RUMAH SAKIT "SYLVANI"

Jl. Perintis Kemerdekaan No. 21 Binjai - Sumatera Utara

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

RINCIAN KWITANSI PENERIMAAN

Sudah diterima dari : JULIANA NASUTION Banyaknya Uang : Rp. 7,211,000.00
Untuk Pembayaran Biaya Perobatan 10:50:36
Nama Pasien : JULIANA NASUTION No. Faktur : RI-140519-0001
Umur Pasien : 49 Tahun No. Rekam Medis : 049351
Jenis Kelamin : P No. Kunjungan : 0002
Alamat : JL KENANGA No. Rawatan : 016240
Status Pasien : BPJS Tanggal Bayar : 14 May 2019
Kamar : Kelas II-309 A Kelas : Kelas II
Tanggal Rawatan : 11-05-2019 S/D 14-05-2019

KETERANGAN HARGA QTY JUMLAH (Rp)

PROSEDUR BEDAH

:Honor Dokter Anastesi Paket Operasi-dr. T. 11/05/19 22:08:55 550,000 1 550,000

Muda Puteh, Sp.An
:Honor Dokter Paket Operasi 11/05/19 22:08:48 2,300,000 1 2,300,000
Histerectomy-dr.Sugianto,Sp.OG
:SEWA KAMAR OK 11/05/19 22:09:05 600,000 1 600,000

JUMLAH 3,450,000
KONSULTASI

:Honor Visite Doctor Spesialis Kelas 11/05/19 23:47:27 85,000 1 85,000

II-dr.Sugianto,Sp.OG
:Honor Visite Doctor Spesialis Kelas 12/05/19 17:48:07 85,000 1 85,000
II-dr.Sugianto,Sp.OG
:Honor Visite Doctor Spesialis Kelas 13/05/19 17:48:34 85,000 1 85,000
II-dr.Sugianto,Sp.OG
:Honor Visite Doctor Spesialis Kelas 14/05/19 10:48:58 85,000 1 85,000
II-dr.Sugianto,Sp.OG
:Konsultasi Dokter Spesialis (Rawat Inap) 11/05/19 16:31:17 60,000 1 60,000
- dr.Sugianto,Sp.OG

:HONOR DOKTER UMUM - dr. Syahadatina 11/05/19 16:31:28 30,000 1 30,000

JUMLAH 430,000
PENUNJANG

:EKG 11/05/19 16:31:48 100,000 1 100,000

JUMLAH 100,000
LABORATORIUM

:Urine Rutin 11/05/19 55,000 1 55,000

:Glukosa Sewaktu 11/05/19 45,000 1 45,000
:Darah Lengkap Automatic 11/05/19 125,000 1 125,000
:Pemeriksaan Jaringan ( PA ) 11/05/19 23:46:46 450,000 1 450,000

JUMLAH 675,000
KAMAR / AKOMODASI

:Kelas II 11/05/19 16:33:42 200,000 4 800,000

JUMLAH 800,000
OBAT
OBAT

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 KETERANGAN HARGA QTY JUMLAH (Rp)
:Aquabidest 25 ml otsu 11/05/19 23:08:28 10,000 1 10,000
:Asam Mefenamat 12/05/19 09:40:02 1,000 3 3,000
:Asam Mefenamat 13/05/19 09:32:52 1,000 3 3,000
:Asam Mefenamat 14/05/19 09:09:38 1,000 10 10,000
:Asam traneksamat injeksi 11/05/19 22:10:45 35,000 2 70,000
:Atropine Sulfat 0,25 mg inj 11/05/19 22:10:45 25,000 1 25,000
:Cefotaxime 1 gr 12/05/19 00:51:59 45,000 2 90,000
:Cefotaxime 1 gr 11/05/19 23:08:28 45,000 1 45,000
:Ciprofloxacin 500 mg 12/05/19 09:40:02 2,000 2 4,000
:Ciprofloxacin 500 mg 13/05/19 09:32:52 2,000 2 4,000
:Ciprofloxacin 500 mg 14/05/19 09:09:38 2,000 10 20,000
:Hypafix 5m x 10cm 14/05/19 09:12:23 2,000 20 40,000
:Hypafix 5m x 10cm 11/05/19 22:10:45 2,000 20 40,000
:Hypafix 5m x 10cm 11/05/19 23:08:28 2,000 10 20,000
:Ketorolac 30 mg inj 11/05/19 22:10:45 37,000 1 37,000
:Ketorolac 30 mg inj 12/05/19 00:51:59 37,000 3 111,000
:NaCl 0,9% 500 ml Wida 11/05/19 22:10:45 30,000 1 30,000
:Ondansetron 4 mg/2 ml inj 11/05/19 22:10:45 35,000 1 35,000
:Ranitidine injeksi 12/05/19 00:51:59 35,000 2 70,000
:Ringer Lactat Sanbe 500 mL 11/05/19 22:10:45 30,000 2 60,000
:Ringer Lactat Sanbe 500 mL 12/05/19 00:51:59 30,000 2 60,000
:Ringer Lactat Sanbe 500 mL 11/05/19 23:08:28 30,000 1 30,000
:Stomach sirup 12/05/19 00:51:59 15,000 1 15,000
:Pyrex tab 12/05/19 00:51:59 1,000 3 3,000
:Regivell 4 ml inj 11/05/19 22:10:45 121,000 1 121,000
:Aqua pro 20 ml 12/05/19 00:51:59 10,000 1 10,000

JUMLAH 966,000
ALKES
ALKES
:Spuit 3 cc onemed 12/05/19 00:51:59 10,000 2 20,000
:Spuit 3 cc onemed 11/05/19 22:10:45 10,000 1 10,000
:Spuit 5 cc onemed 12/05/19 00:51:59 10,000 1 10,000
:Spuit 5 cc onemed 11/05/19 23:08:28 10,000 1 10,000
:Spuit 5 cc onemed 11/05/19 22:10:45 10,000 1 10,000
:Nald no. 27G Terumo 11/05/19 23:08:28 5,000 1 5,000
:Spinocain 256 B.Braun 11/05/19 22:10:45 97,000 1 97,000
:Pisau cukur bilette goal 11/05/19 23:08:28 5,000 1 5,000
:Urin Bag 11/05/19 22:10:45 18,000 1 18,000
:Benang Assucryl No. 3/0 11/05/19 22:10:45 200,000 1 200,000
:Handscoon non steril S 11/05/19 22:10:45 16,000 2 32,000
:Pisau Bisturi No. 23 11/05/19 22:10:45 12,000 1 12,000
:Masker PD Mask 11/05/19 22:10:45 3,000 6 18,000
:Folley chateter No.18 11/05/19 22:10:45 40,000 1 40,000
:Handscoon steril no. 7,5 11/05/19 22:10:45 25,000 3 75,000
:Handscoon steril no. 6,5 11/05/19 22:10:45 25,000 1 25,000
:Infuset dewasa 11/05/19 23:08:28 73,000 1 73,000
:Abbocath no. 18 11/05/19 23:08:28 30,000 1 30,000
:Benang Silk (Side) no. 1 11/05/19 22:10:45 100,000 1 100,000

JUMLAH 790,000

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 KETERANGAN HARGA QTY JUMLAH (Rp)

: Total Rp. 7,211,000

:
: 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. 7,211,000
:
Terbilang : ( Tujuh Juta Dua Ratus Sebelas Ribu Rupiah )

Payment : TIDAK TUNAI

-- TIDAK TUNAI : 7,211,000

Binjai, 14 May 2019

Pasien : Kasir

JULIANA NASUTION Suci Widiarti

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