WOUND HEALING CENTER

PUSKESMAS ATARI JAYA

RINCIAN BIAYA WOUND CARE

Nama Pasien :……………………………………

Umur :……………………………………
Alamat :……………………………………
Tgl Masuk :……………………………………
Tgl Keluar :……………………………………
N Uraian Satuan Biaya Jumlah
o
1 Administrasi Rp.............. Rp..................
.....
2 Biaya Perawatan Rp....................... Rp..................
/Cleansing/Dressing .....
3 Konsultasi Dokter Rp....................... Rp..................
.....
4 asistensi Rp....................... Rp..................
.....
6 BHP / DRESSING Rp....................... Rp..................
.....
 Caiaran NACL, O,9% Rp....................... Rp..................
.....
 Kasa Rp....................... Rp..................
.....
 Crep Bandage Rp....................... Rp..................
.....
 Cohesive Bandage Rp....................... Rp..................
.....
 Vitshoap/Cleansing Rp....................... Rp..................
.....
 Colagen Rp....................... Rp..................
.....
 Colagen Rp....................... Rp..................
.....
 Stokinet Rp....................... Rp..................
.....
 Calsium Alginat Rp....................... Rp..................
.....
 Hidrocoloid Rp....................... Rp..................
.....
 Ortopedic Wall Rp....................... Rp..................
.....
 Foam Rp....................... Rp..................
.....
 Handscoen Rp....................... Rp..................
.....
 Spoit Rp....................... Rp..................
.....
Rp....................... Rp..................
.....
7 Topikal Wound
 Metcovasin Red 10 gr ..........x Rp. 75.000 Rp..................
.....
 Metcovasin Red 25 gr ..........x Rp. 95.000 Rp..................
.....
 Metcovasin Reguler 10 gr ..........x Rp. 65.000 Rp..................
.....
 Metcovasin Reguler 25 gr ..........x Rp. 78.000 Rp..................
.....
 WOUND HEALING CENTER
PUSKESMAS ATARI JAYA

 Metcovasin Reguler 50 gr ..........x Rp. 150.000 Rp..................

.....
 Metcovasin Gold 10 gr ..........x Rp 75.000 Rp..................
.....
 Metcovasin Gold 25 gr ..........x Rp. 155.000 Rp..................
.....

8 Sendal Diabtik Rp. 225.000,- Rp..................

.....
9 Tindakan Rp..................
.....
- Pemeriksaan GDS Rp. 20.000,- Rp..................
x.......Kali .....
- Pemeriksaan Cholesterol Rp. 35.000,- Rp..................
x.......Kali .....
- Pemeriksaan Uric Acid Rp. 25.000,- Rp..................
x........Kali .....
- HB test Rp 20.000,- x Rp..................
......Kali .....
10 Obat
Rp,…………………………
Rp,…………………………
Rp,…………………………
Rp,…………………………
Rp,………………………..
Jumlah Total

Atari Jaya,…………………………
Petugas Jaga Perawatan

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