No : 006/SP_HRD/RSBKD/I/2019 Surabaya, 30 Januari 2019

Lampiran :-
Perihal : Permohonan Pengajuan Alat

Kepada Yth :
Direktur Utama
PT Permata Bunda Bersama
Di tempat

Dengan hormat,
Sehubungan dengan kebutuhan operasional RS Bunda Surabaya sesuai persyaratan dari
Kemenkes (ASPAK), maka bersama surat ini kami mengajukan penambahan alat medis (data
terlampir).
Demikian surat ini kami ajukan. Atas perhatiannya, kami ucapkan terima kasih.

Karumkit RS Bunda Surabaya

dr. Ivan Hardian

 PENGAJUAN ALAT RADIOLOGI SESUAI ASPAK

No Divisi Nama Alat Jumlah kekurangan

1 Rg General X-Ray Emergency Trolley / Resuscitation Crash Cart 1
2   Oxygen Concentrator / Portable Oxygen Generator.  1
3   Printer Processing Film / Paper 1
4   Digital Radiography  
5   Surveymeter 1
6 Kamar Processing Film Printer Processing Film / Paper 1
 PENGAJUAN ALAT LAB SESUAI ASPAK

No Divisi Nama Alat Jumlah kekurangan

1 Rg Kimia Klinik Blood Gas Analyzer 1
2   Electrophoresis apparatus for clinical use/Elektroforesis 1
3 Rg Hematologi Agregometer 1
4   Analisa Hb 1
5   Coagulation instrument/Peralatan koagulasi 1
6   Flow cytometri 1
 PENGAJUAN ALAT HCU SESUAI ASPAK

Jumlah
No Divisi Nama Alat kekurangan
1 HCU Central Monitor 1
2   ECG/EKG/Electrocardiograph 6 CH 1
3   Defibrilator 1
4   X-Ray Film Viewer 1
5   ICU Bed Electric 1
6   Infusion pump 1
7   Infusion warmer 1
8   Matras decubitus 1
9   Oximeter / pulse oximeter / Oksigen Saturasi 1
10   Resusitator Dewasa 1
11   Stetoskop/Stetoskop Dewasa 1
Suction pump/Pompa vakum /Vacuum-powered body fluid suction apparatus; Suction Pump
12   Mobile  1
13   Syringe Pump 1
14   Tensimeter Anaeroid 1
15   Ventilator 1
 PENGAJUAN ALAT RABER SESUAI ASPAK

No Divisi Nama Alat Jumlah kekurangan

1 Rg Persiapan Bersalin Autotransfusion apparatus 1
2   Inkubator infant Tansport 1
3   Bed-side Monitor/Bed-patient monitor/Patient monitor 1
4   Defibrilator 1
5   Embriotomi set 1
6   Obstetric forceps/Forceps obstetrik 1
7   Infusion pump 1
8   Lampu Operasi Bergerak/Operating Lamp Mobile 1
9   Sterilisator Portable 1
10   Syringe Pump 1
11   Tensimeter Anaeroid 1
12   Infant radiant warmer 1

13 RG Bersalin Tanpa Komplikasi Bed-side Monitor/Bed-patient monitor/Patient monitor 1

14   Infusion pump 1
15   Syringe Pump 1
16   ECG/EKG/Electrocardiograph 1
17 Rg Pemulihan / Recovery ECG/EKG/Electrocardiograph 1
18   Bed-side Monitor/Bed-patient monitor/Patient monitor 1
19   Infusion pump 1
20   Syringe Pump 1
21   Oxygen Concentrator / Portable Oxygen Generator.  1
22   Tensimeter Anaeroid 1
23 Rg Bayi normal / transisi Inkubator infant Tansport 1
24   Infant radiant warmer 1
25   Oximeter / pulse oximeter / Oksigen Saturasi 1
26   Tensimeter 1
27 Rg Observasi dgn PE ECG/EKG/Electrocardiograph 1
28 Rg post partum Antidecubitus Matras 6
29   Bed-side Monitor/Bed-patient monitor/Patient monitor 6
30   ECG/EKG/Electrocardiograph 6
31   Infusion pump 6
32   Kursi roda 5
33   Meja Mayo / Meja instrumen / Intrumen table 5
34   Nebulizer 6
35   Stretcher/Brankar 6
36   Stetoskop/Stetoskop Dewasa 4
37   Aspirator/Vacuum/Suction pump portable 6
38   Termometer digital 5
39   X-Ray Film Viewer 6
40   Timbangan dewasa 6
41   Emergency Trolley / Resuscitation Crash Cart 5
42   Tensimeter 4
 PENGAJUAN ALAT RANUM SESUAI ASPAK

No Divisi Nama Alat Jumlah kekurangan

Rg Perawatan
1 Anak Baby Suction Pump 1
2   Toynbee diagnostic tube 2
3   ECG/EKG/Electrocardiograph 1
4   Emergency Trolley / Resuscitation Crash Cart 1
5   X-Ray Film Viewer 1
Examination light / Examination lamp / Lampu periksa / Hanging
6   lamp 1
7   Nebulizer 1
8   Oxygen Concentrator / Portable Oxygen Generator 2
9   Tempat tidur anak / Pediatric Hospital Bed 2
10   Tensimeter Anaeroid / Sphygmomanometer Aneroid 1
11   Termometer digital 1
12   Tensimeter 2
 PENGAJUAN ALAT OK SESUAI ASPAK

Jumlah
No Divisi Nama Alat kekurangan
1 Rg Recovery OK Blanket warmer/Hipotermia unit 1
Rg Bedah Umum
2 OK Laparoscopy 1
3   Colonoscopy 1
4   Gastroscopy 1
5   Endoscopy 1
6   Lampu Operasi Bergerak/Operating Lamp Mobile 1
 PENGAJUAN ALAT IGD SESUAI ASPAK

Jumlah
No Divisi Nama Alat kekurangan
Rg Resusitasi
1 IGD Defibrilator 1
2   Laringoskop 1
3   Syringe Pump 1
4   Infusion pump 1
Rg Observasi
5 IGD Defibrilator 1
6   Infusion pump 1
7   Pneumatic Splint Set 1
8   Syringe Pump 1
9   Tensimeter Digital 1
Rg Tindakan
10 IGD Gynecological Bed/Obstetric table and accessories 2
11   Lampu kepala / head lamp 2
Examination light / Examination lamp / Lampu periksa /
12   Hanging lamp 2
13   Minor Surgery Set 1
14   Bed patient electric 3
 PENGAJUAN ALAT POLI SESUAI ASPAK

No Divisi Nama Alat Jumlah

1 Poli Anak Cool box immunization / Cold Chain (untuk penyimpan vaksin) 1
2   Baby Suction Pump 1
3   Resusitator bayi/neonatus 1
4   Tensimeter Anak 1
5 Poli Obsgyn Colposcope 1
6   Cardiotocograph/CTG 1
7   Forcep Biopsi 1
8   Office histeroscopy 1
9   Aspirator/Vacuum/Suction pump portable 1
10   Tensimeter Anaeroid 1
11   USG 3D 1
12   USG 4D 1
13   Sterilisator Portable 1
14 Poli Umum Tensimeter Anaeroid 1
15 Toilet Poli Wastafel 1