DINAS KESEHATAN KABUPATEN BAN

PUSKESMAS I PURWOKERTO TIMUR

Jl. Adipati Mersi No. 51 Purwokerto 53112

HASIL PEMERIKSAAN LABORATORIUM

Penanggung jawab

: dr. Yuvana Dewanti

No. RM

No. Laboratorium

Nama

Umur/Jenis Kelamin

Alamat

L / P

HEMATOLOGI
PARAMETER

HASIL

KET

NILAI RUJUKAN

Hemoglobin

w: 11-16 , L: 13-18 g/dl

Hematokrit

36-48 %

Jml Eritrosit

w: 3,8-5,6 . L: 4,4-5,6 jt/ul

MCV

80-90 f

MCH

28-34 pg

MCHC
Jml Lekosit

PARAMETER
Gula Darah Sewaktu
Gula Darah Puasa
Gula Darah 2 Jam PP
Kolesterol Total
Trigliserida

32-36 gr/dl

HDL Kolesterol

5.000 - 10.000 /ul

LDL Kolesterol

Hitung Jenis

SGOT

Basofil

0-1 %

SGPT

Eosinofil

1-3 %

Asam Urat

Stab

2-6 %

Ureum

Segmen

50-70 %

Limfosit

20-40 %

Monosit

2-8 %

Jml Trombosit

150.000 - 400.000 /ul

Malaria

Negatif

Golongan Darah

Creatinin

Warna
Kejernihan
Bau

Rhesus
Laju Endap Darah

W: < 20 , L: < 15 mm/jam

IMUNO & SEROLOGI

Berat Jenis
pH

Tes Kehamilan

Lekosit

Hbs Ag

Negatif

Anti HBs

Nitrit
Protein

Widal

Glukosa

Salmonella typii O

Negatif

Keton

Salmonella typii H

Negatif

Urobillinogen

Dengue Blood

Billirubin

Ig G

Negatif

Ig M

Negatif
FESES

Makroskopis

Eritrosit

Eritrosit
Lekosit
Silinder
Epitel

 Jamur
Mikroskopis

Kristal

Eritrosit
Lekosit
Lemak
Sisa Makanan
Telur Cacing

Tidak ditemukan

SEWAKTU I
PAGI
SEWAKTU II

Lain-Lain

Pemeriksaan Lain-lain :

HASIL KELUAR TANGGAL :

Pemeriksa

Keterangan : L = Low , H : High , * : Duplo

Tri Subektiyono, Amd.AK

DINAS KESEHATAN KABUPATEN BAN

PUSKESMAS I PURWOKERTO TIMUR

Jl. Adipati Mersi No. 51 Purwokerto 53112

FORMULIR PERMINTAAN LABORATORIUM

Tanggal

No. RM

:
:

Nama
Umur/Jenis Kelamin

Alamat

L / P
UMUM
BPJS / KIS
KBS

HEMATOLOGI

KIMIA DARAH

Darah Rutin

SGOT

HB

SGPT

Hematokrit

Billirubin Total

Eritrosit

Ureum

Lekosit

Creatinin

Trombosit

Asam Urat

Hitung Jenis

Kolesterol Total

LED

Trigliserida

Golongan Darah & Rh

HDL

Malaria

LDL

SEROLOGI

GLUKOSA DARAH

Widal

Glukosa Sewaktu

Dengue Ig G / Ig M

Glukosa Puasa

 HBsAg

Glukosa 2 Jam PP

Anti HBs

HBa1C

BANYUMAS

MUR

Unit Pengirim :

KIMIA KLINIK
HASIL

KET

NILAI RUJUKAN
< 180 mg/dl
60-110 mg/dl
< 140 mg/dl
50-200 mg/dl
< 150 mg/dl
45-65 mg/dl
< 150 mg/dl
W: < 31 , L: < 37 UL
W: < 31 , L: < 41 UL
W:2,4-6,4 . L:3,4-7,4 mg/dl
10-50 mg/dl
0.5 - 1.2 mg/dl

URINALISIS
Makroskopis
Kuning muda - tua
Jernih
Khas

Kimia
1.003-1.030
4,6 - 8,5
Negatif
Negatif
Negatif
Negatif
Negatif
Negatif
Negatif

Sedimen
0-3 / LPB
0-5 / LPB
Negatif
0-2 / LPK

Negatif
Negatif

MIKROBIOLOGI
BTA SPUTUM
Negatif
Negatif
Negatif

GAL :

Jam :

BANYUMAS

DINAS KES

MUR

PUS

FO

Diagnosa Sementara :

Tanggal

No. RM

:
:

Nama
Tipe Pasien

Umur/Jenis Kelamin

Alamat

: No. Kartu ............................................................................................

: No. Kartu ............................................................................................

