PEMERINTAH KABUPATEN PENAJAM PASER UTARA Salmonella Typhi O Negatif

DINAS KESEHATAN
Salmonella Typhi H Negatif IMUNOLOGI
UPT. PUSKESMAS PETUNG
JL NEGARA KM 18 KEC. PENAJAM KODE POS 76144 TELP 0543-5232949 Salmonella O Paratyphi a Negatif 1 Tes Kehamilan
FORMULIR HASIL PEMERIKSAAN LABORATORIUM Salmonella O Paratyphi b Negatif 2 Syphilis Non Reaktif
Dokter Pengirim :..................................................................................
Pasien 9 Antigen Ncov-19 Negatif 3 HbsAg Non Reaktif
Nama :................................................................................... 10 Pemeriksaan 4 Anti HIV Non Reaktif
Tanggal Lahir/Umur :................................................................................... lain......................................
Jenis Kelamin :................................................................................... 5 Antigen/Antibody Dengue Non Reaktif
Alamat :................................................................................... Petung.,.............................20.... 6 NS 1 Non Reaktif
Jam Sampling-Jam Selesai :...................................................................................
7 Golongan Darah
No JENIS PEMERIKSAAN HASIL NILAI RUJUKAN Rhesus
HEMATOLOGI ( )
8 Widal
1 Hb L: 13-14 mg/dl
PEMERINTAH KABUPATEN PENAJAM PASER UTARA Salmonella Typhi O Negatif
P: 12-16 mg/dl DINAS KESEHATAN
Salmonella Typhi H Negatif
2 Leukosit 3200-10.000/mm³ UPT. PUSKESMAS PETUNG
JL NEGARA KM 18 KEC. PENAJAM KODE POS 76144 TELP 0543-5232949 Salmonella O Paratyphi a Negatif
3 Trombosit 170x10³-380x10³/mm³
FORMULIR HASIL PEMERIKSAAN LABORATORIUM Salmonella O Paratyphi b Negatif
4 Hematokrit L: 40% - 50% Dokter Pengirim :...................................................................................
Pasien 9 Antigen Ncov-19 Negatif
P: 35% - 45%
Nama :................................................................................... 10 Pemeriksaan
KIMIA KLINIK Tanggal Lahir/Umur :................................................................................... lain......................................
Jenis Kelamin :...................................................................................
1 Gula Darah
Alamat :...................................................................................
Petung,.............................20....
- Sewaktu 76 – 180 mg/dl Jam Sampling-Jam Selesai :...................................................................................
- Puasa 70 – 100 mg/dl
No JENIS PEMERIKSAAN HASIL NILAI RUJUKAN
- 2 JPP 76 – 140 mg/dl HEMATOLOGI ( )
2 Asam Urat 1 Hb L: 13-14 mg/dl
PEMERINTAH KABUPATEN PENAJAM PASER UTARA
Laki – Laki 3,0 – 7,2 mg/dl P: 12-16 mg/dl DINAS KESEHATAN
Perempuan 2,0 – 6,0 mg/dl 2 Leukosit 3200-10.000/mm³ UPT. PUSKESMAS PETUNG
JL NEGARA KM 18 KEC. PENAJAM KODE POS 76144 TELP 0543-5232949
3 Cholesterol > 200 mg/dl 3 Trombosit 170x10³-380x10³/mm³
FORMULIR HASIL PEMERIKSAAN LABORATORIUM
MIKROBIOLOGI & 4 Hematokrit L: 40% - 50% Dokter Pengirim :...................................................................................
PARASITOLOGI Pasien
P: 35% - 45%
1 Malaria Negatif Nama :...................................................................................
KIMIA KLINIK Tanggal Lahir/Umur :...................................................................................
Jenis Kelamin :...................................................................................
1 Gula Darah
IMUNOLOGI Alamat :..................................................................................
- Sewaktu 76 – 180 mg/dl Jam Sampling-Jam Selesai :..................................................................................
1 Tes Kehamilan
- Puasa 70 – 100 mg/dl
2 Syphilis Non Reaktif No JENIS PEMERIKSAAN HASIL NILAI RUJUKAN
- 2 JPP 76 – 140 mg/dl HEMATOLOGI
3 HbsAg Non Reaktif
2 Asam Urat 1 Hb L: 13-14 mg/dl
4 Anti HIV Non Reaktif
Laki – Laki 3,0 – 7,2 mg/dl P: 12-16 mg/dl
5 Antigen/Antibody Dengue Non Reaktif
Perempuan 2,0 – 6,0 mg/dl 2 Leukosit 3200-10.000/mm³
6 NS 1 Non Reaktif
3 Cholesterol > 200 mg/dl 3 Trombosit 170x10³-380x10³/mm³
7 Golongan Darah
MIKROBIOLOGI & 4 Hematokrit L: 40% - 50%
Rhesus
PARASITOLOGI
P: 35% - 45%
8 Widal 1 Malaria Negatif
KIMIA KLINIK
1 Gula Darah Alamat :...................................................................................
Jam Sampling-Jam Selesai :...................................................................................
