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KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

DIREKTORAT JENDERAL PELAYANAN KESEHATAN


BALAI BESAR KESEHATAN PARU MASYARAKAT SURAKARTA
Jalan ProfesorDokter R. Soeharso No. 28 Surakarta 57144 Telepon/Faksimile 0271-713055/720002
surat elektronik: bbkpm_surakarta@yahoo.co.id; laman: bbkpmska.com

CLINICAL PATHWAY

Perkiraan Lama Rawat : 7 Hari/ KLS 3


Indikasi : No. Rekam Medis : 119782
Nama Pasien : KASIADI Tgl Masuk : 4/30/2019
Jenis Kelamin : L P Rujukan :
Umur : Pengirim :
Diagnosa Awal : INFEKSI HIV BERAT DPJP :

HARI KE
Unit Cost Tarif
KEGIATAN Vol Total Unit
Satuan Satuan UGD RJ 1 2 3 4 5 6 7 8 9
Cost

ADMINISTRASI PENDAFTARAN 18,975 10,000 1 -

AKOMODASI 140,772 81,000 7 -

PEMERIKSAAN MEDIS -

Pemeriksaan Dokter UGD/UMUM


1 (KU, VS :TD,N,R,S,SpO2) & 133,316 50,000 1 133,316 50,000 40,000 90,000
Edukasi awal

Pemeriksaan Dokter Spesialis &


2 Edukasi awal (KUVS 87,073 36,000 2 -
:TD,N,R,S,SpO2)

Visite Dokter Spesialis (Assesment


3 95,911 54,000 10 -
Klinis) Komplikasi bila ada

4 Konsultasi Dokter spesialis lain 143,070 70,000 -

PEMERIKSAAN PENUNJANG
1 Darah Rutin III 46,843 35,000 1 -
2 Gula Darah Sewaktu 59,291 20,000 1 -
3 Ureum 52,610 25,000 1 -
4 Kreatinin 47,610 25,000 1 -
5 SGPT 48,263 25,000 2 -
6 SGOT 48,363 25,000 2 -
Bilirubin indirect 25,000
Bilirubin Total 25,000
Bilirubin direct 25,000
HBsAG 35,000 1
Chlorida 110,000
Natrium 110,000
7 Elektrolit 240,000 240,000 1 -
8 Analisa Gas Darah 250,000 250,000 1 -
9 Diff count
10 Sputum MO/Gr/K/R 37,000 20,000
Kultur 50,000 1
EKG 30,000 1
11 EKG 91,045 30,000 -
12 Foto Thorak PA 173,315 70,000 1 -
USG
13 Abdomen 150000 1
TINDAKAN MEDIS DIAGNOSTIK
1 Pemeriksaan APE Harian 10,986 8,000 -
2 Uji Bronkodilator 118,683 70,000 -
3 Spirometri saat kondisi stabil 94,296 50,000 -
-
TINDAKAN MEDIS TERAPI
1 Oksigenasi sampai SpO2 > 90% 9,814 3,750 85 -
2 Nebulizer 47,185 20,000 13 -

ASUHAN KEPERAWATAN 37,654 31,500 7 -


Layanan Pendampingan Petugas 150,000 1
TINDAKAN KEPERAWATAN
1 Skin tes 25,000 10,000 1 -
2 Injeksi 8,041 10,000 16 - - -
3 Pemasangan Infus 32,000
4 Pemasangan Infus 49,378 25,000 3 -
5 Plebotomi 6,000 1
6 Melepas Infus 10,000 2
BAHAN HABIS PAKAI
1 Infus Set 9,900 9,900 1 - -
2 Three Way 4,063 4,063 -
3 IV Catheter 10,444 10,444 1
4 Spuit 1 CC 1,953 2
5 Spuit 3 CC 1,953 1,313 16 -
6 Spuit 5 CC 1,685 1,685 1 -
7 Spuit 10 CC 2,238 2,238 16 -
8 canula O2 11,035 1
9 masker nebuliser 35,375 1
10 Sarung tangan non steril 5,313 5,313 -
11 Alkohol swab 1,100 125 9 -
12 Dermafik S 6,394 6,394 1
13 Mangkok Sputum 825
14 Plester Dressing Wound 1,500

OBAT-OBATAN
1 Cairan infus kristaloid
a eas primer inf 435,275
b NaCl 0,9 % 7,150 8,013 2
c RL 8,043 8,937 7
d Aminofusin Hepar 94,187 5
e KA EN infus 12,561
2 Obat Nebulizer
Fenoterol 0,2 mg/8jam 4,875 5,850 -
Ipratropium 0.8 mg/8jam 1,097 1,316 -
meptin neb 7,250 11
Pulmicort 0,5 mg 16,553 9
fluimucil 100 mg 12,500
Bricasma 2,5 8,563
Combivent 5,688 1
Velutine Plus neb 11,688 5

3 Aminophilin drip 0,5-0,9 mg/KgBB/jam


4 Steroid
a Dexamethason 5mg/8j atau
b Metilprenisolon 60-80mg/24 j 12,150 13,500 5 -
c Kalium klorida 4,029

5 Antibiotik:
a Cefotaxim 1gr/12jam atau 55,000 -
b Ceftazidime 1gr/12 jam atau 11,650 -
c Ceftriaxon 2gr/24 jam atau 5,044 5,604 -
d Ciprofloxacin 200 mg/12 jam
e Levofloxacin 500 inj 34,375
f Levofloxacin 750mg inj 138,600 9
g Omeprasole inj 12,373 4
h Antrain inj 18,750 3
i Antrain inj ns 21,250 1
j Prosogan inj 115,044 4
SNMC inj 124,740 3
k Ondansetron MH 10,000 2
Ondansetron NS 12,250 2
Odansetron inj 1,338
6 Azivol inj 229,800
Furosemide MH inj 5,550
7 Analgetik & Antipirektik
Paracetamol 500 mg (bila perlu) -
8 Obat Saluran Cerna
Omeprazole
Lansoprasole kapsul 379
Sulkralfat syr 8,486
9 Obat Oral
Methypred tab 168 20
Lactrin 300 mg 5,445 16
Curcuma tab 907 22
Nistatin suspensi 16,875 1
Candensartan 8 mg tab 649
Nitrokaf Retard kapsul 1,950
Alprazolam tab 1,500 3
Metformin 120 3
Meptin tab 7,568
Liparin tab 8,924 14
Cetiricine tab 226 7
Cotrimoxasol forte 960 mg 374 17
Levofloxacin 500 tab 532
10 Aqua Pro injeksi 25 Ml 3,218 3,575 6
11 Tarif dasar ambulance 70,000 1
NUTRISI 28500 1 - - - - -

MOBILISASI 74,069 20,000 -

PENDIDIKAN KESEHATAN 71,046 10,000 71,046

- 40,000 - - 40,000
HASIL (OUTCOME)
Keadaan Umum
VARIAN
Kesadaran
Tekanan darah
MONITORING
Nadi
Respirasi
I. Nama Dokter
Suhu
Saturasi Oksigen
II. Nama Dokter
Sesak napas
Batuk DIAGNOSIS
Anemia Diagnosis Utama Asma
Infus baik Diagnosis Sekunder -
Toleransi Diet baik
Visite Dokter
Aktivitas sendiri
Edukasi Penyakit
Edukasi Pengobatan Diagnosa Komplikasi
Edukasi tatalaksana
penyakit dan lama
perawatan Kelas keperawatan
Rencana pulang Total Tarif Rumah Sakit
Total Unit Cost
Total Tarif INA CBGs
ATAN REPUBLIK INDONESIA
AL PELAYANAN KESEHATAN
PARU MASYARAKAT SURAKARTA
rakarta 57144 Telepon/Faksimile 0271-713055/720002
arta@yahoo.co.id; laman: bbkpmska.com

AL PATHWAY

DISKRIPSI DRG
J-4-15-I

INFEKSI DAN
PERADANGAN

TARIF RS PER KELAS


Total tarif 3 2 1 VIP

10,000

567,000

90,000

72,000

540,000

-
35,000
20,000
25,000
25,000
50,000
50,000
-
-
-
35,000
-
-
240,000
250,000
-
-
50,000
30,000
-
70,000
150000
-
-
-
-

318,750
260,000
-
220,500
150,000

10,000
160,000
-
75,000
6,000
20,000

9,900
-
10,444
3,906
21,008
1,685
35,808
11,035
35,375
-
1,125
6,394
-
-

-
16,026
62,559
470,935
-

-
-
79,750
148,977
-

5,688
58,440

67,500
-

-
-
-
-

-
1,247,400
49,492
56,250
21,250
460,176
374,220
20,000
24,500
-
-
-

-
-
-

3,360
87,120
19,954
16,875
-
-
4,500
360
-
124,936
1,582
6,358
21,450
70000
28,500

7,214,088
(OUTCOME)

VARIAN

II. Nama Dokter

DIAGNOSIS ICD - 10
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL PELAYANAN KESEHATAN
BALAI BESAR KESEHATAN PARU MASYARAKAT SURAKARTA
Jalan ProfesorDokter R. Soeharso No. 28 Surakarta 57144 Telepon/Faksimile 0271-713055/720002
surat elektronik: bbkpm_surakarta@yahoo.co.id; laman: bbkpmska.com

CLINICAL PATHWAY

Perkiraan Lama Rawat : 5 Hari/ KLS 2


Indikasi : No. Rekam Medis : 120358
Nama Pasien : SAMIN Tgl Masuk : 6/8/2019
Jenis Kelamin : L P Rujukan :
Umur : Pengirim :
Diagnosa Awal : PERADANGAN DAN INFEKSI PERNAFA DPJP :

HARI KE
Unit Cost Tarif
KEGIATAN Vol Total Unit
Satuan Satuan UGD RJ 1 2 3 4 5 6 7 8 9
Cost

ADMINISTRASI PENDAFTARAN 18,975 10,000 1 -

AKOMODASI 140,772 150,000 5 -

PEMERIKSAAN MEDIS -

Pemeriksaan Dokter UGD/UMUM


1 (KU, VS :TD,N,R,S,SpO2) & 133,316 50,000 1 133,316 50,000 40,000 90,000
Edukasi awal

Pemeriksaan Dokter Spesialis &


2 Edukasi awal (KUVS 87,073 -
:TD,N,R,S,SpO2)

Visite Dokter Spesialis (Assesment


3 95,911 100,000 8 -
Klinis) Komplikasi bila ada

4 Konsultasi Dokter spesialis lain 143,070 70,000 -

PEMERIKSAAN PENUNJANG
1 Darah Rutin III 46,843 35,000 1 -
2 Gula Darah Sewaktu 59,291 20,000 2 -
3 Ureum 52,610 35,000 2 -
4 Kreatinin 47,610 35,000 2 -
5 SGPT 48,263 35,000 1 -
6 SGOT 48,363 35,000 1 -
Bilirubin indirect 25,000
Bilirubin Total 25,000
Bilirubin direct 25,000
Calsium 100,000
Chlorida 110,000
Natrium 110,000
7 Elektrolit 240,000 240,000 -
8 Analisa Gas Darah 250,000 250,000 -
9 Diff count
10 Sputum MO/Gr/K/R 37,000 20,000
Kultur 75,000 1
EKG 30,000 1
11 EKG 91,045 30,000 1 -
12 Foto Thorak PA 173,315 70,000 1 -

TINDAKAN MEDIS DIAGNOSTIK


1 Pemeriksaan APE Harian 10,986 8,000 -
2 Uji Bronkodilator 118,683 70,000 -
3 Spirometri saat kondisi stabil 94,296 50,000 -
-
TINDAKAN MEDIS TERAPI
1 Oksigenasi sampai SpO2 > 90% 9,814 3,750 49 -
2 Nebulizer 47,185 20,000 1 -
3 Nebulizer 26,000 10
ASUHAN KEPERAWATAN 37,654 40,000 5 -

TINDAKAN KEPERAWATAN
1 Skin tes 25,000 13,000 2 -
2 Injeksi 8,041 13,000 11 - - -
Pemasangan Infus 32,000 1
3 Pemasangan Infus 49,378 25,000 1 -
4 Melepas Infus 13,000 2
BAHAN HABIS PAKAI
1 Infus Set 9,900 9,900 2 - -
2 Three Way 4,063 4,063 1 -
3 IV Catheter 10,444 10,444 2
4 Spuit 1 CC 1,953 2
5 Spuit 3 CC 1,953 1,313 25 -
6 Spuit 5 CC 1,685 1,685 2 -
7 Spuit 10 CC 2,238 2,238 17 -
8 canula O2 11,035 2
9 masker nebuliser 35,375 1
10 Sarung tangan non steril 5,313 5,313 -
11 Alkohol swab 1,100 125 25 -
12 Dermafik S 6,394 6,394 1
13 Mangkok Sputum 825 1
14 Plester Dressing Wound 1,500

OBAT-OBATAN
1 Cairan infus kristaloid
a eas primer inf 435,275 3
b NaCl 0,9 % 7,150 8,012
c RL 8,043 8,937 14
d KA EN infus 12,561
2 Obat Nebulizer
Fenoterol 0,2 mg/8jam 4,875 5,850 -
Ipratropium 0.8 mg/8jam 1,097 1,316 -
meptin 7,250 9
Pulmicort 0,5 mg 16,553 1
fluimucil 100 mg 12,500 11
Bricasma 2,5 8,563
Combivent 5,688 1

3 Aminophilin drip 0,5-0,9 mg/KgBB/jam


4 Steroid
a Dexamethason 5mg/8j atau
b Metilprenisolon 60-80mg/24 j 12,150 13,500 2 -
c Kalium klorida 4,029
5 Antibiotik:
a Cefotaxim 1gr/12jam atau 55,000 -
b Ceftazidime 1gr/12 jam atau 11,650 -
c Ceftriaxon 2gr/24 jam atau 5,044 5,604 12 -
d Ciprofloxacin 200 mg/12 jam
e Levofloxacin 500 inj 34,375 5
f Levofloxacin 750mg inj 138,600
g Omeprasole inj 12,373 11
h Antrain inj 21,250 3
i Odansetron inj 1,338
6 Furosemide inj 1,666 2
Furosemide MH inj 5,550 5
7 Analgetik & Antipirektik
Paracetamol 500 mg (bila perlu) -
8 Obat Saluran Cerna
Omeprazole
Lansoprasole kapsul 379
Sulkralfat syr 8,486 1
9 Obat Oral
KSR 2,194
Ketosteril kapsul 11,875 16
Keto G 8,807 12
Amlodipin tab 88 8
Candensartan 8 mg tab 649 34
Nitrokaf Retard kapsul 1,950 38
N-Aceticistein 200mg tab 438 18
Meptin tab 7,568 10
Levofloxacin 500 tab 532
10 Aqua Pro injeksi 25 Ml 3,218 3,575 1

NUTRISI 15500 - - - - -

MOBILISASI 74,069 20,000 -

PENDIDIKAN KESEHATAN 71,046 10,000 71,046

- 40,000 - - 40,000
HASIL (OUTCOME)
Keadaan Umum
VARIAN
Kesadaran
Tekanan darah
MONITORING
Nadi
Respirasi
I. Nama Dokter
Suhu
Saturasi Oksigen
II. Nama Dokter
Sesak napas
Batuk DIAGNOSIS
Anemia Diagnosis Utama Asma
Infus baik Diagnosis Sekunder -
Toleransi Diet baik
Visite Dokter
Aktivitas sendiri
Edukasi Penyakit
Edukasi Pengobatan Diagnosa Komplikasi
Edukasi tatalaksana
penyakit dan lama
perawatan Kelas keperawatan
Rencana pulang Total Tarif Rumah Sakit
Total Unit Cost
Total Tarif INA CBGs
ATAN REPUBLIK INDONESIA
AL PELAYANAN KESEHATAN
PARU MASYARAKAT SURAKARTA
rakarta 57144 Telepon/Faksimile 0271-713055/720002
arta@yahoo.co.id; laman: bbkpmska.com

AL PATHWAY

DISKRIPSI DRG
J-4-15-I

INFEKSI DAN
PERADANGAN

TARIF RS PER KELAS


Total tarif 3 2 1 VIP

10,000

750,000

90,000

800,000

-
35,000
40,000
70,000
70,000
35,000
35,000
-
-
-
-
-
-
-
-
-
-
75,000
30,000
30,000
70,000

-
-
-
-

183,750
20,000
260,000
200,000

26,000
143,000
32,000
25,000
26,000
19,800
4,063
20,888
3,906
32,825
3,370
38,046
22,070
35,375
-
3,125
6,394
825
-

1,305,825
-
125,118
-

-
-
65,250
16,553
137,500

5,688

27,000
-
-
-
-
67,248

171,875
-
136,103
63,750
-
3,332
27,750

-
-
8,486

-
190,000
105,684
704
22,066
74,100
7,884
75,680

3,575

5,887,608
(OUTCOME)
VARIAN

II. Nama Dokter

DIAGNOSIS ICD - 10
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL PELAYANAN KESEHATAN
BALAI BESAR KESEHATAN PARU MASYARAKAT SURAKARTA
Jalan ProfesorDokter R. Soeharso No. 28 Surakarta 57144 Telepon/Faksimile 0271-713055/720002
surat elektronik: bbkpm_surakarta@yahoo.co.id; laman: bbkpmska.com

CLINICAL PATHWAY

Perkiraan Lama Rawat : 5 Hari DISKRIPSI DRG


Indikasi : No. Rekam Medis : J-4-18-I
Nama Pasien : Tgl Masuk :
Jenis Kelamin : L P Rujukan : ASTHMA &
BRONKHIOLITIS
Umur : Pengirim : RINGAN
Diagnosa Awal : ASMA EKSASERBASI AKUT DPJP :

