ATK & ART

NO KODE MASTER BARANG Satuan HARGA

Barang

A. 01.A BARANG ATK

1 01.A.001 3 M double Tape 314yr x 24m PCS Rp 50,000
2 01.A.002 Amplop Coklat Folio Tali lembar Rp 900
3 01.A.003 Amplop Coklat Folio Biasa lembar Rp 350
4 01.A.004 Amplop Jaya box Rp 20,000
5 01.A.005 Amplop CD ( Isi 100 ) Pack Rp 25,000
6 01.A.006 Bantex Ring Folio pcs Rp 27,000
7 01.A.007 Binder Clip 105 Box Rp 3,000
8 01.A.008 Binder Clip 107 box Rp 3,000
9 01.A.009 Binder Clip 155 box Rp 6,000
10 01.A.010 Binder Clip 200 box Rp 10,000
11 01.A.011 Binder Clip 260 box Rp 18,000
12 01.A.012 Box CD Pcs Rp 15,000
13 01.A.013 Box File pcs Rp 20,000
14 01.A.014 Buku Agenda pcs Rp 25,000
15 01.A.015 Buku Double Folio pcs Rp 25,000
16 01.A.016 Buku Ekspedisi pack Rp 7,000
17 01.A.017 Buku Folio isi 100 PCS Rp 13,000
18 01.A.018 Buku Folio isi 200 pcs Rp 25,000
20 01.A.020 Buku Folio Kas 100 pcs Rp 18,000
21 01.A.021 Buku Kasbon pcs Rp 3,500
22 01.A.022 Buku Kwarto isi 100 pcs Rp 8,000
23 01.A.023 Buku Saku pcs Rp 5,000
24 01.A.024 Buku Tamu pcs Rp 20,000
25 01.A.025 Bussiness File pcs Rp 2,250
26 01.A.026 Calculator pcs Rp 110,000
27 01.A.027 Calculator Joyko pcs Rp 60,000
28 01.A.028 Card Holder pcs Rp 45,000
29 01.A.029 CDR Sony pcs Rp 2,500
30 01.A.030 Clear Holder isi 40 pcs Rp 25,000
31 01.A.031 Cutter pcs Rp 13,000
32 01.A.032 Dispenser Lakban pcs Rp 20,000
33 01.A.033 Dispenser Solatif pcs Rp 20,000
34 01.A.034 Double Tape 2 cm pcs Rp 6,000
35 01.A.035 DVD Sony pcs Rp 2,500
36 01.A.036 Gantungan Kunci Key Pin pcs Rp 800
37 01.A.037 Gantungan Tembok pcs Rp 5,000
38 01.A.038 Glue Stick pcs Rp 6,250
39 01.A.039 Gunting Besar pcs Rp 12,000
40 01.A.040 Gunting Kenko Sedang pcs Rp 6,000
41 01.A.041 Isi Staples Besar pcs Rp 4,500
42 01.A.042 Isi Staples Kecil pcs Rp 2,500
43 01.A.043 Jam Dinding pcs Rp 75,000
44 01.A.044 Joyko Desk Jet pcs Rp 25,000
45 01.A.045 Kenko isi cutter psc Rp 1,000
46 01.A.046 Kertas HVS F4 Kuning PCS Rp 50
47 01.A.047 Kertas HVS F4 Pink PCS Rp 100
48 01.A.048 Kertas Buram Rim Rp 20,000
49 01.A.049 Kertas C.F 2 PLY Dus Rp 125,000
50 01.A.050 Kertas C.F 3 Ply Dus Rp 210,000