- Sewaktu 76 – 180 mg/dl
( )
- Puasa 70 – 100 mg/dl No JENIS PEMERIKSAAN HASIL NILAI RUJUKAN
URINALISA
- 2 JPP 76 – 140 mg/dl
1 Makroskopi: PEMERINTAH KABUPATEN PENAJAM PASER UTARA
2 Asam Urat
- Warna Kuning DINAS KESEHATAN
Laki – Laki 3,0 – 7,2 mg/dl UPT. PUSKESMAS PETUNG
- Kejernihan Jernih JL NEGARA KM 18 KEC. PENAJAM KODE POS 76144 TELP 0543-5232949
Perempuan 2,0 – 6,0 mg/dl
- Bau FORMULIR HASIL PEMERIKSAAN LABORATORIUM
3 Cholesterol > 200 mg/dl
2 Berat Jenis 1,005 – 1,030 Dokter Pengirim :...................................................................................
MIKROBIOLOGI & Pasien
PARASITOLOGI 3 Leukosit Negatif Nama :...................................................................................
1 Malaria Negatif Tanggal Lahir/Umur :...................................................................................
4 Nitrit Negatif
Jenis Kelamin :...................................................................................
5 PH 5,0 – 7,5 Alamat :...................................................................................
IMUNOLOGI Jam Sampling-Jam Selesai :...................................................................................
6 Urobilinogen Negatif
1 Tes Kehamilan
7 Protein Negatif No JENIS PEMERIKSAAN HASIL NILAI RUJUKAN
2 Syphilis Non Reaktif URINALISA
8 Blood Negatif
3 HbsAg Non Reaktif 1 Makroskopi:
9 Keton Negatif
4 Anti HIV Non Reaktif - Warna Kuning
10 Bilirubin Negatif
5 Antigen/Antibody Dengue Non Reaktif - Kejernihan Jernih
11 Glukose Negatif
6 NS 1 Non Reaktif - Bau
12 Sedimen
7 Golongan Darah 2 Berat Jenis 1,005 – 1,030
- Lekosit 0–5
Rhesus 3 Leukosit Negatif
- Eritrosit 0–1
8 Widal 4 Nitrit Negatif
- Silinder Negatif
Salmonella Typhi O Negatif 5 PH 5,0 – 7,5
- Epitel Positif (+)
Salmonella Typhi H Negatif 6 Urobilinogen Negatif
- Kristal Negatif
Salmonella O Paratyphi a Negatif 7 Protein Negatif
Salmonella O Paratyphi b Negatif 8 Blood Negatif
TINJA
9 Antigen Ncov-19 Negatif 9 Keton Negatif
1 Makroskopis :
10 Pemeriksaan 10 Bilirubin Negatif
- Konsistensi
lain......................................
11 Glukose Negatif
- Warna
Petung.,.............................20.... 12 Sedimen
- Bau
- Lekosit 0–5
- Lendir
- Eritrosit 0-1
- Darah
( )
- Silinder Negatif
2 Darah Samar
PEMERINTAH KABUPATEN PENAJAM PASER UTARA - Epitel Positif (+)
3 Mikroskopis
DINAS KESEHATAN
UPT. PUSKESMAS PETUNG - Kristal Negatif
- Telur Cacing Negatif
JL NEGARA KM 18 KEC. PENAJAM KODE POS 76144 TELP 0543-5232949
- Amuba Negatif
FORMULIR HASIL PEMERIKSAAN LABORATORIUM TINJA
Dokter Pengirim :................................................................................... - Eritrosit Negatif
Pasien 1 Makroskopis :
10 - Lekosit
Nama :...................................................................................
- Konsistensi
Tanggal Lahir/Umur :...................................................................................
Jenis Kelamin :................................................................................... Petung.,.............................20.... - Warna
 - Bau 12 Sedimen
- Lendir - Lekosit 0–5
- Darah - Eritrosit 0–1
2 Darah Samar - Silinder Negatif
3 Mikroskopis - Epitel Positif (+)
- Telur Cacing Negatif - Kristal Negatif
- Amuba Negatif
- Eritrosit Negatif TINJA
10 - Lekosit 1 Makroskopis :
- Konsistensi
Petung,.............................20....
- Warna
- Bau
- Lendir
( )
- Darah
2 Darah Samar
PEMERINTAH KABUPATEN PENAJAM PASER UTARA 3 Mikroskopis
DINAS KESEHATAN
UPT. PUSKESMAS PETUNG - Telur Cacing Negatif
JL NEGARA KM 18 KEC. PENAJAM KODE POS 76144 TELP 0543-5232949 - Amuba Negatif
FORMULIR HASIL PEMERIKSAAN LABORATORIUM - Eritrosit Negatif
Dokter Pengirim :...................................................................................
Pasien 10 - Lekosit
Nama :...................................................................................
Tanggal Lahir/Umur :...................................................................................
Petung.,.............................20....
Jenis Kelamin :...................................................................................
Alamat :...................................................................................
Jam Sampling-Jam Selesai :...................................................................................
( )
No JENIS PEMERIKSAAN HASIL NILAI RUJUKAN
URINALISA
1 Makroskopi:
- Warna Kuning
- Kejernihan Jernih
- Bau
2 Berat Jenis 1,005 – 1,030
3 Leukosit Negatif
4 Nitrit Negatif
5 PH 5,0 – 7,5
6 Urobilinogen Negatif
7 Protein Negatif
8 Blood Negatif
9 Keton Negatif
10 Bilirubin Negatif
11 Glukose Negatif