HARI KE TARIF RS PER KELAS


Unit Cost Tarif
KEGIATAN Vol Total Unit
Satuan Satuan UGD RJ 1 2 3 4 5 Total tarif 3 2 1
Cost

ADMINISTRASI PENDAFTARAN 18,975 10,000 1 18,975 18,975 10,000

AKOMODASI 140,772 90,000 5 140,772 140,772 140,772 140,772 140,772 703,860 450,000

PEMERIKSAAN MEDIS -

Pemeriksaan Dokter UGD (KU,


1 VS :TD,N,R,S,SpO2) & Edukasi 133,316 50,000 1 133,316 - 50,000
awal

Pemeriksaan Dokter Spesialis &


2 Edukasi awal (KUVS 87,073 80,000 5 87,073 87,073 400,000
:TD,N,R,S,SpO2)

Visite Dokter Spesialis (Assesment


3 95,911 60,000 1 95,911 95,911 95,911 95,911 383,644 60,000
Klinis) Komplikasi bila ada

4 Konsultasi Dokter spesialis lain 143,070 70,000 - -

PEMERIKSAAN PENUNJANG 1
1 Darah Rutin III 46,843 35,000 1 46,843 46,843 35,000
2 Gula Darah Sewaktu 59,291 20,000 1 59,291 59,291 20,000
3 Ureum 52,610 25,000 1 52,610 52,610 25,000
4 Kreatinin 47,610 25,000 1 47,610 47,610 25,000
5 SGPT 48,263 25,000 1 48,263 48,263 25,000
6 SGOT 48,363 25,000 1 48,363 48,363 25,000
7 Elektrolit 240,000 240,000 1 240,000 240,000 240,000
8 Analisa Gas Darah 250,000 250,000 250,000 250,000 -
9 Diff count -
10 Sputum MO/Gr/K/R 37,000 20,000 1 20,000
11 EKG 91,045 30,000 1 91,045 91,045 30,000
12 Foto Thorak PA 173,315 70,000 173,315 173,315 -

TINDAKAN MEDIS DIAGNOSTIK 5 -


1 Pemeriksaan APE Harian 10,986 8,000 1 8,000 8,000 8,000 8,000 32,000 8,000
2 Uji Bronkodilator 118,683 70,000 - -
3 Spirometri saat kondisi stabil 94,296 50,000 50,000 50,000 -
-
TINDAKAN MEDIS TERAPI 96
1 Oksigenasi sampai SpO2 > 90% 9,814 3,750 4 90,000 90,000 90,000 90,000 360,000 15,000
2 Nebulizer 47,185 20,000 20,000 20,000 20,000 20,000 80,000 -
4
ASUHAN KEPERAWATAN 37,654 35,000 37,654 37,654 37,654 37,654 150,616 -

TINDAKAN KEPERAWATAN 1
1 Skin tes 25,000 11,500 12 25,000 25,000 25,000 25,000 100,000 138,000
2 Injeksi 8,041 13,000 1 24,123 24,123 48,246 13,000
3 Pemasangan Infus 49,378 25,000 1 49,378 49,378 98,756 25,000
4 Melepas Infus
BAHAN HABIS PAKAI 2
1 Infus Set 9,900 11,880 2 9,900 9,900 19,800 19,800
2 Three Way 4,063 4,876 2 4,063 4063 8,126 8,126
3 IV Catheter 10,444 12,533 1 10,444 10444 20,888 20,888
4 Spuit 1 CC 1,953 2,344 20 1,953 1,953 1,953
5 Spuit 5 CC 1,685 2,022 4 8,425 8,425 8,425 8,425 33,700 33,700
6 Spuit 10 CC 2,238 2,686 4 2,238 2,238 2,238 2,238 8,952 8,952
7 Sarung tangan non steril 5,313 6,376 2 4,000 4,000 4,000 4,000 16,000 16,000
8 Alkohol swab 1,100 12,500 2 11,000 11,000 11,000 11,000 44,000 44,000
9 Dermafik S 6,394 7,673 6,394 6,394 12,788 12,788

OBAT-OBATAN
1 Cairan infus kristaloid 12
a NaCl 0,9 % 7,150 7,865 -
b RL 8,043 8,937 -
2 Obat Nebulizer 12
Fenoterol 0,2 mg/8jam 4,875 5,850 12 14,625 14,625 14,625 14,625 58,500 70,200
Ipratropium 0.8 mg/8jam 1,097 1,316 3,291 3,291 3,291 3,291 13,164 -
Pulmicort 0,5 mg
3 Aminophilin drip 0,5-0,9 mg/KgBB/jam
4 Steroid
a Dexamethason 5mg/8j atau
b Metilprenisolon 60-80mg/24 j 12,150 13,500 9,000 9,000 9,000 9,000 36,000 36,000
5 Antibiotik: 1 -
a Cefotaxim 1gr/12jam atau 55,000 66,000 3 3,218 55,000 58,218 58,218
b Ceftazidime 1gr/12 jam atau 11,650 13,980 11,650 11,650 11,650 34,950 34,950
c Ceftriaxon 2gr/24 jam atau 5,044 5,604 3,575 3,575 3,575 3,575 14,300 14,300
d Ciprofloxacin 200 mg/12 jam
6 Expektoran 3x1 C
7 Analgetik & Antipirektik
Paracetamol 500 mg (bila perlu) 13,424 14,915
8 Obat Saluran Cerna
Omeprazole 12,373
8 Aqua Pro injeksi 25 Ml 3,218 3,575

NUTRISI - - - - - -
1
MOBILISASI 74,069 20,000 74,069 74,069 -
1
PENDIDIKAN KESEHATAN 71,046 10,000 1 71,046 10,000

657,631 995,624 344,369 344,369 561,090 2,903,083 2,003,875


HASIL (OUTCOME)
Keadaan Umum
VARIAN
Kesadaran
Tekanan darah
MONITORING
Nadi
Respirasi
I. Nama Dokter
Suhu
Saturasi Oksigen
II. Nama Dokter
Sesak napas
Batuk DIAGNOSIS ICD - 10
Anemia Diagnosis Utama Asma
Infus baik Diagnosis Sekunder -
Toleransi Diet baik
Visite Dokter
Aktivitas sendiri
Edukasi Penyakit
Edukasi Pengobatan Diagnosa Komplikasi
Edukasi tatalaksana
penyakit dan lama
perawatan Kelas keperawatan Kelas II
Rencana pulang Total Tarif Rumah Sakit 2,549,557
Total Unit Cost 2,903,083
Total Tarif INA CBGs 2,730,500
VIP
VARIAN
II. Nama Dokter
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL PELAYANAN KESEHATAN
BALAI BESAR KESEHATAN PARU MASYARAKAT SURAKARTA
Jalan ProfesorDokter R. Soeharso No. 28 Surakarta 57144 Telepon/Faksimile 0271-713055/720002
surat elektronik: bbkpm_surakarta@yahoo.co.id; laman: bbkpmska.com

CLINICAL PATHWAY

Perkiraan Lama Rawat : 5 Hari DISKRIPSI DRG


Indikasi : No. Rekam Medis : J-4-17-I
Nama Pasien : Tgl Masuk :
Jenis Kelamin : L P Rujukan :
PPOK RINGAN
Umur : Pengirim :
Diagnosa Awal : PPOK EKSASERBASI AKUT DPJP :

HARI KE TARIF RS PER KELAS


Unit Cost Tarif
KEGIATAN Vol Total Unit
Satuan Satuan RJ 1 2 3 4 5 Total tarif 3 2 1 VIP
Cost

ADMINISTRASI PENDAFTARAN 18,975 10,000 1 18,975 18,975 10,000

AKOMODASI 140,772 90,000 5 140,772 140,772 140,772 140,772 140,772 703,860 450,000

PEMERIKSAAN MEDIS -

Pemeriksaan Dokter Spesialis &


1 Edukasi awal (KUVS 87,073 80,000 1 87,073 87,073
:TD,N,R,S,SpO2)
80,000

Visite Dokter Spesialis (Assesment


2 95,911 60,000 5 95,911 95,911 95,911 95,911 95,911 479,555 300,000
Klinis) Komplikasi bila ada

3 Konsultasi Dokter spesialis lain 143,070 70,000 1 70,000

PEMERIKSAAN PENUNJANG
1 Darah Rutin III 46,843 35,000 1 46,843 46,843 35,000
2 Gula Darah Sewaktu 59,291 20,000 1 59,291 59,291 20,000
3 Ureum 52,610 25,000 1 52,610 52,610 25,000
4 Kreatinin 47,610 25,000 1 47,610 47,610 25,000
5 SGPT 48,263 25,000 1 48,263 48,263 25,000
6 SGOT 48,363 25,000 1 48,363 48,363 25,000
7 Elektrolit 240,000 240,000 1 240,000 240,000 240,000
8 Analisa Gas Darah 250,000 250,000 1 250,000 250,000 250,000
9 Diff count -
10 Sputum MO/Gr/K/R 37,000 20,000 -
11 EKG 91,045 30,000 1 91,045 91,045 30,000
12 Foto Thorak PA 173,315 70,000 1 173,315 173,315 70,000

TINDAKAN MEDIS DIAGNOSTIK -


1 Pemeriksaan APE Harian 10,986 8,000 5 8,000 8,000 8,000 8,000 32,000 40,000
2 Uji Bronkodilator 118,683 70,000 1 - 70,000
3 Spirometri saat kondisi stabil 94,296 50,000 50,000 50,000 -
-
TINDAKAN MEDIS TERAPI
1 Oksigenasi sampai SpO2 > 90% 9,814 3,750 96 90,000 90,000 90,000 90,000 360,000 360,000
2 Nebulizer 47,185 20,000 4 20,000 20,000 20,000 20,000 80,000 80,000

ASUHAN KEPERAWATAN 37,654 35,000 4 37,654 37,654 37,654 37,654 37,654 188,270 140,000

TINDAKAN KEPERAWATAN
1 Skin tes 25,000 11,500 1 25,000 25,000 11,500
2 Injeksi 8,041 13,000 12 24,123 24,123 24,123 24,123 96,492 156,000
3 Pemasangan Infus 49,378 25,000 1 49,378 49,378 98,756 25,000
4 Melepas Infus 49,378 14,000 1 49,378 49,378 14,000
BAHAN HABIS PAKAI
1 Infus Set 9,900 11,880 2 9,900 9,900 19,800 23,760
2 Three Way 4,063 4,876 2 4,063 4063 8,126 9,751
3 IV Catheter 10,444 12,533 2 10,444 10444 20,888 25,066
4 Spuit 1 CC 1,953 2,344 1 1,953 1,953 2,344
5 Spuit 5 CC 1,685 2,022 20 8,425 8,425 8,425 8,425 33,700 40,440
6 Spuit 10 CC 2,238 2,686 4 2,238 2,238 2,238 2,238 8,952 10,742
7 Sarung tangan non steril 5,313 6,376 4 4,000 4,000 4,000 4,000 16,000 25,502
8 Alkohol swab 1,100 12,500 2 11,000 11,000 11,000 11,000 44,000 25,000
9 Dermafik S 6,394 7,673 2 6,394 6,394 12,788 15,346

OBAT-OBATAN
1 Cairan infus kristaloid
a NaCl 0,9 % 7,150 7,865 12 23,595 23,595 23,595 23,595 94,380
b RL 8,043 8,937 -
2 Obat Nebulizer
Fenoterol 0,2 mg/8jam 4,875 5,850 12 14,625 14,625 14,625 14,625 58,500 70,200
Ipratropium 0.8 mg/8jam 1,097 1,316 12 3,291 3,291 3,291 3,291 13,164 15,797
Pulmicort 0,5 mg
3 Aminophilin drip 0,5-0,9 mg/KgBB/jam
4 Steroid
a Dexamethason 5mg/8j atau
b Metilprenisolon 60-80mg/24 j 12,150 13,500 9,000 9,000 9,000 9,000 36,000 -
5 Antibiotik:
a Cefotaxim 1gr/12jam atau 55,000 66,000 1 55,000 55,000 66,000
b Ceftazidime 1gr/12 jam atau 11,650 13,980 3 11,650 11,650 11,650 34,950 41,940
c Ceftriaxon 2gr/24 jam atau 5,044 5,604 3,575 3,575 3,575 3,575 14,300 -
d Ciprofloxacin 200 mg/12 jam
6 Expektoran 3x1 C
7 Analgetik & Antipirektik
Paracetamol 500 mg (bila perlu) 13,424 14,915
8 Obat Saluran Cerna
Omeprazole 12,373
8 Aqua Pro injeksi 25 Ml 3,218 3,575

NUTRISI - - - - - -

MOBILISASI 74,069 20,700 1 74,069 74,069 20,700

PENDIDIKAN KESEHATAN 71,046 10,000 1 71,046 71,046 10,000

654,413 1,090,265 367,087 367,087 609,063 3,087,915 3,048,468


HASIL (OUTCOME)
Keadaan Umum
VARIAN
Kesadaran
Tekanan darah
MONITORING
Nadi
Respirasi
I. Nama Dokter
Suhu
Saturasi Oksigen
II. Nama Dokter
II. Nama Dokter
Sesak napas
Batuk DIAGNOSIS ICD - 10
Anemia Diagnosis Utama Asma
Infus baik Diagnosis Sekunder -
Toleransi Diet baik
Visite Dokter
Aktivitas sendiri
Edukasi Penyakit
Edukasi Pengobatan Diagnosa Komplikasi
Edukasi tatalaksana
penyakit dan lama
perawatan Kelas keperawatan Kelas II
Rencana pulang Total Tarif Rumah Sakit 3,048,468
Total Unit Cost 3,087,915
Total Tarif INA CBGs 2,389,700
DATA PENELITIAN

LAPORAN REKAP KLAIM - BP4/BBKPM SURAKARTA


Pasien Rawat Inap dan Rawat Jalan, Periode Tanggal Pulang: 1 Jan 2019 s/d 20 Mei 2019
Filter: / Kelas Rawat = Semua / Severity = Semua / Cara Pulang = Semua / Jenis Tarif = TARIF RS KEL
Tgl. Masuk Tgl. Pulang INACBG Top Up Total Tarif Tarif RS Jenis
5 Mei 2019 9 Mei 2019 A-4-14-I 2,511,000 4,795,178 RI
15 Mar 2019 18 Mar 2019 A-4-14-II 3,048,000 2,289,080 RI
25 Apr 2019 29 Apr 2019 A-4-14-II 3,048,000 5,212,609 RI
1,524,000 6,096,000 7,501,689
8 Mar 2019 11 Mar 2019 A-4-14-III 3,048,000 2,116,787 RI
3,048,000 3,048,000 2,116,787
3 Jan 2019 6 Jan 2019 A-4-15-I 2,866,100 1,895,803 RI
30 Jan 2019 3 Feb 2019 A-4-15-I 2,866,100 4,458,614 RI
10 Apr 2019 11 Apr 2019 A-4-15-I 2,866,100 1,058,254 RI
2,866,100 8,598,300 7,412,671
7 Feb 2019 12 Feb 2019 A-4-15-II 4,290,200 3,821,781 RI
5 Mar 2019 9 Mar 2019 A-4-15-II 4,290,200 3,455,451 RI
1 Mei 2019 4 Mei 2019 A-4-15-II 5,148,200 4,629,731 RI
6 Mei 2019 8 Mei 2019 A-4-15-II 4,290,200 3,262,660 RI
4,504,700 18,018,800 15,169,623
17 Jan 2019 19 Jan 2019 A-4-15-III 5,383,800 2,806,664 RI
30 Apr 2019 6 Mei 2019 A-4-15-III 5,383,800 7,249,899 RI
5,383,800 10,767,600 10,056,563
1 Jan 2019 6 Jan 2019 B-4-13-II 3,807,600 4,557,397 RI
14 Mei 2019 16 Mei 2019 B-4-13-II 3,173,000 1,530,569 RI
3,490,300 6,980,600 6,087,966
1 Feb 2019 5 Feb 2019 D-4-10-III 5,677,500 5,136,514 RI
5,677,500 5,677,500 5,136,514
14 Mar 2019 19 Mar 2019 E-4-10-I 3,164,100 6,365,768 RI
3,164,100 3,164,100 6,365,768
15 Mar 2019 19 Mar 2019 E-4-10-III 5,487,600 4,074,273 RI
5,487,600 5,487,600 4,074,273
2 Jan 2019 6 Jan 2019 E-4-13-II 3,508,400 3,506,715 RI
3,508,400 3,508,400 3,506,715
23 Apr 2019 26 Apr 2019 I-4-12-II 2,604,500 3,407,329 RI
2,604,500 2,604,500 3,407,329
10 Jan 2019 15 Jan 2019 I-4-12-III 3,125,400 4,026,345 RI
29 Jan 2019 5 Feb 2019 I-4-12-III 3,125,400 5,745,243 RI
7 Feb 2019 10 Feb 2019 I-4-12-III 3,125,400 3,837,484 RI
17 Feb 2019 17 Feb 2019 I-4-12-III 3,125,400 2,771,301 RI
18 Feb 2019 22 Feb 2019 I-4-12-III 3,125,400 4,550,346 RI
5 Mar 2019 9 Mar 2019 I-4-12-III 3,125,400 3,066,971 RI
13 Mar 2019 16 Mar 2019 I-4-12-III 3,125,400 3,172,240 RI
25 Mar 2019 27 Mar 2019 I-4-12-III 3,125,400 1,614,817 RI
3,125,400 25,003,200 28,784,747
24 Mar 2019 26 Mar 2019 I-4-16-I 1,362,800 2,146,960 RI
2 Mei 2019 5 Mei 2019 I-4-17-II 1,945,000 1,968,120 RI
22 Jan 2019 26 Jan 2019 I-4-20-II 3,050,200 3,733,586 RI
4 Mar 2019 9 Mar 2019 I-4-20-II 3,050,200 4,838,981 RI
30 Apr 2019 4 Mei 2019 I-4-20-II 3,050,200 4,380,736 RI
10 Mei 2019 12 Mei 2019 I-4-20-II 3,050,200 1,318,537 RI
27 Des 2018 1 Jan 2019 I-4-24-I 2,342,500 4,608,095 RI
7 Feb 2019 12 Feb 2019 J-4-14-I 4,003,900 3,695,801 RI