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 ATK & ART
51 01.A.051 Kertas C.F 4 Ply 3 potong Dus Rp 210,000
52 01.A.052 Kertas Concorde Biru pack Rp 10,000
53 01.A.053 Kertas Concorde Kuning pack Rp 10,000
54 01.A.054 Kertas Concorde Putih pack Rp 10,000
55 01.A.055 Kertas Fax/kasir pcs Rp 3,500
56 01.A.056 Kertas Glossy Pack Rp 18,000
57 01.A.057 Kertas HVS A4 Biru PCS Rp 100
58 01.A.058 Kertas HVS A4 Copy Paper Rim Rp 37,000
59 01.A.059 Kertas Puyer ( 1.000 lembar ) Pack Rp 51,333
60 01.A.060 Kertas HVS A4 Kuning Rim Rp 50,000
61 01.A.061 Kertas HVS A3 80 Gram Rim Rp 90,000
62 01.A.062 Kertas HVS F4 Copy Paper rim Rp 41,000
63 01.A.063 Kertas HVS Hijau PCS Rp 100
64 01.A.064 Kertas Karbon Lembar Rp 1,000
65 01.A.065 Kertas Roll 58x65 Roll Rp 3,500
66 01.A.066 Kertas Roll 65x75 Roll Rp 3,500
67 01.A.067 Kertas Roll 65x75 3 Ply Roll Rp 5,000
68 01.A.068 Kertas Sticker A4 pack Rp 30,000
69 01.A.069 Kwitansi Sidu Besar pcs Rp 3,950
70 01.A.070 Kwitansi Sidu Kecil pcs Rp 1,800
71 01.A.071 Label Barcode Blank Roll Rp 25,000
72 01.A.073 Label / Sticker CD ( isi 100 ) pack Rp 25,000
73 01.A.072 Lakban G tape Bening Roll Rp 9,000
74 01.A.073 Lakban Kertas Roll Rp 10,000
75 01.A.074 Lakban Merah Roll Rp 15,000
76 01.A.075 Lakban Kuning Roll Rp 15,000
77 01.A.076 Lakban Hijau Roll Rp 15,000
78 01.A.077 Magnetic pcs Rp 15,000
80 01.A.078 Map Batik pcs Rp 2,500
80 01.A.080 Map Bening pcs Rp 1,500
81 01.A.081 Map Diamond pcs Rp 1,400
82 01.A.082 Map Kabita pcs Rp 500
83 01.A.083 Map Kancing pcs Rp 4,250
84 01.A.084 Map Sea Gull Hijau pcs Rp 7,917
85 01.A.085 Map Sea Gull Kuning pcs Rp 7,917
86 01.A.086 Map Sea Gull Merah pcs Rp 6,250
88 01.A.088 Ordner 717 Benex Pcs Rp 17,500
89 01.A.089 Ordner 777 Benex Pcs Rp 17,500
90 01.A.090 Papan Jalan Kayu Pcs Rp 12,000
91 01.A.091 Papan Jalan Transparant Pcs Rp 20,000
92 01.A.092 Papan Whiteboard Pcs Rp 80,000
93 01.A.093 Paper Clip NO.5 Pcs Rp 3,500
94 01.A.094 Paper Pastenes pack Rp 7,000
95 01.A.095 Pembatas File Bambie Pack Rp 20,000
96 01.A.096 Pembolong Punch Besar pcs Rp 40,000
97 01.A.097 Pembolong Punch Kecil pcs Rp 13,000
98 01.A.098 Penahan Buku pcs Rp 20,000
99 01.A.099 Penggaris Butterfly pcs Rp 2,000
100 01.A.100 Penggaris Star pcs Rp 10,000
101 01.A.101 Penghapus Kenko pcs Rp 3,000
102 01.A.102 Penghapus White Board pcs Rp 7,000
103 01.A.103 Pensil Faber Castell pcs Rp 3,000
104 01.A.104 Plastik ID Card Merah pcs Rp 1,000

