RUMAH SAKIT "SYLVANI"

Jl. Perintis Kemerdekaan No. 21 Binjai - Sumatera Utara

Telp. (061) 80045925, Fax. (061) 80045923

RINCIAN KWITANSI PENERIMAAN

Sudah diterima dari : ZAINAB Banyaknya Uang : Rp. 12,704,500.00
Untuk Pembayaran Biaya Perobatan 21:14:30
Nama Pasien : ZAINAB No. Faktur : RI-020619-0018
Umur Pasien : 37 Tahun No. Rekam Medis : 049265
Jenis Kelamin : P No. Kunjungan : 0004
Alamat : DUSUN MANDIRI No. Rawatan : 016560
Status Pasien : BPJS Tanggal Bayar : 02 June 2019
Kamar : Kelas I-303 B Kelas : Kelas I
Tanggal Rawatan : 28-05-2019 S/D 02-06-2019

KETERANGAN HARGA QTY JUMLAH (Rp)

dakan Medik :

:Tranfusi Darah 30/05/19 21:37:46 450,000 2 900,000

JUMLAH 900,000
PROSEDUR BEDAH

:Honor Dokter Paket Operasi SC (Sectio 30/05/19 19:37:40 1,700,000 1 1,700,000

Caesaria)-dr.Sugianto,Sp.OG
:Honor Dokter Anastesi Paket Operasi-dr. T. 30/05/19 19:38:02 550,000 1 550,000
Muda Puteh, Sp.An
:Honor Dokter anak mendampingi Operasi SC 30/05/19 19:37:56 225,000 1 225,000
(Sectio Caesaria)-dr.Viviana, Sp.A
:SEWA KAMAR OK 30/05/19 19:38:12 600,000 1 600,000

JUMLAH 3,075,000
KONSULTASI

:Honor Visite Doctor Spesialis Kelas 28/05/19 15:34:16 90,000 1 90,000

I-dr.Sugianto,Sp.OG
:Honor Visite Doctor Spesialis Kelas 02/06/19 19:32:31 90,000 1 90,000
I-dr.Sugianto,Sp.OG
:Honor Visite Doctor Spesialis Kelas 01/06/19 19:32:58 90,000 1 90,000
I-dr.Sugianto,Sp.OG
:Honor Visite Dokter Spesialis ICU-dr. T. 30/05/19 21:38:35 250,000 1 250,000
Muda Puteh, Sp.An
:Honor Visite Dokter Spesialis 31/05/19 20:48:25 250,000 1 250,000
ICU-dr.Sugianto,Sp.OG
:Honor Visite Dokter Spesialis ICU-dr. T. 31/05/19 20:50:03 250,000 1 250,000
Muda Puteh, Sp.An
:Honor Visite Dokter Spesialis 30/05/19 21:38:10 250,000 1 250,000
ICU-dr.Sugianto,Sp.OG
:Konsultasi Dokter Spesialis (Rawat Inap) 28/05/19 11:32:53 60,000 1 60,000
- dr.Sugianto,Sp.OG

:HONOR DOKTER UMUM - dr.Jhon Barnes Manihuruk 28/05/19 11:32:36 30,000 1 30,000

JUMLAH 1,360,000
RADIOLOGI

:USG Kebidanan 3 Dimensi 30/05/19 17:09:24 150,000 1 150,000

JUMLAH 150,000
LABORATORIUM

:Glukosa Sewaktu 28/05/19 45,000 1 45,000

:Darah Lengkap Automatic 28/05/19 125,000 1 125,000
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 KETERANGAN HARGA QTY JUMLAH (Rp)
:Darah Lengkap Automatic 30/05/19 15:38:06 125,000 1 125,000
:Darah Lengkap Automatic 31/05/19 13:15:38 125,000 1 125,000

JUMLAH 420,000
KAMAR / AKOMODASI

:Kelas I 28/05/19 13:59:52 250,000 2 500,000

:Kelas I 01/06/19 20:55:11 250,000 2 500,000
:ICU 30/05/19 18:30:47 800,000 2 1,600,000

