WOUND HEALING CENTER

PUSKESMAS ATARI JAYA

RINCIAN BIAYA WOUND CARE

Nama Pasien :……………………………………

Umur :……………………………………
Alamat :……………………………………
Tgl Masuk :……………………………………
Tgl Keluar :……………………………………
No Uraian Satuan Biaya Jumlah
1 Administrasi Rp.............. Rp.......................
2 Biaya Perawatan /Cleansing/Dressing Rp....................... Rp.......................
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.......................
 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,- x.......Kali Rp.......................
- Pemeriksaan Cholesterol Rp. 35.000,- x.......Kali Rp.......................
- Pemeriksaan Uric Acid Rp. 25.000,- x........Kali Rp.......................
- HB test Rp 20.000,- x ......Kali Rp.......................
10 Obat
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Rp,………………………..
Jumlah Total

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

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