No. Form : FR/14.

1/01
No. Rev : 00

INVOICE
BIAYA PERAWATAN RAWAT INAP
COST OF INPATIENT SERVICES
No. Reg / No. RM : 307688 Dokter Utama : dr. Moch Khalimur Rouf, Sp.PD
Tanggal Masuk : Nov 19, 2020 8:35 PM Spesialisasi : Penyakit Dalam
Nama Pasien : BUDI BAHARUDIN Bangsal : GARDENIA 2302D
Tanggal Lahir : 12 Aug 1984 Kelas : Kelas 3
Penjamin Bayar : INSTANSI Ruang Rawat : GARDENIA
Nama Instansi : G1303 - KEMENTERIAN KESEHATAN (KEMENKES) No. Tempat Tidur : GRD2302D

TRANSAKSI HARIAN

RAWAT INAP EPISODE : 2

NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Asuhan Keperawatan / Nursing Services

GRD / Gardenia
I-GRD-202011000630 Jasa Maksimal Care - Kelas Kelas 3 19/11/2020 1 0.00 0.00 0.00 0.00
Perawat
MAKSIMAL CARE - RS Kelas Kelas 3 19/11/2020 1 85,000.00 0.00 0.00 85,000.00
I-GRD-202011000617 Jasa Injeksi IV - Kelas Kelas 3 20/11/2020 3 0.00 0.00 0.00 0.00
Perawat
Injeksi IV - - RS Kelas Kelas 3 20/11/2020 3 54,000.00 0.00 0.00 54,000.00
Jasa Intermediate Care Kelas Kelas 3 20/11/2020 1 0.00 0.00 0.00 0.00
Perawat
Intermediate Care - RS Kelas Kelas 3 20/11/2020 1 55,000.00 0.00 0.00 55,000.00
Total Unit GRD / Gardenia 194,000.00 0.00 0.00 194,000.00
Subtotal Asuhan Keperawatan / Nursing Services 194,000.00 0.00 0.00 194,000.00
Radiologi / Radiology
RAD / Radiologi
I-RAD-202011000159 BHP CT Scan Thorax Kelas Kelas 3 20/11/2020 1 150,000.00 0.00 0.00 150,000.00
Jasa Dokter Radiologi CT Scan Thorax 20/11/2020 1 120,000.00 0.00 0.00 120,000.00
Kelas Kelas 3
CT Scan Thorax Kelas Kelas 3 20/11/2020 1 1,174,000.00 0.00 0.00 1,174,000.00
Total Unit RAD / Radiologi 1,444,000.00 0.00 0.00 1,444,000.00

LAB / Laboratorium
I-LAB-202011001258 URIN LENGKAP Kelas Kelas 3 20/11/2020 1 116,000.00 0.00 0.00 116,000.00
Total Unit LAB / Laboratorium 116,000.00 0.00 0.00 116,000.00

GRD / Gardenia
I-GRD-202011000601 Kamar Isolasi Non Tekanan Negatif 19/11/2020 1 130,000.00 0.00 0.00 130,000.00
Tanpa Ventilator
I-GRD-202011000611 Kamar Isolasi Non Tekanan Negatif 20/11/2020 1 130,000.00 0.00 0.00 130,000.00
Tanpa Ventilator
I-GRD-202011000612 Kamar Isolasi Non Tekanan Negatif 21/11/2020 1 130,000.00 0.00 0.00 130,000.00
Tanpa Ventilator
Subtotal Kamar / Room 390,000.00 0.00 0.00 390,000.00
NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Farmasi / Pharmacy
DP4 / Depo Farmasi Ri
I-DP4-202011008490 ONDANSETRON 4MG TABLET 20/11/2020 5 11,000.00 0.00 0.00 11,000.00
I-DP4-202011008488 ONDANSETRON 4MG TABLET 20/11/2020 10 22,000.00 0.00 0.00 22,000.00
PARACETAMOL 500 MG TAB (G) 20/11/2020 10 5,000.00 0.00 0.00 5,000.00
AZITROMYCIN 500 MG TAB 20/11/2020 5 68,500.00 0.00 0.00 68,500.00
LANSOPRAZOLE 30 MG CAPSUL** 20/11/2020 10 7,000.00 0.00 0.00 7,000.00

Page 1 of 3 TIDAK BERLAKU SEBAGAI KWITANSI / NOT VALID AS RECEIPT Printed by Novita Indriyani at
23 March 2021, 17:18:07
JL.Ring road Utara No.160,Condong Catur, Depok, Sleman, Yogyakarta 55283
Telp: 0274 4463535 (Hunting), Fax 0274 4463444
Website: www.rs-jih.co.id, Email: info@rs-jih.co.id
 TRANSAKSI HARIAN

