KEPOLISIAN NEGARA REPUBLIK INDONESIA

DAERAH BALI
RUMKIT BHAYANGKARA DENPASAR

RINCIAN ANGGARAN BIAYA STANDAR BIAYA KHUSUS SEBAGAI TOTAL BIAYA KELUARAN

Kementerian negara/lembaga : Kepolisian Negara Republik Indonesia

Unit Eselon I : Polda Bali
Program : Dukungan Manajemen dan Pelaksanaan Tugas Teknis Lainnya Polri
Hasil : Terwujudnya Perawatan Kesehatan Personil Polri dan PNS Polri secara Berkala
Unit Eselon II : Rumkit Bhayangkara Denpasar
Kegiatan : Pelayanan Kesehatan Polri
Indikator Kinerja Kegiatan : Jumlah personil / pasien terlayani dengan baik
Satuan Ukur dan jenis keluaran : Bulan dan layanan perkantoran.
Volume : 12 Bulan

Satuan Biaya
No Tahapan Pelaksanaan dan Rincian Komponen Biaya Volume Jumlah Keterangan
Ukur Satuan Ukur
1 2 3 4 5 6 = ( 3x5 ) 7

3072 Pelayanan Kesehatan Polri

002 Penyelenggaraan Opersional dan Pemeliharaan perkantoran 2,766,357,000

521119 Belanja Barang Operasional Lainnya 455,050,000

1 Jasa Tindakan Konsultan (1 x 1) terdiri dari : 1 THN 382,050,000 382,050,000

- Apendesitis 30 Tindakan 1,312,500 39,375,000

- Varicocele 15 Tindakan 1,260,000 18,900,000

- Hernia 10 Tindakan 1,260,000 12,600,000

- Hemoroid 5 Tindakan 1,050,000 5,250,000

 - Tumor Simple 20 Tindakan 1,050,000 21,000,000

- Fraktur 20 Tindakan 3,500,000 70,000,000

- Aff Plate Screw 20 Tindakan 1,750,000 35,000,000

- Tonsil Hipertropi 20 Tindakan 1,050,000 21,000,000

- Sinusitis 11 Tindakan 1,050,000 11,550,000

- Cerumen Auricular 200 Tindakan 25,000 5,000,000

- Corpus alienum THT 95 Tindakan 25,000 2,375,000

- Visite dokter di rawat inap 3,500 Tindakan 40,000 140,000,000

2 Pelayanan VER 12 BLN 2,100,000 25,200,000

- Jasa dokter 336 x Rp. 40.000,- 336 Tindakan 40,000 13,440,000

- Jasa perawat 336 x Rp. 5.000,- 336 Tindakan 5,000 1,680,000

- Fasilitas RS 336 x Rp. 25.000,- 336 Tindakan 25,000 8,400,000

- Administrasi RS. 336 x 5.000,- 336 Tindakan 5,000 1,680,000

> PERAWATAN PASIEN TAHANAN 47,800,000

1 Rawat Jalan 120 OT 165,000 19,800,000

- Administrasi Rumkit 120 OT 5,000 600,000

- Jasa Medik 120 OT 45,000 5,400,000

- Obat-obatan dan fasilitas RS. 120 OT 115,000 13,800,000
2 Rawat Inap 28 OT 1,000,000 28,000,000

- Kamar 28 OT 300,000 8,400,000

- Jasa medik ( dokter dan perawat ) 28 OT 275,000 7,700,000

- Jaspel gizi & makanan 28 OT 100,000 2,800,000

- Jasa Rumkit 28 OT 125,000 3,500,000

- Obat-obatan 28 OT 190,000 5,320,000

- Administrasi 28 OT 10,000 280,000

525112 Belanja Barang ( BLU ) 697,515,000

1 Peningkatan Gizi Pasien Umum 90,200,000
Umum :

- VIP 115 OT 55,000 6,325,000

- Klas I 527 OT 45,000 23,715,000

- Klas II 7,326 OT 35,000 25,641,000

- Klas III 588 OT 33,000 19,404,000

- ICU 38 OT 48,000 1,825,000

Askes :

- VIP 86 OT 55,000 4,730,000

- Klas I 331 OT 20,000 6,620,000

- Klas II 87 OT 18,000 1,566,000

- ICU 15 OT 25,000 375,000

2 Subsidi silang peningkatan gizi pasien dinas 15,200,000

- VIP 209 OT 17,500 3,657,500

- Klas I 276 OT 6,500 1,794,000

- Klas II / ICU 907 OT 1,500 1,360,500

- Klas III 5,592 OT 1,500 8,388,000

3 Rujukan diagnostik dan terapi pasien dinas 43,030,000

Diagnotis :

