BLANKO PERMINTAAN PEMERIKSAAN LABORATORIUM

DPW PATELKI KALIMANTAN SELATAN

ID ........................ Tanggal........................
Nama ........................
Umur ........................Tahun L/P
Alamat ........................
Dokter ........................
Nama Ruang ........................
HEMATOLOGI URINE KIMIA DARAH
□ Hemoglobin □ Urine Rutin □ Glukosa Puasa
□ Leukosit □ Protein □ Glukosa 2 jam PP
□ Hematrokit □ Glukosa □ Glukosa Sewaktu
□ Trombosit □ Keton □ Protein Total
□ Retikulosit □ Urobilinogen □ Albumin
□ Eritrosit □ Bilirubin □ Globulin
□ LED □ BJ □ Bilirubin Total
□ W. Pendarahan □ Sedimen □ Bilirubin Direct
□ W. Pembekuan □ Leko/LPB □ Bilirubin Indirect
□ W. Protombin □ Eri/LPB □ SGOT
□ Hit. Jenis Leukosit □ Selep/LPB □ SGPT
□ Gol Darah Rhesus □ Kristal □ Ureum
□ Gambaran Darah □ Creatinin
Tepi SEROLOGI □ Asam Urat
□ Widal Test □ Kolesterol
MIKROBIOLOGI □ Tubex Test □ HDL
□ Preparat Gram □ Mantouk Test □ LDL
□ Preparat BTA □ HIV □ Trigliserida
□ Sputum SPS □ HbsAg
□ Troponin I FAECES
ELEKTROLIT □ Ck ckMB □ Faeces Rutin
□ Natrium □ HbA1C □ Lemak
□ Kalium □ hsCRP □ Darah Samar
□ Klorida TTD :
SEPSIS
□ Procalcitonin
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