PEMERINTAH KABUPATEN MALANG PEMERINTAH KABUPATEN MALANG PEMERINTAH KABUPATEN MALANG

DINAS KESEHATAN DINAS KESEHATAN DINAS KESEHATAN

PUSKESMAS BANTUR PUSKESMAS BANTUR PUSKESMAS BANTUR
Jl. Raya Bantur No. 2203 Bantur Malang ( (0341) 841113 Jl. Raya Bantur No. 2203 Bantur Malang ( (0341) 841113 Jl. Raya Bantur No. 2203 Bantur Malang ( (0341) 841113

RINCIAN BIAYA RAWAT INAP RINCIAN BIAYA RAWAT INAP RINCIAN BIAYA RAWAT INAP

NAMA : …………….............……........ ( L / P ) NAMA : …………….............……........ ( L / P ) NAMA : …………….............……........ ( L / P )

UMUR : ………… ( Bulan / Tahun ) UMUR : ………… ( Bulan / Tahun ) UMUR : ………… ( Bulan / Tahun )
ALAMAT : …………….............................................. ALAMAT : …………….............................................. ALAMAT : ……………..............................................
STATUS : UMUM / B P J S STATUS : UMUM / B P J S STATUS : UMUM / B P J S

Tanggal Masuk ………… Tanggal Keluar ………… Tanggal Masuk ………… Tanggal Keluar ………… Tanggal Masuk ………… Tanggal Keluar …………

1. Tindakan Medik : Rp ....................................... 1.Tindakan Medik : Rp ....................................... 1.Tindakan Medik : Rp .......................................

2. Infust Set : Rp ....................................... 2.Infust Set : Rp ....................................... 2.Infust Set : Rp .......................................
3. Abocat : Rp ....................................... 3.Abocat : Rp ....................................... 3.Abocat : Rp .......................................
4. Cairan Infus : Rp ....................................... 4.Cairan Infus : Rp ....................................... 4.Cairan Infus : Rp .......................................
5. Visite Dokter : Rp ....................................... 5.Visite Dokter : Rp ....................................... 5.Visite Dokter : Rp .......................................
6. Pemakaian Obat Injeksi luar : Rp ....................................... 6.Pemakaian Obat Injeksi luar : Rp ....................................... 6.Pemakaian Obat Injeksi luar : Rp .......................................
7. Pemakaian Obat Oral luar : Rp ....................................... 7.Pemakaian Obat Oral luar : Rp ....................................... 7.Pemakaian Obat Oral luar : Rp .......................................
8. Tindakan Perawatan : Rp ....................................... 8.Tindakan Perawatan : Rp ....................................... 8.Tindakan Perawatan : Rp .......................................
9. Biaya Kamar : Rp ....................................... 9.Biaya Kamar : Rp ....................................... 9.Biaya Kamar : Rp .......................................
10. Alat Kesehatan : Rp ....................................... 10Alat Kesehatan : Rp ....................................... 10Alat Kesehatan : Rp .......................................
11. Cuci Linen : Rp ....................................... 11.Cuci Linen : Rp ....................................... 11.Cuci Linen : Rp .......................................
12. Tindakan Lain : 12.Tindakan Lain : 12.Tindakan Lain :
a. Laborat : Rp ....................................... a. Laborat : Rp ....................................... a. Laborat : Rp .......................................
b. Nabulezer : Rp ....................................... b. Nabulezer : Rp ....................................... b. Nabulezer : Rp .......................................
c. Oksigen : Rp ....................................... c. Oksigen : Rp ....................................... c. Oksigen : Rp .......................................
d. Heacting : Rp ....................................... d. Heacting : Rp ....................................... d. Heacting : Rp .......................................
e. Rawat Luka : Rp ....................................... e. Rawat Luka : Rp ....................................... e. Rawat Luka : Rp .......................................
f. Ambulance : Rp ....................................... f. Ambulance : Rp ....................................... f. Ambulance : Rp .......................................
g. ........................... : Rp ....................................... g. ........................... : Rp ....................................... g. ........................... : Rp .......................................

TOTAL : Rp ....................................... TOTAL : Rp ....................................... TOTAL : Rp .......................................

Mengetahui Mengetahui Mengetahui

Kepala Puskesmas Bantur Petugas Jaga Kepala Puskesmas Bantur Petugas Jaga Kepala Puskesmas Bantur Petugas Jaga

dr. Nureko M Samsudi ( ................... ) dr. Nureko M Samsudi ( ................... ) dr. Nureko M Samsudi ( ................... )
Nip. 19730408 200501 1 007 Nip. 19730408 200501 1 007 Nip. 19730408 200501 1 007