- USG 90 OT 300,000 27,000,000

- CT Scan 10 OT 500,000 5,000,000

- Laboratorium 3,665 OT 200,000 7,330,000

Terapi :

- Haemodialisis ( HD ) 2 OT 600,000 1,200,000

- ESWL 1 OT 250,000 2,500,000

4 Subsidi silang obat/alkes/readgen/penunjang umum pasien dinas 549,085,000

- Brancard dorong 2 Buah 12,320,000 24,640,000

- Doppler Bistor Model BI-200 2 Buah 6,490,000 12,980,000

- ECG1/3Chanel Fukuda Denzi 1 Unit 28,215,000 28,215,000

- Kursi Roda 1 Buah 6,050,000 6,050,000

- Stetoscope 5 Set 594,000 2,970,000

- Suction curete 1 Unit 43,560,000 43,560,000
- Thermometer digital 10 Unit 85,800 858,000

- Cautrisasi doctan 40 U 1 Unit 49,500,000 49,500,000

- Ekg fukudda 2 chanel mediana 1 Unit 32,670,000 32,670,000

- Tensimeter digital Hem 907 1 Unit 4,537,500 4,537,500

- Tensimeter digital IA 2 2 Unit 1,815,000 3,630,000

- NaCl 200 Fles 9,768 1,953,600

- NaCl 100 ml 300 Fles 9,559 2,867,700

- Natrium diclofenac 300 Tablet 240 71,940

- Neo k inj 20 Ampul 12,100 242,000

- Netacort Zalf 50 Tube 7,436 371,800

- Neurobion 5000 300 Tablet 2,287 686,070

- Neurobion 5000 inj 200 Ampul 6,292 1,258,400

- Neuroboran inj 100 Vial 8,580 858,000

- Neurosanbe 500 Tablet 957 478,500

- Ngt no 16 3 Buah 21,780 65,340

- Ngt no 18 3 Buah 21,780 65,340

- Ngt no 5 3 Buah 18,480 55,440

- Ngt no 8 3 Buah 18,480 55,440

- Ngt no 8 100 cm 3 Buah 18,480 55,440

- Ngt no 10 3 Buah 21,780 65,340

- Ngt no 12 3 Buah 21,780 65,340

- Ngt no 14 3 Buah 21,780 65,340

- Nifedipin 500 Tablet 131 65,450

- Non Flamin 300 Capsule 3,527 1,057,980

- Norvask 5 mg 180 Tablet 7,662 1,379,070

- Norvom 300 Tablet 358 107,250

- Norvom syr 50 Botol 9,735 486,750

- Novalgin inj 100 Ampul 9,660 966,020

- Nutrifar 500 Tablet 704 352,000

- Obh syr 100 Botol 3,850 385,000

- Obyek gelas 24 Buah 23,797 571,138

- Oco 3 Botol 105,600 316,800

- omnitest 4 Buah 441,320 1,765,280

- Ondancentron 4 mg inj 120 Ampul 6,050 726,000

- Ondancentron 8 mg inj 120 Ampul 8,800 1,056,000

- Otoopain TT 15 Botol 36,300 544,500

- Oxytocin inj 100 Ampul 5,819 581,900

- Pehacain inj 50 Ampul 7,865 393,250

- Pethidin inj 100 Ampul 12,980 1,298,000

- Pharmaton Formula 800 Tablet 2,816 2,252,800

- Phenitoin inj 20 Ampul 68,486 1,369,720

- Phenobarbital 30 mg 1,000 Tablet 55 55,000

- Piracetam 1200 mg 500 Tablet 1,447 723,250

- Piracetam 800 mg 500 Tablet 920 459,800

- Piracetam inj 75 Ampul 24,728 1,854,600

- Pot urine / plastik 150 Buah 1,595 239,250

- Profenid supp 50 Supp 14,718 735,900

- Prolene 1/0 W 742 6 Buah 99,490 596,937

- Prolene 2/0 6 Buah 91,421 548,526

- Prolene 3/0 6 Buah 83,490 500,940

- Prolene 4/0 6 Buah 83,490 500,940

- Prolene 5/0 W 527 6 Buah 83,490 500,940

- Prolene 6/0 W 523 6 Buah 83,490 500,940

- Prostigmin inj 50 Ampul 14,850 742,500

- Pulmicort 50 Ampul 51,667 2,583,350

- Pyridol drop 50 Botol 22,660 1,133,000

- Pyridryl 60 ml 50 Botol 12,650 632,500

- Quantidex syr 75 Botol 10,802 810,150

- Ranitidin inj 100 Ampul 2,816 281,600

Tablet
- Renabetic 5 mg 500 164 81,950
 Tablet
- Restor 100 mg 500 605 302,500
Tablet
- Reverton 500 440 220,000
Botol
- Reverton syr 100 10,615 1,061,500
- Rihest 100 Tablet 1,180 118,030
Botol
- Rivanol 300 ml 12 4,477 53,724
Fles
- RL 250 10,406 2,601,500
Tablet
- Sakaneuron 500 531 265,650
Tablet
- Salbutamol 2 mg 750 98 73,425
500 Tablet
- Salbutamol 4 mg 165 82,500
75 Botol
- Sanadryl 60 ml syr 9,174 688,050
75 Botol
- Sanadryl dmp syr 9,845 738,375
50 Botol
- Sanmag syr 26,840 1,342,000
500 Tablet
- Sanmag Tab 715 357,500
500 Tablet
- Sanmol 500 mg 253 126,500
50 Botol
- Sanmol syr 10,835 541,750
