8.013

0

DO55

1

8.013

8.013

0

10-01-2019

730951

1141-2019

730951

05{'1-2019

730962

0

1-2019

730962

06{1-2019

730962

08-01-2019

730962

0441-2019

730972

06-01-2019

730975

08{1-2019

730975

0M1-20't9

730992

0G01-2019

730992

-01-20'19

730992

08-01-2019

730992

09-01-2019

73'1000

11-O1-2019

731000

11-01-20't9

731000

05-01-20'19

731042

06{1-2019

731125

07-o1-2019

731125

09{1-2019

732399

0s01-20't9

732429

1G0't -2019

733112

1141-20'19

733't't2

10-01-2019

733485

11-O't-2019

733485

06-01-2019

73/-216

09-01-2019

73r'.216

10-01-2019

73r'216

11-O',t-2019

734216

I

734249

09-0'1 -20'1

iTM WIDA D5 - 1/4 NS /TM

ML OTSU NACL 0,9 7o INF 5O0 ML oTSU NACL 0,9 Yo INF 500 ML OTSU NACL 0,9 % INF 500

DO55

Do55

ML D055 PARACETAMOL INFUS 1 cR / 100 ML DO55 PARACETAMOL INFUS '1 GR / '100 ML OO5S PARACETAMOL INFUS I GR/ 100 ML DOsE MINOSEP GARGLE 0,2% 60 ML DO55 KEToROLAC INJ 30 MG/ML D055 KETOROLAC INJ 30 MG/ML DO55 RANITIDIN INJ 50 MG / 2 ML DO55 RANITIDIN INJ 50 MG / 2 I\,IL Do55 RANITIDIN INJ 50 MG / 2 ML D055 RANITIDIN INJ 50 MG / 2 ML D055 CEFTRIAXoNE INJ 1GR Do55 CEFTRIAXONE INJ 1 GR DO55 CEFTRIAXoNE INJ 1 GR D055 PHYToMENADION INJ 10 MG / ML Do55 CEFUROXIM INJ 750 MG DO55 CEFUROXIM INJ 750 MG DO55 AQUAPACK 340 HUDSON DO55 CUSTODIOL INF 1000 ML DO5S LASIX TAB 40 MG Do55 LASIX TAB 40 MG DO55 THROMBO ASPILETS TAB 80 MG DO55 THROMBOASPILETS TAB 80 MG DO55 SPIRONOLACTONE TAB 25 MG DO55 SPIRONOLACTONE TAB 25 MG DO55 SPIRONOLACTONE TAB 25 MG DOSs SPIRONOLACTONE TAB 25 MG DOS5 FUROSEMIDE TAB 40 MG Do55 PARACEIAMOL INFUS 1 GR / '100

1

8.013

8.0'i3

0

2

'14.513

29.026

0

3

14.513

43.539

0

3

'14.513

43.539

0

2

14.513

29.026

0

1

20.900

20.900

0

1

1.306

1.306

0

-1

1.306

-1.30,6

0

2

'1.444

2.888

0

2

't.444

2.888

0

2

1.444

2.888

0

1.444

-2.888

0

2

5-604

11.204

0

2

5.604

11.208

0

2

5.604

11.208

0

1

5.363

5.363

0

4

37.469

149.876

0

4

37-469

-'t49.876

0

56.513

56.513

0

,1

0

4

2.102.760

2

5.355

10.7'10

'1.040

0

6

5.355

32.130

0

8.4

,|

556

556

0

3

556

't.668

0

2

244

488

0

1

244

244

0

1

244

244

0

3

244

732

0

2

96

't92

0

,...\ / --.2

RS. Jantunq & Pemburuh Danh H.ED.n Xrt S. Parman K.v.07, sirpi. Jatarr. B.,dr tr42o Llp:(021) 553'll'tt 0ruoring, Far lo2i) 5€a4130

Jr L.licn

page 6 of 8 Print€d by LAPoRAN RS / Dare : 1201/2018 0s:32:5a

RINCIAN BIAYA SEMENTARA No MR

:

132305

Pengirim

d.

