Nama Pasien : MR: Nama Pasien : MR:

PAKET CURET PAKET CURET

No Alkes/Obat Jmlh Jumlah R/ Jml yg diberi TTD No Alkes/Obat Jmlh Jumlah R/ Jml yg diberi TTD

1 ABOCATH NO.18 1 1 ABOCATH NO.18 1

2 HANSAPLAST 1 2 HANSAPLAST 1
3 INF RL 2 3 INF RL 2
4 ALKOHOL SWAB 1 4 ALKOHOL SWAB 1
5 PITOGIN 2 5 PITOGIN 2
6 METHERGIN INJ 2 6 METHERGIN INJ 2
7 MIDAZOLAM (MILOZ) 1 7 MIDAZOLAM (MILOZ) 1
8 PROFOPOL (SAFOL) 20 8 PROFOPOL (SAFOL) 20
9 BLOOD SET 1 9 BLOOD SET 1
10 SPUIT 3 CC 1 10 SPUIT 3 CC 1
11 SPUIT 10 CC 1 11 SPUIT 10 CC 1
12 SPUIT 5 CC 1 12 SPUIT 5 CC 1
13 alexa handscoon steril 1 13 alexa handscoon steril 1
14 HANSCOON SENSI 2 14 HANSCOON SENSI 2
15 UNDER PAD 1 15 UNDER PAD 1
16 NEDDLE 26 1 16 NEDDLE 26 1
17 CEFTRIAXON INJ 1 17 CEFTRIAXON INJ 1
18 PETIDINE INJ 1 18 PETIDINE INJ 1
19 AQUA PRO INJEKSI 1 19 AQUA PRO INJEKSI 1
20 KETOPROFEN (FETIK SUPP) 1 20 KETOPROFEN (FETIK SUPP) 1
21 OKSIGEN 400 21 OKSIGEN 400
22 RANITIDIN INJ 1 22 RANITIDIN INJ 1
23 GELANG IBU 1 23 GELANG IBU 1
24 AHP CURRET 1 24 AHP CURRET 1

OBAT PULANG OBAT PULANG

1 CEFADROXIL 10 TAB 1 CEFADROXIL 10 TAB
2 ASAM MEFENAMAT 10 TAB 2 ASAM MEFENAMAT 10 TAB
Nama Pasien: MR: Nama Pasien: MR:

PAKET BAYI PAKET BAYI

NO ALKES/OBAT JMLH Jumlah R/ Jmlh yg diberi TTD NO ALKES/OBAT JMLH Jumlah R/ Jmlh yg diberi TTD
1 GELANG BAYI 1 1 GELANG BAYI 1

2 SUCTION TUBE NO.8 1 2 SUCTION TUBE NO.8 1

3 NEEDLE NO 26 1 3 NEEDLE NO 26 1

4 UMBILICAL 1 4 UMBILICAL 1

5 ALKOHOL SWAB 3 5 ALKOHOL SWAB 3

6 SPUIT 1 CC 1 6 SPUIT 1 CC 1

7 NEO K 1 7 NEO K 1

8 KASA STERIL BOX 1 8 KASA STERIL BOX 1

9 POLYGRAN MD 1 9 POLYGRAN MD 1

10 POVIDON IODIN 1 10 POVIDON IODIN 1

11 IMM.POLIO TETES 1 11 IMM.POLIO TETES 1

12 IMM.HBO 1 12 IMM.HBO 1
Nama Pasien : MR:
PAKET SC
No Alkes/Obat Jmlh pemakaian Jumlah R/ Jml yg diberi TTD
1 BUCAINE 1
2 EPEDRIN 1
3 METHERGIN INJ 2
4 OXITOCIN (PITOGIN) 4
5 RANITIDINE 4
6 DEXAMETHASONE 3
7 CEFTRIAXONE 4
9 MIDAZOLAM (MILOZ) 1
10 TRAMADOL/KETOROLAC 3
11 NEEDLE NO 27 1
12 INF RL 6
13 INF NACL 1
14 infus D5% 1
15 AQUADEST 4
16 TRANFUSI SET 1
17 ABOCATH NO. 18 1
18 FOLLEY CATH NO. 14 1
19 URINE BAG 1
20 BISTURI NO 21 1
21 UNDERPPAD 1
22 BENANG VYCRIL no.1 0.5
23 CROMIC 2 1
24 BENANG CROMIC 2/0 1
25 MONO SIN 3/0 0.5
26 SPINOCAIN NO 25 1
27 KASSA DWIPA 5
28 HYPAVIC 40
29 GAMEX 7 dan alexa 5
30 SPUIT 3 CC 2
31 SPUIT 10 CC 1
32 SPUIT 1 CC 1
33 SPUIT 5 CC 1
34 MASKER 7
35 TOPI OPERASI 5
36 OKSIGEN 800
37 HANDSCOON SENSI 4
38 Gelang bayi 1
39 GELANG IBU 1
40 leukomed 1
41 suction no 8 1
42 umbilical cord 1
43 HANSAPLAST 1
44 kassa kotak 1
45 povidon iodin 1
46 GASTRUL 2
47 elektroda cauter 1
48 saturasi portable 1
 OBAT PULANG
1 CEFADROXIL 10 TAB
2 vit c 50 mg 5 TAB
3 ASAM MEFENAMAT 10 TAB
TOTAL
Nama Pasien: MR: Nama Pasien: MR:

PAKET PARTUS NORMAL PAKET PARTUS NORMAL

No Alkes/Obat Jmh Jumlah R/ Jumlah Yg diberi TTD No Alkes/Obat Jmh Jumlah R/ Jumlah Yg diberi
1 OXITOCIN (PITOGIN) 2 1 OXITOCIN (PITOGIN) 2
2 METHERGIN INJ 1 2 METHERGIN INJ 1
3 LIDOCAIN INJ 2 3 LIDOCAIN INJ 2
4 HANSAPLAST 1 4 HANSAPLAST 1
5 INF RL 1 5 INF RL 1
6 ALKOHOL SWAB 4 6 ALKOHOL SWAB 4
8 ABOCATH 18 1 8 ABOCATH 18 1
9 BLOOD SET 1 9 BLOOD SET 1
11 SPUIT 3 CC 1 11 SPUIT 3 CC 1
12 SPUIT 10 CC 1 12 SPUIT 10 CC 1
13 SPUIT 5 CC 1 13 SPUIT 5 CC 1
15 KASSA ROL 1 15 KASSA ROL 1
16 alexa handscoon steril 2 16 alexa handscoon steril 2
17 HANSCOON SENSI 2 17 HANSCOON SENSI 2
18 UNDER PAD 1 18 UNDER PAD 1
19 NEDDLE 23 1 19 NEDDLE 23 1
21 CAT GUT 2/0 1 21 CAT GUT 2/0 1
23 GELANG IBU 1 23 GELANG IBU 1
24 AHP 1 24 AHP 1

OBAT PULANG OBAT PULANG

1 CEFADROXIL 500 MG 10 TAB 1 CEFADROXIL 500 MG 10 TAB
2 METRONIDAZOLE 10 TAB 2 METRONIDAZOLE 10 TAB
3 ASAM MEFENAMAT 10 TAB 3 ASAM MEFENAMAT 10 TAB
TTD
Nama Pasien: MR: Nama Pasien: MR:

PAKET PARTUS PHATOLOGIS PAKET PARTUS PHATOLOGIS

No Alkes/Obat Jmh Jumlah R/ Jumlah yg diberi TTD No Alkes/Obat Jmh Jumlah R/ Jumlah yg diberi
1 OXITOCIN (PITOGIN) 3 1 OXITOCIN (PITOGIN) 3
2 METHERGIN INJ 2 2 METHERGIN INJ 2
3 LIDOCAIN INJ 2 3 LIDOCAIN INJ 2
4 HANSAPLAST 1 4 HANSAPLAST 1
5 INF RL 2 5 INF RL 2
6 ALKOHOL SWAB 1 6 ALKOHOL SWAB 1
7 ABOCATH 18 1 7 ABOCATH 18 1
8 BLOOD SET 1 8 BLOOD SET 1
9 SPUIT 3 CC 1 9 SPUIT 3 CC 1
10 SPUIT 5 CC 1 10 SPUIT 5 CC 1
11 HANDSCOON GAMEX 2 11 HANDSCOON GAMEX 2
12 UNDER PAD 2 12 UNDER PAD 2
13 NEDDLE 23 1 13 NEDDLE 23 1
14 CAT GUT 2/0 1 14 CAT GUT 2/0 1

OBAT PULANG OBAT PULANG

1 CEFADROXIL 500 MG 10 TAB 1 CEFADROXIL 500 MG 10 TAB
2 METRONIDAZOLE 10 TAB 2 METRONIDAZOLE 10 TAB
3 ASAM MEFENAMAT 10 TAB 3 ASAM MEFENAMAT 10 TAB
TTD
 AMPRAHAN OBAT DAN ALKES
Nama Pasien: MR:

PAKET PARTUS PHATOLOGIS

No Alkes/Obat Jmh Satuan Harga
1 OXITOCIN (PITOGIN) 1 14,300
2 METHERGIN INJ 1 6,700
3 LIDOCAIN INJ 2 5,200
4 HANSAPLAST 1 500
5 INF RL 1 9,300
6 ALKOHOL SWAB 2 1,400
7 ABOCATH 18 1 21,500
8 BLOOD SET 1 16,500
9 SPUIT 3 CC 1 2,500
10 SPUIT 1 CC 1 5,300

11 SPUIT 5 CC 1 2,700
12 NEO K 1 19,600
13 HANSCOON SENSI 2 3,000
14 UNDER PAD 1 5,200
15 NEDDLE 23 1 1,600
16 CAT GUT 2/0 1 12,500
17
18 GELANG IBU
AHP 1 1,500

18 SUCTION 8 1 12,900
19 UMBILICAL 1 3,500
20 GELANG ANAK 1 1,200

OBAT PULANG
1 AMOXICILLIN 500MG 10 TAB 6,000
2 ASAM MEFENAMAT 10 TAB 6,000
Nama Pasien: MR: Nama Pasien:

PAKET BAYI PAKET BAYI

NO ALKES/OBAT JMLH Jumlah R/ Jmlh yg diberi Harga NO ALKES/OBAT
1 GELANG BAYI 1 2200 1 GELANG BAYI
2 SUCTION TUBE NO.8 1 13900 2 SUCTION TUBE NO.8
3 NEEDLE NO 26 1 2000 3 NEEDLE NO 26
4 UMBILICAL 1 3900 4 UMBILICAL
5 ALKOHOL SWAB 12 13000 5 ALKOHOL SWAB
6 SPUIT 1 CC 1 3100 6 SPUIT 1 CC
7 NEO K 1 15300 7 NEO K
8 POLYGRAN MD 1 6800 8 KASA STERIL BOX
total 60200 9 POLYGRAN MD
9 IMM.POLIO TETES 1 21100 10 POVIDON IODIN
10 IMM.HBO 1 84400 11 IMM.POLIO TETES
11 MAMYPOKO 6 12000
12 BOTOL SUSU 1 22900 12 IMM.HBO
13 SUSU 1 17000 s/d 183000
157400
total + susu
323400
 MR:

PAKET BAYI
JMLH Jumlah R/ Jmlh yg diberi TTD
1
1
1
1
3
1
1
1
1
1
1