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 ATK & ART
105 01.A.105 Pita Saten Kecil pcs Rp 7,000
106 01.A.106 Plastik Bambie isi 20 pack Rp 20,000
108 01.A.108 Plastik Laminating Joyko Folio Lembar Rp 1,000
109 01.A.109 Plastik Laminating Joyko A3 Lembar Rp 2,000
110 01.A.110 Plastik Undangan A5 pcs Rp 15,750
111 01.A.111 Post it 654 pcs Rp 10,000
112 01.A.112 Post It 656 Pcs Rp 9,000
113 01.A.113 Post it Besar proto Pcs Rp 3,000
114 01.A.114 Post it panah Pcs Rp 10,000
115 01.A.115 Post It Warna-warni Pcs Rp 10,000
116 01.A.116 Pulpen 4 warna Pcs Rp 4,167
117 01.A.117 Pulpen Meja Pcs Rp 6,000
118 01.A.118 Pulpen Merah Pcs Rp 1,500
119 01.A.119 Pulpen Standart Biru Pcs Rp 1,500
120 01.A.120 Pulpen Standart Hitam Pcs Rp 1,500
121 01.A.121 Push Pin Pcs Rp 4,000
122 01.A.122 Rak Formulir Pcs Rp 130,000
123 01.A.123 Rautan Pensil Pcs Rp 5,000
124 01.A.124 Ribbon Barcode DKP W-4 Pcs Rp 28,000
125 01.A.125 Senter Pcs Rp 30,000
126 01.A.126 Solatif Bening 1 cm Pcs Rp 2,500
127 01.A.127 Solatif Hijau Pcs Rp 8,000
128 01.A.128 Solatif Kuning Pcs Rp 8,000
129 01.A.129 Solatif Merah Pcs Rp 8,000
130 01.A.130 Spidol Biru Boardmarker Pcs Rp 7,500
131 01.A.131 Spidol Hitam Boardmarker Pcs Rp 6,250
132 01.A.132 Spidol Hitam Permanent Pcs Rp 5,417
133 01.A.133 Spidol Merah Boardmarker Pcs Rp 6,000
134 01.A.134 Spidol Merah Permanent Pcs Rp 5,417
135 01.A.135 Spidol Snowman 12 Colouring Pcs Rp 3,000
136 01.A.136 Spidol Standart Snowman Biru Pcs Rp 3,000
137 01.A.137 Spidol Standart Snowman Hitam Pcs Rp 3,000
138 01.A.138 Stabilo Pcs Rp 5,000
139 01.A.139 Stamp Pad Hero Pcs Rp 6,000
140 01.A.140 Stamp Pad Joyko Pcs Rp 10,000
141 01.A.141 Stampel Pcs Rp 60,000
142 01.A.142 Staples Besar Pcs Rp 18,000
143 01.A.143 Staples Kecil Pcs Rp 15,000
144 01.A.144 Sterofoam Pcs Rp 6,000
145 01.A.145 Sticker Chlorhexidine Lembar Rp 37,000
146 01.A.146 Sticker High Alert Lembar Rp 37,000
147 01.A.147 Sticker Merah Bulat Lembar Rp 32,000
147 01.A.147 Sticker Lasa Lembar Rp 37,000
148 01.A.148 Sticker Rekam Medis Lembar Rp 32,000
149 01.A.149 Sticker Suhu Lembar Rp 37,000
150 01.A.150 Tancapan Kertas pcs Rp 10,000
151 01.A.151 Tempat CD Oval pcs Rp 1,200
152 01.A.152 Ribbon Colour DTC 1000 pcs Rp 545,000
153 01.A.153 Thermal 80x80 pcs Rp 20,000
154 01.A.154 Thermal Paper 58x48 pcs Rp 6,500
155 01.A.155 Tali Name Tag Merah Jepit Besar pcs Rp 3,500
156 01.A.156 Thermal Paper 80x50 pcs Rp 10,000
157 01.A.157 Thermal Paper fyfax pcs Rp 15,000

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 ATK & ART
158 01.A.158 Tinta Hp 05 A pcs Rp 1,375,000
159 01.A.159 Tinta Canon G2000 Black pcs Rp 35,000
160 01.A.160 Tinta Canon Pixma 57 pcs Rp 210,000
161 01.A.161 Tinta Canon Pixma 47 pcs Rp 120,000
162 01.A.162 Tinta Epson 664 Black pcs Rp 85,000
163 01.A.163 Tinta Epson 664 Blue pcs Rp 85,000
164 01.A.164 Tinta Epson 664 Magenta pcs Rp 85,000
165 01.A.165 Tinta Epson 664 Yellow pcs Rp 85,000
166 01.A.166 Tinta Epson ERC 38 pcs Rp 30,000
167 01.A.167 Tinta Epson LQ-310 pcs Rp 70,000
168 01.A.168 Tinta Epson LX-310 pcs Rp 55,000
169 01.A.169 Tinta Fuji Xerox Drum Cartridge (CT351005) pcs Rp 700,000
170 01.A.170 Tinta Hp 680 Black pcs Rp 135,000
171 01.A.171 Tinta Hp 680 Colour pcs Rp 135,000
172 01.A.172 Tinta Hp 704 Black pcs Rp 140,000
173 01.A.173 Tinta Hp 704 Colour pcs Rp 140,000
174 01.A.174 Tinta Stamp Biru pcs Rp 8,500
175 01.A.175 Tinta Stamp Hijau pcs Rp 8,500
176 01.A.176 Tinta Stamp Hitam pcs Rp 8,500
177 01.A.177 Tinta Stamp Merah pcs Rp 8,500
178 01.A.178 Tinta Stempel tanpa bantalan pcs Rp 10,000
179 01.A.179 Tinta Toner CE 285 A pcs Rp 225,000
180 01.A.180 Tinta Toner CF 280 A pcs Rp 275,000
181 01.A.181 Tinta Toner CB 435 A pcs Rp 380,000
182 01.A.182 Tinta Toner CE 283 A pcs Rp 225,000
183 01.A.183 Tinta Toner CE 400 A Radiologi pcs Rp 850,000
184 01.A.184 Tinta Toner CE 401 A Radiologi pcs Rp 850,000
185 01.A.185 Tinta Toner CE 402 A Radiologi pcs Rp 850,000
186 01.A.186 Tinta Toner CE 403 A Radiologi pcs Rp 850,000
187 01.A.187 Tip ex kenko pcs Rp 7,000
188 01.A.188 Tom & Jerry 103 Pack Rp 4,800
189 01.A.189 Tom & Jerry 108 Pack Rp 4,800
190 01.A.190 Tom n Jerry 115 Pack Rp 4,800
191 01.A.191 Tom n Jerry 97 Merah Pack Rp 7,000
192 01.A.192 Trigonal Clip Pack Rp 1,500
193 01.A.193 U Clip Medical Set Rp 4,500
194 01.A.194 USB 16 GB PCS Rp 60,000
TOTAL
B 02.B KLONTONG
1 02.B.01 Alumunium Foil PCS Rp 30,000
2 02.B.02 Baki Besar PCS Rp 15,000
3 02.B.03 Box Containe CB 95 PCS Rp 135,000
4 02.B.04 Box Container CB 15 PCS Rp 44,000
5 02.B.05 Box Container CB 150 PCS Rp 190,000
6 02.B.06 Box Container CB 190 PCS Rp 290,000
7 02.B.07 Box Container CB 25 PCS Rp 50,000
8 02.B.08 Box Container CB 10 PCS Rp 28,000
9 02.B.09 Box Container CB 47 PCS Rp 80,000
10 02.B.10 Botol Sprayer PCS Rp 7,500
11 02.B.11 Dispenser hand Towel PCS Rp 100,000
12 02.B.12 Dispenser Sabun Cair PCS Rp 35,000
13 02.B.13 Dust Fan PCS Rp 21,000
14 02.B.14 Ember Sedang PCS Rp 40,000

