Rekapitulasi Tagihan Pasien

No. Verifikasi :
Medrec : 000369231 Cr Bayar : JAMSOSTEK/ASTEK
No. Reg : 201105090362 Unit Layanan Akhir : Instalasi Rawat Inap
Nama : SITI ZULFA S.AG NY Rawat Inap
Alamat : TROSO 6/10 Ruang : Flamboyan
Bed : Flamboyan 08
Kelas : VIP Utama
Kelamin : P
Umur : 33 tahun

Akomodasi dan Administrasi

No Tanggal Layanan Medik Tarif Kelas Ruang

1 09/05/2011 00:00 BIAYA PAKET RUANGAN 280.000 VIP Utama Flamboyan - Flamboyan 08
2 09/05/2011 00:00 ADMINISTRASI RAWAT INAP SELAMA PERAWATAN 15.000 VIP Utama Flamboyan - Flamboyan 08
3 10/05/2011 00:00 BIAYA PAKET RUANGAN 280.000 VIP Utama Flamboyan - Flamboyan 08
4 11/05/2011 00:00 BIAYA PAKET RUANGAN 280.000 VIP Utama Flamboyan - Flamboyan 08
5 12/05/2011 08:03 BIAYA PAKET RUANGAN 280.000 VIP Utama Flamboyan - Flamboyan 08
6 13/05/2011 08:50 BIAYA PAKET RUANGAN 280.000 VIP Utama Flamboyan - Flamboyan 08

Subtotal Akomodasi dan Admibnistrasi 1.415.000

Penunjang
No Tanggal Layanan Medik Tarif Kelas Ruang

Rawat Inap
1 09/05/2011 08:00 HEMATOLOGI (SYSMEX) 47.800 VIP Utama
2 09/05/2011 08:01 LED 10.200 VIP Utama
3 09/05/2011 08:02 DIFFCOUNT 10.200 VIP Utama
4 09/05/2011 08:03 URIC ACIS 26.000 VIP Utama
5 09/05/2011 08:04 KALIUM 31.000 VIP Utama
6 09/05/2011 08:04 UREUM 20.000 VIP Utama
7 09/05/2011 08:04 NATRIUM 31.000 VIP Utama
8 09/05/2011 08:05 SPUIT 4.000 VIP Utama
9 09/05/2011 08:05 KONSUL DOKTER PATOLOGI 6.000 VIP Utama

Subtotal Kegiatan Penunjang di Rawat Inap 186.200

Subtotal Penunjang 186.200

Tindakan Medik
No Tanggal Layanan Medik Tarif Kelas Ruang

Rawat Inap

1 10/05/2011 00:00 PASANG INFUS 28.900 VIP Utama Flamboyan - Flamboyan 08

2 10/05/2011 00:00 INJEKSI 1.5 43.350 VIP Utama Flamboyan - Flamboyan 08
3 11/05/2011 00:00 INJEKSI 1.5 43.350 VIP Utama Flamboyan - Flamboyan 08
4 12/05/2011 08:03 INJEKSI 1.5 43.350 VIP Utama Flamboyan - Flamboyan 08
5 12/05/2011 08:49 GANTI BALUT LUKA KECIL - SEDANG. 28.900 VIP Utama Flamboyan - Flamboyan 08
6 13/05/2011 08:50 PASANG INFUS 28.900 VIP Utama Flamboyan - Flamboyan 08
7 13/05/2011 08:50 INJEKSI 1.5 43.350 VIP Utama Flamboyan - Flamboyan 08

Subtotal Tindakan Medik di Rawat Inap 260.100

Subtotal Tindakan Medik 260.100

Konsultasi
No Tanggal Layanan Medik Tarif Kelas Ruang

1 09/05/2011 08:08 VISITE DOKTER SPESIALIS 40.000 VIP Utama Flamboyan - Flamboyan 08
2 09/05/2011 08:08 VISITE DOKTER UMUM 20.000 VIP Utama Flamboyan - Flamboyan 08
3 10/05/2011 08:07 VISITE DOKTER SPESIALIS 40.000 VIP Utama Flamboyan - Flamboyan 08
4 11/05/2011 08:07 VISITE DOKTER SPESIALIS 40.000 VIP Utama Flamboyan - Flamboyan 08
Konsultasi
No Tanggal Layanan Medik Tarif Kelas Ruang

5 12/05/2011 08:07 VISITE DOKTER SPESIALIS 40.000 VIP Utama Flamboyan - Flamboyan 08
6 13/05/2011 08:07 VISITE DOKTER SPESIALIS 40.000 VIP Utama Flamboyan - Flamboyan 08

Subtotal Konsultasi 220.000

Obat/Alkes Habis Pakai

No Tanggal Obat/Alkes Habis Pakai QTY Harga Jumlah Ruang

1 10/05/2011 11:26 Aquabidest 25 ml inj 1 6.659 6.659 Flamboyan - Flamboyan 08

2 10/05/2011 11:26 Broadced inj 2 217.140 434.280 Flamboyan - Flamboyan 08

3 10/05/2011 11:26 FC No. 16 RUSCH 1 28.380 28.380 Flamboyan - Flamboyan 08

4 10/05/2011 11:26 Needle No. 25 1 1.320 1.320 Flamboyan - Flamboyan 08

5 10/05/2011 11:26 Spuit 10 cc Terumo 1 5.478 5.478 Flamboyan - Flamboyan 08

6 10/05/2011 11:26 Spuit 3 cc terumo 2 3.498 6.996 Flamboyan - Flamboyan 08

7 10/05/2011 11:26 Urine Bag 1 6.600 6.600 Flamboyan - Flamboyan 08

8 10/05/2011 11:28 Gastridin 50 mg Inj 2 20.394 40.788 Flamboyan - Flamboyan 08

9 10/05/2011 11:28 Ketorolac 30 mg/ml inj 2 16.038 32.076 Flamboyan - Flamboyan 08

