RUMAH SAKIT BENYAMIN GULUH

Jl. WR Supratman No.16, Lamokato, Kolaka, Kabupaten Kolaka, Sulawesi Tenggara 93511

RINCIAN BIAYA PASIEN

Registrasi / No MR : 20210401-111841-020 / 09-03-09 Nama Pasien : Tn. TABRANI BIN NANDA
Penjamin : BPJS Alamat : JL P[OROS POMALAA
No Peserta : 0000952139046
Tgl/Jam Masuk : 26-03-2021 / 07:39:01 Ruangan : KLINIK BEDAH
Tgl/Jam Keluar : Sex / Umur : LAKI-LAKI / 61 th
Diagnosa :-

RINCIAN BIAYA PERAWATAN

NO LAYANAN TGL KETERANGAN QTY NILAI KLAIM TERBAYAR KEKURANGAN
IGD0000001 - Konsultasi Antar Spesialis
1 Rawat Inap 01-Apr   - dr Kaesar, Sp.AN 1 30,000 30,000 30,000 0
  - Ika Puspitasari, AMK
IGD0000004 - Pasang infuse dewasa
2 Rawat Inap 01-Apr   - dr. Sulfikar, Sp.B 1 20,000 20,000 20,000 0
  - Ika Puspitasari, AMK
IGD0000063 - Ganti Verban Sedang
3 Rawat Inap 01-Apr   - dr. Sulfikar, Sp.B 1 40,000 40,000 40,000 0
  - Ika Puspitasari, AMK
IGD0000105 - Health Education/hari
4 Rawat Inap 01-Apr   - dr. Sulfikar, Sp.B 1 10,000 10,000 10,000 0
  - Ika Puspitasari, AMK
IGD0000118 - Aff Kateter
5 Rawat Inap 01-Apr   - dr. Sulfikar, Sp.B 1 20,000 20,000 20,000 0
  - Ika Puspitasari, AMK
LAB0000001 - Darah Rutin
6 LABORATORIUM 01-Apr 1 100,000 100,000 100,000 0
  - Estevani, Amd.Kep
LAB0000010 - BT (Bleeding Time)
7 LABORATORIUM 01-Apr 1 20,000 20,000 20,000 0
  - Estevani, Amd.Kep
LAB0000011 - CT (Clotting Time)
8 LABORATORIUM 01-Apr 1 20,000 20,000 20,000 0
  - Estevani, Amd.Kep
LAB0000025 - GLUKOSA DARAH
9 LABORATORIUM 01-Apr 1 35,000 35,000 35,000 0
  - Estevani, Amd.Kep
LAB0000026 - UREUM
10 LABORATORIUM 01-Apr 1 60,000 60,000 60,000 0
  - Estevani, Amd.Kep
LAB0000027 - Kreatinin
11 LABORATORIUM 01-Apr 1 40,000 40,000 40,000 0
  - Estevani, Amd.Kep
OPR0000010 - Operasi (OK) Besar
12 OK BEDAH 01-Apr   - dr. Sulfikar, Sp.B 1 4,000,000 4,000,000 4,000,000 0
  - Hendra,AMK
RAD0000028 - Foto Thorax AP
13 RADIOLOGI 01-Apr   - dr. Andi Syarti, Sp.Rad 1 114,000 114,000 114,000 0
  - Ryska Sepryana B.A.Md.Rad
RAD0000050 - USG Abdomen
14 RADIOLOGI 01-Apr   - dr. Andi Syarti, Sp.Rad 1 150,000 150,000 150,000 0
  - Estevani, Amd.Kep
RI00000001 - Visite Dokter Umum
15 Rawat Inap 01-Apr   - dr. hj Sri Noviati 1 10,000 10,000 10,000 0
  - Nurmawati Sinda, AMK
RI00000002 - Visite Dokter Spesialis
16 Rawat Inap 01-Apr   - dr. Sulfikar, Sp.B 3 18,000 54,000 54,000 0
  - Ika Puspitasari, AMK
RI00000003 - Perawatan
17 Rawat Inap 01-Apr   - dr. Sulfikar, Sp.B 5 10,000 50,000 50,000 0
  - Nurmawati Sinda, AMK
RI00000081 - Askep Keperawatan
18 Rawat Inap 01-Apr   - dr. Sulfikar, Sp.B 1 20,000 20,000 20,000 0
  - Ika Puspitasari, AMK
RJ00000005 - Tindakan Suntik/Injeksi
19 Rawat Inap 01-Apr   - dr. Sulfikar, Sp.B 4 13,000 52,000 52,000 0
  - Nurmawati Sinda, AMK
RJ00000066 - BLANGKO CM SET
20 Rawat Inap 01-Apr   - dr. Sulfikar, Sp.B 1 30,000 30,000 30,000 0
  - Ika Puspitasari, AMK
RJ00000284 - Assesment Nyeri (Skor Vas)
21 Rawat Inap 01-Apr   - dr. Sulfikar, Sp.B 1 15,000 15,000 15,000 0
  - Ika Puspitasari, AMK
22 Rawat Inap 01-Apr RI00000124 - Kamar dan Gizi Kelas 3 4 88,000 352,000 352,000 0
 TIN-00665 - Konsultasi Spesialis
