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Dicetak Oleh : muchlis, Sabtu, 09 April 2016, 08:45:22
RS MITRA MEDIKA
JL. HOS COKROAMINOTO no.98 BONDOWOSO - JAWA TIMUR Telp: 0332,421981

Fax:

RINCIAN BIAYA RAWAT INAP PASIEN PERUM PERHUTANI KPH BONDOWOSO

: PraBilling
Status
:
Tanggal
No. Medical Record : 00-02-93-43
Tanggal Rawat : 04/04/2016 - 08/04/2016

No. Transaksi : 160404-0042

Penjamin
:PERUM PERHUTANI KPH BONDOWOSO
Nama Pasien
: BAMBANG S., TN
Dr Pen Jawab : Yahya Amar, Dr. Sp. PD
No #

Layanan

Biaya Tunai

By Jaminan

0
0
0
0

200,000
200,000
200,000
200,000

800,000

Team Perawat IGD 10.00

15,000

2. 04/04/16 TARIF DOKTER IGD

Adkhiatul, dr

1.00

60,000

3. 04/04/16 SpO2 RJ

Team Perawat IGD

1.00

62,500

4. 04/04/16 Ambil Darah

Team Perawat IGD

1.00

31,250

5. 04/04/16 Injeksi/Intramusculer/Intracutan/SCTeam Perawat

IGD
1.00

45,000

6. 04/04/16 Pasang Kateter IGD

Team Perawat IGD

1.00

91,250

7. 04/04/16 Observasi <6 jam

Team Perawat IGD

1.00

46,250

8. 04/04/16 Pasang Venflon Infus

Team Perawat IGD

1.00

56,250

9. 04/04/16 BS Stik IGD

Team Perawat IGD

1.00

18,750

10. 04/04/16 ECG - IGD

Team Perawat IGD

1.00

81,250

11. 04/04/16 ECG - IGD

Team Perawat IGD

1.00

81,250

12. 04/04/16 PASANG O2

Team Perawat IGD

1.00

31,250

13. 04/04/16 Konsul Dokter Spesialis

per-telepon

Nur Wahyudi.,
Dr. Sp JP

1.00

75,000

695,000

Kamar / Ruang Perawatan :

1. 04/04/16 TULIP
2. 05/04/16 TULIP
3. 06/04/16 TULIP
4. 07/04/16 TULIP
Sub Total

Tindakan :
INSTALASI GAWAT DARURAT
1. 04/04/16 GAS O2 PER KG/CM2

Sub Total :
TULIP
1. 04/04/16 Buka Kateter

Team Perawat RI

1.00

42,188

2. 04/04/16 Observasi < 6 Jam

Team Perawat RI

1.00

42,188

3. 04/04/16 Partial Care (4-6 Jam/24

Jam)

Team Perawat RI

1.00

35,156

4. 04/04/16 Pasang O2 RI

Team Perawat RI

1.00

42,188

5. 04/04/16 SpO2

Team Perawat RI

1.00

75,000

6. 04/04/16 Visite Dokter Spesialis

Yahya Amar, Dr.

Sp. PD

1.00

150,000

7. 04/04/16 PAKET KEBERSIHAN RUANGAN & Team Kebersihan

LOUNDRE

1.00

75,000

8. 05/04/16 Barang Habis Pakai

RUMAH SAKIT

1.00

25,000

9. 05/04/16 Materai

RUMAH SAKIT

1.00

7,500

10. 05/04/16 Observasi < 6 Jam

Team Perawat RI

1.00

42,188

11. 05/04/16 Partial Care (4-6 Jam/24

Jam)

Team Perawat RI

1.00

35,156

12. 05/04/16 Visite Dokter Spesialis

Yahya Amar, Dr.

Sp. PD

1.00

150,000

Hal. 2 dari 4

Rincian ke : Perusahaan / Asuransi

Tindakan :
TULIP
13. 06/04/16 Observasi < 6 Jam

Team Perawat RI

1.00

42,188

14. 06/04/16 Partial Care (4-6 Jam/24

Jam)

Team Perawat RI

1.00

35,156

15. 06/04/16 Visite Dokter Spesialis

Yahya Amar, Dr.

Sp. PD

1.00

150,000

16. 07/04/16 GAS O2 PER PSI RI

RUMAH SAKIT

200,000

17. 07/04/16 Observasi < 6 Jam

Team Perawat RI

1.00

42,188

18. 07/04/16 Partial Care (4-6 Jam/24

Jam)

Team Perawat RI

1.00

35,156

19. 07/04/16 Visite Dokter Spesialis

Yahya Amar, Dr.

