RUMAH SAKIT UNIVERSITAS AIRLANGGA

Kampus C Mulyorejo Surabaya, Jawa Timur, Indonesia - Kodepos : 60115

Telp : 031.81153153 (Rawat Inap), 031.5916290 (UGD), 031.77338118 (UGD), 031.5916287 (Poli), Fax :
031.5916291

Website : http://rumahsakit.unair.ac.id

Pasien Bukti Bayar Pemeriksaan dan Penggunaan Obat/Alat

No.RM : 0000155987 Tanggal Perawatan : 2021-02-16 - 2021-02-16 Kelas Perawatan :

Nama Pasien : HAIWAH Umur / (L/P) : 49 / P Status Pasien : BPJS KELAS I

Alamat Pasien : PLOSO 1/75-C No.Bed :

# Tanggal Jenis Pelayanan Jumlah Harga

RAWAT INAP
1 2021-02-16 Sewa Kamar 1 500,000

08:11:29

Farmasi Klinis Rawat jalan 1 10,000

09:25:17

Jasa handling obat kemoterapi 3 450,000

09:25:35

Pemasangan infus dengan kesulitan)* , Perawat Esa Rilasti 1 200,000

09:50:03

Jasa keperawatan kemoterapi , Perawat Esa Rilasti 1 300,000

09:50:22

Pelepasan Infus , Perawat Esa Rilasti 1 15,000

09:50:37

Kemoterapi , Dokter Pradana Zaky Romadhon 1 2,000,000

14:41:49

1 2021-02-16 Intrapur Inline BBraun (Intrapur) 1 108,000

09:23:55

Dexamethasone 5mg/ml Inj Meprofarm (Dexamethasone) 4 5,266

09:23:55

Diphenhydramine 10mg/1ml Inj Lucas Djaja (Diphenhidramin) 2 2,803

09:23:55

Ondansetron 4mg/2ml @2ml Inj Dexa (isi 25) (Ondansetron 2 2,452

4mg/2ml @2ml Inj)

09:23:55

Ranitidine 25mg/ml, 2ml Inj Quantum (isi 100) (Ranitidin) 1 3,510

09:23:55

Intrafix Safeset Needle Free Bbraun (Infusion Set) 1 24,885

09:23:55
# Tanggal Jenis Pelayanan Jumlah Harga

Ecosol NaCl 0,9% 500 ml B-Braun (NaCl 0.9% 500ml) 3 24,481

09:23:55

Paracetamol 500mg tab Bernofarm (Paracetamol Tab) 1 129

09:23:55

Transofix BBraun (TRANSOFIX) 1 4,080

09:23:55

Needle 18G X 1.1/2 (38mm) Terumo (Needle 18G) 2 746

09:23:55

Spuit 50ml Lubang Tengah (Luer Lock) Terumo (Spuit) 1 7,260

09:23:55

Spuit 20ml Lubang pinggir Terumo (Spuit) 1 2,376

09:23:55

Masker N95 (H) (Masker) 1 0

09:23:55

Kasa steril 7.5 x 7.5 cm OneMed (isi 5) (Kasa steril 7.5 x 7.5 cm) 5 3,036

09:23:55

Handscoon sterile Tro-Sensosurge Ukuran 7 (Handscoon) 1 7,194

09:23:55

Three way stopcock with ext. tubing Panjang Troge (THREE WAY 1 38,333
STOPCOCK WITH TUBE )

09:23:55

Cannofix-Pu 6x8cm GDM (IV Hand Adult) 1 8,220

09:23:55

IV catheter 22G X 1 Surflo (IV Catheter ) 1 7,524

09:23:55

Spuit 3ml JMI (Spuit) 4 3,739

09:23:55

Amlodipin 10mg tab Tempo (Amlodipin 10) 1 119

09:23:55

Spuit 5ml JMI (Spuit) 2 2,323

09:23:55

Cyclophosphamide 1g inj Dankos (Cyclophosphamide) 1 232,521

09:24:37

Brexel 80 mg Inj Kalbe (Docetaxel) 1 1,097,979

09:24:37

Herzemab 440mg Inj Kalbe (Trastuzumab) 1 7,139,200

09:24:37

Brexel 20 mg Inj Kalbe (Docetaxel) 2 405,956

09:25:05
# Tanggal Jenis Pelayanan Jumlah Harga

Ecoflac Mix Bbraun (Ecoflac Mix) 1 6,600

11:11:41

WFI/WI (Water Injeksi) 25ml Otsuka (OTSU WFI, 25 mL) 2 6,864

11:11:52

NaCl 0.9% 500ml MJB (NaCl 0.9% 500ml) 2 16,416

11:13:36

Underpad Nonsterile 60 x 90 cm (Underpad) 1 4,995

11:13:36

Lansoprazole 30mg Hexpharm (LANSOPRAZOL 30MG TAB ) 5 3,300

11:27:31

Selesbion Tab (H) (Multivitamin) 10 0

11:27:31

Ondansetron 4mg Tab Yarindo (Ondansentron 4) 20 9,240

11:27:31

Dexamethasone 0.5mg Tab Bernofarm (Dexamethasone) 64 8,279

11:29:56

Glimepirid 2mg tab Dexa (Glimepirid 2) 10 2,484

14:37:31

Amlodipin 10mg tab Tempo (Amlodipin 10) 10 1,188

14:37:31

Poli Penyakit Dalam - HOM

1 2021-02-16 Jasa Asuhan Keperawatan dan Kebidanan Rawat Jalan 1 15,000
/kunjungan

08:30:29

Karcis kunjungan berikutnya 1 15,000

08:54:43

Konsultasi Dokter Spesialis VIP , Dokter Pradana Zaky 1 150,000

Romadhon

08:55:13

TOTAL Rp. 12,846,496

Kasir Surabaya, 19-09-2022

Tirsa Rizky Ersanti

Penerima Invoice

(_____________________) (_____________________)