PEMERINTAH PROVINSI JAWA TIMUR INAS KESEHATAN [RUMAH SAKIT UMUM MOHAMMAD NOER PAMEKASAN 2-17 Tey (0324) 322594-223085 11. Bonorogn| ih ry aa rae = =. == | i Yeansttasen weve une tnunses | Skane re ie pt a ea cane fe 17 Tanggal Pelayanan 06/05/2021 Viki patente’ ne athe Sine priate { Beau Dwar 2B wwraus: } mens mee inwaue | owen a Arter broubizente { 2 Ppol. lita ety mer aed ea rent Pees ar re plsrapa ‘SURAT ELEGIBILITAS PESERTA Sidicesipneyiriseieaie SU MOHAMMAD NOER PAMEKASAN NoSEP < WSTROOZISZ1VOONISS ‘TgLSEP + 2021-05-06 Peserta No. Karty 2 0000775226204 ( MR. 2818/2019 } Nama Peserta = SUNAL Kelannin : Lak aki dns. Rawal Tolan 2 1966-17-01 is. Hak (No.Telepon 087750045910 Kis. Rawat ‘Sub/Spesialc = Instolasi Gawal Darurat Penjamin PJP Yq Melayani: TR! SUSANDH) JUUARTO Faskes Penjuk = Diagnosa Awal = - J45.9- Astana, unspecitied Catatan , "Soyo meryetys BPS Kenetatan meegguratan wie meds pamen ya Sotrhston, “SEP Biko setaage At Senger peer Cesar he $ 6 5-278 257-08 wld 2 PBI (APBN) 2 Kelas 3ous DINAS KESE Rasen OMAN Si. 00°29 i AN fan AYA iT GAWAT DABSBagar ue -UNT ors] gn NO. REG. LGLeNE DATIH : = PROPINSI Jas. Trav PANGGAL PELAYANAN : 28°08 22.2 NAMA PENDERITA Tac furaluh,.. pmisiasy wo.kartupeserta :[ 1 [ TTT] LH uMUR a TAHUN BEAL, DIAGNOSA KODE ICO Ix PELAYANAN YANG DIBERIIKAN Paket 1 —Paket2 | Paket 3 eae eel TANGGAL |parat | Parat | Paraf | Paraf | Paraf | Paraf | Pelayanan | Keterangan| Gorter | Pasion | Dower | Pasien | Dokter| Pasion | _P2/PS TTindak lanjut : Dirawal / Selesai/ Dirujuk ke Puskesmas *) +) Coret Yang Tidak Sesuai Paket1 : Pemeriksaan Medis Paket 2; a, Laboratorium Klinik / PA, . Radiodiagnotik 6. Diagnotk Elektromedis Paket’3 > Tindakan & Rehabiltasi raners~mnaakarr& Renabilitast Pelayanan Tersebut Diatas Telah Diterima Pesorta Tanda TanganRUMAH SAKIT UMUM MOHAMMAD NOER First Name: TN.SUNALTH Last Name: ‘Sample ID; 6125 ‘Gender: Male Age: ‘S$4Year(s) ‘Patient [D> (02818-2019 Department: IG ‘Bed No. Date of Analysis: 06/05/2021 18,25 Made OV-WB-CD Diao: my Gata Rag 1 wec 700 19'3aL «400-1000 2 Newt 395 W3h 200-700 3 Lym a8 103kL 00-400 4 Moot Os ism 012120 5S Eosi a 092 103A 0.02 -0.50 | 6 Bat Ooh 13AL 000-010 | 7 MG 600 1-3ML ——000-999.99 ‘xr ae sto. m00 | 9 Lymm ms 200-400 | 39% 30-120 | | hi Blow 05-50 | os do-10 | a % a0. 