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    Form Lab 1

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    purianggria
    This document contains a laboratory test request form from the Jekanraya Public Health Center in Palangka Raya. The form collects information about the patient such as name, age, gender, address and symptoms. It then lists various types of laboratory tests that can be requested under categories like hematology, urinalysis, clinical chemistry, microbiology, parasitology and immunology. Fields are provided to write the test results. The bottom of the form states the normal reference ranges for test results.

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    Form Lab 1

    Uploaded by

    purianggria
    9 views8 pages
    This document contains a laboratory test request form from the Jekanraya Public Health Center in Palangka Raya. The form collects information about the patient such as name, age, gender, address and symptoms. It then lists various types of laboratory tests that can be requested under categories like hematology, urinalysis, clinical chemistry, microbiology, parasitology and immunology. Fields are provided to write the test results. The bottom of the form states the normal reference ranges for test results.

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    This document contains a laboratory test request form from the Jekanraya Public Health Center in Palangka Raya. The form collects information about the patient such as name, age, gender, address and symptoms. It then lists various types of laboratory tests that can be requested under categories like hematology, urinalysis, clinical chemistry, microbiology, parasitology and immunology. Fields are provided to write the test results. The bottom of the form states the normal reference ranges for test results.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    9 views8 pages

    Form Lab 1

    Uploaded by

    purianggria
    This document contains a laboratory test request form from the Jekanraya Public Health Center in Palangka Raya. The form collects information about the patient such as name, age, gender, address and symptoms. It then lists various types of laboratory tests that can be requested under categories like hematology, urinalysis, clinical chemistry, microbiology, parasitology and immunology. Fields are provided to write the test results. The bottom of the form states the normal reference ranges for test results.

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    of 8

    PEMERINTAH KOTA PALANGKA RAYA

    DINAS KESEHATAN
    UPT PUSKESMAS JEKANRAYA
    JalanTjilik Riwut Km 10,5 Palangka Raya Kode Pos 73112
    Email : puskesmasjekanraya@gmail.com

    FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM

    Pasien : Gejala Penyakit : Spesimen


    Nomor Register : Jenis
    Nama : Asal Bahan
    Tgl/jam
    pengambilan
    Umur : Pengobatan :
    sp
    Jenis Kelamin : Petugas
    Alamat :

    NO. JENIS PEMERIKSAAN NO. JENIS PEMERIKSAAN NO.

    HEMATOLOGI
    KIMIA KLINIK
    1. Hemoglobin 1. Glukosa 1.

    2. Protein 2.

    URINALISA IMUNOLOGI
    1. Protein 1. Tes Kehamilan

    2. Glukosa 2. Golongan Darah

    3. VDRL

    4. HBsAg

    5. Anti HIV
    ATORIUM

    :
    :
    :
    :
    :

    JENIS PEMERIKSAAN

    MIKROBIOLOGI &
    PARASITOLOGI
    Mycobacterium BTA

    Malaria

    Palangka Raya,
    Dokter / Pengirim
    PEMERINTAH KOTA PALANGKA RAYA
    DINAS KESEHATAN
    UPT PUSKESMAS JEKANRAYA
    JalanTjilik Riwut Km 10,5 Palangka Raya Kode Pos 73112
    Email : puskesmasjekanraya@gmail.com

    FORMULIR PERMINTAAN RUJUKAN PEMERIKSAAN LABORATORIUM

    Pasien : Gejala Penyakit : Spesimen


    Nomor Register : Jenis
    Nama : Asal Bahan
    Tgl/jam
    Umur : Pengobatan : pengambilan
    sp
    Jenis Kelamin : Petugas
    Alamat :

    NO. JENIS PEMERIKSAAN NO. JENIS PEMERIKSAAN NO.

    HEMATOLOGI TINJA

    1. Hemoglobin 1. Makroskopis 1.

    2. Hematokrit − Kosistensi 2.

    3. Hitung Eritrosit − Warna 3.

    4. Hitung Trombosit − Bau 4.

    5. Hitung Leukosit − Lendir 5.

    6. Hitung Jenis Leukosit − Darah 6.

    7. Laju Endap Darah 2. Darah Samar 7.

    8. Masa Perdarahan 3. Mikroskopis 8.

    9. Masa Pembekuan

    URINALISA KIMIA KLINIK


    1. Makroskopis 1. Glukosa 1.

    2. PH 2. Protein 2.

    3. Berat Jenis 3. Albumin 3.

    4. Protein 4. Bilirubin Total 4.

    5. Glukosa 5. Bilirubin Direk 5.

    6. Bilirubin 6. SGOT 6.

    7. Urobilinogen 7. SGPT 7.

    8. Keton 8. Akali Fosfatase 8.

    9. Nitrit 9. Asam Urat

    10. Leukosit 10. Ureum / BUN

    11. Eritrosit 11. Kreatinin

    12. Sedimen 12. Trigliserida

    13. Kolesterol Total

    14. kolesterol HDL

    15. Kolesterol LDL


    KSAAN LABORATORIUM

    :
    :
    :

    JENIS PEMERIKSAAN

    MIKROBIOLOGI &
    PARASITOLOGI
    Mycobacterium

    Neisseria Gonnorrhoeae

    Tricomonas Vaginalis

    Candida Albicans

    Bacterial Vaginosis

    Malaria

    Microfilaria

    Jamur Permukaan

    IMUNOLOGI
    Tes Kehamilan

    Golongan Darah

    WIDAL

    VDRL

    HBsAg

    Anti HIV

    Antigen/Antibody Dengue

    Lain - lain

    Palangka Raya,
    Dokter / Pengirim
    PEMERINTAH KOTA PALANGKA RAYA
    DINAS KESEHATAN
    UPT PUSKESMAS JEKANRAYA
    JalanTjilik Riwut Km 10,5 Palangka Raya Kode Pos 73112
    Email : puskesmasjekanraya@gmail.com

    FORMULIR HASIL PEMERIKSAAN LABORATORIUM

    Pasien : Gejala Penyakit : Spesimen


    Nomor Register : Jenis
    Nama : Asal Bahan
    Tgl/jam
    pengambilan
    Umur : Pengobatan :
    sp
    Jenis Kelamin : Petugas
    Alamat :

    NO. JENIS PEMERIKSAAN HASIL

    HEMATOLOGI
    1. Hemoglobin
    2. Hematokrit
    URINALISA
    3. Protein
    4. Glukosa
    KIMIA KLINIK
    5. Glukosa
    6. Asam Urat

    7. Kolesterol
    MIKROBIOLOGI &
    PARASITOLOGI
    8. Mycobacterium BTA
    9. Malaria
    IMUNOLOGI
    10. Tes Kehamilan
    11. Golongan Darah
    12. HbsAg
    13. Anti HIV
    14. VDRL
    RATORIUM

    :
    :
    :
    :
    :

    NILAI RUJUKAN

    L = 13 - 18 g/dl
    P = 12 - 16 g/dl

    Negatif
    Negatif

    70 - 125 mg/dl
    L = 3 - 7,2 mg/dl
    P = 2 - 6 mg/dl
    < 200 mg/dl

    Negatif
    Negatif

    Negatif
    -
    Negatif
    Negatif
    Negatif

    Palangka Raya,
    Pemeriksa,
    ( )

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