10 10/05/2011 17:53 Pepzol 40 mg Inj 1 145.200 145.200 Flamboyan - Flamboyan 08

11 10/05/2011 17:53 NaCl 0,9 % inf 100 ml 1 10.052 10.052 Flamboyan - Flamboyan 08

12 10/05/2011 17:53 Spuit 10 cc Terumo 1 5.478 5.478 Flamboyan - Flamboyan 08

13 11/05/2011 06:14 Inpepsa 200 ml syr 1 88.440 88.440 Flamboyan - Flamboyan 08

14 11/05/2011 07:50 Vomitas 10 3.916 39.160 Flamboyan - Flamboyan 08

15 11/05/2011 07:50 Pepzol 40 mg Inj 1 145.200 145.200 Flamboyan - Flamboyan 08

16 11/05/2011 07:50 NaCl 0,9 % inf 100 ml 1 10.052 10.052 Flamboyan - Flamboyan 08

17 11/05/2011 07:50 Spuit 10 cc Terumo 1 5.478 5.478 Flamboyan - Flamboyan 08

18 11/05/2011 11:01 Aquabidest 25 ml inj 1 6.659 6.659 Flamboyan - Flamboyan 08

19 11/05/2011 11:01 Dextrose 5% OTSU inf 2 12.354 24.708 Flamboyan - Flamboyan 08

20 11/05/2011 11:01 NaCl 0,9 % OTSU inf 1 9.971 9.971 Flamboyan - Flamboyan 08

21 11/05/2011 11:01 Spuit 5 cc Terumo 1 4.224 4.224 Flamboyan - Flamboyan 08

22 11/05/2011 11:01 Spuit 3 cc terumo 1 3.498 3.498 Flamboyan - Flamboyan 08

23 11/05/2011 11:04 Broadced inj 1 217.140 217.140 Flamboyan - Flamboyan 08

24 11/05/2011 11:05 Aquabidest 25 ml inj 1 6.659 6.659 Flamboyan - Flamboyan 08

25 11/05/2011 11:05 Dextrose 5% OTSU inf 1 12.354 12.354 Flamboyan - Flamboyan 08

26 11/05/2011 11:05 NaCl 0,9 % OTSU inf 1 9.971 9.971 Flamboyan - Flamboyan 08

27 11/05/2011 11:05 Spuit 5 cc Terumo 1 4.224 4.224 Flamboyan - Flamboyan 08

28 11/05/2011 11:05 Spuit 3 cc terumo 1 3.498 3.498 Flamboyan - Flamboyan 08

29 12/05/2011 08:05 Pepzol 40 mg Inj 1 145.200 145.200 Flamboyan - Flamboyan 08

30 12/05/2011 08:05 NaCl 0,9 % inf 100 ml 1 10.052 10.052 Flamboyan - Flamboyan 08

31 12/05/2011 08:05 Spuit 3 cc terumo 1 3.498 3.498 Flamboyan - Flamboyan 08

32 12/05/2011 10:30 Dimenhidrinat 10 180 1.800 Flamboyan - Flamboyan 08

33 12/05/2011 10:32 Cefila 10 15.840 158.400 Flamboyan - Flamboyan 08

34 12/05/2011 10:32 Frego 5 Mg Tab 10 4.884 48.840 Flamboyan - Flamboyan 08

35 13/05/2011 08:01 Omeprazole 30 490 14.699 Flamboyan - Flamboyan 08

36 13/05/2011 08:01 RL OTSU inf 3 10.877 32.630 Flamboyan - Flamboyan 08

37 13/05/2011 08:02 Vomitas 10 3.916 39.160 Flamboyan - Flamboyan 08

38 13/05/2011 08:02 Pepzol 40 mg Inj 1 145.200 145.200 Flamboyan - Flamboyan 08

39 13/05/2011 08:02 NaCl 0,9 % OTSU inf 1 9.971 9.971 Flamboyan - Flamboyan 08
Obat/Alkes Habis Pakai
No Tanggal Obat/Alkes Habis Pakai QTY Harga Jumlah Ruang

40 13/05/2011 10:18 Infus set terumo 1 14.520 14.520 Flamboyan - Flamboyan 08

41 13/05/2011 10:18 Venflon 18 (Hijau) 1 36.300 36.300 Flamboyan - Flamboyan 08

42 13/05/2011 10:20 Oxygen 3 ltr/jam 12 3.600 43.200 Flamboyan - Flamboyan 08

43 13/05/2011 11:13 Dulcolax Adult 2 12.907 25.814 Flamboyan - Flamboyan 08

Subtotal Obat/Alkes Habis Pakai 2.043.829

Total Obat 2.043.829

Total Jasa 32.250
2.076.079

Rekap

No Kelompok Pelayanan Nilai Tagihan

1 AKOMODASI DAN ADMINISTRASI 1.415.000,00
2 PENUNJANG MEDIK 259.700,00
3 TINDAKAN MEDIK 260.100,00
4 KONSULTASI DOKTER 220.000,00
5 PELAYANAN OBAT/ALKES 2.076.078,80
Nilai Total Tagihan Pasien 4.230.878,80