Page 1
DATA PENELITIAN

19 Feb 2019 23 Feb 2019 J-4-14-II 4,653,900 3,775,534 RI


26 Des 2018 1 Jan 2019 J-4-15-I 1 3,799,700 7,287,062 RI
30 Des 2018 3 Jan 2019 J-4-15-I 2 5,319,600 3,694,342 RI
30 Des 2018 3 Jan 2019 J-4-15-I 3 3,799,700 2,327,581 RI
2 Jan 2019 4 Jan 2019 J-4-15-I 4 3,799,700 1,826,748 RI
2 Jan 2019 5 Jan 2019 J-4-15-I 5 5,319,600 3,222,711 RI
30 Des 2018 5 Jan 2019 J-4-15-I 6 4,559,600 4,293,789 RI
5 Jan 2019 7 Jan 2019 J-4-15-I 7 3,799,700 1,460,924 RI
5 Jan 2019 8 Jan 2019 J-4-15-I 8 4,559,600 3,630,388 RI
8 Jan 2019 10 Jan 2019 J-4-15-I 9 3,799,700 1,841,582 RI
8 Jan 2019 10 Jan 2019 J-4-15-I 10 3,799,700 1,032,357 RI
9 Jan 2019 11 Jan 2019 J-4-15-I 11 4,559,600 2,468,386 RI
8 Jan 2019 11 Jan 2019 J-4-15-I 12 3,799,700 3,005,368 RI
9 Jan 2019 12 Jan 2019 J-4-15-I 13 3,799,700 2,181,718 RI
14 Jan 2019 18 Jan 2019 J-4-15-I 14 4,559,600 3,473,486 RI
16 Jan 2019 19 Jan 2019 J-4-15-I 15 5,319,600 2,972,568 RI
19 Jan 2019 22 Jan 2019 J-4-15-I 16 3,799,700 3,921,112 RI
23 Jan 2019 25 Jan 2019 J-4-15-I 17 3,799,700 1,406,373 RI
21 Jan 2019 26 Jan 2019 J-4-15-I 18 3,799,700 5,480,262 RI
23 Jan 2019 26 Jan 2019 J-4-15-I 19 3,799,700 2,150,926 RI
25 Jan 2019 29 Jan 2019 J-4-15-I 20 3,799,700 4,121,413 RI
21 Jan 2019 31 Jan 2019 J-4-15-I 21 4,559,600 7,743,348 RI
29 Jan 2019 1 Feb 2019 J-4-15-I 22 3,799,700 2,721,734 RI
30 Jan 2019 5 Feb 2019 J-4-15-I 23 3,799,700 4,744,649 RI
6 Feb 2019 8 Feb 2019 J-4-15-I 24 4,559,600 2,379,026 RI
7 Feb 2019 10 Feb 2019 J-4-15-I 25 3,799,700 2,537,094 RI
7 Feb 2019 11 Feb 2019 J-4-15-I 26 3,799,700 3,494,753 RI
7 Feb 2019 12 Feb 2019 J-4-15-I 27 3,799,700 4,227,654 RI
10 Feb 2019 13 Feb 2019 J-4-15-I 28 4,559,600 3,864,993 RI
11 Feb 2019 13 Feb 2019 J-4-15-I 29 3,799,700 1,724,292 RI
11 Feb 2019 13 Feb 2019 J-4-15-I 30 3,799,700 1,500,110 RI
14 Feb 2019 18 Feb 2019 J-4-15-I 31 3,799,700 2,567,712 RI
18 Feb 2019 21 Feb 2019 J-4-15-I 32 3,799,700 2,723,055 RI
21 Feb 2019 22 Feb 2019 J-4-15-I 33 5,319,600 4,051,812 RI
22 Feb 2019 26 Feb 2019 J-4-15-I 34 3,799,700 4,515,429 RI
24 Feb 2019 27 Feb 2019 J-4-15-I 35 3,799,700 2,430,243 RI
25 Feb 2019 27 Feb 2019 J-4-15-I 36 3,799,700 2,647,947 RI
25 Feb 2019 28 Feb 2019 J-4-15-I 37 4,559,600 3,326,964 RI
25 Feb 2019 28 Feb 2019 J-4-15-I 38 3,799,700 3,499,466 RI
25 Feb 2019 28 Feb 2019 J-4-15-I 39 3,799,700 2,420,317 RI
25 Feb 2019 28 Feb 2019 J-4-15-I 40 3,799,700 2,071,207 RI
26 Feb 2019 1 Mar 2019 J-4-15-I 41 3,799,700 1,439,754 RI
28 Feb 2019 2 Mar 2019 J-4-15-I 42 3,799,700 1,666,614 RI
27 Feb 2019 5 Mar 2019 J-4-15-I 43 3,799,700 5,543,916 RI
6 Mar 2019 8 Mar 2019 J-4-15-I 44 5,319,600 1,924,688 RI
8 Mar 2019 12 Mar 2019 J-4-15-I 45 4,559,600 7,326,490 RI
11 Mar 2019 13 Mar 2019 J-4-15-I 46 4,559,600 2,272,529 RI
12 Mar 2019 14 Mar 2019 J-4-15-I 47 4,559,600 1,995,131 RI
10 Mar 2019 15 Mar 2019 J-4-15-I 48 3,799,700 4,666,817 RI
15 Mar 2019 18 Mar 2019 J-4-15-I 49 4,559,600 3,913,740 RI
14 Mar 2019 18 Mar 2019 J-4-15-I 50 4,559,600 5,507,133 RI
15 Mar 2019 18 Mar 2019 J-4-15-I 51 4,559,600 2,154,877 RI

Page 2
DATA PENELITIAN

19 Mar 2019 21 Mar 2019 J-4-15-I 52 5,319,600 3,166,704 RI


22 Mar 2019 25 Mar 2019 J-4-15-I 53 3,799,700 2,978,633 RI
22 Mar 2019 26 Mar 2019 J-4-15-I 54 3,799,700 4,159,787 RI
23 Mar 2019 26 Mar 2019 J-4-15-I 55 3,799,700 1,416,726 RI
26 Mar 2019 28 Mar 2019 J-4-15-I 56 3,799,700 2,028,283 RI
24 Mar 2019 28 Mar 2019 J-4-15-I 57 3,799,700 4,189,223 RI
28 Mar 2019 30 Mar 2019 J-4-15-I 58 4,559,600 2,571,150 RI
28 Mar 2019 1 Apr 2019 J-4-15-I 59 5,319,600 4,858,749 RI
1 Apr 2019 4 Apr 2019 J-4-15-I 60 4,559,600 2,622,976 RI
1 Apr 2019 5 Apr 2019 J-4-15-I 61 3,799,700 4,504,787 RI
6 Apr 2019 9 Apr 2019 J-4-15-I 62 4,559,600 3,133,795 RI
11 Apr 2019 14 Apr 2019 J-4-15-I 63 3,799,700 2,679,095 RI
11 Apr 2019 14 Apr 2019 J-4-15-I 64 3,799,700 3,061,520 RI
16 Apr 2019 18 Apr 2019 J-4-15-I 65 3,799,700 1,352,451 RI
17 Apr 2019 20 Apr 2019 J-4-15-I 66 3,799,700 3,027,722 RI
22 Apr 2019 24 Apr 2019 J-4-15-I 67 4,559,600 2,826,714 RI
22 Apr 2019 26 Apr 2019 J-4-15-I 68 3,799,700 5,524,299 RI
22 Apr 2019 26 Apr 2019 J-4-15-I 69 3,799,700 2,921,662 RI
2 Mei 2019 6 Mei 2019 J-4-15-I 70 5,319,600 3,906,152 RI
29 Des 2018 1 Jan 2019 J-4-15-II 1 4,539,600 1,997,146 RI
11 Jan 2019 12 Jan 2019 J-4-15-II 2 4,539,600 1,115,679 RI
12 Jan 2019 14 Jan 2019 J-4-15-II 3 4,539,600 3,090,009 RI
15 Jan 2019 18 Jan 2019 J-4-15-II 4 5,447,500 3,579,856 RI
16 Jan 2019 19 Jan 2019 J-4-15-II 5 6,355,400 3,931,842 RI
22 Jan 2019 25 Jan 2019 J-4-15-II 6 5,447,500 2,309,087 RI
29 Jan 2019 1 Feb 2019 J-4-15-II 7 4,539,600 2,761,207 RI
1 Feb 2019 6 Feb 2019 J-4-15-II 8 6,355,400 8,211,932 RI
4 Feb 2019 6 Feb 2019 J-4-15-II 9 4,539,600 2,885,405 RI
12 Feb 2019 15 Feb 2019 J-4-15-II 10 6,355,400 3,502,853 RI
12 Feb 2019 15 Feb 2019 J-4-15-II 11 4,539,600 2,804,964 RI
11 Feb 2019 15 Feb 2019 J-4-15-II 12 4,539,600 2,675,509 RI
13 Feb 2019 16 Feb 2019 J-4-15-II 13 4,539,600 3,602,345 RI
25 Feb 2019 28 Feb 2019 J-4-15-II 14 4,539,600 3,465,314 RI
26 Feb 2019 3 Mar 2019 J-4-15-II 15 6,355,400 4,849,315 RI
4 Mar 2019 7 Mar 2019 J-4-15-II 16 6,355,400 4,743,705 RI
3 Mar 2019 9 Mar 2019 J-4-15-II 17 5,447,500 5,125,337 RI
5 Mar 2019 11 Mar 2019 J-4-15-II 18 4,539,600 5,500,061 RI
10 Mar 2019 15 Mar 2019 J-4-15-II 19 6,355,400 6,719,189 RI
24 Mar 2019 27 Mar 2019 J-4-15-II 20 4,539,600 2,643,350 RI
25 Mar 2019 28 Mar 2019 J-4-15-II 21 4,539,600 3,455,271 RI
25 Mar 2019 29 Mar 2019 J-4-15-II 22 4,539,600 5,261,552 RI
29 Mar 2019 2 Apr 2019 J-4-15-II 23 5,447,500 4,780,248 RI
30 Mar 2019 2 Apr 2019 J-4-15-II 24 4,539,600 2,167,080 RI
2 Apr 2019 6 Apr 2019 J-4-15-II 25 5,447,500 4,654,930 RI
9 Apr 2019 11 Apr 2019 J-4-15-II 26 4,539,600 2,566,479 RI
10 Apr 2019 16 Apr 2019 J-4-15-II 27 6,355,400 7,759,931 RI
27 Apr 2019 1 Mei 2019 J-4-15-II 28 4,539,600 7,036,945 RI
2 Jan 2019 9 Jan 2019 J-4-15-III 1 6,107,600 5,526,402 RI
23 Jan 2019 29 Jan 2019 J-4-15-III 2 6,107,600 6,312,669 RI
25 Apr 2019 25 Apr 2019 J-4-15-III 3 6,107,600 1,151,862 RI
10 Jan 2019 14 Jan 2019 J-4-16-I 1 3,166,000 2,660,973 RI
29 Jan 2019 1 Feb 2019 J-4-16-I 2 3,166,000 2,438,472 RI

Page 3
DATA PENELITIAN

29 Jan 2019 1 Feb 2019 J-4-16-I 3 3,799,100 2,993,149 RI


1 Feb 2019 4 Feb 2019 J-4-16-I 4 3,166,000 2,942,049 RI
2 Feb 2019 6 Feb 2019 J-4-16-I 5 4,432,300 4,713,426 RI
4 Feb 2019 7 Feb 2019 J-4-16-I 6 4,432,300 2,271,135 RI
3 Feb 2019 7 Feb 2019 J-4-16-I 7 4,432,300 5,030,867 RI
6 Feb 2019 8 Feb 2019 J-4-16-I 8 3,166,000 2,451,211 RI
3 Feb 2019 8 Feb 2019 J-4-16-I 9 3,166,000 4,263,324 RI
7 Feb 2019 9 Feb 2019 J-4-16-I 10 3,166,000 4,558,161 RI
8 Feb 2019 10 Feb 2019 J-4-16-I 11 4,432,300 2,066,800 RI
12 Feb 2019 14 Feb 2019 J-4-16-I 12 3,166,000 2,177,856 RI
14 Feb 2019 18 Feb 2019 J-4-16-I 13 3,166,000 2,160,036 RI
12 Feb 2019 19 Feb 2019 J-4-16-I 14 4,432,300 5,998,893 RI
16 Feb 2019 20 Feb 2019 J-4-16-I 15 3,166,000 3,166,985 RI
18 Feb 2019 21 Feb 2019 J-4-16-I 16 3,166,000 3,441,751 RI
19 Feb 2019 21 Feb 2019 J-4-16-I 17 3,799,100 2,363,703 RI
20 Feb 2019 22 Feb 2019 J-4-16-I 18 3,166,000 1,926,530 RI
21 Feb 2019 26 Feb 2019 J-4-16-I 19 3,166,000 4,675,013 RI
27 Feb 2019 4 Mar 2019 J-4-16-I 20 4,432,300 3,090,601 RI
1 Mar 2019 4 Mar 2019 J-4-16-I 21 3,166,000 2,723,944 RI
1 Mar 2019 4 Mar 2019 J-4-16-I 22 3,166,000 2,055,893 RI
2 Mar 2019 5 Mar 2019 J-4-16-I 23 3,166,000 1,635,401 RI
2 Mar 2019 5 Mar 2019 J-4-16-I 24 3,166,000 2,727,586 RI
4 Mar 2019 6 Mar 2019 J-4-16-I 25 3,166,000 1,103,560 RI
4 Mar 2019 7 Mar 2019 J-4-16-I 26 4,432,300 2,071,312 RI
6 Mar 2019 9 Mar 2019 J-4-16-I 27 3,166,000 2,221,997 RI
6 Mar 2019 11 Mar 2019 J-4-16-I 28 3,166,000 3,446,298 RI
8 Mar 2019 11 Mar 2019 J-4-16-I 29 3,799,100 2,946,603 RI
9 Mar 2019 12 Mar 2019 J-4-16-I 30 3,166,000 2,349,154 RI
10 Mar 2019 13 Mar 2019 J-4-16-I 31 3,799,100 3,515,181 RI
9 Mar 2019 13 Mar 2019 J-4-16-I 32 4,432,300 3,182,756 RI
11 Mar 2019 13 Mar 2019 J-4-16-I 33 3,166,000 2,062,869 RI
12 Mar 2019 16 Mar 2019 J-4-16-I 34 3,166,000 3,911,669 RI
18 Mar 2019 20 Mar 2019 J-4-16-I 35 3,166,000 2,239,653 RI
18 Mar 2019 22 Mar 2019 J-4-16-I 36 3,166,000 4,056,373 RI
27 Mar 2019 29 Mar 2019 J-4-16-I 37 3,166,000 1,933,049 RI
11 Apr 2019 14 Apr 2019 J-4-16-I 38 3,799,100 2,401,421 RI
16 Apr 2019 18 Apr 2019 J-4-16-I 39 3,166,000 2,427,045 RI
16 Apr 2019 20 Apr 2019 J-4-16-I 40 3,166,000 2,993,675 RI
22 Apr 2019 25 Apr 2019 J-4-16-I 41 4,432,300 4,221,667 RI
24 Apr 2019 27 Apr 2019 J-4-16-I 42 3,166,000 2,532,174 RI
24 Apr 2019 29 Apr 2019 J-4-16-I 43 3,166,000 3,879,019 RI
27 Apr 2019 30 Apr 2019 J-4-16-I 44 3,799,100 3,514,802 RI
1 Mei 2019 4 Mei 2019 J-4-16-I 45 3,166,000 1,763,370 RI
3 Mei 2019 6 Mei 2019 J-4-16-I 46 3,166,000 3,718,652 RI
6 Mei 2019 8 Mei 2019 J-4-16-I 47 4,432,300 1,781,719 RI
31 Des 2018 7 Jan 2019 J-4-16-II 1 6,228,600 6,051,293 RI
5 Jan 2019 8 Jan 2019 J-4-16-II 2 4,449,000 2,977,994 RI
7 Jan 2019 9 Jan 2019 J-4-16-II 3 4,449,000 2,909,968 RI
7 Jan 2019 10 Jan 2019 J-4-16-II 4 4,449,000 3,228,391 RI
16 Jan 2019 19 Jan 2019 J-4-16-II 5 4,449,000 1,929,806 RI
16 Jan 2019 21 Jan 2019 J-4-16-II 6 4,449,000 3,495,470 RI
2 Feb 2019 6 Feb 2019 J-4-16-II 7 4,449,000 3,153,241 RI