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 ATK & ART
15 02.B.15 Sulo Kuning 120 L PCS Rp 475,000
16 02.B.16 Sulo Hijau 120 L PCS Rp 450,000
17 02.B.17 Hand Glove PCS Rp 17,000
18 02.B.18 Handuk PCS Rp 40,000
19 02.B.19 Kain Kafan Meter Rp 8,000
20 02.B.20 Kanebo PCS Rp 14,250
21 02.B.21 Kain Lap Fiber PCS Rp 6,500
22 02.B.22 Kain Lap Kotak PCS Rp 2,333
23 02.B.23 Gelas Ukur PCS Rp 18,500
24 02.B.24 Karet Gelang PCS Rp 6,000
25 02.B.25 Keranjang Obat PCS Rp 6,000
26 02.B.26 Keranjang Gelas Aqua PCS Rp 70,000
27 02.B.27 Keset Ruang Rawat (Tipis) PCS Rp 16,600
28 02.B.28 Keset VIP PCS Rp 35,000
29 02.B.29 Laci Shinpo 2 tingkat PCS Rp 50,000
30 02.B.30 Mop Holder PCS Rp 14,500
31 02.B.31 Plastik 1 kg pack Rp 9,000
32 02.B.32 Plastik 1/2 kg pack Rp 9,000
33 02.B.33 Pad Holder pcs Rp 175,000
34 02.B.34 Plastik Bening 40x60 Pack Rp 15,000
35 02.B.35 Plastik Bening 60x100 Pack Rp 16,000
36 02.B.36 Plastik Es Pack Rp 10,000
37 02.B.37 Plastik Golongan Darah Pack Rp 35,000
38 02.B.38 Plastik Hitam 50x75 Pack Rp 14,200
39 02.B.39 Plastik Hitam 60x100 Pack Rp 14,200
40 02.B.40 Plastik Hitam 90x120 Pack Rp 14,200
41 02.B.41 Plastik Hitam Kresek Pack Rp 11,200
42 02.B.42 Plastik Klip 10x6 Pack Rp 2,500
43 02.B.43 Plastik Klip 12x20 Pack Rp 13,000
44 02.B.44 Plastik Klip 12x20 Logo Pack Rp 70,000
45 02.B.45 Plastik Klip 15x10 Pack Rp 5,600
46 02.B.46 Plastik Klip 15x10 Logo Pack Rp 50,000
47 02.B.47 Plastik Kuning 50x75 Pack Rp 26,000
48 02.B.48 Plastik Kuning 60 x100 Pack Rp 26,000
49 02.B.49 Plastik Kuning 90x120 Pack Rp 26,000
50 02.B.50 Plastik Kuning Kresek 35 Pack Rp 18,500
51 02.B.51 Plastik Parcel Pack Rp 8,000
52 02.B.52 Plastik putih kresek 24 Pack Rp 14,000
53 02.B.53 Plastik Putih Logo Pack Rp 95,000
54 02.B.54 Rak sepatu 4 Susun Pcs Rp 70,000
55 02.B.55 Rak Cuci Piring Stainless Pcs Rp 70,000
56 02.B.56 Refiil Kain Mop Biru Pcs Rp 14,000
57 02.B.57 Refiil Kain Mop Hijau Pcs Rp 14,000
58 02.B.58 Refiil Kain Mop Kuning Pcs Rp 14,000
59 02.B.59 Refiil Kain Mop Merah Pcs Rp 14,000
60 02.B.60 Tangkai + Frame Lobby Duster Pcs Rp 53,000
61 02.B.61 Sarung Tangan Karet Pcs Rp 11,000
62 02.B.62 Sapu Nilon Pcs Rp 18,500
63 02.B.63 Sapu Lidi Pcs Rp 4,500
64 02.B.64 Sedotan Steril Pcs Rp 25,000
65 02.B.65 Sendal Spon Pcs Rp 5,500
66 02.B.66 Sepatu Booth AP Pcs Rp 85,000
67 02.B.67 Serabut Stainless Pcs Rp 4,000