Sp. PD

1.00

150,000

20. 07/04/16 PAKET PELAYANAN GIZI 4

Team Gizi

1.00

140,000

1,516,252

Sub Total :
LABORATORIUM
1. 04/04/16 Creatinine

Adkhiatul, dr

1.00

23,750

2. 04/04/16 Asam Urat

Adkhiatul, dr

1.00

25,000

3. 04/04/16 BUN

Adkhiatul, dr

1.00

23,750

4. 04/04/16 SGOT

Adkhiatul, dr

1.00

23,750

5. 04/04/16 SGPT

Adkhiatul, dr

1.00

23,750

6. 04/04/16 Darah Lengkap

Adkhiatul, dr

1.00

60,000

7. 04/04/16 CK-MB

Yahya Amar, Dr.

Sp. PD

1.00

220,000

8. 04/04/16 Troponin I

Yahya Amar, Dr.

Sp. PD

1.00

106,250

9. 04/04/16 Cholesterol Total

Adkhiatul, dr

1.00

20,000

10. 04/04/16 Urine Lengkap

Yahya Amar, Dr.

Sp. PD

1.00

37,500

11. 07/04/16 Cholesterol Total

Yahya Amar, Dr.

Sp. PD

1.00

20,000

583,750

45,000

45,000

179,852

Sub Total :
Pemakaian Obat :
TULIP
1. 04/04/16 PAKET RUANGAN
Sub Total

1.00
:

Biaya Resep :
1. 04/04/16

A160400137
INTRAFIX SAFESET
VENFLON NO 20
URINE BAG
FOLLEY CATH GOLDRUSCH NO.16
HANSAPLAST SILVER CARE
AQUABIDEST 25 ML
HANDSCOON STERIL MAXTER 7
OXYFLOW DWS
SPUIT 10 CC TERUMO
SPUIT 3 CC TERUMO
ULCERANIN INJ
FUROSEMIDE INJ
RING AS SP 500 ML

1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
3.00
1.00
1.00
1.00

Hal. 3 dari 4

Rincian ke : Perusahaan / Asuransi

Biaya Resep :
2. 04/04/16

D160400063

D160400064

D160400076

D160400087

D160400088

D160400104

D160400144

36,393

21,929

95,587

165,253

690,762

5.00
5.00
1.00
5.00
5.00

SIBERID 10
FUNDAMIN E TAB
SPUIT 3 CC TERUMO
SIMVASTATIN TAB 20MG
EXFORGE 10/160 MG
Sub Total

1.00
1.00
1.00
1.00
2.00
1.00

SIBERID 10
FASTOR 20 MG
FUNDAMIN E TAB
INFUSAN RL SP
INFUSAN D5 500 SP
EXFORGE 10/160 MG
8. 07/04/16

75,430

1.00

EXFORGE 10/160 MG
7. 06/04/16

2.00

TWYNSTA 40/5
6. 05/04/16

5,318

1.00
1.00
1.00
1.00
1.00
1.00

TWYNSTA 40/5
FASTOR 20 MG
FUNDAMIN E TAB
INFUSAN D5 500 SP
INFUSAN RL SP
SIBERID 10
5. 05/04/16

0
1.00

SPUIT 10 CC TERUMO
4. 05/04/16

111,000

2.00
1.00
2.00
1.00
2.00
1.00

INFUSAN D5 500 SP
SIBERID 10
TWYNSTA 40/5
FASTOR 20 MG
FUNDAMIN E TAB
INFUSAN RL SP
3. 04/04/16

Hal. 4 dari 4

Rincian ke : Perusahaan / Asuransi

Total Transaksi

Rp.

Biaya Administrasi

Rp.

0
0

4,330,764
43,308

Total Biaya

Rp.

4,374,072

Pengurangan :- Return Obat

- Discount

Rp.
Rp.

0
0

50,902
0

Total Biaya Setelah Return dan Discount

Rp.

4,323,170

Pembayaran : - Uang Muka

- Billing Partial

Rp.

Rp.

Saldo Pembayaran ( sblm pembulatan )

Pembulatan

Rp.
Rp.

0
0

4,323,170
0

Saldo Pembayaran ( stlh pembulatan )

Rp.

4,323,170

TERBILANG : # EMPAT JUTA TIGA RATUS DUA PULUH TIGA

RUPIAH #

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RS MITRA MEDIKA