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PEMERINTAH KABUPATEN BARITO SELATAN

KECAMATAN DUSUN UTARA


UPTD PUSKESMAS PENDANG
Jalan Pembangunan No.33 RT.12 Kelurahan Pendang Kode Pos 73752

RINCIAN BIAYA PERAWATAN/PERSALINAN


Nama :
Umur :
Alamat :
Perincian Biaya
1. Sewa Kamar (Rp. 30.000/Hari) Rp. ....................................................
2. BHP (Barang Habis Pakai)
a. Cairan Infus
 RL Rp. ....................................................
 NaCL Rp. ....................................................
 Dextrose Rp. ....................................................
b. Surflu / Jarum Infuse Rp. ....................................................
c. Infus Set Rp. ....................................................
d. Plester, Perban, Kasa, Betadine Rp. ....................................................
e. Lain-lain Rp. ....................................................
3. Obat-obatan
a. .................................................... Rp. ....................................................
b. .................................................... Rp. ....................................................
c. .................................................... Rp. ....................................................
d. .................................................... Rp. ....................................................
e. .................................................... Rp. ....................................................
f. .................................................... Rp. ....................................................
g. .................................................... Rp. ....................................................
h. .................................................... Rp. ....................................................
4. Biaya Tindakan Rp. ....................................................
5. Biaya Persalinan Rp. ....................................................
6. Biaya Keterangan Kelahiran Rp. ....................................................
7. Jasa Perawatan Rp. ....................................................
8. Jasa Visite Dokter Rp. ....................................................
Total Rp. ....................................................

Petugas

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NIP………………………..

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