1000 | | 521 teu 400-330 | Ist pa 20-160 alot 400-540 Meo 300.1000 21 me 770-340 M3 Bal 320.360 M3 110-160 bat 380-860 283 10'3hL 150-480 77 fh 63-120 182 150-170 | are % 108-0282 | | 31 103A 30-90 | L 09 % 110-450 1 R 0.000 10°S/uL 0,000 - 999.999 | | R aco % ‘00 9999 | | 02 10s ee 02% [er Messe) 28° 10M | 653 13M | | 7.00 10°3/uL | | 00 103i | Delivered by: Operated by: admin ‘Validated by: admin ‘Onder Time Draw Time: Time of Printing: 06/05/2021 1827.42 Comments (Tne analysis results only answer to the corresponding sample] “*Forresearch use only, not for diagnostic use.PEMERINTAH PROVINS! JAWA TIMUR DINAS KESEHATAN - RUMAH SAKIT UMUM MOHAMMAD NOER PAMEKASAN J. Bonorogo No. 17, Kecamatan Pademawu, Kabupaten Pamekasan Telp. (0324) 322594 , Fax. (0324) 323085 Email : rsumohnoer jatimprov@gmail.com ‘Website : www.rsumohnoerpamekasan jatimprov.go.id No.RM_:02818-2019 ns. Kelamin : Pria Tol. Lahir : 30-11-1966 |Alamat_: Tambak,kaduara Barat,Jarangan pamekasan Unit isd NAMA PEMERIKSAAN HASIL NORMAL METODE DARAH LENGKAP (DL) 5 DIFF Lekosit 7.000 Cmm | 4.000 - 11.000 /Cmm. LED 6 mmjam 0-20 mmijam Hemoglobin 15.4 gid 11 = 16 gidl. Hematokrit 44% 38-42% Dit 13/1/-15412616 - ‘Trombosit 283,000 /Cmm 150,000 - 450.000 iCmm NLR 20 - GLUKOSA DARAH BS Acak 85 mg/dl < 125 - mg/dl Pamekgsan, 06-05-2021 erika (Ika Rachmawat! Apri Yani, Amak ) Page 1/1PEMERINTAH PROVINS! JAWA TIMUR DINAS KESEHATAN RUMAH SAKIT UMUM MOHAMMAD NOER PAMEKASAN Jl. Bonorogo No. 17, Kecamatan Pademawu, Kabupaten Pamekasan Telp. (0324) 322594 , Fax. (0324) 323085 Email : rsumohnoer jatimprov@gmail.com ‘Website : www.rsumohnoerpamekasan jalimprov.go.id Penanggung Jawab : dr. Siti Hotimah, Sp.PK [Tanggal : 06-05-2021 20:15 No.RM _:02818-2019 No, Lab : 6125 ns, Kelamin : Pria Nama: TN.SUNALIH Tol. Lahr: 30-11-1966 |Alamat_: Tambak kaduara Barat Jarangan,pamekasan Unit isd NAMA PEMERIKSAAN HASIL NILATNORMAL METODE FUNGSI HATI ‘SGOT (AST) 32 UNL <35-UL IFC without PP SGPT (ALT) 21 UML <31-UM Pemer|ksa Pamekasan, 06-05-2021 (Ika Rachmawati Abpri Yani, Amak ) Page t/tJKN 06/05/2021 Kode Rumah Sakit 3528038, elas Rumah Sakit_ : Nama RS RSU MOHAMMAD NOER PAMEKASANIenis Tarif = TARIF RS KELAS D PEMERINTAH Nomor Peserta + 0000775226204 Nomor SEP 1337R0020521v000355 Nomor Rekam Medis : 02818-2019 ‘Tanggal Masuk + 06/05/2021 Umur Tahun : 4 Tanggal Keluar 06/05/2021 Umur Hari 19910 Jenis Perawatan —: 2 - Rawat Jalan ‘Tanggal Lahir 1/11/1966 Cara Pulang 1 ~ Atas Persetujuan Dokter Jenis Kelamin : Ls Lakbtakt Los 2 thart Kelas Perawatan =: Regular Berat Lahir “ Diagnose Utama 145.9 Asthma, unspecified Diagnosa Sekunder : 344.9 Chronic obstructive pulmonary disease, unspecified Prosedur + 93.94 Respiratory medication administered by nebulizer 87.44 Routine chast x-ray, so described 90.59 Microscopic examination