Page 4
DATA PENELITIAN

13 Feb 2019 15 Feb 2019 J-4-16-II 8 4,449,000 3,176,012 RI


20 Feb 2019 23 Feb 2019 J-4-16-II 9 5,338,800 3,503,897 RI
22 Feb 2019 25 Feb 2019 J-4-16-II 10 4,449,000 3,062,640 RI
21 Feb 2019 26 Feb 2019 J-4-16-II 11 4,449,000 4,396,058 RI
28 Feb 2019 4 Mar 2019 J-4-16-II 12 5,338,800 8,333,800 RI
1 Mar 2019 5 Mar 2019 J-4-16-II 13 5,338,800 3,686,220 RI
14 Mar 2019 16 Mar 2019 J-4-16-II 14 5,338,800 3,052,619 RI
15 Mar 2019 18 Mar 2019 J-4-16-II 15 4,449,000 2,416,741 RI
14 Mar 2019 18 Mar 2019 J-4-16-II 16 4,449,000 3,635,136 RI
16 Mar 2019 19 Mar 2019 J-4-16-II 17 4,449,000 2,596,819 RI
16 Mar 2019 19 Mar 2019 J-4-16-II 18 4,449,000 3,462,549 RI
16 Mar 2019 26 Mar 2019 J-4-16-II 19 5,338,800 8,250,310 RI
1 Apr 2019 5 Apr 2019 J-4-16-II 20 4,449,000 3,957,015 RI
1 Apr 2019 5 Apr 2019 J-4-16-II 21 4,449,000 3,710,751 RI
4 Apr 2019 7 Apr 2019 J-4-16-II 22 6,228,600 4,682,372 RI
17 Apr 2019 20 Apr 2019 J-4-16-II 23 4,449,000 2,525,161 RI
16 Apr 2019 20 Apr 2019 J-4-16-II 24 4,449,000 4,154,610 RI
8 Jan 2019 11 Jan 2019 J-4-16-III 1 5,625,100 4,677,360 RI
12 Jan 2019 16 Jan 2019 J-4-16-III 2 7,875,100 6,186,396 RI
18 Jan 2019 21 Jan 2019 J-4-16-III 3 5,625,100 2,175,273 RI
16 Feb 2019 19 Feb 2019 J-4-16-III 4 5,625,100 3,470,981 RI
20 Feb 2019 23 Feb 2019 J-4-16-III 5 5,625,100 1,731,641 RI
27 Feb 2019 7 Mar 2019 J-4-16-III 6 5,625,100 8,410,486 RI

2 Jan 2019 4 Jan 2019 J-4-17-I 1 2,389,700 2,106,816 RI


1 Jan 2019 4 Jan 2019 J-4-17-I 2 2,389,700 4,175,025 RI
4 Jan 2019 7 Jan 2019 J-4-17-I 3 2,389,700 1,550,138 RI
9 Jan 2019 13 Jan 2019 J-4-17-I 4 2,389,700 2,818,224 RI
11 Jan 2019 13 Jan 2019 J-4-17-I 5 2,389,700 2,122,627 RI
15 Jan 2019 17 Jan 2019 J-4-17-I 6 2,389,700 1,919,583 RI
12 Jan 2019 17 Jan 2019 J-4-17-I 7 2,389,700 3,875,367 RI
14 Jan 2019 17 Jan 2019 J-4-17-I 8 2,389,700 2,596,320 RI
17 Jan 2019 19 Jan 2019 J-4-17-I 9 2,389,700 2,578,912 RI
20 Jan 2019 24 Jan 2019 J-4-17-I 10 3,345,600 5,113,948 RI
31 Jan 2019 3 Feb 2019 J-4-17-I 11 2,389,700 2,873,084 RI
31 Jan 2019 4 Feb 2019 J-4-17-I 12 2,389,700 4,785,057 RI
6 Feb 2019 8 Feb 2019 J-4-17-I 13 2,389,700 2,396,430 RI
6 Feb 2019 9 Feb 2019 J-4-17-I 14 2,389,700 2,280,880 RI
11 Feb 2019 14 Feb 2019 J-4-17-I 15 2,389,700 3,757,026 RI
12 Feb 2019 18 Feb 2019 J-4-17-I 16 2,389,700 4,019,439 RI
14 Feb 2019 18 Feb 2019 J-4-17-I 17 2,389,700 2,846,773 RI
15 Feb 2019 18 Feb 2019 J-4-17-I 18 2,389,700 2,222,607 RI
15 Feb 2019 19 Feb 2019 J-4-17-I 19 2,867,700 4,160,015 RI
18 Feb 2019 20 Feb 2019 J-4-17-I 20 2,867,700 1,916,595 RI
16 Feb 2019 20 Feb 2019 J-4-17-I 21 2,389,700 3,860,216 RI
18 Feb 2019 21 Feb 2019 J-4-17-I 22 2,389,700 2,258,965 RI
21 Feb 2019 22 Feb 2019 J-4-17-I 23 3,345,600 1,148,892 RI
19 Feb 2019 22 Feb 2019 J-4-17-I 24 2,389,700 2,153,834 RI
19 Feb 2019 22 Feb 2019 J-4-17-I 25 2,389,700 2,652,904 RI
20 Feb 2019 22 Feb 2019 J-4-17-I 26 2,389,700 1,974,449 RI
21 Feb 2019 23 Feb 2019 J-4-17-I 27 2,389,700 1,620,094 RI
21 Feb 2019 23 Feb 2019 J-4-17-I 28 2,389,700 2,180,440 RI

Page 5
DATA PENELITIAN

22 Feb 2019 25 Feb 2019 J-4-17-I 29 3,345,600 3,463,464 RI


25 Feb 2019 26 Feb 2019 J-4-17-I 30 3,345,600 1,266,173 RI
26 Feb 2019 28 Feb 2019 J-4-17-I 31 2,389,700 2,346,777 RI
25 Feb 2019 28 Feb 2019 J-4-17-I 32 2,389,700 2,103,769 RI
24 Feb 2019 28 Feb 2019 J-4-17-I 33 2,867,700 2,936,455 RI
27 Feb 2019 2 Mar 2019 J-4-17-I 34 2,389,700 1,941,723 RI
6 Mar 2019 8 Mar 2019 J-4-17-I 35 3,345,600 2,778,876 RI
11 Mar 2019 13 Mar 2019 J-4-17-I 36 2,867,700 1,787,844 RI
14 Mar 2019 16 Mar 2019 J-4-17-I 37 3,345,600 2,333,428 RI
13 Mar 2019 16 Mar 2019 J-4-17-I 38 2,389,700 3,461,624 RI
15 Mar 2019 19 Mar 2019 J-4-17-I 39 2,389,700 3,722,431 RI
18 Mar 2019 22 Mar 2019 J-4-17-I 40 2,389,700 3,259,697 RI
18 Mar 2019 22 Mar 2019 J-4-17-I 41 2,389,700 4,940,338 RI
21 Mar 2019 24 Mar 2019 J-4-17-I 42 2,389,700 2,586,216 RI
25 Mar 2019 28 Mar 2019 J-4-17-I 43 2,389,700 2,446,701 RI
25 Mar 2019 29 Mar 2019 J-4-17-I 44 2,389,700 3,866,832 RI
29 Mar 2019 1 Apr 2019 J-4-17-I 45 2,389,700 2,271,988 RI
28 Mar 2019 1 Apr 2019 J-4-17-I 46 2,867,700 4,771,949 RI
31 Mar 2019 2 Apr 2019 J-4-17-I 47 3,345,600 2,499,596 RI
1 Apr 2019 4 Apr 2019 J-4-17-I 48 2,389,700 2,730,216 RI
2 Apr 2019 4 Apr 2019 J-4-17-I 49 2,867,700 2,769,932 RI
2 Apr 2019 5 Apr 2019 J-4-17-I 50 2,389,700 2,833,353 RI
2 Apr 2019 5 Apr 2019 J-4-17-I 51 2,389,700 3,735,436 RI
7 Apr 2019 10 Apr 2019 J-4-17-I 52 2,389,700 2,919,931 RI
9 Apr 2019 11 Apr 2019 J-4-17-I 53 2,389,700 2,385,723 RI
10 Apr 2019 12 Apr 2019 J-4-17-I 54 2,389,700 2,247,816 RI
10 Apr 2019 12 Apr 2019 J-4-17-I 55 2,867,700 2,618,252 RI
10 Apr 2019 12 Apr 2019 J-4-17-I 56 2,389,700 2,437,961 RI
11 Apr 2019 15 Apr 2019 J-4-17-I 57 2,389,700 3,474,847 RI
15 Apr 2019 20 Apr 2019 J-4-17-I 58 3,345,600 4,800,224 RI
2 Mei 2019 5 Mei 2019 J-4-17-I 59 2,867,700 2,744,831 RI
8 Mei 2019 12 Mei 2019 J-4-17-I 60 2,389,700 4,309,141 RI
10 Mei 2019 13 Mei 2019 J-4-17-I 61 2,867,700 2,494,236 RI
157,720,900 175,252,440

16 Jan 2019 16 Jan 2019 J-4-17-II 1 2,861,800 2,368,052 RI


14 Jan 2019 18 Jan 2019 J-4-17-II 2 2,861,800 3,568,685 RI
22 Jan 2019 25 Jan 2019 J-4-17-II 3 2,861,800 4,265,881 RI
28 Jan 2019 30 Jan 2019 J-4-17-II 4 2,861,800 4,059,842 RI
27 Jan 2019 30 Jan 2019 J-4-17-II 5 2,861,800 3,219,306 RI
31 Jan 2019 4 Feb 2019 J-4-17-II 6 2,861,800 5,567,850 RI
1 Feb 2019 5 Feb 2019 J-4-17-II 7 2,861,800 3,209,483 RI
1 Feb 2019 5 Feb 2019 J-4-17-II 8 4,006,500 6,884,915 RI
4 Feb 2019 6 Feb 2019 J-4-17-II 9 2,861,800 2,598,026 RI
9 Feb 2019 11 Feb 2019 J-4-17-II 10 2,861,800 2,339,843 RI
11 Feb 2019 14 Feb 2019 J-4-17-II 11 2,861,800 3,973,921 RI
20 Feb 2019 23 Feb 2019 J-4-17-II 12 3,434,100 3,192,840 RI
25 Feb 2019 28 Feb 2019 J-4-17-II 13 3,434,100 3,010,322 RI
27 Feb 2019 2 Mar 2019 J-4-17-II 14 2,861,800 5,358,832 RI
4 Mar 2019 6 Mar 2019 J-4-17-II 15 2,861,800 3,080,977 RI
4 Mar 2019 8 Mar 2019 J-4-17-II 16 2,861,800 4,267,441 RI
11 Mar 2019 13 Mar 2019 J-4-17-II 17 4,006,500 2,390,167 RI

Page 6
DATA PENELITIAN

11 Mar 2019 14 Mar 2019 J-4-17-II 18 2,861,800 2,873,248 RI


11 Mar 2019 15 Mar 2019 J-4-17-II 19 2,861,800 4,092,520 RI
20 Mar 2019 22 Mar 2019 J-4-17-II 20 2,861,800 2,284,568 RI
20 Mar 2019 26 Mar 2019 J-4-17-II 21 2,861,800 6,330,258 RI
22 Mar 2019 27 Mar 2019 J-4-17-II 22 2,861,800 5,206,364 RI
24 Mar 2019 28 Mar 2019 J-4-17-II 23 2,861,800 4,479,046 RI
24 Mar 2019 28 Mar 2019 J-4-17-II 24 4,006,500 7,310,920 RI
1 Apr 2019 5 Apr 2019 J-4-17-II 25 3,434,100 3,735,436 RI
9 Apr 2019 12 Apr 2019 J-4-17-II 26 2,861,800 3,566,702 RI
18 Apr 2019 19 Apr 2019 J-4-17-II 27 4,006,500 1,676,132 RI
24 Apr 2019 27 Apr 2019 J-4-17-II 28 2,861,800 3,018,522 RI
24 Apr 2019 27 Apr 2019 J-4-17-II 29 3,434,100 5,117,899 RI
25 Apr 2019 28 Apr 2019 J-4-17-II 30 2,861,800 3,192,998 RI
26 Apr 2019 1 Mei 2019 J-4-17-II 31 2,861,800 6,763,676 RI
28 Apr 2019 4 Mei 2019 J-4-17-II 32 2,861,800 4,843,120 RI
3 Mei 2019 6 Mei 2019 J-4-17-II 33 2,861,800 3,761,157 RI
8 Jan 2019 10 Jan 2019 J-4-17-III 1 3,755,500 2,360,327 RI
15 Mar 2019 19 Mar 2019 J-4-17-III 2 3,755,500 2,117,659 RI
18 Mar 2019 21 Mar 2019 J-4-17-III 3 3,755,500 4,574,127 RI
11 Apr 2019 14 Apr 2019 J-4-17-III 4 3,755,500 2,410,511 RI

16 Jan 2019 16 Jan 2019 J-4-18-I 1 1,950,400 2,788,129 RI


15 Jan 2019 17 Jan 2019 J-4-18-I 2 1,950,400 2,311,600 RI
16 Jan 2019 19 Jan 2019 J-4-18-I 3 1,950,400 2,797,961 RI
22 Jan 2019 24 Jan 2019 J-4-18-I 4 1,950,400 1,339,484 RI
1 Feb 2019 4 Feb 2019 J-4-18-I 5 1,950,400 1,715,132 RI
6 Feb 2019 8 Feb 2019 J-4-18-I 6 2,340,400 2,724,265 RI
5 Feb 2019 9 Feb 2019 J-4-18-I 7 1,950,400 3,590,917 RI
11 Feb 2019 14 Feb 2019 J-4-18-I 8 2,730,500 3,294,849 RI
12 Feb 2019 15 Feb 2019 J-4-18-I 9 2,340,400 2,548,362 RI
12 Feb 2019 15 Feb 2019 J-4-18-I 10 1,950,400 2,725,216 RI
25 Feb 2019 27 Feb 2019 J-4-18-I 11 1,950,400 1,859,093 RI
25 Feb 2019 28 Feb 2019 J-4-18-I 12 2,730,500 3,606,926 RI
10 Mar 2019 12 Mar 2019 J-4-18-I 13 1,950,400 2,293,273 RI
29 Mar 2019 2 Apr 2019 J-4-18-I 14 2,340,400 3,023,960 RI
9 Apr 2019 11 Apr 2019 J-4-18-I 15 1,950,400 2,142,946 RI
10 Apr 2019 13 Apr 2019 J-4-18-I 16 2,730,500 3,440,104 RI
11 Apr 2019 14 Apr 2019 J-4-18-I 17 1,950,400 3,641,216 RI
36,667,100 45,843,433
29 Des 2018 3 Jan 2019 J-4-18-II 1 3,755,600 4,212,623 RI
3 Jan 2019 7 Jan 2019 J-4-18-II 2 2,682,500 3,678,362 RI
8 Jan 2019 13 Jan 2019 J-4-18-II 3 2,682,500 3,376,217 RI
3 Jan 2019 5 Jan 2019 J-4-19-I 1 4,712,400 2,625,112 RI
11 Jan 2019 14 Jan 2019 J-4-19-I 2 3,366,000 1,930,533 RI
21 Jan 2019 23 Jan 2019 J-4-19-I 3 3,366,000 2,060,876 RI
1 Mar 2019 4 Mar 2019 J-4-19-I 4 3,366,000 1,891,774 RI
8 Mar 2019 12 Mar 2019 J-4-19-I 5 3,366,000 2,544,805 RI
22 Jan 2019 24 Jan 2019 J-4-20-I 1 3,340,300 2,862,861 RI
8 Feb 2019 11 Feb 2019 J-4-20-I 2 3,340,300 2,706,113 RI
20 Feb 2019 22 Feb 2019 J-4-20-I 3 4,008,400 2,255,130 RI
6 Mar 2019 9 Mar 2019 J-4-20-I 4 3,340,300 2,372,876 RI
14 Mar 2019 16 Mar 2019 J-4-20-I 5 4,676,400 1,526,037 RI

Page 7
DATA PENELITIAN

19 Mar 2019 22 Mar 2019 J-4-20-I 6 4,676,400 4,409,703 RI


28 Mar 2019 1 Apr 2019 J-4-20-I 7 3,340,300 3,295,179 RI
9 Apr 2019 12 Apr 2019 J-4-20-I 8 4,008,400 3,115,816 RI
10 Apr 2019 13 Apr 2019 J-4-20-I 9 3,340,300 2,084,985 RI
11 Apr 2019 15 Apr 2019 J-4-20-I 10 4,008,400 2,246,254 RI
23 Apr 2019 26 Apr 2019 J-4-20-I 11 4,008,400 2,006,328 RI
22 Apr 2019 26 Apr 2019 J-4-20-I 12 3,340,300 3,471,628 RI
24 Apr 2019 27 Apr 2019 J-4-20-I 13 4,008,400 3,294,279 RI
3 Mei 2019 6 Mei 2019 J-4-20-I 14 4,676,400 3,672,752 RI
7 Mei 2019 9 Mei 2019 J-4-20-I 15 4,676,400 3,330,047 RI
13 Feb 2019 16 Feb 2019 J-4-20-II 1 4,628,300 2,635,095 RI
4 Mar 2019 6 Mar 2019 J-4-20-II 2 4,628,300 2,215,766 RI
5 Mar 2019 9 Mar 2019 J-4-20-II 3 4,628,300 4,002,344 RI
11 Mar 2019 13 Mar 2019 J-4-20-II 4 4,628,300 2,686,668 RI
22 Apr 2019 25 Apr 2019 J-4-20-II 5 4,628,300 2,614,986 RI
26 Apr 2019 2 Mei 2019 J-4-20-II 6 6,479,700 5,610,778 RI
5 Apr 2019 8 Apr 2019 J-4-20-III 1 5,425,800 2,046,560 RI
22 Apr 2019 25 Apr 2019 J-4-20-III 2 5,425,800 2,076,736 RI
15 Jan 2019 18 Jan 2019 J-4-21-I 1 3,539,100 2,545,912 RI
24 Jan 2019 26 Jan 2019 J-4-21-I 2 2,527,900 2,606,411 RI
25 Jan 2019 28 Jan 2019 J-4-21-I 3 3,033,500 2,568,782 RI
25 Jan 2019 28 Jan 2019 J-4-21-I 4 2,527,900 2,642,427 RI
3 Mar 2019 5 Mar 2019 J-4-21-I 5 2,527,900 1,725,034 RI
5 Mar 2019 9 Mar 2019 J-4-21-I 6 3,033,500 3,846,202 RI
12 Apr 2019 16 Apr 2019 J-4-21-I 7 2,527,900 3,430,051 RI
1 Mei 2019 3 Mei 2019 J-4-21-I 8 3,033,500 1,656,605 RI
12 Jan 2019 13 Jan 2019 J-4-21-II 1 4,072,400 1,326,999 RI
22 Mar 2019 25 Mar 2019 J-4-21-II 2 4,072,400 3,128,131 RI
25 Mar 2019 29 Mar 2019 J-4-21-II 3 5,701,400 5,530,310 RI
30 Mar 2019 3 Apr 2019 J-4-21-II 4 4,072,400 3,399,049 RI
22 Jan 2019 25 Jan 2019 J-4-21-III 1 5,682,800 2,731,818 RI
21 Feb 2019 23 Feb 2019 K-4-17-II 1 1,618,800 1,912,704 RI
25 Feb 2019 1 Mar 2019 K-4-18-I 1 1,084,000 3,406,838 RI
15 Feb 2019 17 Feb 2019 K-4-18-II 1 1,540,500 1,532,299 RI
10 Apr 2019 14 Apr 2019 K-4-18-II 2 2,156,700 3,370,778 RI
17 Jan 2019 19 Jan 2019 N-4-10-III 1 3,819,200 1,991,235 RI
2 Mei 2019 6 Mei 2019 U-4-13-I 1 1,735,000 3,737,655 RI
Total 1,401,218,900 1,262,068,245
Kode RS: 3372051