Nama Pasien

:

MUHAMMAD ANDRE AJ, TN.

Masuk

0d,IO1DO'19 09,17:27

Alamat

:

PERUM BUMI MAS U3 01/04 MOJOREJO. TAMAN MADIUN

No. Kunjungan

1901 04EE02R0027

Kota

:

MADIUN

Proses Masuk

RSCC

Jaminan

:01

Nama Doliter

POPPY S. ROEBIONO

Tanggal

Kode Yan/ltem Layanan

PRIBADI

otv

Sp/CARYPaT/Analddll

Tarif

Subtotal

Diskon

Umum 09{1-2019

7U345 73/345

0{1-201s

07-o',-2019

CAPTOPRIL TAB 12,5 MG

D055

'100

900

0

D055

100

300

0

734345

CAPTOPRIL TAB 12,5 MG CAPTOPRIL TAB ,I2,5 MG

D055

3

100

300

0

11-01-2019

73{345

CAPTOPRIL TAB 12,5 MG

10

'100

I

D055

1.000

0

734727

FLEET ENEMA

D055

,|

44.688

44.688

0

04-01-2019

900091

REHAB FASE

1

o050

1

110.000

110.000

0

1

't

04-01 -20't

07-01-2019

900091

REHAB FASE

D050

1

1'10.000

110.000

0

08{1-2019

9000s8

FISIOTERAPI

D050

1

80.000

80.000

0

09-01-2019

900098

FISIOTERAPI

D050

,|

80.000

80.000

0

't0.01-2019

900098

FISIOTERAPI

D050

1

80.000

80.000

0

05{1-2019

900r/0

05{1-20'19

901021

Pemasangan dan Tata Laksana Ventilato. s061 WES Rasteily Prosedure + Contegta D099

05-01-2019

751149

06-01-2019

751149

CoMPLETE BLOOD CoUNT(CBC:Hb,Ht, D054 CoMPLETE BLOOD COUNT(CBC:Hb,Ht, D054

1 1

8.500.000 203_4sO.000

8.500.000

0

203.450.000

0

1

85-000

85.000

0

1

85.000

85.000

0 0

07-01-2019

751149

COMPLETE BLoOD COUNT(CBC:Hb,HI,

D054

1

85.000

85.000

0&01-2019

751150

CBC + Difi.Count (Hitung Jenis)