50 Vial
- Sanpicillin inj 17,490 874,500
24 Buah
- Sarung tangan gynocologi 22,990 551,760
75 Box
- Sarung tangan non steril 55,000 4,125,000
357 Tablet
- Scopamin 1,100 392,700
50 Ampul
- Scopamin inj 12,100 605,000
 250 Tablet
- Scopamin Plus 1,375 343,750
- Selvim 500 Tablet 1,122 561,000
100 Box
- Septocain inj 407,000 40,700,000
3 Casset
- Side 2/0 638,000 1,914,000
3 Casset
- Side 3/0 590,964 1,772,892
3 Casset
- Side 4/0 649,000 1,947,000
500 Tablet
- Silum 5mg 3,388 1,694,000
500 Tablet
- Simvastatin 10 mg 564 282,150
50 Buah
- Spinal nedle 27 G BD 39,600 1,980,000
50 Buah
- Spinal nedle 29 G B Braund 53,900 2,695,000
15 Botol
- Spritus 30,140 452,100
250 Botol
- Spuit 10 cc 4,950 1,237,500
500 Buah
- Spuit 3 cc 3,157 1,578,500
250 Buah
- Spuit 5 cc 3,850 962,500
50 Buah
- Spuitzonde 11,880 594,000
2 Liter
- Stabimed 968,000 1,936,000
150 Tablet
- Stelazine 5 mg 835 125,235
25 Supp
- Stesolid supp 28,820 720,500
4 Box
- Stik optium 845,064 3,380,256
Lembar
- Supratull 75 16,060 1,204,500
- Tabung centrifuge 150 Buah 2,365 354,750
Botol
- Tarivid TT 15 75,020 1,125,300
Tablet
- Teamic 500 500 967 483,450
Buah
- Three way stop cock 12 23,595 283,140
Ampul
- Tracrium inj 10 51,150 511,500
Tablet
- Tramadol 500 504 251,900
Ampul
- Tramadol inj 25 7,376 184,388
Tablet
- Transamin 200 3,480 696,080
Ampul
- Transamin inj 25 12,705 317,625
Tablet
- Trianta 500 395 197,450
Botol
- Trianta syr 76 8,239 626,164
Tablet
- Trihexyphenidyl 2 mg 150 44 6,600
Tablet
- Trimensa 500 958 479,050
Ampul
- Trolac inj 50 28,435 1,421,750
Tablet
- Tromilin 500 500 1,075 537,350
Botol
- Tromillin syr 60 ml 100 13,123 1,312,300
Tablet
- Tuzalos 500 664 332,200
Tablet
- Ultravita 750 1,069 801,900
Buah
- Urine bag 60 5,444 326,634
Ampul
- Valisanbe inj 30 11,990 359,700
 Tablet
- Valisanbe 5 mg 250 230 57,475
Ampul
- Ventolin nebuleser 50 9,680 484,000
Roll
- Verban 10 cm 99 2,080 205,930
Tablet
- Vesperum 350 612 214,060
Botol
- Vesperum syr 50 11,605 580,250
Botol
- Vicalcin syr 50 9,295 464,750
Pcs
- Vicryl 0 W 9141 5 91,597 457,985
Pcs
- Vicryl 1 W 9431 5 101,673 508,365
Buah
- Vicryl 2/0 9121 75 cm 5 90,640 453,200
Buah
- Vicryl 2/0 9463 90 cm 5 100,320 501,600
Pcs
- Vicryl 3/0 9511 catting 5 98,846 494,230
- Vicryl 3/0 W 9120 5 Pcs 90,750 453,750
Pcs
- Vicryl 4/0 W 9113 5 86,020 430,100
Pcs
- Vicryl 5/0 W 9105 5 88,924 444,620
Tablet
- Vitamin C 600 22 13,200
Ampul
- Vitamin C inj 160 1,718 274,912
Ampul
- Vitamin K inj 100 3,300 330,000
Tablet
- Vitamulti 200 990 198,000
Tube
- Voltaren gel 12 42,625 511,500
Buah
- Wing nedle no 25 50 10,890 544,500
 Vial
- Xilomidon inj 50 6,655 332,750
Zak
- Yellow tip 6 423,500 2,541,000
Tablet
- Yusimox 700 1,307 914,760
Botol
- Yusimox syr 100 9,422 942,150
Ampul
- Zantadin inj 50 18,150 907,500
Tablet
- Zantifar 600 770 462,000
Tablet
- Zendiab 600 847 508,200
Tablet
- Zink 500 523 261,250
Botol
- O2 Besar 60 96,800 5,808,000
- O2 kecil 100 Botol 55,000 5,500,000
Kg
- N2O 25 122,100 3,052,500
Kit
- Bilirubin total / direc 5 1,620,438 8,102,188
Kit
- Bilirubin inderec 5 1,444,300 7,221,500
Kit
- Bun 500 ml 5 2,228,820 11,144,100
Botol
- Celloclean E 500 ml 5 1,322,200 6,611,000
Kit
- Cholesterol 5 5,892,563 29,462,813
Kit
- Cholesterol HDL 5 10,128,250 50,641,250
Kit
- Cleaner C 5 715,000 3,575,000
Buah
- Combur test 5 438,995 2,194,975
Botol
- Control para 12 5 641,300 3,206,500
 Kit
- Creatine 5 3,300,000 16,500,000
5 Botol
- Diluen 4,725,270 23,626,350
5 Kit
- Golongan darah 562,650 2,813,250
5 Box
- HbSAG 1,028,500 5,142,500
5 Kit
- Hdl 200 ml 1,537,910 7,689,550
5 Botol
- Reagen Benedict 488,180 2,440,900