JUMLAH 2,600,000
OBAT
OBAT
:Aquabidest 25 ml otsu 30/05/19 23:37:47 10,000 2 20,000
:Aquabidest 25 ml otsu 30/05/19 17:36:10 10,000 1 10,000
:Aquabidest 25 ml otsu 30/05/19 23:47:56 10,000 1 10,000
:Asam Mefenamat 02/06/19 09:17:20 1,000 10 10,000
:Asam Mefenamat 01/06/19 10:02:25 1,000 3 3,000
:Asam Mefenamat 31/05/19 21:01:33 1,000 2 2,000
:Asam traneksamat injeksi 30/05/19 09:27:45 35,000 3 105,000
:Asam traneksamat injeksi 28/05/19 11:23:58 35,000 1 35,000
:Asam traneksamat injeksi 28/05/19 14:04:15 35,000 3 105,000
:Asam traneksamat injeksi 29/05/19 09:38:03 35,000 3 105,000
:Asam traneksamat injeksi 31/05/19 08:32:57 35,000 3 105,000
:Asam traneksamat injeksi 30/05/19 19:39:09 35,000 2 70,000
:Bledstop @100 30/05/19 09:27:45 3,500 1 3,500
:Bledstop @100 28/05/19 21:36:30 3,500 1 3,500
:Bledstop @100 29/05/19 09:38:03 3,500 1 3,500
:Cefotaxime 1 gr 30/05/19 17:36:10 45,000 1 45,000
:Cefotaxime 1 gr 30/05/19 23:37:47 45,000 3 135,000
:Cefotaxime 1 gr 30/05/19 23:47:56 45,000 1 45,000
:Ciprofloxacin 500 mg 01/06/19 10:02:25 2,000 2 4,000
:Ciprofloxacin 500 mg 02/06/19 09:17:20 2,000 10 20,000
:Ciprofloxacin 500 mg 31/05/19 21:01:33 2,000 2 4,000
:Dexamethason inj 30/05/19 20:21:46 25,000 1 25,000
:Dexamethason inj 30/05/19 17:34:38 25,000 3 75,000
:Dexamethason inj 30/05/19 19:39:09 25,000 1 25,000
:Duvadilan tab 30/05/19 09:27:45 8,000 1 8,000
:Duvadilan tab 29/05/19 23:27:38 8,000 1 8,000
:Hypafix 5m x 10cm 02/06/19 09:17:20 2,000 20 40,000
:Hypafix 5m x 10cm 28/05/19 11:23:58 2,000 10 20,000
:Hypafix 5m x 10cm 30/05/19 19:39:09 2,000 20 40,000
:Hypafix 5m x 10cm 30/05/19 23:47:56 2,000 10 20,000
:Ketamin inj 30/05/19 19:39:09 300,000 1 300,000
:Ketorolac 30 mg inj 30/05/19 23:37:47 37,000 3 111,000
:Ketorolac 30 mg inj 30/05/19 19:39:09 37,000 1 37,000
:NaCl 0,9% 500 ml Wida 30/05/19 19:39:09 30,000 1 30,000
:Ondansetron 4 mg/2 ml inj 30/05/19 19:39:09 35,000 1 35,000
:Ringer Lactat Sanbe 500 mL 30/05/19 09:27:45 30,000 3 90,000
:Ringer Lactat Sanbe 500 mL 30/05/19 19:39:09 30,000 2 60,000
:Ringer Lactat Sanbe 500 mL 30/05/19 17:36:10 30,000 1 30,000
:Ringer Lactat Sanbe 500 mL 28/05/19 11:23:58 30,000 1 30,000
:Ringer Lactat Sanbe 500 mL 30/05/19 23:37:47 30,000 2 60,000
:Ringer Lactat Sanbe 500 mL 28/05/19 14:04:15 30,000 3 90,000

