RUMAH SAKIT "SYLVANI"

Jl. Perintis Kemerdekaan No. 21 Binjai - Sumatera Utara

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

RINCIAN KWITANSI PENERIMAAN

Sudah diterima dari : TANIA IMELDA Banyaknya Uang : Rp. 2,172,000.00
Untuk Pembayaran Biaya Perobatan 20:55:15
Nama Pasien : TANIA IMELDA No. Faktur : RI-210519-0001
Umur Pasien : 2 Tahun No. Rekam Medis : 045230
Jenis Kelamin : P No. Kunjungan : 0007
Alamat : JL MELATI No. Rawatan : 016380
Status Pasien : BPJS Tanggal Bayar : 21 May 2019
Kamar : Kelas III-209 B Kelas : Kelas III
Tanggal Rawatan : 18-05-2019 S/D 21-05-2019

KETERANGAN HARGA QTY JUMLAH (Rp)

KONSULTASI

:Honor Visite Doctor Spesialis Kelas 21/05/19 09:15:33 80,000 1 80,000

III-dr.Viviana, Sp.A
:Honor Visite Doctor Spesialis Kelas 19/05/19 10:54:24 80,000 1 80,000
III-dr.Viviana, Sp.A
:Honor Visite Doctor Spesialis Kelas 20/05/19 08:54:40 80,000 1 80,000
III-dr.Viviana, Sp.A
:Konsultasi Dokter Spesialis (Rawat Inap) 18/05/19 15:50:35 60,000 1 60,000
- dr.Viviana, Sp.A

:HONOR DOKTER UMUM - dr.Siti Fatimah 18/05/19 15:50:42 30,000 1 30,000

JUMLAH 330,000
LABORATORIUM

:FAECES RUTIN 19/05/19 09:35:11 80,000 1 80,000

:Darah Lengkap Automatic 18/05/19 21:31:00 125,000 1 125,000

JUMLAH 205,000
KAMAR / AKOMODASI

:Kelas III 18/05/19 17:14:48 150,000 4 600,000

JUMLAH 600,000
OBAT
OBAT
:Hypafix 5m x 10cm 18/05/19 15:51:37 2,000 10 20,000
:L-bio Sachet 19/05/19 08:57:33 10,000 2 20,000
:L-bio Sachet 18/05/19 17:46:52 10,000 10 100,000
:L-bio Sachet 18/05/19 15:51:37 10,000 2 20,000
:Ondansetron 4 mg/2 ml inj 20/05/19 09:51:54 35,000 1 35,000
:Ondansetron 4 mg/2 ml inj 19/05/19 08:57:33 35,000 1 35,000
:Ondansetron 4 mg/2 ml inj 18/05/19 15:51:37 35,000 1 35,000
:Pragesol inj @10 amp 20/05/19 09:51:54 35,000 1 35,000
:Pragesol inj @10 amp 18/05/19 15:51:37 35,000 1 35,000
:Pragesol inj @10 amp 19/05/19 08:57:33 35,000 1 35,000
:Ringer Lactat Sanbe 500 mL 19/05/19 08:57:33 30,000 3 90,000
:Ringer Lactat Sanbe 500 mL 20/05/19 09:51:54 30,000 3 90,000
:Domperidon syr 18/05/19 17:46:52 45,000 1 45,000
:Zinkid Syr 18/05/19 15:51:37 54,000 1 54,000
:Paracetamol syr 18/05/19 17:46:52 15,000 1 15,000
:Ringer Lactat 500 ml ECOSOL Bbraun 18/05/19 15:51:37 30,000 1 30,000
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 KETERANGAN HARGA QTY JUMLAH (Rp)
:Vitacur syr 18/05/19 17:46:52 45,000 1 45,000
:Pyrex Drop 21/05/19 09:13:25 40,000 1 40,000

JUMLAH 779,000
ALKES
ALKES
:Spuit 3 cc onemed 19/05/19 08:57:33 10,000 1 10,000
:Spuit 3 cc onemed 18/05/19 15:51:37 10,000 2 20,000
:Spuit 5 cc onemed 19/05/19 08:57:33 10,000 1 10,000
:Extension Tube 18/05/19 15:51:37 83,000 1 83,000
:Infuset Anak 18/05/19 15:51:37 75,000 1 75,000
:Abbocat no. 24 18/05/19 15:51:37 30,000 2 60,000

JUMLAH 258,000

: Total Rp. 2,172,000

:
: 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. 2,172,000
:
Terbilang : ( Dua Juta Seratus Tujuh Puluh Dua Ribu Rupiah )

Payment : TIDAK TUNAI

-- TIDAK TUNAI : 2,172,000

Binjai, 21 May 2019

Pasien : Kasir

TANIA IMELDA Suci Widiarti

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