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 ATK & ART
68 02.B.68 Sikat Eterna Pcs Rp 2,500
69 02.B.69 Sikat WC Pcs Rp 6,000
70 02.B.70 Sticky Mat Pcs Rp 95,000
71 02.B.71 Tempat Sampah 10 L Pcs Rp 70,000
72 02.B.72 Tempat Sampah 25 L Pcs Rp 122,500
73 02.B.73 Tempat Sampah 50 L Pcs Rp 175,000
74 02.B.74 Tempat sampah Goyang 15 L Pcs Rp 25,000
75 02.B.75 Tempat Tissu Kotak Pcs Rp 30,000
76 02.B.76 Tempat Tissu Roll Pcs Rp 37,000
77 02.B.77 Tepes Busa Pcs Rp 2,500
78 02.B.78 Tepes Tanpa Busa Pcs Rp 1,084
79 02.B.79 Tissu Bed Pcs Rp 55,000
80 02.B.80 Tissu Halus 250’S Pcs Rp 9,633
81 02.B.81 Tissu Halus See u 750’S Pcs Rp 14,250
83 02.B.83 Tissu Imperium Pcs Rp 25,000
84 02.B.84 Tissu roll Emboss Pcs Rp 1,500
85 02.B.85 Tissu roll See U Pcs Rp 1,600
86 02.B.86 Tissu Towel See U Pcs Rp 7,500
88 02.B.88 Tong Air Green Leaf 90 L Pcs Rp 135,000
89 02.B.89 Tudoor Pcs Rp 10,500
90 02.B.90 Tusuk Gigi Pcs Rp 150
91 02.B.91 Wiper Pcs Rp 30,500
92 02.B.92 Wrapping Besar Pcs Rp 145,000
94 02.B.94 Wrapping Kecil Pcs Rp 16,000
TOTAL
03.C SABUN
1 03.C.001 Baby Oil 100 ml Botol Rp 17,500
2 03.C.002 Hand soap Yuri Refiil Pack Rp 15,100
3 03.C.003 Shampo Lifeboy 70 ml Botol Rp 7,400
4 03.C.004 Minyak Kayu Putih 30 ml Botol Rp 11,100
5 03.C.005 Minyak Kelapa Klaper 100 ml Botol Rp 63,000
6 03.C.006 sabun Mandi Dewasa Lifeboy Cair Pack Rp 23,400
7 03.C.007 Sabun Top to toe wash Botol Rp 17,500
8 03.C.008 Shampo Cussons Baby Botol Rp 10,000