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 KETERANGAN HARGA QTY JUMLAH (Rp)
:Ringer Lactat Sanbe 500 mL 29/05/19 09:38:03 30,000 2 60,000
:Ringer Lactat Sanbe 500 mL 30/05/19 23:47:56 30,000 1 30,000
:Widahes 30/05/19 19:39:09 250,000 1 250,000
:Folavit 400 mcg 30/05/19 09:27:45 2,000 1 2,000
:Folavit 400 mcg 28/05/19 21:36:30 2,000 1 2,000
:Folavit 400 mcg 29/05/19 09:38:03 2,000 1 2,000
:Methylergometrine injeksi 30/05/19 19:39:09 25,000 1 25,000
:Oksitosin injeksi 30/05/19 19:39:09 25,000 2 50,000
:Stomach sirup 30/05/19 23:37:47 15,000 1 15,000
:Emibion Cap 30/05/19 09:27:45 3,000 1 3,000
:Emibion Cap 28/05/19 21:36:30 3,000 1 3,000
:Emibion Cap 29/05/19 09:38:03 3,000 1 3,000
:Fentanyl inj 30/05/19 19:39:09 70,000 1 70,000

JUMLAH 2,492,500
ALKES

:Monitoring ICU/ hari 30/05/19 21:09:47 150,000 1 150,000

:Monitoring ICU/ hari 31/05/19 20:50:35 150,000 1 150,000

JUMLAH 300,000
ALKES
:Spuit 3 cc onemed 30/05/19 20:21:46 10,000 1 10,000
:Spuit 3 cc onemed 30/05/19 19:39:09 10,000 2 20,000
:Spuit 3 cc onemed 30/05/19 23:37:47 10,000 3 30,000
:Spuit 5 cc onemed 30/05/19 23:47:56 10,000 1 10,000
:Spuit 5 cc onemed 28/05/19 11:23:58 10,000 2 20,000
:Spuit 5 cc onemed 30/05/19 17:36:10 10,000 1 10,000
:Spuit 5 cc onemed 30/05/19 23:37:47 10,000 1 10,000
:Nald no. 27G Terumo 30/05/19 23:47:56 5,000 1 5,000
:Nald no. 27G Terumo 30/05/19 17:36:10 5,000 1 5,000
:Spuit 10 cc onemed 30/05/19 19:39:09 15,000 2 30,000
:Pisau cukur bilette goal 30/05/19 23:47:56 5,000 1 5,000
:Urin Bag 30/05/19 19:39:09 18,000 1 18,000
:Abbocath NO. 20 28/05/19 11:23:58 30,000 1 30,000
:Abbocath NO. 22 28/05/19 11:23:58 30,000 1 30,000
:Benang Assucryl No.1 30/05/19 19:39:09 200,000 1 200,000
:Benang Assucryl No. 3/0 30/05/19 19:39:09 200,000 1 200,000
:Handscoon non steril S 30/05/19 19:39:09 16,000 2 32,000
:Masker PD Mask 30/05/19 19:39:09 3,000 6 18,000
:Folley chateter No.18 30/05/19 19:39:09 40,000 1 40,000
:Handscoon steril no. 7,5 30/05/19 19:39:09 25,000 3 75,000
:Handscoon steril no. 6,5 30/05/19 19:39:09 25,000 1 25,000
:Infuset dewasa 28/05/19 11:23:58 73,000 1 73,000
:Infuset dewasa 30/05/19 17:36:10 73,000 1 73,000
:Infuset dewasa 30/05/19 23:47:56 73,000 1 73,000
:Abbocath no. 18 30/05/19 23:47:56 30,000 1 30,000
:Blood Transfusion Set 30/05/19 20:21:46 60,000 1 60,000

JUMLAH 1,132,000
BMHP

:Oksigen Central/ Jam dewasa 31/05/19 20:51:06 25,000 1 25,000

JUMLAH 25,000

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 KETERANGAN HARGA QTY JUMLAH (Rp)
ALAT MEDIS

:Pemasangan Infus Pump 31/05/19 20:50:46 250,000 1 250,000

JUMLAH 250,000

: Total Rp. 12,704,500

:
: Discount Jasa Honor Dokter Rp. 0
: Jasa Rumah Sakit Rp. 0
Retur Obat / Alkes Rp. 0
Total Discount/pot. Retur Rp. 0
Deposite Pasien Rp.
: Total Bayar Rp. 12,704,500
:
Terbilang : ( Dua Belas Juta Tujuh Ratus Empat Ribu Lima Ratus Rupiah )

Payment : TIDAK TUNAI

-- TIDAK TUNAI : 12,704,500

Binjai, 02 June 2019

Pasien : Kasir

ZAINAB Suci Widiarti

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