Page 8
DATA PENELITIAN

2,511,000 4,795,178

3,048,000 3,750,845

2,866,100 1,895,803

4,290,200 3,638,616

5,383,800 5,028,282

3,125,400 3,504,862

Page 9
DATA PENELITIAN

3,799,700 2,975,601

4,539,600 3,541,355

6,107,600 5,526,402

Page 10
DATA PENELITIAN

3,166,000 2,723,944

Page 11
DATA PENELITIAN

4,449,000 3,479,010

5,625,100 4,074,171

Page 12
DATA PENELITIAN

2,389,700 2,618,252

Page 13
DATA PENELITIAN

2,861,800 3,735,436

3,755,500 2,385,419

1,950,400 2,725,216

2,682,500 3,678,362

3,366,000 2,060,876

Page 14
DATA PENELITIAN

4,008,400 2,584,959

4,628,300 2,660,882

5,425,800 2,061,648

2,780,700 2,587,597

4,072,400
5,682,800

Page 15
CLINICAL PATHWAY

Perkiraan Lama Rawat : 6 Hari


Indikasi : No. Rekam Medis :
Nama Pasien : Tgl Masuk :
Jenis Kelamin : Laki-laki Perempuan Rujukan : Tidak
Umur : Pengirim :
Diagnosa Awal : PPOK EKSASERBASI AKUT DPJP :

HARI KE TARIF RS PER KELAS


KEGIATAN Harga Volume URAIAN KEGIATAN
RJ 1 2 3 4 5 6

87,073 Pemeriksaan Dokter 87,073 87,073


- KUVS :TD,N,R,S,SpO2 -
10,355 Penilaian arus puncak ekspirasi (APE) -
awal
DIAGNOSIS
95,911 Pemeriksaan fisik/Visite
Assesment Klinis
Komplikasi bila ada
143,070 Konsultasi bila diperlukan 143,070 143,070

46,843 Darah Rutin III 46,843 46,843


59,291 Gula Darah Sewaktu 59,291 59,291
52,610 Ureum 52,610 52,610
47,610 Kreatinin 47,610 47,610
48,263 SGPT 48,263 48,263
48,363 SGOT 48,363 48,363
240,000 Elektrolit 240,000 240,000
250,000 Analisa Gas Darah 250,000 250,000
Diff count
PEMERIKSAAN PENUNJANG
37,000 Sputum MO/Gr/K/R
91,045 EKG 91,045 91,045
173,315 Foto Thorak posisi PA kondisi paru 173,315 173,315
PEMERIKSAAN PENUNJANG

9,814 Oksigenasi untuk mencapai SpO2 > 90% 117,768 117,768 117,768 117,768 117,768 117,768 706,608
47,185 Nebulizer: Fenoterol 0.2 mg dan/atau 141,555 141,555 141,555 141,555 141,555 141,555 849,330
Ipratropium 0.8 mg/20 menit
TINDAKAN MEDIS 49,378 Pemasangan Infus 49,378 49,378 98,756
- APE Harian - - - - - -
Spirometri saat kondisi stabil 94,296 94,296
Visite 95,911 95,911 95,911 95,911 95,911 95,911 575,466
AKOMODASI 140,772 140,772 140,772 140,772 140,772 140,772 140,772 844,632
ASUHAN KEPERAWATAN 37,654 37,654 37,654 37,654 37,654 37,654 37,654 225,924
1 Skin tes 5,000 5,000 5,000
BAHAN HABIS PAKAI
1 Infus Set 9,900 9,900 9,900 19,800
2 Three Way 4,063 4,063 4063 8,126
3 IV Catheter 10,444 10,444 10444 20,888
4 Spuit 1 CC 1,953 1,953 1,953
5 Spuit 5 CC 8,425 8,425 8,425
6 Spuit 10 CC 2,238 2,238 2,238
7 Sarung tangan non steri 5,313 4,000 4,000 4,000 4,000 4,000 4,000 24,000
8 Alkohol swab 125 1,250 1,250 1,250 1,250 1,250 1,250 7,500
9 Dermafik S 6,394 6,394 6,394 12,788
21,450 Cairan infus : kristaloid (NaCl 0,9%/RL) 21,450 21,450 21,450 21,450 21,450 21,450 128,700
13,650 Nebulizer: Fenoterol 0.2 mg dan/atau 13,650 13,650 13,650 13,650 13,650 13,650 81,900
Ipratropium 0.8 mg/8jam
14,625 Aminophilin drip 0,5-0,9 mg/KgBB/jam 14,625 14,625 14,625 14,625 14,625 73,125
3,291 Steroid : Dexamethason 5mg/8j atau 3,291 3,291 3,291 3,291 3,291 16,455
metilprenisolon 60-80mg/24 j
OBAT-OBATAN
OBAT-OBATAN Antibiotik: Cefotaxim 1gr/12jam atau
Ceftazidime 1gr/12 jam atau
9,000 Ceftriaxon 2gr/24 jam atau 9,000 9,000 9,000 9,000 9,000 45,000
Ciprofloxacin 200 mg/12 jam
55,000 Expektoran 3x1 C 55,000 55,000 110,000
11,650 Paracetamol 500 mg (bila perlu) 11,650 11,650 11,650 34,950
3,575 Aqua Pro injeksi 25 Ml 3,575 3,575 3,575 3,575 3,575 3,575 21,450

NUTRISI Tinggi kalori tinggi protein - - - - - - -

MOBILISASI 74,069 74,069 74,069 222,207

PENDIDIKAN KESEHATAN 71,046 71,046

797,483 1,258,946 616,151 616,151 758,749 678,570 871,996 5,598,046

HASIL (OUTCOME)
Keadaan Umum Baik Tidak Baik VARIAN
Kesadaran CM Samnolen Apatis Koma
Tekanan darah Normal Tidak normal MONITORING
Nadi Normal Tidak normal
Respirasi Normal Tidak normal I. Nama Dokter
Suhu Normal Tidak normal
Saturasi Oksigen Normal Tidak normal II. Nama Dokter
Sesak napas Ya Tidak
Batuk Ya Tidak DIAGNOSIS
Anemia Ya Tidak Diagnosis Utama
Infus baik Ya Tidak Diagnosis Sekender
Toleransi Diet baik Ya Tidak
Visite Dokter Ya Tidak
Aktivitas sendiri Ya Tidak
Edukasi Penyakit Ya Tidak
Edukasi Pengobatan Ya Tidak Diagnosa Komplikasi
Edukasi tatalaksana
penyakit dan lama Ya Tidak
perawatan Kelas keperawatan 3 2
Rencana pulang Total Biaya Rumah Sakit
CLINICAL PATHWAY

DISKRIPSI DRG
J-4-18-I

ASTHMA &
BRONKHIOLITIS RINGAN

TARIF RS PER KELAS


KET
HASIL (OUTCOME)

DIAGNOSIS ICD - 10
1 VIP B VIP A VVIP
CLINICAL PATHWAY
DESKRIPSI DRG
Perkiraan Lama Rawat : 9 Hari
Indikasi : No. Rekam Medis :
Nama Pasien : Tgl Masuk :
Jenis Kelamin : Laki-laki Perempuan Rujukan : Tidak
Umur : Pengirim :
Diagnosa Awal : TB BTA +/- dengan Hemoptisis DPJP :

HARI KE TARIF PER KELAS KETERANGAN


KEGIATAN ICD-9 Bill Code URAIAN KEGIATAN RJ POLI 3 2 1 VIP A VIP B VVIP
/IGD 1 2 3

Pemeriksaan Dokter √ √ √ √
KUVS :TD,N,R,S,SpO2 √ √ √ √
Pemeriksaan fisik √ √ √ √
Status cairan (ukur input dan output) √ √ √ √
DIAGNOSIS
Kesadaran √ √ √ √
Assesment Klinis √ √ √ √
Komplikasi bila ada √ √ √ √
Konsultasi bila diperlukan √ √ √ √

Darah Rutin I √
Gula Darah Sewaktu √
Ureum √
Kreatinin √
SGPT √
SGOT √
Elektrolit √
Analisa Gas Darah √
Diff count √
PEMERIKSAAN PENUNJANG Sputum MO/Gr/K/R √
Sputum BTA √ √ √
Hb cito (k/p) √
LED I/II √
GDN √
LFT √
HbsAg √
PT/APTT √
EKG √
Foto Thorak posisi PA/lateral kondisi paru √

Oksigenasi sesuai AGD √ √ √ √


Bronkoskopi: hemoptisis topical √
TINDAKAN MEDIS sampel pemeriksaan √
Pemasangan Infus/Aff Infus √

Cairan infus : kristaloid (NaCl 0,9%/RL) √ √ √


OAT: regimen sesuai kasu TB √ √ √
Dosis sesuai berat badan
Pengobatan Hemoptisis sesuai klasifikasi √ √ √
jumlah perdarahan, berat badan dan
OBAT-OBATAN (Tranfusi darah bila ada indikasi)
penyakit penyerta, bila perlu:
Asam tranexamat: 25 mg/kgbb peroral
vit K 1 mg/kgBB
Vit C 2-60mg/kgBB
Codein 15-30 mg/3-4Jam (k/p)

NUTRISI Tinggi kalori tinggi protein √ √ √ √

MOBILISASI Tergantung klasifikasi perdarahan √ √ √ √

HASIL (OUTCOME)
Keadaan Umum Baik Tidak Baik VARIAN
Kesadaran CM Samnolen Apatis Koma
Tekanan darah Normal Tidak normal MONITORING
Nadi Normal Tidak normal
Respirasi Normal Tidak normal I. Nama Dokter
Suhu Normal Tidak normal
Saturasi Oksigen Normal Tidak normal II. Nama Dokter
Sesak napas Ya Tidak
Batuk Ya Tidak DIAGNOSIS ICD - 10
Anemia Ya Tidak Diagnosis Utama
Infus baik Ya Tidak Diagnosis Sekender
Toleransi Diet baik Ya Tidak
Visite Dokter Ya Tidak
Aktivitas sendiri Ya Tidak
Edukasi Penyakit Ya Tidak
Edukasi Pengobatan Ya Tidak Diagnosa Komplikasi
Edukasi tatalaksana
penyakit dan lama Ya Tidak
perawatan Kelas keperawatan VIP A VVIP
Rencana pulang Total Biaya Rumah Sakit
CAL PATHWAY
CLINICAL PATHWAY
DESKRIPSI DRG
Perkiraan Lama Rawat : 9 Hari
Indikasi : No. Rekam Medis :
Nama Pasien : Tgl Masuk :
Jenis Kelamin : Laki-laki Perempuan Rujukan : Ya Tidak
Umur : Pengirim :
Diagnosa Awal : TB BTA +/- dengan Hemoptisis DPJP :

HARI KE TARIF PER KELAS


KEGIATAN ICD-9 Bill Code URAIAN KEGIATAN RJ POLI 3 2 1
/IGD 1 2 3 4 5 6 7 8 9

Pemeriksaan Dokter √ √ √ √ √ √ √ √ √ √
KUVS :TD,N,R,S,SpO2 √ √ √ √ √ √ √ √ √ √
Pemeriksaan fisik √ √ √ √ √ √ √ √ √ √
Status cairan (ukur input dan output) √ √ √ √ √ √ √ √ √ √
DIAGNOSIS
Kesadaran √ √ √ √ √ √ √ √ √ √
Assesment Klinis √ √ √ √ √ √ √ √ √ √
Komplikasi bila ada √ √ √ √ √ √ √ √ √ √
Konsultasi bila diperlukan √ √ √ √ √ √ √ √ √ √

Darah Rutin I √
Gula Darah Sewaktu √
Ureum √
Kreatinin √
SGPT √
SGOT √
Elektrolit √
Analisa Gas Darah √
Diff count √
PEMERIKSAAN PENUNJANG Sputum MO/Gr/K/R √
Sputum BTA √ √ √
Hb cito (k/p) √ √ √ √ √ √ √
LED I/II √
GDN √
LFT √
HbsAg √
PT/APTT √
EKG √ √
Foto Thorak posisi PA/lateral kondisi paru √ √

Oksigenasi sesuai AGD √ √ √ √ √ √ √ √ √ √


Bronkoskopi: hemoptisis topical √
TINDAKAN MEDIS sampel pemeriksaan √
Pemasangan Infus/Aff Infus √ √ √

Cairan infus : kristaloid (NaCl 0,9%/RL) √ √ √ √ √ √ √ √ √


OAT: regimen sesuai kasu TB √ √ √ √ √ √ √ √ √
Dosis sesuai berat badan
Pengobatan Hemoptisis sesuai klasifikasi √ √ √ √ √ √ √ √ √
jumlah perdarahan, berat badan dan
OBAT-OBATAN (Tranfusi darah bila ada indikasi)
penyakit penyerta, bila perlu:
Asam tranexamat: 25 mg/kgbb peroral
vit K 1 mg/kgBB
Vit C 2-60mg/kgBB
Codein 15-30 mg/3-4Jam (k/p)

NUTRISI Tinggi kalori tinggi protein √ √ √ √ √ √ √ √ √ √

MOBILISASI Tergantung klasifikasi perdarahan √ √ √ √ √ √ √ √ √ √

HASIL (OUTCOME)
Keadaan Umum Baik Tidak Baik VARIAN
Kesadaran CM Samnolen Apatis Koma
Tekanan darah Normal Tidak normal MONITORING
Nadi Normal Tidak normal
Respirasi Normal Tidak normal I. Nama Dokter
Suhu Normal Tidak normal
Saturasi Oksigen Normal Tidak normal II. Nama Dokter
Sesak napas Ya Tidak
Batuk Ya Tidak DIAGNOSIS ICD - 10
Anemia Ya Tidak Diagnosis Utama
Infus baik Ya Tidak Diagnosis Sekender
Toleransi Diet baik Ya Tidak
Visite Dokter Ya Tidak
Aktivitas sendiri Ya Tidak
Edukasi Penyakit Ya Tidak
Edukasi Pengobatan Ya Tidak Diagnosa Komplikasi
Edukasi tatalaksana
penyakit dan lama Ya Tidak
perawatan Kelas keperawatan 3 2 1 VIP B VIP A VVIP
Rencana pulang Total Biaya Rumah Sakit
NICAL PATHWAY
DESKRIPSI DRG

TARIF PER KELAS KETERANGAN


VIP A VIP B VVIP
ICD - 10
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL PELAYANAN KESEHATAN
BALAI BESAR KESEHATAN PARU MASYARAKAT SURAKARTA
Jalan ProfesorDokter R. Soeharso No. 28 Surakarta 57144 Telepon/Faksimile 0271-713055/720002
surat elektronik: bbkpm_surakarta@yahoo.co.id; laman: bbkpmska.com

CLINICAL PATHWAY

Perkiraan Lama Rawat : 8 Hari /KLS 3


Indikasi : No. Rekam Medis : 114017
Nama Pasien : JASMAN Tgl Masuk : 1/2/2019
Jenis Kelamin : L P Rujukan :
Umur : Pengirim :
Diagnosa Awal : PERADANGAN DAN INFEKSI PERNAFA DPJP :

HARI KE
Unit Cost Tarif
KEGIATAN Vol Total Unit
Satuan Satuan UGD RJ 1 2 3 4 5 6 7 8 9
Cost

ADMINISTRASI PENDAFTARAN 18,975 8,000 1 -

AKOMODASI 140,772 81,000 81,000 81,000 81,000 81,000 81,000 81,000 81,000 36,000 684,000

PEMERIKSAAN MEDIS -

Pemeriksaan Dokter UGD/UMUM


1 (KU, VS :TD,N,R,S,SpO2) & 133,316 50,000 1 133,316 50,000 40,000 90,000
Edukasi awal

Pemeriksaan Dokter Spesialis &


2 Edukasi awal (KUVS 87,073 -
:TD,N,R,S,SpO2)

Visite Dokter Spesialis (Assesment


3 95,911 54,000 1 54,000 54,000 54000 54000 54000 54000 54000 54000 54000 486,000
Klinis) Komplikasi bila ada