TOTAL
D 04.D BARANG B3
1 04.D.001 ABC Baterai R14 C Pcs Rp 4,650
2 04.D.002 ABC Baterai R205 Pcs Rp 6,000
3 04.D.002 Baterai ABC Kotak 9 V Pcs Rp 12,500
4 04.D.003 Alkaline 9 V Pcs Rp 30,000
5 04.D.003 Alkaline AA Pcs Rp 5,000
6 04.D.004 Alkaline AAA Pcs Rp 5,000
7 04.D.004 Astonis Stainless steel Pcs Rp 3
8 04.D.005 Astonis Cleaner & Sponge Pcs Rp 80,000
9 04.D.005 Baterai L1130 Pcs Rp 5,000
10 04.D.006 Baterai Sony CR 2032 Pcs Rp 19,000
10 04.D.006 Baterai Maxell CR 2032 Pcs Rp 6,000
11 04.D.006 Baterai Sony CR 2430 Pcs Rp 50,000
12 04.D.007 Baterai Sony CR 2450 Pcs Rp 69,500
13 04.D.007 Baterai Termometer (LR41) Pcs Rp 12,500
14 04.D.008 Baterai CR2450 Pcs Rp 50,000
15 04.D.008 Bay fresh 225 ml Botol Rp 12,900

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 ATK & ART
16 04.D.009 BayClean 500 ml Botol Rp 7,350
17 04.D.009 BayClean 1000 ml Botol Rp 12,165
18 04.D.010 Baygon 275 ml Botol Rp 17,400
20 04.D.011 Buffing Pad Merah Pcs Rp 41,000
21 04.D.011 Buffing Pad Putih Pcs Rp 41,000
22 04.D.012 Chemical Kristal (CR-1T) Botol Rp 200,000
23 04.D.012 Chemical Kristal Revontulet Botol Rp 225,000
24 04.D.013 Cling Pembersih Kaca pack Rp 3,625
25 04.D.013 Degreaser Jerigen Rp 48,600
26 04.D.014 Minyak Lobby Jerigen Rp 90,000
27 04.D.014 Kamper wc bola pack Rp 17,300
28 04.D.015 Kispray Refiil pack Rp 4,500
29 04.D.015 Oxy Magic pack Rp 30,000
30 04.D.016 Pledge Aerosol Botol Rp 31,500
31 04.D.016 Porstek pembersih kramik pack Rp 16,100
32 04.D.017 Rinso Sachet Pcs Rp 813
33 04.D.017 Shampoo Carpet Botol Rp 240,100
34 04.D.018 So klin Lantai pack Rp 9,600
35 04.D.018 Stella Gantung Pcs Rp 8,800
36 04.D.019 Stella Refiil Botol Rp 27,500
39 04.D.020 Sunlight 780 ml pack Rp 14,300
41 04.D.021 Vanish Botol Botol Rp 40,500
42 04.D.022 Wipol pack Rp 13,867
43 04.D.022 Waxtrip Jerigen Rp 21,600
44 04.D.023 New Complete Jerigen Rp 305,200

Page 7
 CETAKAN
DAFTAR CETAKAN

NO NAMA BARANG SATUAN HARGA

1 Amplop Radiologi Besar Lembar Rp7,250

2 Amplop Radiologi Kecil Lembar Rp5,750
3 Amplop JHC Lembar Rp450
4 Buku Absen DPJP pack Rp22,000
5 Copy Resep Pack Rp8,500
6 Form Amprah Darah Pack Rp60,000
7 Form Assesment Dr. Spesialis Kedokteran ( Rehab Medik) Lembar Rp160
8 Form Audit bundle IADP Lembar Rp180
9 Form Audit bundle IDO Lembar Rp180
10 Form Audit bundle ISK Lembar Rp180
11 Form Audit bundle VAP Lembar Rp180
12 Form Behavior Pain Scale Lembar Rp160
13 Form Berita Acara Pelaksanaan Resusitasi Lembar Rp160
14 Form Bpjs Tidak Sesuai Kelas Lembar Rp160
15 Form Catatan CPB Lembar Rp180
16 Form Catatan Keperawatan Pra Operasi Lembar Rp160
17 Form Catatan Keperawatan Instruksi Pasca Operasi Lembar Rp160
18 Form Catatan Keperawatan Intra Operatif Terintegrasi Lembar Rp180
19 Form Catatan Pelaksanaan Transfusi Lembar Rp180
20 Form Catatan Perfusi Lembar Rp160
21 Form Cek List Keselamatan Pasien Operasi Lembar Rp180
22 Form Cek list Orientasi pasien baru Lembar Rp160
Form Cek List Pasien Pemberian Kontras Intravena (IV) & Riwayat Penyakit
23 Pemeriksaan Radiologi Lembar Rp160
24 Form Cek List Pasien Pulang Lembar Rp160
25 Form Cek list persiapan ranap Pasien Baru Lembar Rp160
26 Form Cek list persiapan tindakan Diagnostik & Intervensi Lembar Rp160
27 Form Ceklist Persiapan Ekstubasi Lembar Rp160
28 Form Check List Persiapan Pra Bedah Lembar Rp160
29 Form Checklist Kelengkapan Trolley Emergency 2 Shift Lembar Rp160
30 Form Checklist Kelengkapan Trolley Emergency 3 Shift Lembar Rp180
31 Form CP Coros Kiv Lembar Rp160
32 Form CP tindakan Kateterisasi Anak Lembar Rp160
33 Form CPPT Lembar Rp180
34 Form Cuti Dokter Lembar Rp160
35 Form Daftar Tilik Penyimpangan Mortalitas Lembar Rp160
36 Form Dokumen Pelaksanaan Resusitasi Lembar Rp160
37 Form Echocardiography Report Lembar Rp160
38 Form Edukasi Pasien & Keluarga Rawat Jalan Lembar Rp180
39 Form Edukasi pasien rawat inap hal.1 Lembar Rp180
40 Form Edukasi pasien rawat inap hal.2 Lembar Rp180
41 Form edukasi pemberian darah dan produk darah Lembar Rp160
42 Form Edukasi Persiapan CT-Scan Cardiac/Arteri Koroneri dengan kontras Lembar Rp160
43 Form edukasi tindakan anestesi dan Sedasi Lembar Rp160
44 Form Edukasi Tindakan Kateterisasi Lembar Rp160
45 Form Financial Consent hal.1 Lembar Rp180
46 Form Financial Consent Hal.2 Lembar Rp180
47 Form General Consent Lembar Rp180

