KWITANSI

Bukti Pembayaran

Invoice No. : RF16-0154939/F16-1406347 Page : 1 of 1

Visit No. : BS0072294359 Location : BSD_KSR01
Patient : ANITA DEWI LESTARI Date/Time : 24-OCT-2020 12:47
PRN : 0072294882 Admission Date : 24-OCT-2020 14:02
Payer : ANITA DEWI LESTARI

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Date Item Code Description Quantity Amount (Rp)
Admin Fee

24/10/20 ADM002 ADM PASIEN 1 50,000

Extemp Items

24/10/20 MCU002 MEDICAL CHECKUP PACKAGE - FEMALE (dr. Suwendi, SpPD)1 1,600,000
Medication

OP-Consultation
24/10/20 DCR001 KONSULTASI DOKTER SPESIALIS (dr. Suwendi, SpPD) 1 250,000

Medical Room

24/10/20 CBR003 RUANG MCU 1 0

TOTAL : 1,900,000
DEPOSIT : 0
PATIENT ROUNDING : 0
-----------
NET PAYABLE : 1,900,000
PAID BY :
CASH/CREDIT 1,900,000
Reference : SELF
ONE MILLION NINE HUNDRED THOUSAND RUPIAH.
Tangerang Selatan, 24-OCT-2020

_______________ ____________ NIA NURJANAH

Tanda Tangan pasien/Penanggung Jawab Cashier
Patien Sign/Guarantor
1. Invoice ini merupakan tanda terima pembayaran resmi, setelah di stempel oleh kasir
This is an official payment receipt, upon cashier stamp
2. Barang yang sudah di beli tidak dapat ditukar/dikembalikan
Change or return after purchase are not allowed
3. Untuk Barang kena pajak, harga termasuk PPN
VAT is included for taxable goods N.P.W.P : 02.275.900.5-411.000

PT. PELITA RELIANCE INTERNATIONAL HOSPITAL

Central Business District Lot IX, BSD City, Tangerang. 15321. Phone : (021) 3100 928 | Fax : (021) 3100 929
Email : infobsd@ekahospital.com
Invoice No. : RF16-0154939/F16-1406347 Page : 1 of 3
Visit No. : BS0072294359 Location : BSD_KSR01
Patient : ANITA DEWI LESTARI Date/Time : 24-OCT-2020 12:47
PRN : 0072294882 Admission Date : 24-OCT-2020 14:02
Payer : ANITA DEWI LESTARI Lab : 1 Of 3
Blood Type : O
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_________________________________________
Detail

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Pemeriksaan Hasil Nilai Rujukan Satuan Keterangan

HEMATOLOGI
HEMOGLOBIN 14.8 14.0-18.0 g/dl

LED 1 0.101 mm

LEKOSIT 6800 5.000-10.000 /uL

HITUNG JENIS
BASOFIL 0 0-1 %

EOSINOFIL 3 1-3 %

BATANG 2 2-6 %

SEGMEN 51 50-70 %

LIMFOSIT 23 21-40 %

MONOSIT 4 2-8 %

HEMATOKRIT 52 42-52 VOL%

TROMBOSIT 367.000 150.000-450.000 /uL

ERITROSIT 5.27 4.50-5.50 juta/uL

M C V, M C H, M C H C
MCV 81 81-92 fL

MCH 32 27-31 pg

MCHC 31 32-36 %

KOAGULASI
MASA PENDARAHAN 3.1 1.0-6.0 menit

MASA PEMBEKUAN 12.2 10.0-15.0 menit

KIMIA
FUNGSI HATI

SGOT 32 0-35 u/L

SGPT 33 0-45 u/L

GAMMA GT 19 15-85 u/L

FUNGSI GINJAL
UREUM 25 15-39 mg/dL
PT. PELITA RELIANCE INTERNATIONAL HOSPITAL
Central Business District Lot IX, BSD City, Tangerang. 15321. Phone : (021) 3100 928 | Fax : (021) 3100 929
Email : infobsd@ekahospital.com
Invoice No. : RF16-0154939/F16-1406347 Page : 2 of 3
Visit No. : BS0072294359 Location : BSD_KSR01
Patient : ANITA DEWI LESTARI Date/Time : 24-OCT-2020 12:47
PRN : 0072294882 Admission Date : 24-OCT-2020 14:02
Payer : ANITA DEWI LESTARI Lab : 2 Of 3
Blood Type : O
_________________________________________
_________________________________________
Detail

_________________________________________
Pemeriksaan Hasil Nilai Rujukan Satuan Keterangan

.
CREATININ 1.2 0.6-1.3 mg/dl

ASAM URAT 3.6 3.5-7.2 mg/dl

DIABETES
GLUKOSA PUASA
BAIK : 80-109
GLUKOSA DARAH PUASA 122 mg/dl SEDANG : 110-125
BURUK : >=126
HBA1C 7.8 % BAIK : 4-5.9
SEDANG : 6-8
BURUK : >8
LEMAK BAIK : <200
CHOLESTEROL TOTAL 241 mg/dl SEDANG : 200-239
BURUK : >=240
BAIK : <130
LDL CHLOSTEROL DIREK 162 mg/dl SEDANG : 130-159
BURUK : >=160
HDL CHLOSTEROL DIREK 47 mg/dl BAIK : <45
SEDANG : 36-44
BURUK : >=45
TRIGLISERIDA 215 mg/dl BAIK : <150
SEDANG : 150-199
URINALISA BURUK : >=200

WARNA KUNING JENUH KUNING JENUH

BJ 1.050 1.005-1.030

pH 64 5.0-8.5

KETON NEGATIVE NEGATIVE

PROTEIN/ALBUMIN NEGATIVE NEGATIVE

GLUKOSA NEGATIVE NEGATIVE

BILIRUBIN NEGATIVE NEGATIVE

BP 139/90

PT. PELITA RELIANCE INTERNATIONAL HOSPITAL

Central Business District Lot IX, BSD City, Tangerang. 15321. Phone : (021) 3100 928 | Fax : (021) 3100 929
Email : infobsd@ekahospital.com
Invoice No. : RF16-0154939/F16-1406347 Page : 3 of 3
Visit No. : BS0072294359 Location : BSD_KSR01
Patient : ANITA DEWI LESTARI Date/Time : 24-OCT-2020 12:47
PRN : 0072294882 Admission Date : 24-OCT-2020 14:02
Payer : ANITA DEWI LESTARI Lab : 3 Of 3
Blood Type : O
_________________________________________
_________________________________________
Detail

_________________________________________
Pemeriksaan Hasil Nilai Rujukan Satuan Keterangan

.
DARAH SAMAR NEGATIVE NEGATIVE

NITRAT NEGATIVE NEGATIVE

UROBILINOGEN 1.0 0.2-1.0

SEDIMEN URINE

LEKOSIT 0-1 0-5 /LPB

ERITROSIT 0-1 0-2 /LPB

SILINDER NEGATIVE NEGATIVE

EPITEL POSITIVE POSITIVE

BAKTERI NEGATIVE NEGATIVE

KRISTAL NEGATIVE NEGATIVE

LAIN-LAIN NEGATIVE NEGATIVE

PT. PELITA RELIANCE INTERNATIONAL HOSPITAL

Central Business District Lot IX, BSD City, Tangerang. 15321. Phone : (021) 3100 928 | Fax : (021) 3100 929
Email : infobsd@ekahospital.com