23 KLINIK BEDAH 01-Apr   - dr. Sulfikar, Sp.B 1 30,000 30,000 30,000 0
  - Estevani, Amd.Kep
PATEN00001470 - Inbumin 250 mg (Striatin) Tab @ 30 (Dexa/AAM)
24 Rawat Inap 01-Apr 10 6,417 64,170 64,170 0
  - Novi Nurmayanti
GEN0000000738 - Aqua Pro Inj 25 ml BTL (OTSU/M)
25 Rawat Inap 01-Apr   - drg. Andriani Harsanti, MM., Sp.Ort (K) 3 3,575 10,725 10,725 0
  - drg. Andriani Harsanti, MM., Sp.Ort (K)
GEN0000000470 - Ceftriaxone Dry Powder 1g Inj @2(HJ/TSJ)
26 Rawat Inap 01-Apr   - dr. RONAL GESTANO.W, Sp.B 6 6,022 36,132 36,132 0
  - Sita Rahmasari
GEN0000000599 - CEFIXIME 100 mg Cap @ 50 (HJ/TSJ)
27 Rawat Inap 01-Apr 20 938 18,760 18,760 0
  - HERI KUSUMA
BHP0000000750 - I.V CATHETER 20 (Terumo) MBS
28 Rawat Inap 01-Apr 1 7,841 7,841 7,841 0
  - Tri Hesti Hastuti, SKM
BHP0000001133 - Infusion Set Macro (Nipro) @50 KF
29 Rawat Inap 01-Apr 1 11,192 11,192 11,192 0
  - Wisnu Saputra, A.Md.Prs
30 Rawat Inap 01-Apr BHP0000001303 - Alcohol Swab Prep Pad (AXIMED) @100 7 148 1,036 1,036 0
BHP0000001696 - Disposable Syringe With Needle 3cc(Terumo/APL)@100
31 Rawat Inap 01-Apr   - dr. Triana Martiani 6 1,422 8,532 8,532 0
  - dr. Triana Martiani
BHP0000001726 - Disposable Syringe With Needle 1 cc (AXIMED) @100
32 Rawat Inap 01-Apr 1 1,282 1,282 1,282 0
  - Wisnu Saputra, A.Md.Prs
BHP0000001753 - Disposable Syringe With Needle 5cc(Terumo/APL)@100
33 Rawat Inap 01-Apr 1 2,000 2,000 2,000 0
  - Wisnu Saputra, A.Md.Prs
GEN0000001310 - Mefenamic Acid 500 mg Kapl @ 100(NOVA/BIS)
34 Rawat Inap 01-Apr   - Dr. drg. Arlette S. Puspa Pertiwi, Sp.KGA. 10 308 3,080 3,080 0
  - Dedi Jumaedi
PATEN00001554 - Natrium Chlorida 0,9% 500ml (MJB/KF/BPJS)
35 Rawat Inap 01-Apr 2 8,550 17,100 17,100 0
  - PIPIT LINDASARI
BHP0000001713 - Fixomull Transparent 10cm x 10m (BSN/AAM)
36 Rawat Inap 01-Apr 50 506 25,300 25,300 0
  - Nada Yunita
BHP0000001498 - Urine Drainage Bag (AXIMED/KF)
37 Rawat Inap 01-Apr 1 7,862 7,862 7,862 0
  - dr. RAHMA YUNITA
GEN0000001052 - Ranitidin 25mg/ml 2 ml Inj Amp @ 10 (HJ/TSJ)
38 Rawat Inap 01-Apr   - dr. RONAL GESTANO.W, Sp.B 7 1,650 11,550 11,550 0
  - Sita Rahmasari
GEN0000001279 - Ketorolac 30 mg Inj Amp @ 10 (QUANTUM/PPG)
39 Rawat Inap 01-Apr   - dr. RONAL GESTANO.W, Sp.B 6 8,250 49,500 49,500 0
  - Sita Rahmasari
GEN0000001302 - Ketorolac 30 mg Inj Amp @ 10 (QUANTUM/APL)
40 Rawat Inap 01-Apr 3 8,250 24,750 24,750 0
  - Hany Mutia Putri
GEN0000001059 - Ringer Laktat 500 ml BTL Inf (SATORIA/KF)
41 Rawat Inap 01-Apr   - dr. RONAL GESTANO.W, Sp.B 6 9,537 57,222 57,222 0
  - Sita Rahmasari
BHP0000001708 - ULTRAPRO Monocryl Prolene 6cm x 11cm (ETHICON/APL)
42 Rawat Inap 01-Apr 1 335,004 335,004 335,004 0
  - Tira Nurmita
BHP0000001843 - Disposable Syringe With Needle 10ml (BD/AMU) @100
43 Rawat Inap 01-Apr 3 6,875 20,625 20,625 0
  - Nadia Rismayanti
  TOTAL   5,985,663 5,985,663 5,985,663 0

RINCIAN PEMBAYARAN
KETERANGAN TOTAL Kolaka, 01 July 2021
Bill Dalam Perawatan 5,985,663
TUNAI 5,985,663
Total Tagihan 0 SUPERADMIN
Terbilang : ( Lima Juta Sembilan Ratus Delapan Puluh Lima Ribu Enam Ratus Enam Puluh Tiga Rupiah )