Page 8
 CETAKAN
48 Form Hasil gambar Echo Lembar Rp160
49 Form Hasil Pemeriksaan EKG Lembar Rp190
50 Form Hasil pemeriksaan Ekokardiography Lembar Rp160
51 Form Hasil Pemeriksaan Ekokardiography Anak Lembar Rp160
52 Form Inform Consent Lembar Rp160
53 Form Informasi Obat Pulang Lembar Rp160
54 Form Initial Assesment Keperawatan Rawat Jalan Anak Lembar Rp180
55 Form Initial Assesment Medis anak Lembar Rp160
56 Form Initial Assesment Rawat Jalan Dewasa Lembar Rp180
57 Form Initial Assesment Terintegrasi Ranap Anak Lembar Rp180
58 Form Initial Assesment Terintegrasi Ranap Dewasa Lembar Rp180
59 Form Keamanan Pasien Lembar Rp160
60 Form kelebihan & kelemahan teknik sedasi Lembar Rp160
61 Form Kepuasan Pasien Terhadap asuhan Kperawatan Lembar Rp160
62 Form Keseimbangan Cairan Lembar Rp160
63 Form Keterangan Sakit Lembar Rp160
64 Form Konsultasi Lembar Rp160
65 Form Laboratorium Diagnosis Lembar Rp160
66 Form Lembar saran pelanggan rawat inap Lembar Rp160
67 Form Lembar Saran Pelanggan Rawat Inap Keperawatan Lembar Rp160
68 Form MEWS Dewasa( Modified Early Warning System ) Lembar Rp300
69 Form Observasi dan Implementasi Harian Perawatan Intensif Kardiovaskular ( ChartLembar Rp4,500
70 Form Observasi Keperawatan Kardiovaskular Lembar Rp190
71 Form Observasi Selama Transportasi Lembar Rp160
72 Form Pediatric Early Warning system Lembar Rp300
73 Form Pemantauan Nyeri Pasien Bayi/Anak Lembar Rp160
74 Form Pemantauan Pemberian Obat Lembar Rp160
75 Form Pemantauan Resiko Jatuh Anak Lembar Rp180
76 Form Pemantauan Resiko Jatuh Dewasa Lembar Rp180
77 Form Pemeriksaan Doppler Carotid Lembar Rp160
78 Form Pemeriksaan Doppler Ekstremitas Lembar Rp160
79 Form Pemeriksaan khusus Lembar Rp160
80 Form Pemeriksaan Radiologi Lembar Rp160
81 Form Pemeriksaan TEE Operasi Lembar Rp160
82 Form Pengajuan Jadwal Tindakan Di Laboratorium Kateterisasi Lembar Rp160
83 Form Pengajuan Jadwal Tindakan Operasi Lembar Rp160
84 Form Pengkajian Resiko Luka Dekubitus Lembar Rp160
85 Form Penilaian Resiko Jatuh Pasien Geriatri Lembar Rp180
86 Form Penolakan Ruang Rawat ICU/IC Lembar Rp160
87 Form Penolakan Tindakan Kedokteran Lembar Rp160
88 Form Perbaikan Teknik Pack Rp11,000
89 Form Permintaan Barang Keluar Lembar Rp80
90 Form Permintaan Laboratorium Lembar Rp180
91 Form Pernyataan Alih Rawat Dokter Lembar Rp160
92 Form Pernyataan Pasien BPJS Lembar Rp160
93 Form Pernyataan Pasien Umum Lembar Rp160
94 Form Persetujuan pemberian darah dan produk darah Lembar Rp160
95 Form Persetujuan prosedur tindakan radiologi Lembar Rp160
96 Form Persetujuan Tindakan dengan menggunakan Kontras Lembar Rp160
97 Form Persetujuan tindakan kedokteran Lembar Rp160
98 Form Persetujuan/Penolakan pemerksaan Rdaiologi dengan bahan kontras Lembar Rp180
99 Form Pra Anestasi dan Sedasi Lembar Rp160
100 FORM PULANG ATAS PERMINTAAN SENDIRI Lembar Rp160