of blood, Other microscopic examination 93.99 Other respiratory procedures [ADL Sub Acute : ADL Chronic - Hasil Grouping INA-CBG : J-3-13-0 PROSEDUR TERAPI SALURAN PERNAFASAN Rp 282,900.00 Sub Acute - - Rp 0.00 Chronic B= - Rp 0.00 Special CMG = - Rp 0.00 Total Tarif Rp 292,900.00 3 08:108 Tembart7PEMERINTAH PROVINS! JAWA TIMUR DINAS KESEHATAN RUMAH SAKIT UMUM MOHAMMAD NOER PAMEKASAN ‘Jl Bonorogo No. 17, Kecamatan Pademawu, Kabupaten Pamekasan, Telp. (0324) 322594 , Fax. (0324) 323085, Email: rsumohnoer jatimprov@amail.com , Website : www.rsumohnoerpamekasan jatimprov.go.id ‘Laporan Rincian Tagihan Pasien NoRM 02616-2019 TolMulei —: 06-05-2021 17:38 ‘Noma Pasion. Thasunalih Tol Selesai + 06-05-2021 2125 ‘Namat Tambak kadvara Beralarangan,pamekasan Kelss ELAS IHR Kel. Desa: Kaduara Barat RTIRW I Status Pasien : Bis denis Kelamin Hak Kelas: Kes il f= Tindakan [—“Tanggai [Samia [Binyamin 30 [TUR Biaya] TAB PK darah engkan (4) at 06-05-2021 1816 85.000 55.000 ° sua darah acak 06-06-2021 1818 2000 12000 ° got 06-05-2021 2015 17000 17.000 ° soot 06-05-2021 20:15 47.000 ___17.000 0 Sub Total 707.000 fo'.000 ° a o o o 160 regitras!pasien tama 06-05-2021 1795 10.000 10.000 ° pemerksaan doktr (98) 06-05-2021 1754 30000 30000, ° memaseng infu dewesa 06-05-2021 1754 30.000 30000 ° ‘mengambil dareh vena dewasa 6-05-2021 1754 25.000 25.000 ° rmematang 02 per tabung 06-05-2021 1754 20.000 20000, ° 62 3imenit periam 0605-2021 17541 8.000 6.000 ° Injeksi per tindakan 06-05-2021 1812 7.000 7.000 ° nebulizer 06-05-2021 1917 40.000 40.000, o Sub Total 168.000 168.000 ° ‘Bayar o 0 ° RADIOLOSI thorax appa 06.08.2021 1850 80.000 ___ 80.000, ° Sub Tot 30.000 80.000 ° o o ° bat -Obatan isd ‘tT Susandh Jufato, MAMKes -APY/060621/0212 - KREDIT Dexamethasone Ineks 0605202118111 1.73 ° Infusion Set Dewase 060520211811 t 10.808 ° Iv Catheter 20 Pink o6o5202t 1811 t 18.798 ° Iv Gathetor22- Blue 0505202118111 15158 ° Nasal 02 Canute Dewasa os05z021 1811 t 6.864 ° Ringer Laciate 500 ta Wise 060520718111 9:55 ° Spult3 Ce 06052021 1811 1.888 o ‘Sub Total 62.600 ° Bayar 0 4. TW Susanchi Jutart, MMKes ~ AP11060521/0237 - KREDIT ‘Maker Nebulzer Dewas 06.05.2021 18521 33987 33987 ° asker 02 Dewasa 0605202118521 2378723787 ° Vertlin Nebut (06.05.2021 19:52 9.626 o 400 =A 1706052110248 - KREDIT ‘Chlorphonamine Maleate 4 (ctm) Tab (06-05-2021 21:08, Coden 20 Mg (06-05-2021 21:08, ‘Meshylprednisolon 16 Tab (06-05-2021 21:08, Sabbulamol 4 Mg (06-05-2021 21:08, Puyer Capsul (06:05-2021 21:08, Total Biays 7a7.500 ° (Rika Anggraint trawan, Amd.Ak )