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    Vee Sagala
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    This document contains forms related to laboratory examination requests and results from the Barong Tongkok Public Health Center (UPT Puskesmas Barong Tongkok) in West Kutai Regency, Indonesia. The first form is a laboratory examination request form containing fields for patient information like name, age, gender, address and symptoms. It also contains tables to select hematology, clinical chemistry, microbiology, parasitology and serology tests. The second form is a referral form containing similar patient and test selection fields. The third form displays the laboratory results for a referred patient, listing the examination type, results, and reference values. It includes results for hematology, urinalysis, clinical

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    Formulir pemeriksaan laboratorium

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    This document contains forms related to laboratory examination requests and results from the Barong Tongkok Public Health Center (UPT Puskesmas Barong Tongkok) in West Kutai Regency, Indonesia. The first form is a laboratory examination request form containing fields for patient information like name, age, gender, address and symptoms. It also contains tables to select hematology, clinical chemistry, microbiology, parasitology and serology tests. The second form is a referral form containing similar patient and test selection fields. The third form displays the laboratory results for a referred patient, listing the examination type, results, and reference values. It includes results for hematology, urinalysis, clinical

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    10 views4 pages

    Form Lab New

    Uploaded by

    Vee Sagala
    This document contains forms related to laboratory examination requests and results from the Barong Tongkok Public Health Center (UPT Puskesmas Barong Tongkok) in West Kutai Regency, Indonesia. The first form is a laboratory examination request form containing fields for patient information like name, age, gender, address and symptoms. It also contains tables to select hematology, clinical chemistry, microbiology, parasitology and serology tests. The second form is a referral form containing similar patient and test selection fields. The third form displays the laboratory results for a referred patient, listing the examination type, results, and reference values. It includes results for hematology, urinalysis, clinical

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 4

    PEMERINTAH KABUPATEN KUTAI BARAT

    UPT.PUSKESMAS BARONG TONGKOK


    JL. R.A. Kartini RT.III Barong Tongkok
    FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM
    Pasien :
    - Nomor Register
    - Nama
    - Umur
    - Jenis Kelamin
    - Alamat

    Gejala Penyakit :
    : ...........................
    :............................
    :............................
    :............................
    :............................

    No

    Jenis Pemeriksaan

    Pengobatan :

    No

    HEMATOLOGI
    1
    2
    3
    4
    5
    6
    7

    Hemoglobin (Hb)
    Hematokrit
    eritrosit
    Trombosit
    Lekosit
    E/B/M
    MCV,MCH,MCHC

    1
    2
    3
    4
    5
    6
    7
    9
    10

    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12

    URINALISA

    11

    Makroskopis

    12

    - Warna
    - Kejernihan

    13

    PH
    Berat Jenis
    Protein
    Glukosa
    Bilirubin
    Urobilinogen
    Keton
    Nitrit
    Lekosit
    Eritrosit
    Sedimen

    Jenis Pemeriksaan

    No

    KIMIA KLINIK

    Spesimen
    Jenis
    :..............
    Asal Bahan :..............
    Tgl/jam pengambilan sp :.......
    Petugas : ...........................

    14
    15
    16

    Glukosa
    GDP
    GD2PP
    Protein
    Albumin
    Bilirubin Total
    Bilirubin Direk
    SGOT
    SGPT
    Asam Urat
    Ureum / BUN
    Kreatinin
    Trigliserida
    Kolesterol Total
    Kolesterol HDL
    Kolesterol LDL

    Jenis Pemeriksaan
    MIKROBIOLOGI &
    PARASITOLOGI

    1
    2
    3

    Malaria
    Filaria
    Lepra

    SEROLOGI

    1
    2
    3
    4
    5

    Golongan Darah
    WIDAL
    HBsAg
    HIV
    Dengue
    Lain-lain :

    ................,........,.........
    Dokter / Pengirim

    PEMERINTAH KABUPATEN KUTAI BARAT

    UPT.PUSKESMAS BARONG TONGKOK


    JL. R.A. Kartini RT.III Barong Tongkok
    FORMULIR PERMINTAAN RUJUKAN PEMERIKSAAN LABORATORIUM
    Pasien / Spesimen Rujukan
    Pasien
    Nomor Register
    Nama
    Umur
    Jenis Kelamin
    Alamat