525113 Belanja Jasa ( BLU ) 1,613,792,000

1 Rawat Jalan 351,798,000
Pemeriksaan :
2380 Orang
- dokter spesialis ( Medis, paramedis ) 55,000 130,900,000
7363,26 Orang
- dokter umum ( Medis, paramedis ) 30,000 220,898,000

2 Bedah Sentral 563,597,000

36 tindakan
- Operasi ringan 1,011,375 36,409,500
95 tindakan
- Operasi sedang 1,750,000 166,250,000
115 tindakan
- Operasi berat 2,187,500 251,562,500
20 tindakan
- Operasi extra berat / khusus 5,468,750 109,375,000
3 Jasa Penunjang Medik 90,000,000
Laboratorium : 48,000,000
161 tindakan
- Hematologi rutin 65,000 10,465,000
- Kimia klinik :
268 tindakan
Glukosa 25,000 6,700,000
115 tindakan
Cholesterol 30,000 3,450,000
85 tindakan
Trigliseride 35,000 2,975,000
10 tindakan
HDL Cholesterol 40,000 400,000
6 tindakan
LDL Cholesterol 55,000 330,000
105 tindakan
Ureum 30,000 3,150,000
152 tindakan
Creatinin 30,000 4,560,000
109 tindakan
Urice Acid 35,000 3,815,000
86 tindakan
SGOT 30,000 2,580,000
86 tindakan
SGPT 30,000 2,580,000
3 tindakan
Billirubin 35,000 105,000
- Imunoserologi :
16 tindakan
Widal 50,000 800,000
10 tindakan
HBsAg 50,000 500,000
124 tindakan
- Urine lengkap : 30,000 3,720,000
- Lain-lain :
2 tindakan
Faeses lengkap 35,000 70,000
35 tindakan
Bliding Time 17,500 612,500
 Clooting Time 35 tindakan 17,500 612,500
15 tindakan
Golongan darah 25,000 375,000
8 tindakan
PP test 25,000 200,000

600 tindakan
Radiologi 70,000 42,000,000

4 Insentif Petugas Siaga Ambulance

- Jasa para medis ( perawat ) 80 Giat 30,000 2,400,000
80 Giat
- Jasa sopir 30,000 2,400,000

5 Rawat Inap : 603,597,000

- VIP 264 Or 445,000 117,480,000
480 Or
- Klas I 376,000 180,480,000
660 Or
- Klas II 256,000 168,960,000
672 Or
- ICU 203,388 136,677,000

TOTAL BIAYA KELUARAN 2,766,357,000

Denpasar, Oktober 2011

Paraf Petugas Penelaah KARUMKIT BHAYANGKARA DENPASAR
K/L DJA Selaku
…………….. …………….. KUASA PENGGUNA ANGGARAN

dr. DIDIET SETIOBOEDI,Sp.THT-KL.DFM

AJUN KOMISARIS BESAR POLISI NRP 66050672