D054

1

100.000

100.000

0

05{1-2019

751205

PT

o054

1

60.000

60.000

0

06{1-2019

751205

PT

D054

1

60.000

60.000

0

07-01-2019

751205

PT

D054

1

60-000

60.000

0

10{1-2019

751205

PT

D054

,|

60-000

60.000

0

11-01-2019

751205

PT

D054

1

60.000

60.000

0 0

05-01-201S

751206

APTT

D054

1

65-000

65.000

06-01-2019

751206

APTT

D054

1

65.000

65_000

0

07{1-2019

751206

APTT

0054

1

65.000

65.000

0

09{1-2019

751206

APTT

D054

1

65.000

65.000

0

09-01-20't 9

751206

APTT

D054

,|

65.000

65.000

0

1G01-2019

75'1206

APTT

0054

I

65.000

65.000

0

11-01-2019

751206

APTT

0054

1

65.000

65.000

0

05-0't-2019

751207

TT

D054

,|

60.000

60.000

0

07-01-2019

751207

TT

D054

I

60.000

60.000

0

0$01-2019

751204

FIBRINOGEN

D054

I

100_000

100.000

0

06{'t-2019

75120A

FIBRINOGEN

D054

1

100.000

100.000

0

07-01-20',t9

751204

FIBRINOGEN

D054

1

100.000

't

00.000

0

0t0'1-2019

752102

ALBUMIN

DO

1

30.000

30.000

0

05-01-2019

752401

UREUM

D054

,|

25.000

25.000

0

05-01-2019

752402

CREATININ

D054

1

25.000

25.000

0

05-01-2019

752404

OSMOLALITAS SERUM

D054

1

50.000

50.000

0

10-01-2019

752621

GD Sowaktu POCT

D054

1

25.000

25.000

0

10-01-2019

752621

GD Sewaktu POCT

D054

1

25.000

25.000

0

'1041-2019

752621

GD Setlraktu POCT

D054

1

25.000

25.000

0

10{1-201S

752621

GD S6waktu POCT

,|

25.000

25.000

0

D054

,,-\ -,/ /

RS. Jantunq A Pembutuh OaEh HaEban Kira Jl. Le{en s. Pamah lGvl/, sttpt, JEt rt BaEr 1t4,au Ierp: {o2i) 5631111 thu.rlnqt Fu:1021t 56a.t130

pagc 7 of 8 Printed by LAPORAN RS / Dare : 12y01/20.19 09:32:58

RINCIAN BIAYA SEMENTARA

NoMR Nama

Pasien

:

132305

Pengi.im

dr Sp/CAR/ParuiAnaUdll

:

MUHAMMADANDRE AJ, TN.

Masuk

O4lO1t2O19 09:17.27

No.Kunjungan

190104EE02R0027

Proses Masuk

RSCC

Nama Dokter

POPPY S. ROEBIONO

Alamat : PERUM BUMI MAS U3 01/04 MOJOREJO, Kota : MADIUN Jaminan : 01 PRIBAD| Tanggal

TAMAN MADTUN

Kode Yan/ltem Layanan

otv

Tarif

Subtotal

Diskon

Umum 05-01-2019

752701

ANALISA GAS DARAH

D054

145.000

145.000

0

05-01-2019

752701

ANALISA GAS DARAH

D054

1

145.000

145.000

0

0s01-2019

752701

ANALISA GAS DARAH

D054

1

145.000

145.000

0

06-01-2019

752701

ANALISA GAS DARAH

D054

1

145.000

'145.000

0

06-01-2019

752701

ANALISA GAS DARAH

D054

1

'145.000

145-000

0

i-01-2019

752701

ANALISA GAS DARAH

D0g

1

145.000

'145.000

0

752701

ANALISA GAS DARAH

D054

1

'145.000

145-000

0

07-o1-20 t9

752701

ANALISA GAS DARAH

D054

,1

145.000

145.000

0

08-0't-2019

752701

ANALISA GAS DARAH

D054

1

'!45.000

145.000

0

08-01-2019

752704

CALSIUM TOTAL

D054

1

35.000

s5.000

0

'nt-o1-2019

,|

10-01-20'19

752704

CALSIUM TOTAL

D054

1

35.000

35.000

0

11-0'1-2019

752704

CALSIUM TOTAL

D054

1

35.000

3s.000

0

08-01-2019

752707

MAGNESIUM

D054

1

35.000

35.000

0

10-01-2019

752707

MAGNESIUIVI

D054

1

35.000

35.000

0

'11-01-2019

752707

MAGNESIUM

D054

1

35.000

35.000

0

05-01-2019

752718

Analisa Gas Darah

D0g

1

145.000

145.000

0

0H1-2019

752718

Analisa Gas Darah

D054

1

145.000

145.000

0

06-01-2019

752718

Analisa Gas Darah

D054

1

145.000

145_000

0

08-0'1-2019

752720

09,01-2019

752720

10-01-2019

752720

11-01-2019

752720

Cl Cl Na, K, Cl Na, K, Cl

01-2019

753602

CRP

E-01-2019

753629

PROCALCITONIN

09-01-2019

756101

URINE RUTIN

04-01-2019

758'130

Biaya pengolahan darah

04-01-2019

758130

Biaya pengolahan darah

04-01-2019

754134

PMI/ PRC

05-0'1-2019

758135

PA/llI/

FFP

D054

05-01-20'19

758136

PMI/AHF

04-01-2019

758138

PMI/TC

04-01-2019

758'138

PMI/TC

D054

05-01-20'19

900043

THORAX PAJAP

Na, K,

(Natrium, Kalium, Chlorida)