HEMATOLOGI

URINE
Urin Rutin

Darah Rutin

Sedimen Urin

HB

Protein Urin

Hematokrit

Glukosa urin

Eritrosit

PP Test

Lekosit

Drug Tes / Napza

Trombosit
FESES

Hitung Jenis

Feses Rutin

LED

Telur Cacing

Golongan Darah & Rh

MIKROBIOLOGI

Malaria
SEROLOGI

BTA S P S
PEMERIKSAAN LAIN :
1......................................................

Widal
Dengue Ig G / Ig M

L / P

2......................................................

HBsAg

3......................................................

(......................................................................)

KESEHATAN KABUPATEN BANYUMAS

PUSKESMAS I PURWOKERTO TIMUR

Jl. Adipati Mersi No. 51 Purwokerto 53112

FORMULIR PERMINTAAN LABORATORIUM

Diagnosa Sementara :

Tipe Pasien
UMUM
BPJS / KIS
KBS

: No. Kartu ...........................................................................................

: No. Kartu ...........................................................................................

KIMIA DARAH

URINE

SGOT

Urin Rutin

SGPT

Sedimen Urin

Billirubin Total

Protein Urin

Ureum

Glukosa urin

Creatinin

PP Test

Asam Urat

Drug Tes / Napza

Kolesterol Total

FESES

Trigliserida

Feses Rutin

HDL

Telur Cacing

LDL

MIKROBIOLOGI
GLUKOSA DARAH

Glukosa Sewaktu
Glukosa Puasa

BTA S P S
PEMERIKSAAN LAIN :
1......................................................

 Glukosa 2 Jam PP

2......................................................

HBa1C

3......................................................

(......................................................................)

PUSKESMAS I PURWOKERTO TIMUR

Jl. Adipati Mersi No. 51 Purwokerto 53112
"KONSUL GIZI"
Tanggal

No. RM

NAMA

ALAMAT

:
JENIS TINDAKAN

BIAYA

1.....................................................................

Rp.........................

2.....................................................................

Rp.........................

3.....................................................................

Rp.........................

4.....................................................................

Rp.........................

5.....................................................................

Rp.........................

6.....................................................................

Rp.........................

7.....................................................................

Rp.........................

JUMLAH

Rp.........................

PUSKESMAS I PURWOKERTO TIMUR

Jl. Adipati Mersi No. 51 Purwokerto 53112
"KONSUL GIZI"
Tanggal

No. RM

NAMA

ALAMAT

:
JENIS TINDAKAN

BIAYA

1.....................................................................

Rp.........................

2.....................................................................

Rp.........................

3.....................................................................

Rp.........................

4.....................................................................

Rp.........................

5.....................................................................

Rp.........................

6.....................................................................

Rp.........................

7.....................................................................

Rp.........................

JUMLAH

Rp.........................

PUSKESMAS I PURWOKERTO TIMUR

Jl. Adipati Mersi No. 51 Purwokerto 53112
"KONSUL GIZI"
Tanggal

No. RM

NAMA

ALAMAT

:
JENIS TINDAKAN

BIAYA

1.....................................................................

Rp.........................

2.....................................................................

Rp.........................

3.....................................................................

Rp.........................

4.....................................................................

Rp.........................

5.....................................................................

Rp.........................

6.....................................................................

Rp.........................

7.....................................................................

Rp.........................

JUMLAH

Rp.........................

PUSKESMAS I PURWOKERTO TIMUR

Jl. Adipati Mersi No. 51 Purwokerto 53112
"KONSUL GIZI"
Tanggal

No. RM

NAMA

ALAMAT

:
JENIS TINDAKAN

BIAYA

1.....................................................................

Rp.........................

2.....................................................................

Rp.........................

3.....................................................................

Rp.........................

4.....................................................................

Rp.........................

5.....................................................................

Rp.........................

6.....................................................................

Rp.........................

7.....................................................................

Rp.........................

JUMLAH

Rp.........................

PUSKESMAS I PURWOKERTO TIMUR

Jl. Adipati Mersi No. 51 Purwokerto 53112
"KONSUL GIZI"
Tanggal

No. RM

NAMA

ALAMAT

:
JENIS TINDAKAN

BIAYA

1.....................................................................

Rp.........................

2.....................................................................

Rp.........................

3.....................................................................

Rp.........................

4.....................................................................

Rp.........................

5.....................................................................

Rp.........................

6.....................................................................

Rp.........................

7.....................................................................

Rp.........................

JUMLAH

Rp.........................

PUSKESMAS I PURWOKERTO TIMUR

Jl. Adipati Mersi No. 51 Purwokerto 53112
"KONSUL GIZI"
Tanggal

No. RM

NAMA

ALAMAT

:
JENIS TINDAKAN

BIAYA

1.....................................................................

Rp.........................

2.....................................................................

Rp.........................

3.....................................................................

Rp.........................

4.....................................................................

Rp.........................

5.....................................................................

Rp.........................

6.....................................................................

Rp.........................

7.....................................................................

Rp.........................

JUMLAH

Rp.........................