PEMERINTAH KABUPATEN TABANAN

DINAS KESEHATAN
UPTD PUSKESMAS SELEMADEG BARAT
Jln. Raya Denpasar-Gilimanuk, Br. Dinas Suraberata
Desa Lalanglinggah Kec. Selemadeg Barat Kode Pos. 82162
Telp/Fax. 0361 8311286, E-mail : puskesmas_selbar@yahoo.co.id

ID DEP.

NAMA GENDER

UMUR TESTER

PARAMETER REF. RANGE RESULT

WBC 4,0 - 10,0 µl

Lymph# 0,8 - 4,0 µl

Mid# 0,1 -1,5 µl

Grand# 2,0 - 7,0 µl

Lymph% 20,0 - 40,0 µl

Mid% 3,0 - 15,0 µl

Grand% 50,0 - 70,0 µl

HGB 11,0 - 15,0 µl

RBC 3,50 - 5,00 µl

HCT 37,0 - 47,0 µl

MCV 80,0 - 100,0 µl

MCH 27,0 - 34,0 µl

MCHC 32,0 - 36,0 µl

RDW-CV 11,0 - 16,0 µl

RDW-SD 35,0 -56,0 µl

PLT 150 - 400 µl

MPV 6,5 - 12,0 µl

PDW 9,0 -17,0 µl

PCT 0,108 - 0,282 µl

Lalang Linggah
Pemeriksa
ID DEP

NAMA GENDER

UMUR

PARAMETER REF. RANGE RESULT PARAMETER REF. RANGE

WBC 4,0 - 10,0 µl WBC 4,0 - 10,0 µl
Lymph# 0,8 - 4,0 µl Lymph# 0,8 - 4,0 µl

Mid# 0,1 -1,5 µl Mid# 0,1 -1,5 µl

Grand# 2,0 - 7,0 µl Grand# 2,0 - 7,0 µl

Lymph% 20,0 - 40,0 µl Lymph% 20,0 - 40,0 µl
Mid% 3,0 - 15,0 µl Mid% 3,0 - 15,0 µl

Grand% 50,0 - 70,0 µl Grand% 50,0 - 70,0 µl

HGB 11,0 - 15,0 µl HGB 11,0 - 15,0 µl

RBC 3,50 - 5,00 µl RBC 3,50 - 5,00 µl

HCT 37,0 - 47,0 µl HCT 37,0 - 47,0 µl

MCV 80,0 - 100,0 µl MCV 80,0 - 100,0 µl

MCH 27,0 - 34,0 µl MCH 27,0 - 34,0 µl

MCHC 32,0 - 36,0 µl MCHC 32,0 - 36,0 µl

RDW-CV 11,0 - 16,0 µl RDW-CV 11,0 - 16,0 µl
RDW-SD 35,0 -56,0 µl RDW-SD 35,0 -56,0 µl
PLT 150 - 400 µl PLT 150 - 400 µl
MPV 6,5 - 12,0 µl MPV 6,5 - 12,0 µl
PDW 9,0 -17,0 µl PDW 9,0 -17,0 µl
PCT 0,108 - 0,282 µl PCT 0,108 - 0,282 µl
RESULT
ID DEP
NAMA GENDER
UMUR

PARAMETER REF. RANGE RESULT

WBC 4,0 - 10,0 µl
Lymph# 0,8 - 4,0 µl
Mid# 0,1 -1,5 µl
Grand# 2,0 - 7,0 µl
Lymph% 20,0 - 40,0 µl
Mid% 3,0 - 15,0 µl
Grand% 50,0 - 70,0 µl
HGB 11,0 - 15,0 µl
RBC 3,50 - 5,00 µl
HCT 37,0 - 47,0 µl
MCV 80,0 - 100,0 µl
MCH 27,0 - 34,0 µl
MCHC 32,0 - 36,0 µl
RDW-CV 11,0 - 16,0 µl
RDW-SD 35,0 -56,0 µl
PLT 150 - 400 µl
MPV 6,5 - 12,0 µl
PDW 9,0 -17,0 µl
PCT 0,108 - 0,282 µl
ID
NAMA
UMUR

PARAMETER REF. RANGE

WBC 4,0 - 10,0 µl
Lymph# 0,8 - 4,0 µl
Mid# 0,1 -1,5 µl
Grand# 2,0 - 7,0 µl
Lymph% 20,0 - 40,0 µl
Mid% 3,0 - 15,0 µl
Grand% 50,0 - 70,0 µl
HGB 11,0 - 15,0 µl
RBC 3,50 - 5,00 µl
HCT 37,0 - 47,0 µl
MCV 80,0 - 100,0 µl
MCH 27,0 - 34,0 µl
MCHC 32,0 - 36,0 µl
RDW-CV 11,0 - 16,0 µl
RDW-SD 35,0 -56,0 µl
PLT 150 - 400 µl
MPV 6,5 - 12,0 µl
PDW 9,0 -17,0 µl
PCT 0,108 - 0,282 µl
DEP
GENDER

RESULT
 PEMERINTAH KABUPATEN TABANAN
DINAS KESEHATAN
UPTD PUSKESMAS SELEMADEG BARAT
Jln. Raya Denpasar-Gilimanuk, Br. Dinas Suraberata
Desa Lalanglinggah Kec. Selemadeg Barat Kode Pos. 82162
Telp/Fax. 0361 8311286, E-mail : puskesmas_selbar@yahoo.co.id
PERMINTAAN PEMERIKSAAN LABORATORIUM

No. Reg : Dokter :

Nama : Telp. :
Umur : Tanggal :
Alamat :

Hematologi Faal/Hemostasis
Hematologi Rutin Waktu Pendarahan (BT)
LED/ESR Waktu Pembekuan (CT)
Golongan Darah
Hb (Hemoglobin)
Malaria

Kimia Darah Lemak Ginjal

Glukosa Sewaktu Cholesterol Total Ureum
Glukosa Puasa Trigliserida Kreatinin
Glukosa 2 Jam PP Asam Urat

Urinalisa Imuno/Serologi
Urine lengkap SGOT Widal
Test Kehamilan SGPT NS 1 Ag
Protein urine Ig G & Ig M
Glukosa Urine HIV

Feces Lain-Lain
Feces Lengkap Sputum BTA
Cacing