REKAPITULASI PELAYANAN

RAWAT INAP TINGKAT PERTAMA (RITP)

NAMA PUSKESMAS/KLINIK : SUKAKARYA
BULAN/ TAHUN PELAYANAN : JULI 2016

ALAMAT JUMLAH BESARAN

NO. HANDPHONE TANGGAL TANGGAL
NOMOR IDENTITAS TEMPAT HARI TARIF PAKET/ JUMLAH TAGIHAN
NO. NAMA PENDERITA YANG DAPAT DIAGNOSA AKHIR TINDAKAN YANG DIBERIKAN MASUK KELUAR
(Kartu JKN) TINGGAL RAWATAN HR (Rp.)
DIHUBUNGI PERAWATAN PERAWATAN
(DESA) (hari) (Rp.)

1 2 3 4 5 6 7 8 9 10 11 12

1 JULIANA 0000228612824 PAYA SEUNARA 085360062791 Dyspepsia IVFD RL kec 20 tts/i 30/07/2016 31/07/2016 1 Hari Rp. 100.000 100,000

Relapsing fever,
2 SYAFRIDAH 0001429533325 KRUENG RAYA 082364420736
unspecified
IVFD NaCl kec 20 tts/i 29/07/2016 31/07/2016 2 Hari Rp. 100.000 200,000

ABDUL THALEB Other secondary

3 0000229359014 PAYA SEUNARA 082367265786
hypertension
IVFD RL kec 20 tts/i 26/07/2016 29/07/2016 1 Hari Rp. 100.000 300,000
PUTEH
ASYIFATUL Relapsing fever,
4 0001908787566 PAYA -
unspecified
IVFD RL kec 20 tts/i 26/07/2016 27/07/2016 2 Hari Rp. 100.000 100,000
HAIFA
Nausea and
5 SITI HARIS 0001838842683 COT BA’U 085372800817
vomiting
IVFD NaCl kec 20 tts/i 24/07/2016 26/07/2016 1 Hari Rp.100.000 200,000

6 YUSNIAR 0000979776652 PAYA SEUNARA 081262133560 Dyspepsia IVFD RL kec 20 tts/i 20/07/2016 23/07/2016 3 Hari Rp. 100.000 300,000
Urinary tract
7 ZULKIFLI R 0000218284727 ACEH BESAR 082276833383 infection, site not IVFD RL kec 20 tts/i 19/07/2016 22/07/2016 1 Hari Rp. 100.000 300,000
specified
MUHAMMAD Migraine,
8 0000229414015 KRUENG RAYA 082369266528 IVFD NaCl kec 20 tts/i 16/07/2016 19/07/2016 2 Hari Rp. 100.000 300,000
HAJI unspecified
Dengue fever
9 TIA AMANDA 0000229827947 BATEE SHOK 082372292872 IVFD RL kec 20 tts/i 15/07/2016 17/07/2016 2 Hari Rp. 100.000 200,000
[classical dengue]
Accidental puncture
10 JULIARMAN 0000229087675 KRUENG RAYA 082360717058 IVFD RL kec 20 tts/i 13/07/2016 14/07/2016 1 Hari Rp. 100.000 100,000
and laceration

11 TI HALIMAH 0001438959554 PAYA SEUNARA 082370910985 Dyspepsia IVFD RL kec 30 tts/i 13/07/2016 14/07/2016 1 Hari Rp. 100.000 100,000
 Other acute upper
12 WAHYUDI.T 0001868340565 PAYA SEUNARA 081262974416 respiratory IVFD RL kec 20 tts/i 13/07/2016 15/07/2016 2 Hari Rp. 100.000 200,000
infections
Motorcycle rider
13 NYAK MUSA 0000228671109 BATEE SHOK 081377409531 injured in collision IVFD RL kec 20 tts/i 11/07/2016 12/07/2016 1 Hari Rp.100.000 100,000
with animal

14 KAMARULLAH 0001481714651 PAYA SEUNARA 085358849326 Tuberculosis of lung IVFD RL kec 20 tts/i 11/07/2016 14/07/2016 3 Hari Rp. 100.000 300,000
Toxic effect of
15 FITRIANI 0000228193492 PAYA SEUNARA 085260741958 organophosphate IVFD RL kec 20 tts/i 09/07/2016 10/07/2016 1 Hari Rp. 100.000 100,000
insecticides

16 INTAN SAFITRI 0000228509076 PAYA SEUNARA 082360318879 Dyspepsia IVFD RL kec 20 tts/i 09/07/2016 11/07/2016 2 Hari Rp. 100.000 200,000

17 YENI ARISKA 0000229001681 PAYA SEUNARA 082366937285 Dyspepsia IVFD RL kec 20 tts/i 09/07/2016 11/07/2016 2 Hari Rp.100.000 200,000
Pain localized to
18 ADNAN 0001904535562 PAYA SEUNARA 085260850471 other parts of lower IVFD RL kec 20 tts/i 08/07/2016 09/07/2016 1 Hari Rp. 100.000 100,000
abdomen
Other peripheral
19 SAIDAH 0001115973876 PAYA SEUNARA 085277088713
vertigo
IVFD RL kec 20 tts/i 03/07/2016 05/07/2016 2 Hari Rp. 100.000 200,000
Other iron
DESI
20 0001110831434 KEUNEUKAI 081269271453 deficiency IVFD RL kec 30 tts/i 30/06/2016 02/07/2016 2 Hari Rp. 100.000 200,000
AGUSTIANI anaemias

JUMLAH SELURUH TAGIHAN 38 Hari Rp.3,800,000

Menyetujui, Sabang, 2 Agustus 2016

Pembuat Laporan
Kepala UPTD Puskesmas Kec. Sukakarya
Kota Sabang

JUNI SAFRIDA
YUNIDAR, S.ST NIP. 19780623 200701 2 004
NIP.19770613 200604 2 003 .