4 Konsultasi Dokter spesialis lain 143,070 70,000 -

PEMERIKSAAN PENUNJANG 1
1 Darah Rutin III 46,843 35,000 1 -
2 Gula Darah Sewaktu 59,291 20,000 1 -
3 Ureum 52,610 25,000 1 -
4 Kreatinin 47,610 25,000 1 -
5 SGPT 48,263 25,000 1 -
6 SGOT 48,363 25,000 1 -
Bilirubin indirect 25,000 1
Bilirubin Total 25,000 1
Bilirubin direct 25,000 1
Calsium 100,000 1
Chlorida 110,000 2
Natrium 110,000 2
7 Elektrolit 240,000 240,000 -
8 Analisa Gas Darah 250,000 250,000 -
9 Diff count
10 Sputum MO/Gr/K/R 37,000 20,000
EKG 31,000 5
11 EKG 91,045 30,000 1 -
12 Foto Thorak PA 173,315 70,000 -

TINDAKAN MEDIS DIAGNOSTIK


1 Pemeriksaan APE Harian 10,986 8,000 -
2 Uji Bronkodilator 118,683 70,000 -
3 Spirometri saat kondisi stabil 94,296 50,000 -
-
TINDAKAN MEDIS TERAPI
1 Oksigenasi sampai SpO2 > 90% 9,814 3,750 85 -
2 Nebulizer 47,185 20,000 16 -

ASUHAN KEPERAWATAN 37,654 31,500 8 -

TINDAKAN KEPERAWATAN
1 Skin tes 25,000 10,000 1 -
2 Injeksi 8,041 10,000 18 - - -
3 Pemasangan Infus 49,378 25,000 4 -
4 Melepas Infus 10,000 4
BAHAN HABIS PAKAI 2
1 Infus Set 9,900 9,900 4 - -
2 Three Way 4,063 4,063 2 -
3 IV Catheter 10,444 10,444 5
4 Spuit 1 CC 1,953 1
5 Spuit 3 CC 1,953 1,313 11 -
6 Spuit 5 CC 1,685 1,685 6 -
7 Spuit 10 CC 2,238 2,238 7 -
8 canula O2 11,035 1
9 masker nebuliser 35,375 1
10 Sarung tangan non steril 5,313 5,313 7 -
11 Alkohol swab 1,100 125 15 -
12 Dermafik S 6,394 6,394 3
13 Mangkok Sputum 825 3
14 Plester Dressing Wound 1,500 1

OBAT-OBATAN
1 Cairan infus kristaloid
a NaCl 3 % 34,788 1
b NaCl 0,9 % 7,150 8,012 10
c RL 8,043 8,937 11
d KA EN infus 12,561 4
2 Obat Nebulizer
Fenoterol 0,2 mg/8jam 4,875 5,850 12 -
Ipratropium 0.8 mg/8jam 1,097 1,316 -
meptin 7,250 1
Pulmicort 0,5 mg 16,553 14
fluimucil 100 mg 12,500 6
Bricasma 2,5 8,563
Combivent 5,688 14

3 Aminophilin drip 0,5-0,9 mg/KgBB/jam


4 Steroid
a Dexamethason 5mg/8j atau
b Metilprenisolon 60-80mg/24 j - -
c Kalium klorida 4,029 4

5 Antibiotik:
a Cefotaxim 1gr/12jam atau 55,000 -
b Ceftazidime 1gr/12 jam atau 11,650 -
c Ceftriaxon 2gr/24 jam atau - -
d Ciprofloxacin 200 mg/12 jam
e Levofloxacin 750mg inj 138,600 5
f Omeprasole inj 12,373 8
g Odansetron inj 1,338 8
6 Ondansetron tab
7 Analgetik & Antipirektik
Paracetamol 500 mg (bila perlu) -
8 Obat Saluran Cerna
Omeprazole
Lansoprasole kapsul 379 10
9 Obat Oral
KSR 2,194 39
Pro TB 4 21
Metformin 500 mg tab 120 10
Glimepiride 2mg 259 6
N-Aceticistein 200mg tab 438 20
Levofloxacin 500 tab 532 5
10 Aqua Pro injeksi 25 Ml 3,218 3,438 7

NUTRISI 15500 2 - - - - -
1
MOBILISASI 74,069 20,000 -
1
PENDIDIKAN KESEHATAN 71,046 10,000 1 71,046

- 94,000 54,000 54,000 202,000


HASIL (OUTCOME)
Keadaan Umum
VARIAN
Kesadaran
Tekanan darah
MONITORING
Nadi
Respirasi
I. Nama Dokter
Suhu
Saturasi Oksigen
II. Nama Dokter
Sesak napas
Batuk DIAGNOSIS
Anemia Diagnosis Utama Asma
Infus baik Diagnosis Sekunder -
Toleransi Diet baik
Visite Dokter
Aktivitas sendiri
Edukasi Penyakit
Edukasi Pengobatan Diagnosa Komplikasi
Edukasi tatalaksana
penyakit dan lama
perawatan Kelas keperawatan
Rencana pulang Total Tarif Rumah Sakit
Total Unit Cost
Total Tarif INA CBGs
ATAN REPUBLIK INDONESIA
AL PELAYANAN KESEHATAN
PARU MASYARAKAT SURAKARTA
rakarta 57144 Telepon/Faksimile 0271-713055/720002
arta@yahoo.co.id; laman: bbkpmska.com

AL PATHWAY

DISKRIPSI DRG
J-4-15-I

INFEKSI DAN
PERADANGAN

TARIF RS PER KELAS


Total tarif 3 2 1 VIP

8,000

684,000

90,000

54,000

-
35,000
20,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
100,000
220,000
220,000
-
-
-
-
155,000
30,000
-

-
-
-
-

318,750
320,000

252,000

10,000
180,000
100,000
40,000

39,600
8,126
52,220
1,953
14,443
10,110
15,666
11,035
35,375
37,191
1,875
19,182
2,475
1,500

34,788
80,120
98,307
50,244

70,200
-
7,250
231,742
75,000

79,632

16,116

-
-
-
-

693,000
98,984
10,704
-

-
3,790

85,566

24,066

31,000

10,000

4,963,010
(OUTCOME)

VARIAN

II. Nama Dokter

DIAGNOSIS ICD - 10
DATA PASIEN 2019

LAPORAN REKAP KLAIM - BP4/BBKPM SURAKARTA


Pasien Rawat Inap dan Rawat Jalan, Periode Tanggal Pulang: 1 Jan 2019 s/d 20 Mei 2019
Filter: / Kelas Rawat = Semua / Severity = Semua / Cara Pulang = Semua / Jenis Tarif = TARIF RS KEL
Tgl. Masuk Tgl. Pulang INACBG Top Up Total Tarif Tarif RS Jenis
5 Mei 2019 9 Mei 2019 A-4-14-I 2,511,000 4,795,178 RI
15 Mar 2019 18 Mar 2019 A-4-14-II 3,048,000 2,289,080 RI
25 Apr 2019 29 Apr 2019 A-4-14-II 3,048,000 5,212,609 RI
1,524,000 6,096,000 7,501,689
8 Mar 2019 11 Mar 2019 A-4-14-III 3,048,000 2,116,787 RI
3,048,000 3,048,000 2,116,787
3 Jan 2019 6 Jan 2019 A-4-15-I 2,866,100 1,895,803 RI
30 Jan 2019 3 Feb 2019 A-4-15-I 2,866,100 4,458,614 RI
10 Apr 2019 11 Apr 2019 A-4-15-I 2,866,100 1,058,254 RI
2,866,100 8,598,300 7,412,671
7 Feb 2019 12 Feb 2019 A-4-15-II 4,290,200 3,821,781 RI
5 Mar 2019 9 Mar 2019 A-4-15-II 4,290,200 3,455,451 RI
1 Mei 2019 4 Mei 2019 A-4-15-II 5,148,200 4,629,731 RI
6 Mei 2019 8 Mei 2019 A-4-15-II 4,290,200 3,262,660 RI
4,504,700 18,018,800 15,169,623
17 Jan 2019 19 Jan 2019 A-4-15-III 5,383,800 2,806,664 RI
30 Apr 2019 6 Mei 2019 A-4-15-III 5,383,800 7,249,899 RI
5,383,800 10,767,600 10,056,563
1 Jan 2019 6 Jan 2019 B-4-13-II 3,807,600 4,557,397 RI
14 Mei 2019 16 Mei 2019 B-4-13-II 3,173,000 1,530,569 RI
3,490,300 6,980,600 6,087,966
1 Feb 2019 5 Feb 2019 D-4-10-III 5,677,500 5,136,514 RI
5,677,500 5,677,500 5,136,514
14 Mar 2019 19 Mar 2019 E-4-10-I 3,164,100 6,365,768 RI
3,164,100 3,164,100 6,365,768
15 Mar 2019 19 Mar 2019 E-4-10-III 5,487,600 4,074,273 RI
5,487,600 5,487,600 4,074,273
2 Jan 2019 6 Jan 2019 E-4-13-II 3,508,400 3,506,715 RI
3,508,400 3,508,400 3,506,715
23 Apr 2019 26 Apr 2019 I-4-12-II 2,604,500 3,407,329 RI
2,604,500 2,604,500 3,407,329
10 Jan 2019 15 Jan 2019 I-4-12-III 3,125,400 4,026,345 RI
29 Jan 2019 5 Feb 2019 I-4-12-III 3,125,400 5,745,243 RI
7 Feb 2019 10 Feb 2019 I-4-12-III 3,125,400 3,837,484 RI
17 Feb 2019 17 Feb 2019 I-4-12-III 3,125,400 2,771,301 RI
18 Feb 2019 22 Feb 2019 I-4-12-III 3,125,400 4,550,346 RI
5 Mar 2019 9 Mar 2019 I-4-12-III 3,125,400 3,066,971 RI
13 Mar 2019 16 Mar 2019 I-4-12-III 3,125,400 3,172,240 RI
25 Mar 2019 27 Mar 2019 I-4-12-III 3,125,400 1,614,817 RI
3,125,400 25,003,200 28,784,747
24 Mar 2019 26 Mar 2019 I-4-16-I 1,362,800 2,146,960 RI
2 Mei 2019 5 Mei 2019 I-4-17-II 1,945,000 1,968,120 RI
22 Jan 2019 26 Jan 2019 I-4-20-II 3,050,200 3,733,586 RI
4 Mar 2019 9 Mar 2019 I-4-20-II 3,050,200 4,838,981 RI
30 Apr 2019 4 Mei 2019 I-4-20-II 3,050,200 4,380,736 RI
10 Mei 2019 12 Mei 2019 I-4-20-II 3,050,200 1,318,537 RI
27 Des 2018 1 Jan 2019 I-4-24-I 2,342,500 4,608,095 RI
7 Feb 2019 12 Feb 2019 J-4-14-I 4,003,900 3,695,801 RI

Page 1
DATA PASIEN 2019

19 Feb 2019 23 Feb 2019 J-4-14-II 4,653,900 3,775,534 RI


26 Des 2018 1 Jan 2019 J-4-15-I 1 3,799,700 7,287,062 RI
30 Des 2018 3 Jan 2019 J-4-15-I 2 5,319,600 3,694,342 RI
30 Des 2018 3 Jan 2019 J-4-15-I 3 3,799,700 2,327,581 RI
2 Jan 2019 4 Jan 2019 J-4-15-I 4 3,799,700 1,826,748 RI
2 Jan 2019 5 Jan 2019 J-4-15-I 5 5,319,600 3,222,711 RI
30 Des 2018 5 Jan 2019 J-4-15-I 6 4,559,600 4,293,789 RI
5 Jan 2019 7 Jan 2019 J-4-15-I 7 3,799,700 1,460,924 RI
5 Jan 2019 8 Jan 2019 J-4-15-I 8 4,559,600 3,630,388 RI
8 Jan 2019 10 Jan 2019 J-4-15-I 9 3,799,700 1,841,582 RI
8 Jan 2019 10 Jan 2019 J-4-15-I 10 3,799,700 1,032,357 RI
9 Jan 2019 11 Jan 2019 J-4-15-I 11 4,559,600 2,468,386 RI
8 Jan 2019 11 Jan 2019 J-4-15-I 12 3,799,700 3,005,368 RI
9 Jan 2019 12 Jan 2019 J-4-15-I 13 3,799,700 2,181,718 RI
14 Jan 2019 18 Jan 2019 J-4-15-I 14 4,559,600 3,473,486 RI
16 Jan 2019 19 Jan 2019 J-4-15-I 15 5,319,600 2,972,568 RI
19 Jan 2019 22 Jan 2019 J-4-15-I 16 3,799,700 3,921,112 RI
23 Jan 2019 25 Jan 2019 J-4-15-I 17 3,799,700 1,406,373 RI
21 Jan 2019 26 Jan 2019 J-4-15-I 18 3,799,700 5,480,262 RI
23 Jan 2019 26 Jan 2019 J-4-15-I 19 3,799,700 2,150,926 RI
25 Jan 2019 29 Jan 2019 J-4-15-I 20 3,799,700 4,121,413 RI
21 Jan 2019 31 Jan 2019 J-4-15-I 21 4,559,600 7,743,348 RI
29 Jan 2019 1 Feb 2019 J-4-15-I 22 3,799,700 2,721,734 RI
30 Jan 2019 5 Feb 2019 J-4-15-I 23 3,799,700 4,744,649 RI
6 Feb 2019 8 Feb 2019 J-4-15-I 24 4,559,600 2,379,026 RI
7 Feb 2019 10 Feb 2019 J-4-15-I 25 3,799,700 2,537,094 RI
7 Feb 2019 11 Feb 2019 J-4-15-I 26 3,799,700 3,494,753 RI
7 Feb 2019 12 Feb 2019 J-4-15-I 27 3,799,700 4,227,654 RI
10 Feb 2019 13 Feb 2019 J-4-15-I 28 4,559,600 3,864,993 RI
11 Feb 2019 13 Feb 2019 J-4-15-I 29 3,799,700 1,724,292 RI
11 Feb 2019 13 Feb 2019 J-4-15-I 30 3,799,700 1,500,110 RI
14 Feb 2019 18 Feb 2019 J-4-15-I 31 3,799,700 2,567,712 RI
18 Feb 2019 21 Feb 2019 J-4-15-I 32 3,799,700 2,723,055 RI
21 Feb 2019 22 Feb 2019 J-4-15-I 33 5,319,600 4,051,812 RI
22 Feb 2019 26 Feb 2019 J-4-15-I 34 3,799,700 4,515,429 RI
24 Feb 2019 27 Feb 2019 J-4-15-I 35 3,799,700 2,430,243 RI
25 Feb 2019 27 Feb 2019 J-4-15-I 36 3,799,700 2,647,947 RI
25 Feb 2019 28 Feb 2019 J-4-15-I 37 4,559,600 3,326,964 RI
25 Feb 2019 28 Feb 2019 J-4-15-I 38 3,799,700 3,499,466 RI
25 Feb 2019 28 Feb 2019 J-4-15-I 39 3,799,700 2,420,317 RI
25 Feb 2019 28 Feb 2019 J-4-15-I 40 3,799,700 2,071,207 RI
26 Feb 2019 1 Mar 2019 J-4-15-I 41 3,799,700 1,439,754 RI
28 Feb 2019 2 Mar 2019 J-4-15-I 42 3,799,700 1,666,614 RI
27 Feb 2019 5 Mar 2019 J-4-15-I 43 3,799,700 5,543,916 RI
6 Mar 2019 8 Mar 2019 J-4-15-I 44 5,319,600 1,924,688 RI
8 Mar 2019 12 Mar 2019 J-4-15-I 45 4,559,600 7,326,490 RI
11 Mar 2019 13 Mar 2019 J-4-15-I 46 4,559,600 2,272,529 RI
12 Mar 2019 14 Mar 2019 J-4-15-I 47 4,559,600 1,995,131 RI
10 Mar 2019 15 Mar 2019 J-4-15-I 48 3,799,700 4,666,817 RI
15 Mar 2019 18 Mar 2019 J-4-15-I 49 4,559,600 3,913,740 RI
14 Mar 2019 18 Mar 2019 J-4-15-I 50 4,559,600 5,507,133 RI
15 Mar 2019 18 Mar 2019 J-4-15-I 51 4,559,600 2,154,877 RI

