RUMAH SAKIT

ANUGERAH BUNDA KHATULISTIWA

Jl. Jend. A. Yani , Pontianak – Kalimantan Barat – Indonesia |Telpon : +62 561-581818 (hunting) Fax : +62 561 – 584100

“RUANG UNIT GAWAT DARURAT”

Lampirkan bukti pemakaian bahan medik habis pakai

1. Tanggal : / /
2. Nama :
3. No. RM :
4. Tanggal Lahir/Umur : / Tahun

No Nama Bahan No Nama Obat

A Unit Harga Jumlah B Unit Harga Jumlah
Alat Kesehatan / BMHP Alat Obat / BMHP
1 Benang Slik No. 1 Aspilet Tablet
2 Benang Cutgat No. 2 Antrain
3 Bisturi No. 3 Aminophilin
4 Chest Pace Ecg 4 Bisolvon Drop
5 Comporming / Elastomull 5 Buscopan 20 mg
6 Endotracheal Tube No. 6 Cedocard 5 Mg Tablet
7 Extension Tube Purfusior 7 Dipenhidramin
8 Feeding Tube No. 8 Duvadilan / Proterin
9 Foley Catheter No. 9 Dobutamin / Inotrop
10 Handschone Non Steril 10 Dopamin / Indop
11 Handschone Steril No. 11 Epinephrin
12 Hypafik / Transpore 12 Farbivent / Combivent
13 Gypsona 13 Flixotide / Pulmicort
14 Infus Set Adult 14 Lasacom / Velutin
15 Infus Set Pediatrik 15 Indexon
16 Infus Transfusi Set Tipe Y 16 Invomit
17 Iv Catheter No. 17 Kalnex / Plasminex
18 Kapas Pastik / E.Care 18 Lasix
19 Kasa Steril ( Lembar ) 19 Lasarcom
20 Leukosan Strip 20 Lidocain
21 Leukocrepe 15 Cm X 4,5 M 21 Onetik 8 mg
22 Masker 22 Pamol Suppo 125 mg
23 Masker NRM Bayi / Anak / Dewasa 23 Pamol Suppo 250 mg
24 Nasal Canula Bayi / Anak / Dewasa 24 Propyretic Suppo 80 mg
25 Opsite No. 25 Propyretic Suppo 160 mg
26 Soffban Synthetic Besar / Kecil 26 Propyretic Suppo 240 mg
27 Securefix IV 27 Stesolid Rectal 5 mg
28 Spuit 1cc 28 Stesolid Rectal 10 mg
29 Spuit 3cc 29 Sanmol Infus 1000 mg
30 Spuit 5cc 30 Sulfas Atropin (SA)
31 Spuit 10cc
32 Spuit 20cc
33 Spuit 50cc
34 Stomach Tube No.
35 Sufratule zalf / daryantulle / Cuticell No Nama Bahan
36 Surplug D Cairan Infus/ BMHP Unit Harga Jumlah
37 Three Way / Stop Coch 1 Aquadest 1000 cc / Otsu water
38 Urine Bag 2 Dextrose 10 % Sanbe 500 cc
39 Underpad Solamed 3 Dextrose 5 % Sanbe 500 cc
40 Xylocaine Jelly 4 Dextrose ½ NS Sanbe 500 cc
5 Dextrose ¼ NS Sanbe 500 cc
6 Futrolit
7 Haes – Steril / Sanbe Hes
8 Nacl Sanbe 500 cc
No Nama Bahan 9 Otsu I aquadest 25 ml
C Alkes Logistik / BMHP Unit Harga Jumlah 10 Otsu I Nacl 25 ml
1 Oksigen 0-2 l/m (jam) 11 Otsu MgSo4 25 ml
2 Oksigen 2-4 l/m (jam) 12 Otsu D40 25 ml
3 Oksigen 4-6 l/m (jam) 13 Otsu KCL 25 ml
4 Oksigen 6-8 l/m (jam) 14 Ring As
5 Oksigen 8-10 l/m (jam) 15 Ringer Lactat Sanbe
6 Pisau cukur
7 Klip Rawat Inap Kuning / Merah

NO PEMAKAIAN ALAT-ALAT MEDIS Unit Harga Jumlah

1
2
3
4
5
6

Sub. Total Sub. Total

Grand Total Grand Total

Mengetahui,
Koordinator Ruangan. Yang Membuat

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