LEMBAR BUKTI PELAYANAN PASIEN RAWAT INAP

RUMAH SAKIT UMUM DAERAH KABUPATEN BUTON

No.RM : Cara Masuk :

Nama Pasien : Jenis Pasien :

Sex : No.SEP :
Cara Keluar : 1. Sembuh 2. Rujuk
3. Pulpak 4. Dirawat 5. Meninggal
Tgl Lahir : Berat Badan : …………………. Gram

Umur :

RI
Perawatan Tanggal Masuk : ……………………………… Pukul :..………..… Wita

……………………………….. Tanggal Keluar RS : ……………………………… Pukul :………….... Wita

Kelas : ………….. Lama Rawat : ………….. Hari

dr. penanggung jawab (1) : Konsul ke dokter (2) :

Diagnosa Masuk :
DIAGNOSA ICD 10 TTD Dokter
(Ditulis Dengan Huruf Kapital) (oleh koder)
Primer
: ……………………………………………………………………………………… …………….. 1 2
Sekunder 1.: ………………………………………………………………………………….. ……………..

2. : …………………………………………………………………………………. …………….. TTD Pasien

3. : …………………………………………………………………………………. ……………..

4. : …………………………………………………………………………………. …………….. 1 2

5. : …………………………………………………………………………………. ……………..

TINDAKAN DAN PEMERIKSAAN PENUNJANG KODE ICD 9-CM Paraf Petugas

(Ditulis Dengan Huruf Kapital) (Diisi Oleh Koder)

1 ……………………………………………… 6 ……………………………………………… 1 ……………… 6 ……………… …………………….

2 ……………………………………………… 7 ……………………………………………… 2 ……………… 7 ……………… …………………….
3 ……………………………………………… 8 ……………………………………………… 3 ……………… 8 ……………… …………………….
4 ……………………………………………… 9 ……………………………………………… 4 ……………… 9 ……………… …………………….
5 ……………………………………………… 10 ……………………………………………… 5 ……………… 10 ……………… …………………….

Biaya Riil RS Rp. Tarif INA-CBGs Rp. Selisih Rp.

Catatan khusus :
Petugas RS,

( …………………………………………. )
 LEMBAR BUKTI PELAYANAN PASIEN JKN UGD
RUMAH SAKIT UMUM DAERAH PASARWAJO KAB. BUTON

No. RM Nama Pasien Tanggal Lahir Tgl Pelayanan

Pasien : JKN
......................... ................................................ ...... / ...... /...... ....... /....... /....... No.KP :
Jenis Kelamin : LK / PR Surat Rujukan : .................................. No.SEP : 0343R001.......................
Cara Pulang : 1. Pulang 3. Meninggal 5. Pulpak Tarif INA-CBG's : Rp. ................................
2. Opname 4. Rujuk ke......... Biaya Riil RS : Rp. ................................
Poliklinik : UGD Ruj.Intern RS : .................................................
Dokter (1) : ....................................................................... Dokter (2) : .................................................
DIAGNOSA ICD.10 TTD.Dokter TTD.Pasien

Utama : .................................................................................................. ..............

Penyerta a. ............................................................................................... .............. 1.: 2.:
Komplikasi b. ............................................................................................... ..............
c. ............................................................................................... ..............
1.: 2.:
d. ............................................................................................... ..............
No. TINDAKAN ICD 9 CM No. TINDAKAN ICD 9 CM
1 ...................................................................... .................... 6 ................................................................ .................
2 ...................................................................... .................... 7 ................................................................ .................
3 ...................................................................... .................... 8 ................................................................ .................
4 ...................................................................... .................... 9 ................................................................ .................
5 ...................................................................... .................... 10 ................................................................ .................

Catatan : ........................................................................................................................................................................................

Petugas Registrasi

( .......................................... )
 LEMBAR BUKTI PELAYANAN PASIEN JKN RAWAT JALAN / UGD
RUMAH SAKIT UMUM DAERAH PASARWAJO KAB. BUTON

No. RM Nama Pasien Tanggal Lahir Tgl Pelayanan

Pasien :
No.KP :
Jenis Kelamin : Surat Rujukan : No.SEP :
Cara Pulang : 1. Pulang 3. Meninggal 5. Pulpak Tarif INA-CBG's : Rp. ................................
2. Opname 4. Rujuk ke......... Biaya Riil RS : Rp. ................................
Poliklinik : Ruj.Intern RS : .................................................
Dokter (1) : Dokter (2) : .................................................
DIAGNOSA ICD.10 TTD.Dokter TTD.Pasien

Utama : .................................................................................................. ..............

Penyerta a. ............................................................................................... .............. 1.: 2.:
Komplikasi b. ............................................................................................... ..............
c. ............................................................................................... ..............
1.: 2.:
d. ............................................................................................... ..............
No. TINDAKAN ICD 9 CM No. TINDAKAN ICD 9 CM
1 ...................................................................... .................... 6 ................................................................ .................
2 ...................................................................... .................... 7 ................................................................ .................
3 ...................................................................... .................... 8 ................................................................ .................
4 ...................................................................... .................... 9 ................................................................ .................
5 ...................................................................... .................... 10 ................................................................ .................

Catatan : ........................................................................................................................................................................................

Petugas Registrasi

( .......................................... )