D054

1

75.000

75.000

0

Na, K,

(Natrium, Kalium, Chlorida)

D054

'l

75.000

75.000

0

(Natrium, Kalium, Chlorida)

D054

1

75.000

75.000

0

(Natrium, Kalium, Chlorida)

D054

1

75.000

75.000

0

D054

1

145.000

'145.000

0

D054

I

455.000

455-000

0

D054

'|

30.000

30.000

0

D054

3

70.000

210.000

0

D054

't5

70-000

1.050.000

0

D054

3

535.000

1.605.000

0

535.000

2.675.000

0

06-01-2019

900043

THORAX PA./AP

07-01-2019

900043

THORAX PA/AP

D054

4

535_000

2.140-000

0

D054

3

535.000

1.605.000

0

535.000

'1.605.000

0

1

160,000

'160.000

0

,|

160.000

160.000

0

'160.000

160.000

0

907S

1

,,-t / --,/

RS, J.nlu.o A P.mbuluh O.r.h H.ED.. Kit Jl. LctiGn S. Pirrnan Xav87, Stilr. J.klria AlEt 1la2o lerp: lo2l, s6atlt,t tHunfng, fu: tt 2t, !ir,r413r,

I

Pago 8 of Priflted by LAPOMN RS / Date : 1ZO1l2019 09:32:50

RINCIAN BIAYA SEMENTARA No MR

:

132305

Pengirim

dr. Sp/CAFYPatu/Analddll

Nama Pasien

:

MUHAMMAD ANDRE AJ, TN.

Masuk

O4lO1l2O19 09:17:27

Alamat

:

PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN

No.Kunjungan

'190104EE02R0027

Kota

:

MADIUN

Proses Masuk

RSCC

Jaminan

:

O,I

Nama Dokter

POPPY S. ROEBIONO

Tanggal

Kode Yan/ltom Lat6nan

PRIBADI

atv

Tarif

Subtotal

Diskon

[Jmum

08{1-2019 12-01-2019

900043

THORAX PfuAP

1

Bill Umum

160.000

160.000

302.742.975

Bill Non Askes

0

Bill Tslpon

0

Jumlah Tarif

302.742.975

Diskon

0

t,rl fd

*

Total Tagihan

Deposit

302.742.975

{

Sisa Tagihan

CATATAN

0

PERINCIAN INI TIDAK BERLAKU SEBAGAI TANDA BUKTI PEMBAYARAN

&'t"'

302.742.975

402 -/

'i2 97e

6C)

(

:A8 6u- -:Le rl

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&o

ztlb ,4,'/ -/6E

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.HUHAI,II.IAO

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ANDRE AJ

,

Ke:

1

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1

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Uang banyaknya The amount of

3r+8,

Pasien/No.Rl,l

t'a gG) s.9

Patient/HR

3g

No.

a :

tluHAt"tftAD ANoRE AJ

3UJ

TN.

/

1

13?305

Ho Kunjungan: 190104EE0?R00?7

Untuk ln payment of

FE

,

/

N9

Billins:

19011?EAo60OOO4

1

:

Pembayaran Uang Huka Biaya Pelayanan Rumah Sakit

lv

cix

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Pasien/No"Rt4 Patient/MR No.

'iEs1

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oali .c.E;

DEBIT

U F=6

I,IUHAIIT,IAD ANDRE

AJ,

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TN .

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15?305 No. Kunj ungan :19o102EE02Ro1?4

I1UHAI1MAO ANORE

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'Pembayaran Pelayanan PoLI EKSEKUT IF No Tagi han : 190102800001^4

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