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101 Form Rehabilitasi Jantung Lembar Rp160
102 Form Rekam Anestesia Lembar Rp160
103 Form Rekonsiliasi Obat Lembar Rp160
104 Form Resep Pack Rp9,250
105 Form Resume Medis 3 Rangkap Pack Rp33,000
106 Form Resume Polyklinik (Summary List) Lembar Rp160
107 Form Ringkasan Diagnosa dan Tindakan Lembar Rp190
108 Form Rujukan Pasien Lembar Rp160
109 Form Rujukan Pasien Kerumah Sakit Asal Lembar Rp160
110 Form Rujukan/Pindah Ke Rs Lain ( 2 Rangkap ) Pack Rp25,000
111 Form Sambungan Resum Medis 3 Rangkap Pack Rp33,000
112 Form Sambungan Rujukan/Pindah Ke Rs Lain ( 2 Rangkap ) Pack Rp25,000
113 Form Serah Terima Barang Pack Rp22,000
114 Form Sertifikat Medis Penyebab Kematian ( 4 Rangkap ) Pack Rp65,000
115 Form Skrining Gizi Anak Lembar Rp80
116 Form Skrining gizi dewasa Lembar Rp80
117 Form Slip Tindakan Kedokteran Pack Rp11,000
118 Form SPR Lembar Rp160
119 Form Strategi Pelaksanaan Tindakan Operasi Lembar Rp160
120 Form Surat Keterangan Dirawat Lembar Rp160
121 Form Surat Penolakan Tindakan Resusitasi ( DNR ) Lembar Rp160
122 Form Surat Persetujuan Tindakan Resusitasi Lembar Rp160
123 Form Surveillance HAIs Lembar Rp180
124 Form Tabel Pemantauan Suhu & Kelembaban Thermohygrometer 2 Shift Lembar Rp160
125 Form Tabel Pemantauan Suhu & Kelembaban Thermohygrometer 3 Shift Lembar Rp180
126 Form Tata Tertib Dormitory Lembar Rp180
127 Form Tata tertib Rawat Inap Lembar Rp180
128 Form Tata tertib Ruang Tunggu Lembar Rp160
129 Form Tindakan Keperawatan Pack Rp8,500
130 Form Transfer Pasien Admisi - Ruang Rawat Lembar Rp160
131 Form Transfer Pasien operasi Lembar Rp160
132 Form Transfer Pasien untuk Pemeriksaan Diagnostik Lembar Rp180
133 Form Treadmill Excersie Report Lembar Rp160
134 Form Triase & Initial Assesment IGD Lembar Rp300
135 formulir cheklist Apar Lembar Rp500
136 formulir cheklist Hydrant Lembar Rp500
137 Kartu Persetujuan Pulang Lembar Rp450
138 Kartu Rehab Lembar
139 Kartu stock Pink Lembar Rp500
140 Kartu Stock Putih Pack Rp8,500
141 Kertas Tagihan JHC Lembar Rp300
142 Kop Surat A4 Lembar Rp240
143 Kop Surat F4 Lembar Rp250
144 Map Echo Lembar Rp4,750
145 Map Medical Check Up Lembar Rp3,750
146 Map Medical Record Pcs Rp3,750
147 Pembatas Status Set Rp11,500
148 Site Marking Lembar Rp160
149 Slip tindakan kedokteran Pack Rp11,000
150 Surat rekomendasi DPJP Lembar Rp160
151 Form Surat Keterangan Sakit Lembar Rp80
152 Form Surat Persetujuan Biaya (Financial Consent) Lembar Rp160
153 Form Surat Keterangan Sehat Lembar Rp80

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