RAWAT INAP EPISODE : 2

NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Farmasi / Pharmacy
DP4 / Depo Farmasi Ri
I-DP4-202011008453 BRAXIDIN TAB (P) 20/11/2020 1 1,700.00 0.00 0.00 1,700.00
I-DP4-202011008264 FUTROLIT INF 20/11/2020 1 88,900.00 0.00 0.00 88,900.00
PANTOPRAZOLE INJ 20/11/2020 1 91,100.00 0.00 0.00 91,100.00
SPUIT 10 CC OM** 20/11/2020 1 1,400.00 0.00 0.00 1,400.00
ONDANSETRON 4 MG INJ 20/11/2020 1 10,700.00 0.00 0.00 10,700.00
SPUIT 3 CC OM ** 20/11/2020 1 900.00 0.00 0.00 900.00
SUKRALFATE SYR ** 20/11/2020 1 19,300.00 0.00 0.00 19,300.00
I-DP4-202011008332 SPUIT 3 CC TERUMO 20/11/2020 1 7,000.00 0.00 0.00 7,000.00
RL 500 ML (SANBE) SINGLE POT 20/11/2020 1 27,300.00 0.00 0.00 27,300.00
I-DP4-202011008319 INTERLAC TAB (FS) 20/11/2020 1 14,200.00 0.00 0.00 14,200.00
BRAXIDIN TAB (P) 20/11/2020 1 1,700.00 0.00 0.00 1,700.00
I-DP4-202011008266 INTERLAC TAB (FS) 20/11/2020 1 14,200.00 0.00 0.00 14,200.00
BRAXIDIN TAB (P) 20/11/2020 1 1,700.00 0.00 0.00 1,700.00
I-DP4-202011008453 INTERLAC TAB (FS) 20/11/2020 1 14,200.00 0.00 0.00 14,200.00
I-DP4-202011008436 ONDANSETRON 4 MG INJ 20/11/2020 1 10,700.00 0.00 0.00 10,700.00
SPUIT 3 CC OM ** 20/11/2020 1 900.00 0.00 0.00 900.00
I-DP4-202011008332 PANTOPRAZOLE INJ 20/11/2020 1 91,100.00 0.00 0.00 91,100.00
ONDANSETRON 4 MG INJ 20/11/2020 1 10,700.00 0.00 0.00 10,700.00
SPUIT 10 CC TERUMO 20/11/2020 1 11,100.00 0.00 0.00 11,100.00
RTI-DP4-202011001085 SPUIT 10 CC OM** 20/11/2020 1 -1,400.00 0.00 0.00 -1,400.00
RTI-DP4-202011001084 FUTROLIT INF 20/11/2020 1 -88,900.00 0.00 0.00 -88,900.00
SPUIT 3 CC OM ** 20/11/2020 1 -900.00 0.00 0.00 -900.00
RTI-DP4-202011001083 PANTOPRAZOLE INJ 20/11/2020 1 -91,100.00 0.00 0.00 -91,100.00
ONDANSETRON 4 MG INJ 20/11/2020 1 -10,700.00 0.00 0.00 -10,700.00
RTI-DP4-202011001082 BRAXIDIN TAB (P) 20/11/2020 1 -1,700.00 0.00 0.00 -1,700.00
INTERLAC TAB (FS) 20/11/2020 1 -14,200.00 0.00 0.00 -14,200.00
Total Unit DP4 / Depo Farmasi Ri 323,400.00 0.00 0.00 323,400.00
UGD / UGD
I-UGD-202011000391 SPUIT 3 CC TERUMO 19/11/2020 2 14,000.00 0.00 0.00 14,000.00
RL 500 ML (SANBE) SINGLE POT 19/11/2020 1 27,300.00 0.00 0.00 27,300.00
SOLUTION ADM SET TERUMO 19/11/2020 1 60,200.00 0.00 0.00 60,200.00
(TI*PU300L MACROSET)
TEGADERM 6 CM X 7 CM 1623W 19/11/2020 1 10,300.00 0.00 0.00 10,300.00
IV. CAT. VENFLON NO.22 19/11/2020 1 40,600.00 0.00 0.00 40,600.00
KETOROLAC 30 MG INJ 19/11/2020 1 7,800.00 0.00 0.00 7,800.00
DIPHENHYDRAMINE INJ 19/11/2020 1 2,400.00 0.00 0.00 2,400.00
EMBALASE RJ R2 Kelas Kelas 3 19/11/2020 2 10,000.00 0.00 0.00 10,000.00
Total Unit UGD / UGD 172,600.00 0.00 0.00 172,600.00
Subtotal Farmasi / Pharmacy 496,000.00 0.00 0.00 496,000.00
Biaya Admin / Administration Fee
DP4 / Depo Farmasi Ri
I-DP4-202011008488 EMBALASE RANAP Kelas Kelas 3 20/11/2020 1 10,000.00 0.00 0.00 10,000.00
Total Unit DP4 / Depo Farmasi Ri 10,000.00 0.00 0.00 10,000.00
Subtotal Biaya Admin / Administration Fee 10,000.00 0.00 0.00 10,000.00
Total Biaya RAWAT INAP 2,650,000.00 0.00 0.00 2,650,000.00

Grand Total Rp. 3,774,700.00

Administrasi Rp. 52,235.00
Grand Total (Round Up) Rp. 3,826,935.00

Terima Kasih Yogyakarta, 23 Mar 2021

Thank You Manajer Keuangan

Page 2 of 3 TIDAK BERLAKU SEBAGAI KWITANSI / NOT VALID AS RECEIPT Printed by Novita Indriyani at
23 March 2021, 17:18:07
JL.Ring road Utara No.160,Condong Catur, Depok, Sleman, Yogyakarta 55283
Telp: 0274 4463535 (Hunting), Fax 0274 4463444
Website: www.rs-jih.co.id, Email: info@rs-jih.co.id
 NB : Tagihan tersebut belum termasuk biaya Materai Anien Dinaringtyas, SE
This Bill Not Include Legal Stamp

Page 3 of 3 TIDAK BERLAKU SEBAGAI KWITANSI / NOT VALID AS RECEIPT Printed by Novita Indriyani at
23 March 2021, 17:18:07
JL.Ring road Utara No.160,Condong Catur, Depok, Sleman, Yogyakarta 55283
Telp: 0274 4463535 (Hunting), Fax 0274 4463444
Website: www.rs-jih.co.id, Email: info@rs-jih.co.id