Page 2
DATA PASIEN 2019

19 Mar 2019 21 Mar 2019 J-4-15-I 52 5,319,600 3,166,704 RI


22 Mar 2019 25 Mar 2019 J-4-15-I 53 3,799,700 2,978,633 RI
22 Mar 2019 26 Mar 2019 J-4-15-I 54 3,799,700 4,159,787 RI
23 Mar 2019 26 Mar 2019 J-4-15-I 55 3,799,700 1,416,726 RI
26 Mar 2019 28 Mar 2019 J-4-15-I 56 3,799,700 2,028,283 RI
24 Mar 2019 28 Mar 2019 J-4-15-I 57 3,799,700 4,189,223 RI
28 Mar 2019 30 Mar 2019 J-4-15-I 58 4,559,600 2,571,150 RI
28 Mar 2019 1 Apr 2019 J-4-15-I 59 5,319,600 4,858,749 RI
1 Apr 2019 4 Apr 2019 J-4-15-I 60 4,559,600 2,622,976 RI
1 Apr 2019 5 Apr 2019 J-4-15-I 61 3,799,700 4,504,787 RI
6 Apr 2019 9 Apr 2019 J-4-15-I 62 4,559,600 3,133,795 RI
11 Apr 2019 14 Apr 2019 J-4-15-I 63 3,799,700 2,679,095 RI
11 Apr 2019 14 Apr 2019 J-4-15-I 64 3,799,700 3,061,520 RI
16 Apr 2019 18 Apr 2019 J-4-15-I 65 3,799,700 1,352,451 RI
17 Apr 2019 20 Apr 2019 J-4-15-I 66 3,799,700 3,027,722 RI
22 Apr 2019 24 Apr 2019 J-4-15-I 67 4,559,600 2,826,714 RI
22 Apr 2019 26 Apr 2019 J-4-15-I 68 3,799,700 5,524,299 RI
22 Apr 2019 26 Apr 2019 J-4-15-I 69 3,799,700 2,921,662 RI
2 Mei 2019 6 Mei 2019 J-4-15-I 70 5,319,600 3,906,152 RI
29 Des 2018 1 Jan 2019 J-4-15-II 1 4,539,600 1,997,146 RI
11 Jan 2019 12 Jan 2019 J-4-15-II 2 4,539,600 1,115,679 RI
12 Jan 2019 14 Jan 2019 J-4-15-II 3 4,539,600 3,090,009 RI
15 Jan 2019 18 Jan 2019 J-4-15-II 4 5,447,500 3,579,856 RI
16 Jan 2019 19 Jan 2019 J-4-15-II 5 6,355,400 3,931,842 RI
22 Jan 2019 25 Jan 2019 J-4-15-II 6 5,447,500 2,309,087 RI
29 Jan 2019 1 Feb 2019 J-4-15-II 7 4,539,600 2,761,207 RI
1 Feb 2019 6 Feb 2019 J-4-15-II 8 6,355,400 8,211,932 RI
4 Feb 2019 6 Feb 2019 J-4-15-II 9 4,539,600 2,885,405 RI
12 Feb 2019 15 Feb 2019 J-4-15-II 10 6,355,400 3,502,853 RI
12 Feb 2019 15 Feb 2019 J-4-15-II 11 4,539,600 2,804,964 RI
11 Feb 2019 15 Feb 2019 J-4-15-II 12 4,539,600 2,675,509 RI
13 Feb 2019 16 Feb 2019 J-4-15-II 13 4,539,600 3,602,345 RI
25 Feb 2019 28 Feb 2019 J-4-15-II 14 4,539,600 3,465,314 RI
26 Feb 2019 3 Mar 2019 J-4-15-II 15 6,355,400 4,849,315 RI
4 Mar 2019 7 Mar 2019 J-4-15-II 16 6,355,400 4,743,705 RI
3 Mar 2019 9 Mar 2019 J-4-15-II 17 5,447,500 5,125,337 RI
5 Mar 2019 11 Mar 2019 J-4-15-II 18 4,539,600 5,500,061 RI
10 Mar 2019 15 Mar 2019 J-4-15-II 19 6,355,400 6,719,189 RI
24 Mar 2019 27 Mar 2019 J-4-15-II 20 4,539,600 2,643,350 RI
25 Mar 2019 28 Mar 2019 J-4-15-II 21 4,539,600 3,455,271 RI
25 Mar 2019 29 Mar 2019 J-4-15-II 22 4,539,600 5,261,552 RI
29 Mar 2019 2 Apr 2019 J-4-15-II 23 5,447,500 4,780,248 RI
30 Mar 2019 2 Apr 2019 J-4-15-II 24 4,539,600 2,167,080 RI
2 Apr 2019 6 Apr 2019 J-4-15-II 25 5,447,500 4,654,930 RI
9 Apr 2019 11 Apr 2019 J-4-15-II 26 4,539,600 2,566,479 RI
10 Apr 2019 16 Apr 2019 J-4-15-II 27 6,355,400 7,759,931 RI
27 Apr 2019 1 Mei 2019 J-4-15-II 28 4,539,600 7,036,945 RI
2 Jan 2019 9 Jan 2019 J-4-15-III 1 6,107,600 5,526,402 RI
23 Jan 2019 29 Jan 2019 J-4-15-III 2 6,107,600 6,312,669 RI
25 Apr 2019 25 Apr 2019 J-4-15-III 3 6,107,600 1,151,862 RI
10 Jan 2019 14 Jan 2019 J-4-16-I 1 3,166,000 2,660,973 RI
29 Jan 2019 1 Feb 2019 J-4-16-I 2 3,166,000 2,438,472 RI

Page 3
DATA PASIEN 2019

29 Jan 2019 1 Feb 2019 J-4-16-I 3 3,799,100 2,993,149 RI


1 Feb 2019 4 Feb 2019 J-4-16-I 4 3,166,000 2,942,049 RI
2 Feb 2019 6 Feb 2019 J-4-16-I 5 4,432,300 4,713,426 RI
4 Feb 2019 7 Feb 2019 J-4-16-I 6 4,432,300 2,271,135 RI
3 Feb 2019 7 Feb 2019 J-4-16-I 7 4,432,300 5,030,867 RI
6 Feb 2019 8 Feb 2019 J-4-16-I 8 3,166,000 2,451,211 RI
3 Feb 2019 8 Feb 2019 J-4-16-I 9 3,166,000 4,263,324 RI
7 Feb 2019 9 Feb 2019 J-4-16-I 10 3,166,000 4,558,161 RI
8 Feb 2019 10 Feb 2019 J-4-16-I 11 4,432,300 2,066,800 RI
12 Feb 2019 14 Feb 2019 J-4-16-I 12 3,166,000 2,177,856 RI
14 Feb 2019 18 Feb 2019 J-4-16-I 13 3,166,000 2,160,036 RI
12 Feb 2019 19 Feb 2019 J-4-16-I 14 4,432,300 5,998,893 RI
16 Feb 2019 20 Feb 2019 J-4-16-I 15 3,166,000 3,166,985 RI
18 Feb 2019 21 Feb 2019 J-4-16-I 16 3,166,000 3,441,751 RI
19 Feb 2019 21 Feb 2019 J-4-16-I 17 3,799,100 2,363,703 RI
20 Feb 2019 22 Feb 2019 J-4-16-I 18 3,166,000 1,926,530 RI
21 Feb 2019 26 Feb 2019 J-4-16-I 19 3,166,000 4,675,013 RI
27 Feb 2019 4 Mar 2019 J-4-16-I 20 4,432,300 3,090,601 RI
1 Mar 2019 4 Mar 2019 J-4-16-I 21 3,166,000 2,723,944 RI
1 Mar 2019 4 Mar 2019 J-4-16-I 22 3,166,000 2,055,893 RI
2 Mar 2019 5 Mar 2019 J-4-16-I 23 3,166,000 1,635,401 RI
2 Mar 2019 5 Mar 2019 J-4-16-I 24 3,166,000 2,727,586 RI
4 Mar 2019 6 Mar 2019 J-4-16-I 25 3,166,000 1,103,560 RI
4 Mar 2019 7 Mar 2019 J-4-16-I 26 4,432,300 2,071,312 RI
6 Mar 2019 9 Mar 2019 J-4-16-I 27 3,166,000 2,221,997 RI
6 Mar 2019 11 Mar 2019 J-4-16-I 28 3,166,000 3,446,298 RI
8 Mar 2019 11 Mar 2019 J-4-16-I 29 3,799,100 2,946,603 RI
9 Mar 2019 12 Mar 2019 J-4-16-I 30 3,166,000 2,349,154 RI
10 Mar 2019 13 Mar 2019 J-4-16-I 31 3,799,100 3,515,181 RI
9 Mar 2019 13 Mar 2019 J-4-16-I 32 4,432,300 3,182,756 RI
11 Mar 2019 13 Mar 2019 J-4-16-I 33 3,166,000 2,062,869 RI
12 Mar 2019 16 Mar 2019 J-4-16-I 34 3,166,000 3,911,669 RI
18 Mar 2019 20 Mar 2019 J-4-16-I 35 3,166,000 2,239,653 RI
18 Mar 2019 22 Mar 2019 J-4-16-I 36 3,166,000 4,056,373 RI
27 Mar 2019 29 Mar 2019 J-4-16-I 37 3,166,000 1,933,049 RI
11 Apr 2019 14 Apr 2019 J-4-16-I 38 3,799,100 2,401,421 RI
16 Apr 2019 18 Apr 2019 J-4-16-I 39 3,166,000 2,427,045 RI
16 Apr 2019 20 Apr 2019 J-4-16-I 40 3,166,000 2,993,675 RI
22 Apr 2019 25 Apr 2019 J-4-16-I 41 4,432,300 4,221,667 RI
24 Apr 2019 27 Apr 2019 J-4-16-I 42 3,166,000 2,532,174 RI
24 Apr 2019 29 Apr 2019 J-4-16-I 43 3,166,000 3,879,019 RI
27 Apr 2019 30 Apr 2019 J-4-16-I 44 3,799,100 3,514,802 RI
1 Mei 2019 4 Mei 2019 J-4-16-I 45 3,166,000 1,763,370 RI
3 Mei 2019 6 Mei 2019 J-4-16-I 46 3,166,000 3,718,652 RI
6 Mei 2019 8 Mei 2019 J-4-16-I 47 4,432,300 1,781,719 RI
31 Des 2018 7 Jan 2019 J-4-16-II 1 6,228,600 6,051,293 RI
5 Jan 2019 8 Jan 2019 J-4-16-II 2 4,449,000 2,977,994 RI
7 Jan 2019 9 Jan 2019 J-4-16-II 3 4,449,000 2,909,968 RI
7 Jan 2019 10 Jan 2019 J-4-16-II 4 4,449,000 3,228,391 RI
16 Jan 2019 19 Jan 2019 J-4-16-II 5 4,449,000 1,929,806 RI
16 Jan 2019 21 Jan 2019 J-4-16-II 6 4,449,000 3,495,470 RI
2 Feb 2019 6 Feb 2019 J-4-16-II 7 4,449,000 3,153,241 RI

Page 4
DATA PASIEN 2019

13 Feb 2019 15 Feb 2019 J-4-16-II 8 4,449,000 3,176,012 RI


20 Feb 2019 23 Feb 2019 J-4-16-II 9 5,338,800 3,503,897 RI
22 Feb 2019 25 Feb 2019 J-4-16-II 10 4,449,000 3,062,640 RI
21 Feb 2019 26 Feb 2019 J-4-16-II 11 4,449,000 4,396,058 RI
28 Feb 2019 4 Mar 2019 J-4-16-II 12 5,338,800 8,333,800 RI
1 Mar 2019 5 Mar 2019 J-4-16-II 13 5,338,800 3,686,220 RI
14 Mar 2019 16 Mar 2019 J-4-16-II 14 5,338,800 3,052,619 RI
15 Mar 2019 18 Mar 2019 J-4-16-II 15 4,449,000 2,416,741 RI
14 Mar 2019 18 Mar 2019 J-4-16-II 16 4,449,000 3,635,136 RI
16 Mar 2019 19 Mar 2019 J-4-16-II 17 4,449,000 2,596,819 RI
16 Mar 2019 19 Mar 2019 J-4-16-II 18 4,449,000 3,462,549 RI
16 Mar 2019 26 Mar 2019 J-4-16-II 19 5,338,800 8,250,310 RI
1 Apr 2019 5 Apr 2019 J-4-16-II 20 4,449,000 3,957,015 RI
1 Apr 2019 5 Apr 2019 J-4-16-II 21 4,449,000 3,710,751 RI
4 Apr 2019 7 Apr 2019 J-4-16-II 22 6,228,600 4,682,372 RI
17 Apr 2019 20 Apr 2019 J-4-16-II 23 4,449,000 2,525,161 RI
16 Apr 2019 20 Apr 2019 J-4-16-II 24 4,449,000 4,154,610 RI
8 Jan 2019 11 Jan 2019 J-4-16-III 1 5,625,100 4,677,360 RI
12 Jan 2019 16 Jan 2019 J-4-16-III 2 7,875,100 6,186,396 RI
18 Jan 2019 21 Jan 2019 J-4-16-III 3 5,625,100 2,175,273 RI
16 Feb 2019 19 Feb 2019 J-4-16-III 4 5,625,100 3,470,981 RI
20 Feb 2019 23 Feb 2019 J-4-16-III 5 5,625,100 1,731,641 RI
27 Feb 2019 7 Mar 2019 J-4-16-III 6 5,625,100 8,410,486 RI

2 Jan 2019 4 Jan 2019 J-4-17-I 1 2,389,700 2,106,816 RI


1 Jan 2019 4 Jan 2019 J-4-17-I 2 2,389,700 4,175,025 RI
4 Jan 2019 7 Jan 2019 J-4-17-I 3 2,389,700 1,550,138 RI
9 Jan 2019 13 Jan 2019 J-4-17-I 4 2,389,700 2,818,224 RI
11 Jan 2019 13 Jan 2019 J-4-17-I 5 2,389,700 2,122,627 RI
15 Jan 2019 17 Jan 2019 J-4-17-I 6 2,389,700 1,919,583 RI
12 Jan 2019 17 Jan 2019 J-4-17-I 7 2,389,700 3,875,367 RI
14 Jan 2019 17 Jan 2019 J-4-17-I 8 2,389,700 2,596,320 RI
17 Jan 2019 19 Jan 2019 J-4-17-I 9 2,389,700 2,578,912 RI
20 Jan 2019 24 Jan 2019 J-4-17-I 10 3,345,600 5,113,948 RI
31 Jan 2019 3 Feb 2019 J-4-17-I 11 2,389,700 2,873,084 RI
31 Jan 2019 4 Feb 2019 J-4-17-I 12 2,389,700 4,785,057 RI
6 Feb 2019 8 Feb 2019 J-4-17-I 13 2,389,700 2,396,430 RI
6 Feb 2019 9 Feb 2019 J-4-17-I 14 2,389,700 2,280,880 RI
11 Feb 2019 14 Feb 2019 J-4-17-I 15 2,389,700 3,757,026 RI
12 Feb 2019 18 Feb 2019 J-4-17-I 16 2,389,700 4,019,439 RI
14 Feb 2019 18 Feb 2019 J-4-17-I 17 2,389,700 2,846,773 RI
15 Feb 2019 18 Feb 2019 J-4-17-I 18 2,389,700 2,222,607 RI
15 Feb 2019 19 Feb 2019 J-4-17-I 19 2,867,700 4,160,015 RI
18 Feb 2019 20 Feb 2019 J-4-17-I 20 2,867,700 1,916,595 RI
16 Feb 2019 20 Feb 2019 J-4-17-I 21 2,389,700 3,860,216 RI
18 Feb 2019 21 Feb 2019 J-4-17-I 22 2,389,700 2,258,965 RI
21 Feb 2019 22 Feb 2019 J-4-17-I 23 3,345,600 1,148,892 RI
19 Feb 2019 22 Feb 2019 J-4-17-I 24 2,389,700 2,153,834 RI
19 Feb 2019 22 Feb 2019 J-4-17-I 25 2,389,700 2,652,904 RI
20 Feb 2019 22 Feb 2019 J-4-17-I 26 2,389,700 1,974,449 RI
21 Feb 2019 23 Feb 2019 J-4-17-I 27 2,389,700 1,620,094 RI
21 Feb 2019 23 Feb 2019 J-4-17-I 28 2,389,700 2,180,440 RI

Page 5
DATA PASIEN 2019

22 Feb 2019 25 Feb 2019 J-4-17-I 29 3,345,600 3,463,464 RI


25 Feb 2019 26 Feb 2019 J-4-17-I 30 3,345,600 1,266,173 RI
26 Feb 2019 28 Feb 2019 J-4-17-I 31 2,389,700 2,346,777 RI
25 Feb 2019 28 Feb 2019 J-4-17-I 32 2,389,700 2,103,769 RI
24 Feb 2019 28 Feb 2019 J-4-17-I 33 2,867,700 2,936,455 RI
27 Feb 2019 2 Mar 2019 J-4-17-I 34 2,389,700 1,941,723 RI
6 Mar 2019 8 Mar 2019 J-4-17-I 35 3,345,600 2,778,876 RI
11 Mar 2019 13 Mar 2019 J-4-17-I 36 2,867,700 1,787,844 RI
14 Mar 2019 16 Mar 2019 J-4-17-I 37 3,345,600 2,333,428 RI
13 Mar 2019 16 Mar 2019 J-4-17-I 38 2,389,700 3,461,624 RI
15 Mar 2019 19 Mar 2019 J-4-17-I 39 2,389,700 3,722,431 RI
18 Mar 2019 22 Mar 2019 J-4-17-I 40 2,389,700 3,259,697 RI
18 Mar 2019 22 Mar 2019 J-4-17-I 41 2,389,700 4,940,338 RI
21 Mar 2019 24 Mar 2019 J-4-17-I 42 2,389,700 2,586,216 RI
25 Mar 2019 28 Mar 2019 J-4-17-I 43 2,389,700 2,446,701 RI
25 Mar 2019 29 Mar 2019 J-4-17-I 44 2,389,700 3,866,832 RI
29 Mar 2019 1 Apr 2019 J-4-17-I 45 2,389,700 2,271,988 RI
28 Mar 2019 1 Apr 2019 J-4-17-I 46 2,867,700 4,771,949 RI
31 Mar 2019 2 Apr 2019 J-4-17-I 47 3,345,600 2,499,596 RI
1 Apr 2019 4 Apr 2019 J-4-17-I 48 2,389,700 2,730,216 RI
2 Apr 2019 4 Apr 2019 J-4-17-I 49 2,867,700 2,769,932 RI
2 Apr 2019 5 Apr 2019 J-4-17-I 50 2,389,700 2,833,353 RI
2 Apr 2019 5 Apr 2019 J-4-17-I 51 2,389,700 3,735,436 RI
7 Apr 2019 10 Apr 2019 J-4-17-I 52 2,389,700 2,919,931 RI
9 Apr 2019 11 Apr 2019 J-4-17-I 53 2,389,700 2,385,723 RI
10 Apr 2019 12 Apr 2019 J-4-17-I 54 2,389,700 2,247,816 RI
10 Apr 2019 12 Apr 2019 J-4-17-I 55 2,867,700 2,618,252 RI
10 Apr 2019 12 Apr 2019 J-4-17-I 56 2,389,700 2,437,961 RI
11 Apr 2019 15 Apr 2019 J-4-17-I 57 2,389,700 3,474,847 RI
15 Apr 2019 20 Apr 2019 J-4-17-I 58 3,345,600 4,800,224 RI
2 Mei 2019 5 Mei 2019 J-4-17-I 59 2,867,700 2,744,831 RI
8 Mei 2019 12 Mei 2019 J-4-17-I 60 2,389,700 4,309,141 RI
10 Mei 2019 13 Mei 2019 J-4-17-I 61 2,867,700 2,494,236 RI
157,720,900 175,252,440