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

    No

    Jenis Pemeriksaan

    Gejala Penyakit :

    Pengobatan :

    No

    HEMATOLOGI
    1
    2
    3
    4
    5
    6
    7
    8
    9

    Hemoglobin (Hb)
    Hematokrit
    eritrosit
    Trombosit
    Lekosit
    E/B/M
    MCV,MCH,MCHC
    Masa Perdarahan
    Masa Pembekuan
    URINALISA

    Makroskopis
    - Warna
    - Kejernihan

    3
    4
    5
    6
    7
    8
    9
    10
    11
    12

    PH
    Berat Jenis
    Protein
    Glukosa
    Bilirubin
    Urobilinogen
    Keton
    Nitrit
    Lekosit
    Eritrosit
    Sedimen

    Jenis Pemeriksaan

    No

    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12
    13
    15
    16

    Glukosa
    GDP
    GD2PP
    Protein
    Albumin
    Bilirubin Total
    Bilirubin Direk
    SGOT
    SGPT
    Asam Urat
    Ureum / BUN
    Kreatinin
    Trigliserida
    Kolesterol Total
    Kolesterol HDL
    Kolesterol LDL

    Jenis Pemeriksaan
    MIKROBIOLOGI &
    PARASITOLOGI

    KIMIA KLINIK

    14

    Spesimen
    Jenis
    :..............
    Asal Bahan :..............
    Tgl/jam pengambilan sp :.......
    Petugas : ...........................

    1
    2
    3

    Malaria
    Filaria
    Lepra

    SEROLOGI
    1
    2
    3
    4
    5
    6

    Golongan Darah
    WIDAL
    HBsAg
    HIV
    Dengue
    Lain-lain :

    ................,........,.........
    Dokter / Pengirim

    PEMERINTAH KABUPATEN KUTAI BARAT

    UPT.PUSKESMAS BARONG TONGKOK


    JL. R.A. Kartini RT.III Barong Tongkok
    FORMULIR HASIL PEMERIKSAAN LABORATORIUM
    Pasien / Spesimen Rujukan
    Dokter Pengirim
    Pasien
    Nomor Register
    Nama
    Umur
    Jenis Kelamin
    Alamat
    No
    .

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

    JENIS PEMERIKSAAN

    HASIL

    Spesimen
    Jenis
    :..............
    Asal Bahan :..............
    Tgl/jam pengambilan sp :..........
    Tgl/ jam pemeriksaan :...........

    NILAI
    RUJUKAN

    No.

    JENIS PEMERIKSAAN

    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15
    16

    KIMIA KLINIK
    GDS
    GDP
    GD2PP
    Total Protein
    Albumin
    Bilirubin Total
    Bilirubin Direk
    SGOT
    SGPT
    Asam Urat
    Ureum/ BUN
    Kreatinin
    Trigliserida
    Kolesterol Total
    Kolesterol HDL
    Kolesterol LDL

    HEMATOLOGI
    1
    2
    3
    4
    5
    6
    7
    8
    9

    Hemoglobin (Hb)
    Hematokrit
    Eritrosit
    Trombosit
    Lekosit
    E/B/M
    MCV/MCH/MCHC
    Masa Perdarahan
    Masa Pembekuan
    URINALISA

    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12

    Makroskopis
    - Warna
    - Kejernihan
    PH
    Berat Jenis
    Protein
    Glukosa
    Bilirubin
    Urobilinogen
    Keton
    Nitrit
    Lekosit
    Eritrosit
    Sedimen

    HASIL

    MIKROBIOLOGI &
    PARASITOLOGI
    1

    2
    3
    4
    5

    Malaria

    Hasil
    Stadium
    Spesies

    RDT
    Filaria
    Lepra
    BTA

    IMUNOLOGI
    1
    2
    3
    4
    5

    Golongan Darah
    WIDAL
    HBsAg
    HIV
    Dengue

    Lain-lain ::

    ........, ...................
    Dokter

    Pemeriksa,

    NILAI
    RUJUKAN

    (dr.)

    (Ahli Teknologi Laboratorium Medik)

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