16 Jan 2019 16 Jan 2019 J-4-17-II 1 2,861,800 2,368,052 RI


14 Jan 2019 18 Jan 2019 J-4-17-II 2 2,861,800 3,568,685 RI
22 Jan 2019 25 Jan 2019 J-4-17-II 3 2,861,800 4,265,881 RI
28 Jan 2019 30 Jan 2019 J-4-17-II 4 2,861,800 4,059,842 RI
27 Jan 2019 30 Jan 2019 J-4-17-II 5 2,861,800 3,219,306 RI
31 Jan 2019 4 Feb 2019 J-4-17-II 6 2,861,800 5,567,850 RI
1 Feb 2019 5 Feb 2019 J-4-17-II 7 2,861,800 3,209,483 RI
1 Feb 2019 5 Feb 2019 J-4-17-II 8 4,006,500 6,884,915 RI
4 Feb 2019 6 Feb 2019 J-4-17-II 9 2,861,800 2,598,026 RI
9 Feb 2019 11 Feb 2019 J-4-17-II 10 2,861,800 2,339,843 RI
11 Feb 2019 14 Feb 2019 J-4-17-II 11 2,861,800 3,973,921 RI
20 Feb 2019 23 Feb 2019 J-4-17-II 12 3,434,100 3,192,840 RI
25 Feb 2019 28 Feb 2019 J-4-17-II 13 3,434,100 3,010,322 RI
27 Feb 2019 2 Mar 2019 J-4-17-II 14 2,861,800 5,358,832 RI
4 Mar 2019 6 Mar 2019 J-4-17-II 15 2,861,800 3,080,977 RI
4 Mar 2019 8 Mar 2019 J-4-17-II 16 2,861,800 4,267,441 RI
11 Mar 2019 13 Mar 2019 J-4-17-II 17 4,006,500 2,390,167 RI

Page 6
DATA PASIEN 2019

11 Mar 2019 14 Mar 2019 J-4-17-II 18 2,861,800 2,873,248 RI


11 Mar 2019 15 Mar 2019 J-4-17-II 19 2,861,800 4,092,520 RI
20 Mar 2019 22 Mar 2019 J-4-17-II 20 2,861,800 2,284,568 RI
20 Mar 2019 26 Mar 2019 J-4-17-II 21 2,861,800 6,330,258 RI
22 Mar 2019 27 Mar 2019 J-4-17-II 22 2,861,800 5,206,364 RI
24 Mar 2019 28 Mar 2019 J-4-17-II 23 2,861,800 4,479,046 RI
24 Mar 2019 28 Mar 2019 J-4-17-II 24 4,006,500 7,310,920 RI
1 Apr 2019 5 Apr 2019 J-4-17-II 25 3,434,100 3,735,436 RI
9 Apr 2019 12 Apr 2019 J-4-17-II 26 2,861,800 3,566,702 RI
18 Apr 2019 19 Apr 2019 J-4-17-II 27 4,006,500 1,676,132 RI
24 Apr 2019 27 Apr 2019 J-4-17-II 28 2,861,800 3,018,522 RI
24 Apr 2019 27 Apr 2019 J-4-17-II 29 3,434,100 5,117,899 RI
25 Apr 2019 28 Apr 2019 J-4-17-II 30 2,861,800 3,192,998 RI
26 Apr 2019 1 Mei 2019 J-4-17-II 31 2,861,800 6,763,676 RI
28 Apr 2019 4 Mei 2019 J-4-17-II 32 2,861,800 4,843,120 RI
3 Mei 2019 6 Mei 2019 J-4-17-II 33 2,861,800 3,761,157 RI
8 Jan 2019 10 Jan 2019 J-4-17-III 1 3,755,500 2,360,327 RI
15 Mar 2019 19 Mar 2019 J-4-17-III 2 3,755,500 2,117,659 RI
18 Mar 2019 21 Mar 2019 J-4-17-III 3 3,755,500 4,574,127 RI
11 Apr 2019 14 Apr 2019 J-4-17-III 4 3,755,500 2,410,511 RI

16 Jan 2019 16 Jan 2019 J-4-18-I 1 1,950,400 2,788,129 RI


15 Jan 2019 17 Jan 2019 J-4-18-I 2 1,950,400 2,311,600 RI
16 Jan 2019 19 Jan 2019 J-4-18-I 3 1,950,400 2,797,961 RI
22 Jan 2019 24 Jan 2019 J-4-18-I 4 1,950,400 1,339,484 RI
1 Feb 2019 4 Feb 2019 J-4-18-I 5 1,950,400 1,715,132 RI
6 Feb 2019 8 Feb 2019 J-4-18-I 6 2,340,400 2,724,265 RI
5 Feb 2019 9 Feb 2019 J-4-18-I 7 1,950,400 3,590,917 RI
11 Feb 2019 14 Feb 2019 J-4-18-I 8 2,730,500 3,294,849 RI
12 Feb 2019 15 Feb 2019 J-4-18-I 9 2,340,400 2,548,362 RI
12 Feb 2019 15 Feb 2019 J-4-18-I 10 1,950,400 2,725,216 RI
25 Feb 2019 27 Feb 2019 J-4-18-I 11 1,950,400 1,859,093 RI
25 Feb 2019 28 Feb 2019 J-4-18-I 12 2,730,500 3,606,926 RI
10 Mar 2019 12 Mar 2019 J-4-18-I 13 1,950,400 2,293,273 RI
29 Mar 2019 2 Apr 2019 J-4-18-I 14 2,340,400 3,023,960 RI
9 Apr 2019 11 Apr 2019 J-4-18-I 15 1,950,400 2,142,946 RI
10 Apr 2019 13 Apr 2019 J-4-18-I 16 2,730,500 3,440,104 RI
11 Apr 2019 14 Apr 2019 J-4-18-I 17 1,950,400 3,641,216 RI
36,667,100 45,843,433
29 Des 2018 3 Jan 2019 J-4-18-II 1 3,755,600 4,212,623 RI
3 Jan 2019 7 Jan 2019 J-4-18-II 2 2,682,500 3,678,362 RI
8 Jan 2019 13 Jan 2019 J-4-18-II 3 2,682,500 3,376,217 RI
3 Jan 2019 5 Jan 2019 J-4-19-I 1 4,712,400 2,625,112 RI
11 Jan 2019 14 Jan 2019 J-4-19-I 2 3,366,000 1,930,533 RI
21 Jan 2019 23 Jan 2019 J-4-19-I 3 3,366,000 2,060,876 RI
1 Mar 2019 4 Mar 2019 J-4-19-I 4 3,366,000 1,891,774 RI
8 Mar 2019 12 Mar 2019 J-4-19-I 5 3,366,000 2,544,805 RI
22 Jan 2019 24 Jan 2019 J-4-20-I 1 3,340,300 2,862,861 RI
8 Feb 2019 11 Feb 2019 J-4-20-I 2 3,340,300 2,706,113 RI
20 Feb 2019 22 Feb 2019 J-4-20-I 3 4,008,400 2,255,130 RI
6 Mar 2019 9 Mar 2019 J-4-20-I 4 3,340,300 2,372,876 RI
14 Mar 2019 16 Mar 2019 J-4-20-I 5 4,676,400 1,526,037 RI

Page 7
DATA PASIEN 2019

19 Mar 2019 22 Mar 2019 J-4-20-I 6 4,676,400 4,409,703 RI


28 Mar 2019 1 Apr 2019 J-4-20-I 7 3,340,300 3,295,179 RI
9 Apr 2019 12 Apr 2019 J-4-20-I 8 4,008,400 3,115,816 RI
10 Apr 2019 13 Apr 2019 J-4-20-I 9 3,340,300 2,084,985 RI
11 Apr 2019 15 Apr 2019 J-4-20-I 10 4,008,400 2,246,254 RI
23 Apr 2019 26 Apr 2019 J-4-20-I 11 4,008,400 2,006,328 RI
22 Apr 2019 26 Apr 2019 J-4-20-I 12 3,340,300 3,471,628 RI
24 Apr 2019 27 Apr 2019 J-4-20-I 13 4,008,400 3,294,279 RI
3 Mei 2019 6 Mei 2019 J-4-20-I 14 4,676,400 3,672,752 RI
7 Mei 2019 9 Mei 2019 J-4-20-I 15 4,676,400 3,330,047 RI
13 Feb 2019 16 Feb 2019 J-4-20-II 1 4,628,300 2,635,095 RI
4 Mar 2019 6 Mar 2019 J-4-20-II 2 4,628,300 2,215,766 RI
5 Mar 2019 9 Mar 2019 J-4-20-II 3 4,628,300 4,002,344 RI
11 Mar 2019 13 Mar 2019 J-4-20-II 4 4,628,300 2,686,668 RI
22 Apr 2019 25 Apr 2019 J-4-20-II 5 4,628,300 2,614,986 RI
26 Apr 2019 2 Mei 2019 J-4-20-II 6 6,479,700 5,610,778 RI
5 Apr 2019 8 Apr 2019 J-4-20-III 1 5,425,800 2,046,560 RI
22 Apr 2019 25 Apr 2019 J-4-20-III 2 5,425,800 2,076,736 RI
15 Jan 2019 18 Jan 2019 J-4-21-I 1 3,539,100 2,545,912 RI
24 Jan 2019 26 Jan 2019 J-4-21-I 2 2,527,900 2,606,411 RI
25 Jan 2019 28 Jan 2019 J-4-21-I 3 3,033,500 2,568,782 RI
25 Jan 2019 28 Jan 2019 J-4-21-I 4 2,527,900 2,642,427 RI
3 Mar 2019 5 Mar 2019 J-4-21-I 5 2,527,900 1,725,034 RI
5 Mar 2019 9 Mar 2019 J-4-21-I 6 3,033,500 3,846,202 RI
12 Apr 2019 16 Apr 2019 J-4-21-I 7 2,527,900 3,430,051 RI
1 Mei 2019 3 Mei 2019 J-4-21-I 8 3,033,500 1,656,605 RI
12 Jan 2019 13 Jan 2019 J-4-21-II 1 4,072,400 1,326,999 RI
22 Mar 2019 25 Mar 2019 J-4-21-II 2 4,072,400 3,128,131 RI
25 Mar 2019 29 Mar 2019 J-4-21-II 3 5,701,400 5,530,310 RI
30 Mar 2019 3 Apr 2019 J-4-21-II 4 4,072,400 3,399,049 RI
22 Jan 2019 25 Jan 2019 J-4-21-III 1 5,682,800 2,731,818 RI
21 Feb 2019 23 Feb 2019 K-4-17-II 1 1,618,800 1,912,704 RI
25 Feb 2019 1 Mar 2019 K-4-18-I 1 1,084,000 3,406,838 RI
15 Feb 2019 17 Feb 2019 K-4-18-II 1 1,540,500 1,532,299 RI
10 Apr 2019 14 Apr 2019 K-4-18-II 2 2,156,700 3,370,778 RI
17 Jan 2019 19 Jan 2019 N-4-10-III 1 3,819,200 1,991,235 RI
2 Mei 2019 6 Mei 2019 U-4-13-I 1 1,735,000 3,737,655 RI
Total 1,401,218,900 1,262,068,245
Kode RS: 3372051

Page 8
DATA PASIEN 2019

2,511,000 4,795,178

3,048,000 3,750,845

2,866,100 1,895,803

4,290,200 3,638,616

5,383,800 5,028,282

3,125,400 3,504,862

Page 9
DATA PASIEN 2019

3,799,700 2,975,601

4,539,600 3,541,355

6,107,600 5,526,402

Page 10
DATA PASIEN 2019

3,166,000 2,723,944

Page 11
DATA PASIEN 2019

4,449,000 3,479,010

5,625,100 4,074,171

Page 12
DATA PASIEN 2019

2,389,700 2,618,252

Page 13
DATA PASIEN 2019

2,861,800 3,735,436

3,755,500 2,385,419

1,950,400 2,725,216

2,682,500 3,678,362

3,366,000 2,060,876

Page 14
DATA PASIEN 2019

4,008,400 2,584,959

4,628,300 2,660,882

5,425,800 2,061,648

2,780,700 2,587,597

4,072,400
5,682,800

Page 15
UNIT COST
KODE INA DIAGNOSIS
NO DIAGNOSIS SEKUNDER HR NAMA PENYAKIT
CBGs PRIMER I II III

TB LUNG CONFIRM SPUTUM WITH OR WITH OUT


1 J-4-15-I A15.0 Tanpa Komplikasi 4 6,383,520 5,380,328 4,179,670
CULTURE (RINGAN)
TB LUNG CONFIRM SPUTUM WITH OR WITH OUT
1 J-4-15-II A15.0 I50.0,K29.7,D64.9 6 7,944,250 6,428,050 4,993,560
CULTURE (SEDANG)
TB LUNG CONFIRM SPUTUM WITH OR WITH OUT
1 J-4-15-III A15.0 I11.0, N18.9 7 8,794,920 8,648,338 6,718,360
CULTURE(BERAT)
TB LUNG CONFIRM SPUTUM WITH OR WITH OUT
2 J-4-16-I J18.9 Tanpa Komplikasi 4 5,318,760 4,482,938 3,482,600
CULTURE (RINGAN)
TB LUNG CONFIRM SPUTUM WITH OR WITH OUT
2 J-4-16-II J18.9 I50.0 &I25.9 6 7,474,320 6,299,784 4,893,900
CULTURE (SEDANG)
TB LUNG CONFIRM SPUTUM WITH OR WITH OUT
2 J-4-16-III J18.9 I50.0 ,I25.5,E11.9,B90.9 7 9,450,120 6,299,784 6,187,610
CULTURE (BERAT)

3 J-4-17-I J44.1 Tanpa Komplikasi 4 PENYAKIT PARU OBSTRUKSI KRONIK (RINGAN) 4,014,720 3,383,886 2,628,670

3 J-4-17-II J44.1 I11.0, N18.9 6 PENYAKIT PARU OBSTRUKSI KRONIK (SEDANG) 4,807,800 4,052,238 3,147,980

3 J-4-17-III J44.1 7 PENYAKIT PARU OBSTRUKSI KRONIK (BERAT) 4,807,800 4,052,238 4,131,050

4 J-4-18-I J46 Tanpa Komplikasi 4 ASTHMA & BRONKHIOLITIS (RINGAN) 3,276,600 2,761,672 2,145,440

4 J-4-18-II J46 6 ASTHMA & BRONKHIOLITIS (SEDANG) 4,506,720 4,431,608 2,950,750

4 J-4-18-III J46 7 ASTHMA & BRONKHIOLITIS (BERAT) 4,807,168 4,431,608 2,987,525

5 J-4-20-I J90 Tanpa Komplikasi 4 PLEURAL EFUSI DAN PNEUMOTORAK (RINGAN) 5,611,680 4,729,912 3,674,330

5 J-4-20-II J90 I50.0 &I25.9 6 PLEURAL EFUSI DAN PNEUMOTORAK (SEDANG) 7,775,640 6,553,720 5,091,130

5 J-4-20-III J90 7 PLEURAL EFUSI DAN PNEUMOTORAK (BERAT) 8,099,625 6,553,720 5,968,380
6 J-4-21-I Tanpa Komplikasi 4 4,246,920 3,579,530 2,780,690
J.98.1 GEJALA,TANDADAN DIAGNOSISSISTEM PERNAFASAN LAIN LAIN (RINGAN)
6 J-4-21-II J.98.1 J18.9, B90.9 GEJALA,TANDADAN
6 6,841,680
DIAGNOSISSISTEM PERNAFASAN LAIN LAIN (SEDANG) 3,579,530 4,479,640

6 J-4-21-III 7 7,126,750 8,046,774 6,251,080


J.98.1 I11.0, I27.9 GEJALA,TANDADAN DIAGNOSISSISTEM PERNAFASAN LAIN LAIN (BERAT)
TARIF PER KELAS INA CBGs TARIF RUMAH SAKIT PER KELAS USULAN TARIF

I II III I II III I II III

5,319,600 4,559,600 3,799,700 3,694,342 2,826,714 2,683,305

6,355,400 5,447,500 4,539,600 4,796,510 4,132,526 3,444,647

- 7,329,100.00 6,107,600 - 5,447,500 3,339,132

4,432,300 3,799,100 3,166,000 3,136,679 2,969,876 2,578,634

6,228,600 5,338,800 4,449,000 5,774,100 3,686,220 3,442,290

7,875,100 - 5,625,100 6,186,396 - 4,677,360

3,345,600 2,867,700 2,389,700 2,843,763 2,744,831 2,730,216

4,006,500 3,434,100 2,861,800 4,135,824 3,108,064 3,225,975

- - 3,755,500 - - 4,574,127

2,730,500 2,340,400 1,950,400 4,875,950 2,715,932 2,293,273

3,755,600 - 2,682,500 4,212,623 -


3,376,217

4,676,400 4,008,400 3,340,300 4,219,400 2,720,099 2,534,152

5,554,000 4,628,300 4,556,224 2,861,520


6,479,700 6,107,015

- - 5,425,800 - - 4,628,300
3,539,100 3,033,500 2,527,900 3,755,600 2,568,782 2,624,419

5,701,400 - 4,072,400 5,530,310 - 2,794,511

- 6,819,300 5,682,800 - 5,136,514 4,187,698